1999 aviation accident
Si Fly Flight 3275 (KSV3275) was a non-scheduled international passenger flight from the Italian capital of Rome to Pristina, Kosovo. The flight was operated by Italian airliner Si Fly using an ATR 42-300 series. On 12 November 1999, the aircraft struck a mountain during the approach to Pristina, killing everyone on board. With 24 deaths, the accident remains as the deadliest aviation disaster in Kosovo's history.
The investigation attributed the causes of the crash to multiple factors. The crew was experiencing fatigue due to their high roster and failed to execute the appropriate approach procedure to Pristina. The on-duty ATC personnel accidentally forgot to track the flight during the approach phase and did not pay enough attention during radar vectoring. Due to these issues combined with the faulty GPWS warning system, which was caused by the company's decision to postpone the rectification of the device, the aircraft failed to fly clear of terrain and crashed onto the mountain.
Background.
From 1998 to 1999, a war between the Federal Government of Yugoslavia and Kosovo Liberation Army broke out in Kosovo. Due to reports of ethnic cleansing of Albanians, North Atlantic Treaty Organization (NATO) forces invaded Yugoslavia in March 1999, resulting in the closure of airspace within the area of conflict. The United Nations passed Resolution 1244 and thus all civil activities were handed over to United Nations Interim Administration Mission in Kosovo (UNMIK). The resolution also stated that Kosovo Force (KFOR) would be deployed in order to maintain peace. An agreement was signed to define the airspace that would be controlled by KFOR.
Following the result of agreements that was signed in June 1999 in Helsinki, the operation of Pristina Airport was handed over to the Russian Army. At the same time, members of United Kingdom's Royal Air Force were ordered to be in charge of the air traffic control services and meteorological services in Pristina. The first RAF detachment arrived in June and the airport was reopened in July. Commercial flight at the airport was resumed in October.
Aircraft.
The aircraft was an ATR 42-312, registered as F-OHFV with a serial number of 012. It was delivered to Simmons Airlines and American Eagle with a U.S. registry number of N420MQ, later re-registered as N12MQ. In 1999, the aircraft was leased to Si Fly.
When it was delivered to Si Fly, the aircraft had more than 24,000 flying hours. The aircraft had been properly maintained. According to the technical logbook, there were no recorded defects on the aircraft.
Passengers and crew.
Most of the passengers were UN officials. Others were reported to be journalists and aid workers. The Italian newspaper "la Repubblica" reported that up to 12 Italians, including all three crew members, were on board the aircraft. There were also three Spanish citizens from UNMIK, three Britons representing their relief organizations, and one each from Australia, Bangladesh, Canada, Germany, Iraq and Kenya. The sole Canadian on board was a member of Correctional Service of Canada, representing the government of Canada
The captain, identified as 59-year-old Andrea Maccaferro, received his airline transport pilot license (ATPL) in 1989 and received his type rating on the ATR 42 in 1995. He had 18,000 flight hours, including 5,000 hours on the ATR 42. The first officer, identified as 49-year-old Antonio Canzolino, had logged 5,000 flight hours, with 1,800 of them on the ATR 42, and was the pilot flying (PF) on the accident flight. Both pilots were Italian nationals, had previous experience in landing at Pristina, and were former Italian Air Force pilots.
Flight.
Flight 3275 was a shuttle flight from Rome's Leonardo da Vinci–Fiumicino Airport to Pristina International Airport in Kosovo. It was a six-day-a-week flight and was chartered by World Food Programme for aid works in Kosovo following the war in the region. The flight was mainly used by aid workers, UN officials and journalists.
Flight 3275 departed Rome at 09:11 a.m for Pristina, Kosovo with 3 crew members and 21 passengers. The flight was piloted by Captain Andrea Maccaferro and Antonio Canzolino. After flying for nearly two hours, the aircraft reached the Macedonian airspace and the communication was handed over from Skopje ATC to Pristina ATC. After being identified by Pristina, the flight crew changed their flight conditions to visual flight rules (VFR). At 10:58 a.m, Pristina gave a series of headings for the crew to intercept the airport's ILS, which was acknowledged by Flight 3275. The controller reminded the crew that the airport could only provide limited radar service due to poor radar performance. He then gave the crew another heading and asked them to descend to before he ordered another descent to .
Disappearance.
While approaching the airport, the crew decided to make a call to Pristina ATC. The controller stated that he could hear them loud and clear, adding that they were number two for landing and giving the crew an advice regarding the presence of another aircraft which was located approximately ahead of them. He later asked the crew to stay on their heading and turned his attention towards the other flights. At 11:13 a.m, the crew declared "I want to land" and the controller gave another heading to the crew. After confirming their position, the controller gave the last heading of 180. The crew responded "Kosovo three two seven five roger turn left heading one eight zero". This was the last transmission from Flight 3275.
Search and rescue.
ATC noted that radio contact with the aircraft was lost, followed by radar contact at 11:20 local time. Kosovo Force was informed about the loss of contact at 11:45 p.m. Royal Air Force initially stated that the aircraft had landed in the Albanian capital of Tirana at 13:30 p.m, but the statement was immediately retracted as it was deemed to be false. Flight 3275 was later officially declared as missing.
At 14:30 local time, a search and rescue team assembled by NATO was deployed. Helicopters and 500 soldiers took part in the search and rescue operation. Search and rescue team searched for the aircraft overnight with thermal imaging and night-vision equipment. Search and rescue operation was hampered by weather, mountainous terrain, and mines in the area.
The wreckage of the aircraft was found later on the evening of 12 November, on a steep mountainside approximately from the town of Mitrovica. The aircraft failed to clear the mountain top by just . There were no signs of life among the wreckage. The first responder who arrived first at the scene stated that several charred bodies were found around the wreckage of the aircraft.
The aircraft initially impacted a tree before slamming onto terrain. Moments after impacting terrain, the tail and the left stabilizer immediately detached while the lower fuselage disintegrated. The rest of the aircraft then impacted terrain for the second time before it came to rest at the other side of the mountain. The wings and the cockpit were found in upside down position. Dozens of troops immediately cordoned the scene. On 14 November, the bodies of all 24 victims had been successfully recovered from the crash site.
Investigation.
The crash was investigated by France, Italy and the United Kingdom. ATR stated that they would send a team of experts to assist the investigation. The flight recorders were recovered on 13 November and were sent to BEA on the next day for a readout. Both recorders were found in good condition.
On 20 November, French investigators recommended Pristina Airport to close operation to all civilian flights. KFOR and UNMIK immediately followed the recommendation and temporarily suspended all civilian flights from entering and flying out of the airport on 21 November. Military flights were still allowed to operate in the airport.
Crew error.
The cockpit voice recorder revealed that during the flight the crew was not following the appropriate procedure for an approach to Pristina. While approaching Pristina, the flight preparation was conducted hastily. During the briefing for the arrival, safety altitudes were not mentioned by the First officer and the Captain didn't ask any questions about it. Their actions were apparently influenced by the high amount of flights to Pristina, creating a sense of routine. This might have caused the crew to think that they didn't need to strictly follow the appropriate briefing as they would get assistance from the ATC anyway and thus would be cleared from the mountainous terrain in the area.
Further findings revealed more procedural deviations from the crew and also from the ATC. The ATC managed to give the crew with altitudes lower than the minimum safety altitude that was written in the crew's approach chart, but the crew somehow didn't respond to the anomaly. The crew also selected a decision height of , far lower than the airport's minimum decision height of . While preparing for the approach, the crew elected to use an ILS approach without a glidepath, a clear violation of the airline's policy which prohibited the crew from taking such action.
Even though these deviations were caused by the crew's routine, there were indications that they were feeling fatigued during the flight. Based on an examination conducted by University of Paris, both flight crews were suffering from high level of fatigue, particularly the Captain. The Captain had lack of sleep and rest. Two days prior to the crash, he had flown a flight for 14 hours and on the next day he continued to fly for another 5 flights.
The fatigued state of the crew, their reliance with assistance from the ATC and added with their successful approaches in previous flights, caused them to feel confident enough that they would successfully conduct another typical approach to Pristina.
ATC failure.
The war in Kosovo prompted the United Nations to pass Resolution 1244, meaning that all civil activities would be operated by military personnel, including the daily operation of the airport. They would provide limited ATC services to aircraft operators. Among the provided services was Radar Information Service (RIS), which was given upon request during meteorological condition that might affect visibility. Other than RIS, the ATC would provide radar vectoring as well. If the controller was requested by the crew to provide radar vectoring, then it was mandatory for the controller to pay attention to the flight and to clear them from terrain.
After the bombing of Yugoslavia by NATO forces in March 1999, the ATC operation was conducted by British RAF. On the day of the accident, the controller who was supposed to be on duty that day was unable to attend and was eventually replaced by a terminal control director. He received approximately just five hours of training for the approach radar position and was not familiar enough with the correct civil procedure. He didn't have experience with airports in mountainous area.
That day, two aircraft, including Flight 3275, had contacted the tower within seven minutes and were flying under visual flight condition. Flight 3275 was the number one to land, while the other aircraft was the second, both approaching from the south of the airport. The other aircraft was flying at , significantly faster than Flight 3275. This surprised the controller and caused him to swap the landing order of each aircraft, with Flight 3275 being the second to land. At the time, Flight 3275's position was a bit north than the other aircraft and the crew was asked to maintain their heading. Later, the controller gave Flight 3275 a series of headings and altitudes for the approach to the airport's ILS, but by then Flight 3275 had entered an area where the minimum safety altitude was not at anymore, but at . The rise in elevation eventually caused their radar plot to drop due to poor signal in the mountainous region.
The controller then turned his focus to the other aircraft. As there was no more radar plot from Flight 3275, the controller wasn't aware about the existence of Flight 3275. The crew of Flight 3275 eventually stated their intention to land and the controller gave them a westerly heading. He later blindly gave them another heading to the south of the airport. The controller was noted for being unresponsive regarding the low altitude of the aircraft. Apparently, he thought that the aircraft was still flying visually, even though the crew had not informed him about any changes on flight conditions. The aircraft maintained its low altitude and eventually flew into a layer of compact clouds before it impacted terrain.
GPWS malfunction.
The cockpit voice recorder didn't record the