Investigation Summary
The accident occurred as the Boeing 737-800 was at a height of approximately 136 feet on final approach. The First Officer was the Pilot Flying (PF) for the leg, while the Captain acted as Pilot Monitoring (PM). The Captain observed a dense flock of starlings and initiated a go-around by activating the TO/GA (Take-off/Go-around) switches. Almost simultaneously, the aircraft collided with the birds. The engines, which were at approximately 62% N1, ingested multiple birds, causing them to surge and lose thrust, with N1 dropping to 41%. The sudden loss of power during the high-drag go-around configuration led to a rapid decay in airspeed and an increase in the angle of attack. The stick shaker activated at 21 feet, and the aircraft struck the runway with a vertical acceleration of 2.66g. The left main landing gear detached from its anchorages. The aircraft briefly veered off runway 15 before the flight crew maneuvered it back onto the runway surface, where it slid on its left engine nacelle and tail section before coming to a rest.
Final Conclusions
The Italian National Agency for the Safety of Flight (ANSV) concluded that the accident was caused by the unexpected loss of thrust in both engines due to a massive bird strike during a go-around maneuver. The investigation identified that the Captain's decision to go around, while standard for an obstructed flight path, was a contributing factor because the engines were more susceptible to severe damage at the high RPM settings required for a go-around. Other contributing factors included the inadequate effectiveness of bird dispersal measures at Ciampino Airport and a lack of specific training for flight crews on managing 'startle' effects or procedures for multiple bird strikes during the landing phase. The final report was issued on 20 December 2018.
Photographic Evidence (1)
Video Analysis
Ryanair Flight 4102: The Go-Around That Caused Both Engines to Fail — A detailed look at the bird strike encounter at Rome Ciampino that led to a dual engine failure and the subsequent crash landing of a Ryanair Boeing 737.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
44-year-old Belgian pilot Frédéric Colson
First Officer
23-year-old Dutch pilot Alexander Vet
Systems & Failure Modes
CFM56-7B26/3 Engines
Both engines ingested a massive number of starlings, causing compressor stalls (surges) and a critical loss of thrust during the go-around phase.
Main Landing Gear
The left main landing gear detached from its attachment points due to the high vertical loads (2.66g) during the hard landing.
Stick Shaker
The stall warning system activated at 21 feet as the aircraft lost airspeed and exceeded the critical angle of attack.
Interesting Facts
- 01The aircraft struck approximately 86 to 90 starlings, which is significantly above certification requirements for bird ingestion.
- 02Both engines suffered repeated surges and lost approximately 20% of their N1 fan speed almost instantly.
- 03The aircraft (MSN 33639) was only 8 months old at the time of the accident and was subsequently written off.
- 04Ten people received hospital treatment for minor injuries, including two crew members.
- 05The airport was closed for 36 hours following the accident to recover the aircraft and repair the runway.
Safety Actions & Advisories
ANSV Recommendation 12/1525-08/1/A/8
Recommended that EASA and FAA provide guidelines stating that if landing is assured during a bird strike encounter on final approach, it is preferable to land at low power rather than attempting a go-around, as high RPM increases engine damage risk.
ANSV Recommendation 13/1525-08/2/A/18
Recommended specific training for flight crews to cope with the 'surprise' and 'startle' effects during critical phases of flight like approach and landing.