Investigation Summary
The flight was a scheduled international service from London to Entebbe via Rome. Upon arrival in the Rome area, the crew was informed of deteriorating visibility due to fog. After two unsuccessful missed approaches to Runway 16L, the crew attempted a third approach. During this final attempt, the aircraft descended below the minimum descent altitude without having the runway environment in sight. The aircraft struck a residential building approximately 800 meters short of the runway threshold before impacting the ground and breaking apart.
Final Conclusions
The primary cause was the flight crew's failure to follow established procedures for low-visibility approaches. Specifically, the crew continued the descent below the decision height without visual contact with the runway. Contributing factors included the crew's fatigue and the pressure to complete the landing after multiple failed attempts in challenging meteorological conditions.
Video Analysis
No video analysis linked for this case file yet.
Systems & Failure Modes
Instrument Landing System (ILS)
The ground-based system used to provide lateral and vertical guidance to the aircraft during approach.
Altimeter
The instrument used to measure the aircraft's altitude; the crew failed to level off at the required minimums.
Interesting Facts
- 01The aircraft was a Boeing 707-338C originally delivered to Qantas in 1968.
- 02Visibility at the time of the crash was reported as 100 meters in fog.
- 03The crash resulted in 33 fatalities among the 52 occupants; 19 people survived with injuries.
- 04The flight was a 'fifth freedom' service between London and Rome.
- 05The captain was highly experienced but had limited recent experience with the specific ILS procedures at Fiumicino.
Safety Actions & Advisories
Crew Resource Management (CRM) Training
The accident highlighted the need for improved CRM to ensure that junior crew members feel empowered to challenge a captain's decision to descend below safety minimums.
Adherence to Minimums
Regulatory bodies reinforced the strict requirement for pilots to execute an immediate missed approach if visual cues are not present at the Decision Height (DH).