National Transportation Safety Board

Aviation Accident Final Report

Location: NEWARK, NJ Accident Number: NYC97FA098

Date & Time: 05/22/1997, 1438 EDT Registration: IDEIL
Aircraft: Boeing 767-300 Aircraft Damage: Substantial
Defining Event: Injuries: 168 None
Flight Conducted Under: Part 129: Foreign

Analysis
During landing with a gusty crosswind, the pilot received an onboard wind shear alert about 5
seconds prior to touchdown, and the airplane touched down with a 1.8 G load on the main
landing gear, followed 2 seconds later by a 2.8 G spike on the nose landing gear. After
touchdown, the first officer, the operating pilot, continued to push the control column forward,
and the airplane pitched nose down, as the main landing gear alternately lifted off the ground
and the ground spoilers retracted. The nose landing gear and surrounding structure were
damaged. The captain and first officer had 150 hours and 68 hours respectively, in make and
model. The ATIS contained, '...Low level windshear advisories are in effect...' which was
acknowledged by the flight crew. The local controller had advised preceding flights prior to the
airplane's arrival on frequency that, '...gain or loss of 15 knots below 300 feet reported by
several aircraft...' He also gave this information to his relief about 1 minute prior to the
airplane landing. However, it was not given to the accident flight. ATC controllers were not
required to repeat the warning when it was on the ATIS.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The improper landing flare by the co-pilot and the inadequate supervision of the flight by the
pilot-in-command. Other related factors were the gusty crosswind, windshear, and the lack of
familiarity with the airplane by both pilots.

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Findings

Occurrence #1: HARD LANDING

Phase of Operation: LANDING

Findings
1. (F) WEATHER CONDITION - CROSSWIND
2. (F) WEATHER CONDITION - GUSTS
3. (F) WEATHER CONDITION - WINDSHEAR
4. (C) FLARE - IMPROPER - COPILOT/SECOND PILOT
5. (F) ELEVATOR - IMPROPER USE OF - COPILOT/SECOND PILOT
6. (F) LACK OF FAMILIARITY WITH AIRCRAFT - COPILOT/SECOND PILOT
7. (F) SUPERVISION - INADEQUATE - PILOT IN COMMAND
8. (F) LACK OF FAMILIARITY WITH AIRCRAFT - PILOT IN COMMAND

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Factual Information
HISTORY OF FLIGHT
On May 22, 1997, at 1438 eastern daylight time, a Boeing 767-300, I-DEIL, operated by
Alitalia Airlines as flight 600 (AZA 600), was substantially damaged while landing at Newark
International Airport (KEWR), Newark, New Jersey. The 10 crewmembers, and 158
passengers were not injured. Visual meteorological conditions prevailed for the scheduled
international passenger flight that originated at Milano, Italy. Flight 600 was operated on an
instrument flight rules (IFR) flight plan under 14 CFR Part 129.
According to air traffic control records, from the Federal Aviation Administration (FAA),
the following Automatic Terminal Information Service (ATIS) was in effect at the time that
flight AZA 600 arrived in the New York terminal area, and remained in effect through the time
of the accident.
"Newark tower information whiskey one seven five one zulu, wind three five zero at two four
[knots], visibility one zero [miles], ceiling seven thousand broken, temperature one seven
[Celsius], dewpoint one [Celsius], altimeter two niner niner four, i l s four right approach in
use, landing runway four right, departing runway four left...low Level windshear advisories are
in effect...."
Flight 600 made initial contact with the New York Terminal Radar Approach Control
(TRACON) at 1412, and was told to expect an ILS Runway 4R approach, and was issued the
current altimeter. About 10 second after the initial contact, the crew from flight 600 reported
they had information WHISKEY, which was acknowledged by the controller.
Examination of the air/ground voice communications tape from Newark Air Traffic
Control Tower revealed that at 1427:55, and again at 1428:09, the local controller reported to
arriving airplanes:
"...gain or loss of fifteen knots below three hundred feet reported by several aircraft."
At 1432:47, Flight 600 made initial contact with Newark air traffic control tower and
transmitted, "newark tower good afternoon alitalia six hundred heavy intercepting zero four
right I l s."
At 1432:52, the local controller replied, "alitalia six hundred heavy newark tower good
afternoon runway four right number five wind three four zero at one seven gusts two niner
cleared to land."
Flight 600 replied, "cleared to land number five alitalia six hundred copy wind."
At 1434:02, the local controller transmitted to a departing flight, "...wind three four zero
at one six...."
At 1434:27, flight 600 was advised of a nearby helicopter which was acknowledged.
At 1434:57, the local controller transmitted as part of a landing clearance to a preceding
flight, "...wind three three zero at one seven...."
At 1435:16, the local controller began a relief briefing which was not transmitted outside
of the facility, but was recorded on the air/ground communications tape. The relief briefing
was interrupted twice, and continued at 1435:52, and again at 1437:25, when it was completed.

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The controller being relieved stated in part, "...two nine belongs to you its active its
available...just waiting for your use...some guys been requesting [it] as the wind gusted
up...your weather is v f r the winds have been doing this I've been getting gusts up to
40...[there] was a loss gain or loss of fifteen knots below three hundred by several aircraft
maybe about fifteen minutes ago...."
At 1437:29, the voice on local control had changed.
At 1439:05, the local controller transmitted, "alitalia six hundred heavy left turn left
turn sir", and flight 600 replied, "...negative negative alitalia six hundred heavy...our gear has
collapsed we have to stop this position."
Emergency response equipment was notified, and the passengers were eventually
offloaded by the use of portable stairs.
The captain stated:
"We were cleared for the approach (ILS RNWY 04R); our indicated airspeed was 180 knots.
We contacted the EWR tower and were cleared to land 04R, number five. Wind was reported
330/19/29. Our reference speed was 135 knots and, based on the reported winds, we adjusted
our speed to a target of 150 knots approximately 7 N. miles from the airport."
"We cleared the fence stabilized in all respects on the approach. Well below 50 ft, AGL, the
aircraft windshear detection system was activated. Within 2-3 seconds thereafter, the aircraft's
left main landing gear touched down, followed by the right main and nose gear in that order.
Given our altitude, speed, and power settings, we did not have an opportunity to react. We
were, however, able to maintain directional control of the aircraft and prevent further damage
to the aircraft and any injury to our passengers, who were safely evacuated via moveable steps."
A follow-up interview with the captain by an NTSB Investigator disclosed:
"...The captain observed the FO leaning forward during the impact, and the captain stated that
the hardest impact was on the nose gear. Once the nose gear touched down, the crew kept the
airplane on the runway with the yoke. After impact, the captain recognized that the power
levers were not at idle, and he reduced the power levers to the idle position and into reverse.
The speed brakes, which were in the armed position, deployed once the captain reduced the
power levers to idle. Also, after impact, the steering was not working and the nose of the
airplane was slightly tilted to the right side...."
The first officer stated:
"...After touchdown and the sudden dropping of the nose-gear to the runway, (as described by
Capt. Vincenti), I was pushed forward and in the process, also pushed the yoke forward. Upon
recovery, we immediately commenced appropriate roll-out procedures, which included placing
the throttle to idle, this stopping the aircraft."
A follow-up interview with the first officer by an NTSB Investigator disclosed:
"When asked what 'target speed' was, the FO stated it was the approach speed (Vref 135 KIAS)
plus 15 knots. This is predetermined by Alitalia's policy which calls for adding half the
headwind component plus the gust. The minimum and maximum that can be added are 5 and
20 knots respectively. The headwind component was determined to be 5 knots with the wind
60 degrees off of runway centerline, plus the gust factor provided a plus 15 knots component to
Vref."

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"During the approach, as the airplane descended through 1,000 feet, the airspeed was
dropping from 150 to about 145 KIAS. The airspeed then increased from 150 to 160 KIAS, at
which time the FO reduced the power levers. There were small corrections made for airspeed
throughout the approach. The airplane crossed the runway threshold below 50 feet above
ground level (AGL). The airplane then rolled left which the FO corrected. The Ground
Proximity Warning System (GPWS) then gave one wind shear warning alert, followed by the
airplane's descent and contact with the runway. The airplane contacted the runway with the
left main landing gear, followed by the right main landing gear and nose gear. The FO
attempted to pull aft on the yoke to minimize the vertical speed prior to contact. The FO stated
that the first contact with the runway on the main landing gear was 'very strong,' and he pulled
back on the yoke; however, [the] nose came down very hard. The impact was so hard that his
headphones fell off falling between his feet, and he found himself looking down on his lap.
After the landing, the FO looked up to see that the airplane was on the runway centerline, at
which time the captain reduced the power levers to idle and into reverse, while the FO was
applying maximum braking with the pedals. The Captain reached for the power levers about
one second before the FO."
A witness stated:
"We were positioned in AF 747 at entrance rd. Alitalia A/C appeared to be in a normal landing
situation until what appeared to be at about 40-75 Ft above the ground...At that point the
aircraft abruptly dipped its right wing and the...[right] main gear contacted the ground. The
A/C then bounced over to the left gear. A/C nose was still up this oscillation occurred from my
recollection 1-2 more times. During that, the nose gear came down and contacted the runway
the main gear looked to have lifted off the ground for about 50-100 Ft of distance. All gear
settled down and the A/C taxied down and then pulled off to the...[right] side of the runway
and stopped...."
Another witness stated:
"A CAL DC-10 had just blown a tire on landing...The next A/C to land was Alitalia 767. The
A/C was in a normal approach. During roll-out the A/C abruptly pitched...[right] wing down.
[Right]...MLG contacted runway. A/C bounced up and to the left, and out of camera view."
PERSONNEL INFORMATION
Both pilots had been issued pilot certificates and medical certificates in accordance with
the Italian government. Both pilots had type ratings in the Boeing 767.
The captain had about 9,800 hours of flight experience, with 4,000 hours as pilot-in-
command, and 150 hours in the Boeing 767. In addition, the Captain was also a crew resource
management (CRM) instructor.
The captain had qualified on the airplane about 1 1/2 months prior to the accident flight.
He reported that he elected to communicate on the radio due to his greater command of the
English language, and allowed the first officer to perform the landing due his greater
familiarity with KEWR.
The first officer had approximately 2,500 hours of flight experience, of which 2,000
hours were in DC-9's and 68 hours were in the Boeing 767.
The accident flight was the first officer's second trip into KEWR, and his first trip
without a flight instructor onboard. His first trip into KEWR occurred on May 12, 1997. The

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first officer hand flew the approach from 1,000 feet above ground level.
ORGANIZATIONAL AND MANAGEMENT INFORMATION
The investigation revealed that the Boeing 767 was new to the Alitalia fleet, and had only
been on line for one month. Although operational control of the flight remained with the
captain, both pilots had received the same training. There were no restrictions on first officers
for takeoffs and landings.
FLIGHT RECORDERS
The digital flight data recorder (DFDR) was forwarded to the NTSB Vehicle
Performance Division for readout. The DFDR read out revealed that about 5 seconds prior to
touchdown, the fight crew received a windshear alert. The flight crew continued with the
approach and touched down in a 4 degree nose high pitch attitude, and with a 1.8 G load. The
right and then the left main landing gear tilt switches transitioned to the ground position, and
the speed brake handle deployed.
Following main landing gear touchdown, the airplane pitched down at a rate of about 3
degrees per second. Two seconds after touchdown, a second G spike was recorded at 2.8 Gs.
This coincided with a momentary level off of the nose down pitch attitude at 1.2 degrees. This
was followed by first, the left, and then the right main landing gear tilt switches transitioning
back to the flight mode, and the speed brake handle returning to the stowed position. Four
seconds after the initial touchdown, the airplane achieved a -2.8 degrees nose down pitch
attitude.
A check of the elevator position revealed that after main landing gear touchdown and
the 2.8 G spike, the elevator trailing edge momentarily increased about 2-3 degrees up for one
second, and then continued to move to a trailing edge down position.
WRECKAGE AND IMPACT INFORMATION
Examination of the airplane revealed that the nose landing gear trunions remained
attached to the bulkhead that they were affixed to; however, the bulkhead was torn loose from
surrounding structure. There were multiple broken stringers and cracked frames, and
wrinkled fuselage skin in the vicinity of the nose landing gear. In addition, hydraulic lines were
ripped and hydraulic fluid (Skydrol) was sprayed into the electronic equipment bay. The
damage to the nose landing gear prevented use of the cockpit actuated nose wheel steering. In
addition, due to failure of the nose landing gear bulkhead, the nose landing gear was canted at
an angle.
The cost of repairs was in excess of $20,000,000 US.
ADDITIONAL INFORMATION
According to the Newark Airport Informal Runway Use Program:
"If runways are dry, the crosswind component must not be greater than 20 knots and the
tailwind component must not be greater than 5 knots."
According to Page AP-4-2 of the Newark Tower Standard Operating Procedures the
maximum winds for runway 4 including gusts were:
Wind Direction Maximum Velocity

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 300 20 knots 310
20 knots 320 21 knots 330
23 knots 340 26 knots
350 28 knots 360 31
knots
The program also stated:
"Participation in the program is voluntary for aircraft operators/pilots. Whenever a request is
made for other than the assigned runway, the pilot will be advised that the requested runway is
not the noise abatement runway. If the assigned runway is still unacceptable, the pilot will be
assigned the runway requested."
A view of the air/ground communications between Newark Tower, and AZA 600
revealed that the runway assignment of Runway 4R was accepted without question.
A check of the runways revealed that Runway 4R/22L was 9,980 feet long and 150 feet
wide, with an asphalt surface. Runway 29/11 was 6,800 feet long and 150 feet wide, with an
asphalt surface.
According to the FAA Air Traffic Handbook, 7110.65, Section 3-1-8, Low Level
windshear Advisories:
"When low level windshear is reported by pilots or detected on any of the Doppler or Low Level
Windshear Alert Systems (LLWAS), controllers shall issue the alert to all arriving and
departing aircraft until the alert is broadcast on the ATIS and pilots indicate that they have
received the appropriate ATIS code. A statement shall be included on the ATIS for 20 minutes
following the last report or indication of windshear."
The specified terminology for windshear was, "WINDSHEAR ADVISORIES IN
EFFECT."
The local controller stated in his written statement:
"I cleared AZA600 to land Runway 4R. Wind information was given and no reports of wind
shear were noted from other aircraft for approximately 15 minutes. Wind shear advisories
were on the ATIS. I observed nothing abnormal about AZA600 on final. I did not observe his
landing."
A review of the weather from KEWR revealed gusty winds were first recorded on the
0751 weather report and continued through the 2051 report.
The vertical acceleration sensor was located on the wing spar in the wheel well area.
The investigation revealed that the accelerometer was sampled at a rate of eight times per
second. The accelerometer recorded the G load at the time of sampling and not necessarily the
peak G load.
The investigation revealed that the retraction of the speed brake lever after touchdown
coincided with the main landing tilt switches transitioning to the flight mode again. Further
investigation revealed that once the speed brake lever returned to the stowed position and the
speed brake panels on the wings retracted, a further return to the ground position of the tilt
switches would not re-deploy the speed brakes. They would have to be manually re-deployed.
According to the Alitalia B 767 Operations Manual:

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"The policy for the flight crew in coping with windshear is to avoid areas of known severe
windshear....Severe windshear is that which produces airspeed changes greater than 15 knots
or vertical speed changes greater than 500 feet per minute."
According to the Boeing 767 Flight Crew Training manual:
"...Avoid all areas of known severe windshear. Severe windshear is that which produces
airspeed changes greater than 15 knots. If severe windshear is indicated, delay takeoff or do
not continue an approach until conditions improve...."
During a post accident interview, the captain was asked why he did not perform a
missed approach. He reported there was no time once the wind shear alert sounded, and that
he envisioned a tail strike if a missed approach was performed from that position.
The following caution and additional information was found in the Boeing 767 Flight
Crew Training Manual:
"CAUTION: Pitch rates sufficient to cause airplane structural damage can occur if large nose
down control column movement is made prior to nose wheel touchdown."
"If the airplane should bounce, hold or re-establish a normal landing attitude and add thrust as
necessary to control the rate of descent. Thrust need not be added for a shallow bounce or
skip. When a high hard bounce occurs, initiate a go-around. Apply go-around thrust and use
normal go-around procedures. A second touchdown may occur during the go-around. Do not
retract the landing gear until a positive rate of climb is established."
Nothing was found in the Boeing 767 Flight Crew Training Manual, or the Alitalia 767
Operations Manual that would have restricted or prohibited a go-around.
A check with Continental Airlines failed to identify the DC-10 with a blown tire or to
obtain a copy of the video tape of the landing.

Pilot Information
Certificate: Airline Transport Age: 48, Male
Airplane Rating(s): Multi-engine Land Seat Occupied: Left
Other Aircraft Rating(s): None Restraint Used: Seatbelt, Shoulder
harness
Instrument Rating(s): Airplane Second Pilot Present: Yes
Instructor Rating(s): Airplane Multi-engine; Airplane Toxicology Performed: No
Single-engine; Instrument Airplane
Medical Certification: Class 1 Valid Medical--no Last FAA Medical Exam: 03/24/1997
waivers/lim.
Occupational Pilot: Last Flight Review or Equivalent:
Flight Time: 9880 hours (Total, all aircraft), 156 hours (Total, this make and model), 4196 hours (Pilot In
Command, all aircraft), 103 hours (Last 90 days, all aircraft), 42 hours (Last 30 days, all
aircraft), 9 hours (Last 24 hours, all aircraft)

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Aircraft and Owner/Operator Information
Aircraft Make: Boeing Registration: IDEIL
Model/Series: 767-300 767-300 Aircraft Category: Airplane
Year of Manufacture: Amateur Built: No
Airworthiness Certificate: Transport Serial Number: 28147
Landing Gear Type: Retractable - Tricycle Seats: 238
Date/Type of Last Inspection: 04/15/1997, Continuous Certified Max Gross Wt.: 399700 lbs
Airworthiness
Time Since Last Inspection: 344 Hours Engines: 2 Turbo Fan
Airframe Total Time: 4917 Hours Engine Manufacturer: GE
ELT: Engine Model/Series: CF6-80-C2B6F
Registered Owner: ALITALIA AIRLINES Rated Power:
Operator: ALITALIA AIRLINES Operating Certificate(s) None
Held:
Operator Does Business As: Operator Designator Code: AAPF

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions Condition of Light: Day
Observation Facility, Elevation: EWR, 18 ft msl Distance from Accident Site: 0 Nautical Miles
Observation Time: 1451 EDT Direction from Accident Site: 0°
Lowest Cloud Condition: Scattered / 7500 ft agl Visibility 10 Miles
Lowest Ceiling: None / 0 ft agl Visibility (RVR): 0 ft
Wind Speed/Gusts: 16 knots / 25 knots Turbulence Type /
Forecast/Actual:
Wind Direction: 320° Turbulence Severity /
Forecast/Actual:
Altimeter Setting: 29 inches Hg Temperature/Dew Point: 17°C / 1°C
Precipitation and Obscuration:
Departure Point: MILANO, ITALY, OF (LIMC) Type of Flight Plan Filed: IFR
Destination: (EWR) Type of Clearance: IFR
Departure Time: 0540 EDT Type of Airspace: Class B

Airport Information
Airport: NEWARK INTERNATIONAL (EWR) Runway Surface Type: Asphalt
Airport Elevation: 18 ft Runway Surface Condition: Dry
Runway Used: 4R IFR Approach: ILS
Runway Length/Width: 9300 ft / 150 ft VFR Approach/Landing: Full Stop

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Wreckage and Impact Information
Crew Injuries: 10 None Aircraft Damage: Substantial
Passenger Injuries: 158 None Aircraft Fire: None
Ground Injuries: N/A Aircraft Explosion: None
Total Injuries: 168 None Latitude, Longitude:

Administrative Information
Investigator In Charge (IIC): ROBERT L HANCOCK Report Date: 07/23/1999
Additional Participating Persons: NATE C GLINBIZZI; TETERBORO, NJ
DOMENICO ZONNO; ROMA, ITALY,
Publish Date:
Investigation Docket: NTSB accident and incident dockets serve as permanent archival information for the NTSB’s
investigations. Dockets released prior to June 1, 2009 are publicly available from the NTSB’s
Record Management Division at [email protected], or at 800-877-6799. Dockets released after
this date are available at http://dms.ntsb.gov/pubdms/.

The National Transportation Safety Board (NTSB), established in 1967, is an independent federal agency mandated
by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine
the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate
the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and
decisions through accident reports, safety studies, special investigation reports, safety recommendations, and
statistical reviews.

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence
or use of any part of an NTSB report related to an incident or accident in a civil action for damages resulting from a
matter mentioned in the report. A factual report that may be admissible under 49 U.S.C. § 1154(b) is available here.

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