Night CFIT Accident Near Cagliari Involving Medical Transport Flight (OE-FAN)

Flight Details and Accident Sequence The aircraft departed Rome-Ciampino Airport on an ambulance flight to Cagliari. The crew of three pilots and three doctors was transporting a cooler containing a heart for a patient. The descent to Cagliari-Elmas Airport began at night under visual flight rules (VFR). After the crew received clearance to descend to 2,500 feet, air traffic control reported that runway 32 was in use and requested the crew to report on short final. Approximately two minutes later, at an altitude of 3,333 feet, the aircraft struck the slope of Mt Su Baccu Malu, located 32 km northeast of Cagliari Airport. The impact forces destroyed the aircraft, and all six occupants were killed. ## Official Findings The accident was classified as controlled flight into terrain (CFIT). The official probable cause was the conduct of the flight at a height significantly below the Area Minimum Altitude, which was insufficient to maintain separation from the ground during a night visual approach without adequate visual reference. ## Contributory Factors The investigation identified several possible contributory factors. The aircraft did not have a ground proximity warning system (GPWS) or terrain awareness and warning system (TAWS), and their installation was not required by law. The crew made an erroneous descent using visual flight references, possibly confusing the Elmas runway lights. The crew had no special familiarity with the Cagliari area, and perspective illusions, specifically the “black hole approach,” may have occurred. There was also a misunderstanding of the Cagliari Approach controller’s instruction to transfer to Elmas Tower, which may have created the impression that the descent was free of obstructions. The crew failed to use published procedures and available instruments during a descent to a closer airport in an unfamiliar area under total darkness. Anticipation of a deviation from the airway may have led the crew to try to speed up arrival, causing them to overfly areas of higher elevation. Errors in reading elevations on the maps consulted were facilitated by the lack of ground color representation. Finally, an extended period of wakefulness without adequate rest may have reduced crew performance.