What happened
A medical transport mission traveling from Rome-Ciampino Airport to Cagliari-Elmas Airport ended in a fatal accident during the night. The aircraft was operating under Visual Flight Rules (VFR) and was carrying six people: three pilots and three doctors, along with a cooler containing a heart intended for transplant.
During the descent toward the destination, air traffic control cleared the crew to descend to 2,500 feet and advised that runway 32 was active. While flying at approximately 3,333 feet, the aircraft collided with the slope of Mt Su Baccu Malu, located roughly 32 km northeast of the airport. The impact resulted in the total destruction of the aircraft and the deaths of all six occupants.
Findings
Investigations determined the accident was a Controlled Flight Into Terrain (CFIT) caused by the flight operating at an altitude significantly lower than the required Area Minimum Altitude. Several contributing factors were identified:
- The crew experienced a "black hole approach" illusion, where the lights of the Elmas runway were misidentified during the night visual approach.
- There was a misunderstanding regarding instructions from Cagliari Approach concerning the transfer to Elmas Tower, which led the crew to believe the descent path was clear of obstacles.
- The aircraft was not equipped with GPWS or TAWS instrumentation.
- The flight crew lacked familiarity with the local terrain and failed to follow published procedures for descending into an unfamiliar area at night.
- Errors in reading elevation data from aeronautical charts were noted, potentially exacerbated by the lack of ground color representation on the maps.
- A possible attempt to expedite arrival may have caused a deviation from the planned airway over higher terrain.
- Fatigue due to an extended period of wakefulness without sufficient rest may have impaired crew performance.