Accident Details
At 0554LT, the crew was cleared for takeoff from Rome-Ciampino Airport. The aircraft departed runway 15 at 0600LT on a positioning flight to Bologna to pick up a medical team for an ambulance mission. During initial climb, after being cleared to Bolsena at FL240, the aircraft entered an uncontrolled descent and crashed near a cattle barn. The aircraft disintegrated on impact.
Weather Conditions
At the time of the accident, wind was from 140 degrees at 18 knots, light rain, few clouds at 1,800 feet, broken at 3,000 feet, scattered at 7,000 feet. OAT was 13°C.
Crew and Occupants
Both pilots were killed. The captain was the pilot flying (PF); the first officer was the pilot not flying (PNF). The source notes a considerable gradient of experience on the airplane and hierarchy between the captain and first officer.
Probable Cause
The cause of the accident was due to an impact with the ground resulting from the loss of control of the aircraft by the captain. It appears very likely that during the initial phase inadequate attention was replaced by a phase of spatial disorientation, resulting in a loss of situational awareness, which prompted an inadequate intervention on the flight controls by the PF, resulting in total loss of control of the aircraft (having accentuated the tilt to the left wing, instead of leveling the aircraft). It is reasonable to assume that the PF, based on the conviction of being in a right turn for Bolsena in IMC night conditions, misinterpreted the unusual turn, using the controls in order to accentuate the bank angle to the left, drastically reducing the vertical component of lift. This turn caused the aircraft to assume an attitude of increasing bank, aggravated by continued application on the controls of a positive load factor in order to stop the sudden loss of altitude, without first leveling the wings. The aircraft stabilized in a pronounced downward spiral to the left.
The first officer, engaged in management of navigation equipment, failed to recognize the unusual turn. The considerable gradient of experience and hierarchy probably prevented him from intervening in a more directive or authoritative way. Also contributing was the lack of detail in crew procedures and inadequate adherence to basic principles of CRM/MCC, with reference to monitoring and statement of navigation modes active, navigation procedures, lack of requests for inclusion of turns and routes, deficiency in performance of controls and optimization of automation that could lighten workload in a time unfavorable from the point of view of circadian rhythm and IMC night.
The source notes that spatial disorientation, though known and studied for decades, is still relevant, and that the only way to counter it is application of proper use of instruments in compliance with basic CRM/MCC principles, which should be part of normal operating procedures. This is especially true when working outside normal circadian rhythms, when cognitive processes slow.