What happened
On January 24, 2017, an AW139 helicopter, registration EC-KJT, was performing a Helicopter Emergency Medical Service (HEMS) mission near Monte Cefalone, in the Lucoli area (L'Aquila). The aircraft was operating under single-pilot conditions, with a medical technician on board to assist with the mission. During the flight, the crew encountered deteriorating meteorological conditions, transitioning from Visual Flight Rules (VFR) to Instrument Meteorological Conditions (IMC). While navigating the complex mountainous terrain, the aircraft struck the ground, resulting in fatalities and significant damage to the airframe.
The investigation
The ANSV investigation focused on the flight's progression through changing weather and the crew's ability to maintain situational awareness. Investigators examined the cockpit voice recorder (CVR) and flight data to reconstruct the sequence of events leading to the impact. The inquiry scrutinized the technical configuration of the aircraft, specifically noting that this particular unit lacked an Enhanced Ground Proximity Warning System (E-GPWS), unlike other aircraft in the operator's fleet. The investigation also reviewed the organizational procedures regarding crew composition and the communication protocols between the flight crew and the 118 emergency dispatch center.
Findings
Several contributing factors were identified in the crash. The primary cause was the loss of situational awareness as the pilot encountered spatial disorientation while flying in IMC. This was exacerbated by the challenging orography of the L'Aquila region and rapidly changing weather. Key contributing factors included:
- The absence of an E-GPWS on the aircraft, which could have provided critical terrain warnings.
- The risks associated with single-pilot operations in complex terrain, particularly when the medical technician is seated in the passenger cabin rather than the co-pilot seat.
- A lack of specialized aeronautical training for 118 dispatch personnel, which can lead to a disconnect between operational tasks and the actual environmental risks faced by the crew.
- Inadequate real-time supervision or flight-following tools to support the pilot's decision-making during high-pressure missions.