What happened
On February 7, 2009, a Cessna 650, registration I-FEEV, crashed near Trigoria, Rome, approximately three minutes after departing from Rome Ciampino Airport. The aircraft was operating a medical transport mission, tasked with transferring a medical team from Bologna to Cagliari for an organ transplant procedure.
Shortly after takeoff, the flight crew received instructions from Roma ACC to deviate from their original flight plan, performing a right turn toward Bolsena to shorten the flight path. During the climb, the aircraft entered a steep left bank. The flight crew realized the anomaly only moments before impact, during which the aircraft's GPWS issued "sink rate" and "overspeed" warnings. The impact resulted in the total destruction of the aircraft and the deaths of both the commander and the first officer.
The investigation
The ANSV investigation examined flight data from the FDR and cockpit voice recordings from the CVR. Investigators analyzed the flight path, the crew's radio communications, and the aircraft's performance during the final moments of flight. The investigation also included flight simulator tests to reconstruct the crew's actions.
Key elements examined included the crew's adherence to standard operating procedures, specifically regarding the monitoring of navigation modes and the use of automation. The investigation also looked at the impact of the night-time IMC (Instrument Meteorological Conditions) and the crew's workload during the deviation from the original flight plan.
Findings
- The primary cause of the accident was a loss of control by the commander, who was acting as the pilot flying.
- The crew likely experienced a loss of situational awareness, which transitioned into spatial disorientation.
- Believing the aircraft was turning right toward Bolsena, the pilot flying likely misinterpreted the aircraft's actual left-hand bank and applied incorrect control inputs, inadvertently increasing the bank angle and inducing a descending spiral.
- The pilot flying applied continuous positive G-loading in an attempt to arrest the altitude loss without first leveling the wings.
- The hierarchy and experience gap between the commander and the first officer likely prevented the first officer from taking more assertive action to intervene during the recovery attempt.
- Contributing factors included inadequate adherence to CRM/MCC principles, specifically regarding the monitoring of active navigation modes and the failure to verbally confirm heading and altitude changes during the flight deviation.