Summary
On 7 February 2009, around 05:00 UTC (06:00 local time), a Cessna 650, registration I-FEEV, impacted the ground in Trigoria, Rome, approximately three minutes after departing from Rome Ciampino Airport bound for Bologna. The aircraft was destroyed and both crew members died.
Factual Information
History of the Flight
The flight was organized by Avionord of Milan, acting on a request from the Bologna 118 emergency medical service for an organ transport mission. The plan was to fly a medical team from Bologna to Cagliari for an organ harvest and then return to Bologna. The accident occurred shortly after takeoff from Ciampino.
Injuries to Persons
Both crew members suffered fatal injuries.
Damage to Aircraft
The aircraft was completely destroyed.
Other Damage
No other damage was reported.
Personnel Information
The crew consisted of two pilots. Their qualifications and experience are detailed in the report.
Aircraft Information
The aircraft was a Cessna 650 (Citation III) with registration I-FEEV. Specific details include its serial number, maintenance history, and equipment.
Meteorological Information
The report includes meteorological data from the time of the accident, including METAR reports, but no specific conditions are cited as causal.
Aids to Navigation
Navigation aids available at Ciampino and along the route were recorded.
Communications
Recordings of communications between the crew and air traffic control were reviewed. The aircraft departed from Ciampino and was in contact with approach control.
Aerodrome Information
Rome Ciampino Airport (LIRA) is a civil airport with appropriate facilities.
Flight Recorders
Both the Cockpit Voice Recorder (CVR) and Flight Data Recorder (FDR) were recovered and their data were extracted and analyzed.
Wreckage and Impact Information
The wreckage was found in an open field in Trigoria. The impact signatures and distribution of debris were consistent with a high-energy collision with terrain.
Medical and Pathological Information
Autopsies and toxicological tests on the crew were conducted; results are documented in the report.
Fire
A post-impact fire occurred and consumed much of the wreckage.
Survival Aspects
The impact was not survivable given the destruction.
Tests and Research
Detailed examinations of the wreckage, engines, and systems were performed, along with simulations.
Organizational and Management Information
The flight was operated by an air carrier holding an Air Operator Certificate. Crew training and procedures were reviewed.
Additional Information
The report includes transcripts of CVR recordings and radar data.
Useful or Effective Investigation Techniques
Flight simulation and analysis of recorded data were employed.
Conclusions
Findings
A comprehensive list of findings is provided in the report, covering technical, environmental, and human factors.
Causes
The accident was caused by a loss of control in flight due to inadequate airspeed monitoring by the crew. Their actions on the fuel system led to the starting and stopping of one engine, making it impossible to maintain the fly-up after a stick shaker activation, in a context of high workload and improper application of Crew Resource Management (CRM) procedures.
Safety Recommendations
The report includes safety recommendations aimed at preventing similar occurrences.