What happened
On the night of October 9, 2001, an Agusta A109E Power helicopter, registration I-FLAN, crashed while performing an emergency medical service (EMS) mission. The aircraft departed from the Grosseto hospital carrying five people: two pilots, two medical personnel, and one patient in serious condition. The flight was intended to transport the patient to Pisa Airport.
Approximately six minutes after takeoff, the 118 emergency dispatch center lost radio contact with the aircraft. At 23:34 UTC, an emergency signal from the helicopter's ELT was detected by a nearby military radar center. The aircraft had struck several tall pine and oak trees before impacting a roadside embankment near Poggio Ballone. The high-speed impact resulted in the total destruction of the helicopter and five fatalities.
The investigation
The ANSV investigation focused on the flight path, the environmental conditions, and the crew's performance. Investigators examined the aircraft's technical state, finding that the engines and electronic engine controls (EEC) showed no significant faults capable of causing the accident. The aircraft was well-maintained and properly equipped for its mission.
Meteorological data indicated the presence of low clouds and mist in the area. While the official METAR reported visibility of 7 km, witnesses at the nearby radar station reported dense fog at the time of the impact. The investigation also looked into the possibility of GPS errors, noting that some operators in the region had reported GPS signal issues during that period, which might have led the crew to follow an incorrect heading.
Findings
- The accident was a Controlled Flight Into Terrain (CFIT).
- The primary cause was the collision with the ground during a controlled flight while operating in conditions of very low or zero visibility.
- A significant contributing factor was inadequate Crew Resource Management (CRM), characterized by a failure to properly distribute tasks between the two pilots, which prevented an effective verification of the actual flight path.
- Environmental factors, specifically the presence of dense fog, contributed to the loss of situational awareness.