What happened
On August 13, 2003, an Agusta Bell AB 412 SP, registration I-SEIQ, was engaged in a mountain rescue mission near Passo Ables in the S. Caterina Valfurva region. The mission was initiated to recover an injured hiker. After an initial reconnaissance and a brief landing at a lower altitude to drop off medical personnel and equipment, the crew returned to the rescue site.
The pilot attempted to position the aircraft for a hoist operation but encountered difficulties maintaining a steady hover due to the terrain and environmental conditions. The pilot subsequently decided to approach a different location along a path to pick up the patient via hovering without the use of a hoist. As the helicopter approached the target area, the main rotor blades struck a rocky outcrop. The impact caused the aircraft to lose stability, strike the ground with the right skid, and roll down a steep ravine, where it eventually caught fire and was destroyed. The two fatalities were the pilot and the flight technician.
The investigation
The ANSV investigation examined the aircraft's maintenance records, the pilot's flight experience, and the meteorological conditions at the time of the accident. The investigation noted that while the aircraft was well-maintained and mechanically efficient, the crew had been operating under significant pressure. The investigation also reviewed amateur video footage of the final moments of the flight, which showed no evidence of mechanical failure prior to the rotor strike.
Investigators also looked into the crew's recent duty history. Evidence suggested that the crew had likely exceeded permitted flight and duty time limits in the 24 hours preceding the accident. Specifically, the flight technician had been working shifts with insufficient rest periods. Furthermore, the investigation highlighted that the mission's high-stakes nature—the urgent need to save a life—may have compromised the crew's objective judgment regarding the risks of the chosen landing site.
Findings
- The primary cause of the accident was an inadequate assessment of the chosen site for the hovering embarkation maneuver, leading to the rotor strike.
- Operational fatigue was identified as a contributing factor, as the crew had likely exceeded legal duty time limits.
- Environmental factors, including high temperatures and turbulence caused by the mountain terrain, complicated the flight maneuvers.
- The mission's objective (emergency medical rescue) likely influenced the crew to accept excessive operational risks.