What happened
On February 24, 2004, at approximately 04:49 UTC, a Cessna 500 Citation, registration OE-FAN, crashed into the summit of Monte Su Baccu Malu near the municipality of Sinnai, Italy. The aircraft was operating flight CIT 124, traveling from Rome Ciampino to Cagliari Elmas. The flight was part of a medical mission to transport a medical team for an organ transplant.
While descending toward Cagliari, the crew reported having the airfield in sight and requested authorization for a visual approach. Shortly after receiving this clearance, the aircraft struck the terrain at an elevation of 3,333 feet, approximately 18 nautical miles east of the destination airport. The impact resulted in the destruction of the aircraft and the deaths of all six people on board.
The investigation
The ANSV investigation examined the flight's descent profile, the crew's use of visual approach procedures, and the aircraft's available instrumentation. Investigators analyzed radar data, wreckage distribution, and the cockpit's navigational equipment. The inquiry also reviewed the coordination between air traffic control units at Cagliari APP and Elmas Tower, as well as the accuracy of the aeronautical information published in the AIP Italia.
Findings
Several factors contributed to the controlled flight into terrain (CFIT). The investigation identified the following key elements:
- The aircraft was not equipped with a Terrain Awareness and Warning System (TAWS), which could have alerted the crew to the proximity of the mountain.
- The crew may have been subject to optical illusions, specifically the "black hole approach" phenomenon, which can lead to errors in altitude perception during night visual approaches.
- There were discrepancies in the altitude requirements for visual approaches between the instructions from Cagliari APP and the Elmas Tower.
- Inconsistencies were noted in the aeronautical information published in the AIP Italia regarding visual approach regulations.
- Radar coverage limitations in the eastern sector of the Cagliari CTR were identified, as primary and secondary radar coverage was not guaranteed below FL 110 in certain areas.