Italy

The analysis of the technical, operational and organizational context in which the event took place (impact of the end of the right wing of the aircraft, during taxiing, against the rear body of a truck that was parked for work within the protection area of the taxiway that leads from the Bravo connection to the parking area) has allowed to determine the following causes, which are attributable to human and environmental factors.
- Failure to close the Bravo taxiway with the issue of the relative NOTAM of the works in progress.
- Failure of the Torre control to provide the pilots with essential information on the condition of the airport, as provided for by ICAO in ICAO Doc. 4444 PANS-ATM.
- Vertical and horizontal ground signs do not correspond to those specified in ICAO Annex 14.
- Failure to comply with the ENAC circular (APT-11), applicable for the type of work in progress at the airport.
- Insufficient surveillance of the airport area affected by the works by ENAC and the airport management company Aeroporto FVG.
- Lack of an airport Safety Management System .
- Inadequate surveillance of the external space during taxiing by the flight crew, resulting in incorrect assessment of the position of the aircraft with respect to the obstacle.

The accident, classified as CFIT, was caused by the conduct of the flight at a height significantly below the Area Minimum Altitude, insufficient to maintain the separation from the ground during a night visual approach in the absence of adequate visual reference.
possible contributory factors that have been identified:
- The aircraft instrumentation did not include a GPWS or TAWS, whose installation is not required by law;
- The erroneous descent by visual flight references, confusing the Elmas runway lights, given that the crew had no special familiarity with the area of Cagliari, the onset of a perspective illusions phenomena, with specific reference to the so-called "black hole approach";
- The misunderstanding by crew members, of the Cagliari Approach controllers instruction to transfer to Elmas TWR ('CIT 124 continue not below 2500 feet, further descent with Elmas TWR 120.6 bye') which may have created the impression, despite the crew had confirmed that they are able to separate themselves from the obstacles that the descent down was free of obstructions;
- Failure to use published procedures and available instruments in a descent to a closer airport and in an unfamiliar area , under conditions of total darkness;
- The anticipation of the deviation from the airway perhaps caused [the crew] to try to speed up the arrival at destination, which determined overflying areas of higher elevation;
- Read errors of the elevations listed in the maps consulted, facilitated by the non representation of the ground color;
- The extended period of wakefulness without adequate rest, which may have contributed to a reduction in the performance of the crew.

The cause of the accident is attributable to the human factor and can be identified in the impact of the aircraft against certain trees following the setting of an inadequate escape manoeuvre.
The following causal factors may have contributed to the dynamics of the accident:
- The crew's failure to strictly comply with the Operator's Manual of Operations, which provided that the route of attack and escape should not be made uphill, unless there were very limited differences in level that could be overcome without power fluctuations,
- The failure to carry out, as a precautionary measure, since the trajectory of the attack route has changed (from descending to ascending), a new reconnaissance with subsequent briefing by the crew, in order to properly assess the different perspective of all the elements of interest (orography, escape route, etc..), even if the Operating Manual provided for a new reconnaissance by the crew with a subsequent briefing only in the case of a different target, even within the same fire, not even if the target had remained unchanged, but had changed the trajectory of the attack,
- The attack to the fire in unstabilized conditions, therefore not in line with what is previewed from the operating manual, even if the Operating Manual provided for a new reconnaissance by the crew with a subsequent briefing only in the case of a different target, even within the same fire, not even if the target had remained unchanged, but had changed the trajectory of the attack,
- The attack to the fire in not stabilized conditions, therefore not in line with what is previewed from the operating manual;
- The existence of communication problems within the cockpit, deriving from the fact that there was no information flow between the co-pilot (depositary of the information necessary for the assumption of the most appropriate operational decisions) and the commander, responsible for the final decisions; in this regard, it should be noted that radio communications with the DOCFS were made by the co-pilot in Italian, as the latter was not known by the commander, of Canadian nationality,
- The significant difference in experience and age between the two crew members, with possible negative effects in terms of crew coordination,
- The presence of critical points in the operating manuals, partly eliminated after the accident,
- The presence of locally significant turbulence.

The event, triggered by a multiple impact with birds during take-off, was caused by the loss of control in flight of the aircraft, due to an aerodynamic stall during the return to the departure airport, which could not be recovered due to the reduced altitude available.
The following factors contributed to the event:
- The non-implementation of the procedure provided for in the Flight Manual for engine failure after V1, with particular reference to configuration control (undercarriage and flaps), thrust lever management, definition and achievement of safety altitude, maintenance of expected speeds,
- The lack of CRM, already detectable in the ground procedures phase, but significantly worsened as a result of the emergency,
- The lack of experience of FO, on its first flight of line training on the type of aircraft,
- The inadequacy of the measures and of the bird control activity in the manoeuvring area.