On 8th October 2001, a Boeing MD-87 being operated by SAS and departing Milan Linate on a scheduled passenger flight to Copenhagen in thick fog in daylight collided at high speed with a German-operated Cessna Citation taxiing for departure on a non scheduled passenger flight from Paris Le Bourget. The MD-87 failed to get airborne and continued along the ground until it impacted, still at high speed, a ground handling building. Both aircraft caught fire and were destroyed. All 114 occupants of both aircraft and 4 personnel on the ground, were killed.
An Investigation was carried out by the Agenzia Nazionale per la Sicurezza del Volo (Italy) (ANSV). It was found that, unknown to ATC because of the prevailing thick fog, the Cessna had failed to follow the taxi clearance issued and correctly acknowledged and had eventually entered the active runway after crossing a lit red stop bar just as the departing MD-87 was reaching VR at the same point. The Investigation was unable to find any evidence that either of the Cessna pilots was trained or authorised to operate a public transport flight departure in the prevailing low visibility. The majority of the investigation concentrated on documenting the widespread organisational failings which, although they had not been the direct cause of the accident and its aftermath, it was concluded had facilitated the accident scenario.
The Investigation found that: “the Immediate Cause of the Accident (was)the runway incursion in the active runway by the Cessna” and noted that “The obvious consideration is that the human factor related action of the Cessna crew during low visibility conditions must be (weighed) against the scenario that allowed the course of events that led to the fatal collision; equally it can be stated that the system in place at Milan Linate airport was not capable of trapping misunderstandings (or the consequences of) inadequate procedures, blatant human errors and (a) faulty airport layout.”
The Investigation Final Report provided a list of the “Immediate and Systemic causes that led to the Accident” as follows:
- the visibility was low, between 50 and 100 metres;
- the traffic volume was high;
- the lack of adequate visual aids;
- the Cessna crew used the wrong taxiway and entered the runway without specific clearance;
- the failure to check the Cessna crew qualification;
- the nature of the flight might have exerted a certain pressure on the Cessna crew to commence the flight despite the prevailing weather conditions;
- the Cessna crew was not aided properly with correct publications (AIP Italy & Jeppesen), lights (red bar lights and taxiway lights), markings (contrary to) standard format and unpublished, S4) and signs (non existing, TWY R6) to enhance their situational awareness;
- official documentation failing to report the presence of unpublished markings (S4, S5, etc) that were unknown to air traffic controllers, thus preventing the ATC controller from interpreting the unambiguous information from the Cessna crew, a position report mentioning S4;
- operational procedures allowing high traffic volume (high number of ground movements) in weather conditions as were current the day of the accident (reduced visibility) and in the absence of technical aids;
- radio communications were not performed using standard phraseology (read back) or were not consistently adhered to (resulting in untraced misunderstandings in relevant radio communications);
- radio communications were performed in Italian and English language;
- Air Traffic Control (ATC) personnel did not realize that Cessna was on taxiway R6;
- the ground controller issued a taxi clearance towards Main apron although the reported position S4 did not have any meaning to him;
- instructions, training and the prevailing environmental situation prevented the ATC personnel from having full control over the aircraft movements on ground.
It also stated that: “Furthermore:
- the aerodrome standard did not comply with ICAO Annex 14; required markings, lights and signs did either not exist (TWY R6) or were in dismal order and were hard to recognise especially under low visibility conditions (R5-R6), other markings were unknown to operators (S4);
- no functional Safety Management System was in operation;
- the competence maintenance and requirements for recent experience for ATC personnel did not fully comply with ICAO Annex 1;
- the LVO implementation by ENAV (DOP 2/97) did not conform with the requirements provided in the corresponding and referenced ICAO DOC 9476.”
And concluded that “the combined effect of these factors, contemporaneously present on the 8 October 2001 at Milano Linate, (served to) neutralise any possible error corrective action and therefore allowed the accident”.
A total of 18 Safety Recommendations were issued as a result of the Investigation as follows:
Six were published in the Second Interim Report on 9 July 2002:
- That ENAC (Italian CAA) and ENAV (Italian Civil ANSP) mandate that the ICAO requirements regarding the usage of the English language shall be enforced and that its abidance shall be monitored. It is also felt necessary that standard read back procedures are enforced (ICAO Annex 10, paragraph 22.214.171.124 - Exchange of communications 126.96.36.199.2.2 PANS) (and enforce) the new ICAO recommended procedure that calls for explicit clearance to be issued when “runways crossings” are involved and containing explicit mention of the runway denomination of the runway to be engaged (ICAO DOC 4444 and Doc 9432-An/925 “Manual of Radiotelephony”) (with) exceptions….confined to situations that emanate from a typical domestic only traffic and/or that the usage of the domestic language would facilitate handling of an emergency situation. [17/113-1/A/02]
- That ENAC should check that the state of airport Visual Aids of all domestic airports as well as the published taxi procedures is in accordance to published AIP. All information shall be unequivocal and in conformity with Internationally adopted standards (ICAO Annex 14); furthermore such correspondence shall be reflected in Operators documentation. [18/113-2/A/02]
- That ENAC and ENAV should adopt procedures to systematically report any incident or abnormal operation in breach of Safety. Registration of such events should be monitored by ENAC with a view to updating and enhancing the quality of procedures and their compliance by all concerned, to achieve and maintain adequate Operational Safety. [19/113-3/A/02]
- That ENAC and ENAV should mandate increased training and recurrent training of all Air Traffic Controllers, necessary to validate individual continuing proficiency for the task required for ATC. [20/113-4/A/02]
- That ENAC and ENAV adopt the model clearly defined in the ICAO Aerodrome Design Manual for the denomination of all elements of the airport movement area. Such model shall allow the implementation of “standard taxi routings” containing all necessary information to air crews (denomination, routing, compulsory stop points). Such model should be adoptable by all airports. ENAV should further ensure that Stop bar lights (are) controlled by GND Controllers in respect of On/Off control function, as described in ICAO Annex 14. [21/113-5/A/02]
- That ENAC and ENAV apply the same regulations, now compulsory for Commercial aircraft, to all aircraft involved in Low Visibility Operations (LVO-CAT II-III, LVTO). [22/113-6/A/02]
And a further 12 were published in the Final Report on 20 January 2004:
- That the Ministry of Infrastructure and Transport as national competent Authority (should) work in the international air transport organisations (for) a full and quick implementation of the European Action Plan for Prevention of Runway Incursions. [1/113-7/A/04]
- That the Ministry of Infrastructure and Transport and ENAC as national competent Authority should ensure that the design and operation of all (Italian) Aerodromes (is) in compliance with the safety standards as specified in ICAO Annex 14. [1/113-8/A/04]
- That the Ministry of Infrastructure and Transport and ENAC as national competent Authority, (should) ensure that all Aerodromes in Italy have a functional Safety Management System, according to ICAO Annex 14, vol.1 paragraph 1.3.4. [1/113-9/A/04]
- That the Ministry of Infrastructure and Transport, ENAC and ENAV as national competent Authority, should ensure that (requirements for the achievement and maintenance of competence and the) requirements for recent experience for ATC personnel fully comply with ICAO Annex 1 Standards. [1/113-10/A/04]
- That ENAC and ENAV as national competent Authority, should ensure that all required information to operate safely is contained in the AIP Italy and updated as needed. [1/113-11/A/04]
- That that the Ministry of Infrastructure and Transport and ENAC as national competent Authority forward proposals to ICAO regarding mandatory installation of Cockpit Voice Recorder equipment in (any) aircraft operated under an AOC or equivalent approval. [1/113-12/A/04]
- That the Ministry of Infrastructure and Transport and ENAC as national competent Authority seek to encourage (all) ECAC States to (promote) the additional requirements in ESARR 5, SRC DOC 5, to the ICAO Council with the objective of getting the ICAO Council adopt corresponding changes to ICAO Annex 1. [1/113-13/A/04]
- That the Ministry of Infrastructure and Transport and ENAC as the national competent Authority (work to encourage) European Civil Aviation Conference (ECAC) States (to) establish standardisation teams which on behalf of the Member States can perform checks of air traffic management units similar to the established functions of the JAA standardisation teams. [1/113-14/A/04]
- That the Ministry of Internal Affairs and ENAC, the national competent Authority should evaluate the need to design the airport emergency plans applicable to all Italian airports in accordance with the ICAO (Annex 14 paragraph 9.1.12.) provisions and to establish guidelines applicable to all Italian airports, paying a special attention to the following requirements:
a) The plan shall cater for an immediate dissemination of all necessary information (aircraft type, dangerous goods, fuel, persons on board) so as to allow correct rescue and fire fighting procedures to be followed.
b) Reference maps shall contain the official denomination of key positions (locations) and made public.
c) The plan shall be updated, made public and verified with periodic limited exercises (regarding communication and vehicle movement), full exercises (regarding also Fire Station crews intervention). They should be conducted without prior notice; exercises results shall be conducive to implementation of corrective measures, when needed.
d) Fire Station crews shall inform duly the TWR for the necessary coordination.
e) The plan shall make provision for priority radio and telephone links and a mandatory coded information flow between control centres of organisations.
f) The plan shall require that a specific telephone line will be dedicated to non-operational information flow to avoid overloading essential communication.
g) The plan shall contain guidelines to participating organisations for other important aspects to be taken into account, such as the continuing alertness by all involved (organisational aspects like personnel shift times, new recruits training, etc,). [1/113-15/A/04]
- That in respect of ATC equipment and procedures, ENAV and ENAC, the national competent Authority, should evaluate the following:
a) TWR personnel (to) be invited to on-site periodic recognition of existing markings, lightings and signs of airport manoeuvre area;
b) the TWR airport emergency signal equipment should be recorded and time stamped;
c) the emergency frequency speaker system should be positioned so as to be audible from all controller of the TWR control room;
d) the addition of visual recognition capability (light source) to the ELT activation signal;
e) the installation of the necessary equipment (radio and frequency) to allow TWR to monitor firemen service communications, when needed;
f) giving TWR immediate access the necessary information to make available to rescue personnel prior to their intervention on accident site (persons on board, fuel, dangerous goods, etc,…). [1/113-16/A/04]
- That the Ministry of Internal Affairs and ENAC as the national competent Authority should require in respect of Airport fire station organisation that:
a) in case of accident the essential information should be shared by TWR and fire station using the dedicated communication equipment provided;
b) the Fire Station Control Centre should have immediately available the necessary information (number of passengers, fuel, dangerous goods, etc,…) to adopt the appropriate intervention technique;
c) all communication lines of the fire station shall be recorded and time stamped;
d) the internal alarm signal of the fire station shall be connected directly to the TWR signal;
e) the number of fixed replenishing tanks shall guarantee that many equipment (vehicles) can be serviced at the same time; [1/113-17/A/04]
- That ENAC as national competent Authority should request all DCAs (Aerodrome Authorities) that in low visibility condition operations, the random rate checking of aircraft documental certification and of the licenses and qualifications of the pilots, should be increased with the objective of verifying the coherence of such documental check with the actual meteorological conditions. [1/113-18/A/04]
The Final ANSV Report of the Investigation the was published on 20 January 2004.