DAVID KAMINSKI-MORROW & DAVID LEARMOUNT / LONDON
Report into fatal runway collision highlights pilot mistakes and lack of safety management system at the airport
The final report into the 8 October 2001 runway collision at fog-bound Milan Linate airport, in which 118 people were killed, criticises the pilots of a business jet that took the wrong taxiway for a series of mistakes and slams managers at the airport. Linate had no safety management system, recurrent training for air traffic control personnel, aerodrome operations manual or incident reporting procedure.
Those who died included all 110 people on board a Scandinavian Airlines (SAS) Boeing MD-87 that was taking off, the four people in an Air Evex Cessna Citation CJ2 crossing the runway uncleared, and four people in an airport building.
The report says several opportunities to avoid the accident were missed owing to slack air traffic communications procedures and inadequate airport layout information. It says the accident ultimately resulted from the Cessna crew's human error in taking an incorrect taxiway and straying on to the active runway. The Cessna taxied across several markers, including a stop line and an illuminated bar of red stop lights without communicating with air traffic control.
But the report stresses that, while the Cessna crew made the original error, basic inadequacies in airport signage and poor communication meant that opportunities to correct it were missed.
"The obvious consideration is that the human-factor related action of the Cessna crew - during low-visibility conditions - must be weighted against the scenario that allowed the course of events that led to the collision," says the report.
"Equally, it can be stated that the system in place at Milan Linate airport was not geared to trap misunderstandings, let alone inadequate procedures, blatant human errors and faulty airport layout."
The Cessna crew landed the aircraft about an hour before the accident, despite not being qualified to land in the low-visibility conditions, put at 50-100m (165-330ft).
Before its planned departure, air traffic controllers instructed the CJ2 to follow the northern R5 taxiway from the front apron, but the crew mistakenly took the southern R6 taxiway that led to the runway. There were no identification signs for taxiway R6 along its length.
Air/ground communications on the radio channels were in Italian and English, the report says, and phraseology used by pilots and air traffic controllers did not comply with International Civil Aviation Organisation recommendations.
Crucially, while taxiing, the Cessna crew twice transmitted a position report to the ground controller stating that the aircraft was approaching the "Sierra 4" taxiway marking, which, while located on taxiway R6, was not shown on aeronautical charts and was not recognised or understood by the controller. The report says the Cessna crew was "not aided properly" by correct signage and lighting.
Having not picked up on the Cessna's incorrect location, the controller remained "positively certain" that the Cessna was on taxiway R5 - heading for Linate's northern apron - and instructed the jet to continue taxiing. The Cessna crew, it points out, crossed several potential warning markers before reaching the runway, but did not advise controllers.
"Before entering the runway the Cessna crossed a white 'Stop' marking, an ICAO type B holding position marking, a bar of [illuminated] red lights, an ICAO type A holding marking and then followed the green taxiway centreline lights without any further radio communication," it says.
The report says that required markings, lights and signs at Linate either "did not exist or were in dismal order".
Source: Flight International
