Airports have had less external regulation and oversight than any other aviation sector. While that is changing, it is too late for Linate
Last week saw two complementary events. First, Eurocontrol held a meeting of high-level air navigation service providers (ANSP) and regulatory chiefs at which the organisation launched its European Strategic Safety Action Plan (SSAP). Then, the day after the meeting, the long-awaited report on the October 2001 runway collision at Milan Linate airport, Italy, was published.
If Eurocontrol needed something to drive home just how badly Europe needs the SSAP - which includes action for runway safety - the Linate report provided it. It also emphasised the urgent need for the new European Aviation Safety Agency (EASA) to accelerate its advance from its present airworthiness-only mandate into the operations arena. Coincidentally, airports are just becoming Eurocontrol's final focus area. Although they are the origin and destination ATM service providers, they had been the last item on Eurocontrol's agenda, as they had been for the Joint Aviation Authorities.
Every trip begins with an aircraft taxiing from the stand/apron to the runway. This is just as much a part of the ATM safety task as the airborne phases of flight. It was during that taxiing phase that the Linate disaster happened, and the report on it is shocking even for those who thought they knew basically what it would contain.
The Cessna Citation pilots, while the most obvious target for blame because they failed to follow simple taxiing instructions and finally entered the active runway uncleared, were only part of the cause. The report says that Linate did not have a safety system of any kind - it was an accident waiting to happen. Even when the collision had occurred, the way in which the emergency services were deployed, controlled and monitored was a complete shambles. The fire and rescue services were alerted by the airport police, not the tower. Meanwhile, four aircraft were left in various positions on the airport in thick fog with their engines running for some time - the nightmare could have included a second collision with just a little more bad luck. It took the tower controller five calls to the SAS aircraft over 1.5min to accept that there would be no reply, and the ground controller was still vainly voicing its callsign 5min after the SAS Boeing MD-87 had been destroyed.
At the time of the accident the Linate tower and ground air traffic controllers were close to overload, clearing aircraft they could not see through thick fog at the busiest time of the morning. Their main mistakes appear to have been a combination of not being strict with their use of ATC language, using a combination of English and Italian depending on which aircraft they were addressing, and investing too much trust in pilots when their position reports and read-backs were often incomplete, ambiguous and uninformative. Perhaps a greater sin was the airport's for not ordering that operations should be deliberately slowed during very poor visibility, from which Linate often suffers.
Although it is difficult to understand how the Citation pilot could have exited the general aviation apron to the south-east on R6 when he was given explicit instructions to exit to the north on R5, the taxiway he entered had no sign identifying it. It was, however, the taxiway he knew - he had used it to taxi from the runway to the apron 1h before. Holding points, while marked on the surface, were worn and the investigators believe they would have been difficult to see in the prevailing conditions. But why the pilot taxied over a lit red stop bar is difficult to determine, because that designates an absolute no-go area. Did he know that, or was he too distracted by his confusion as to why some of the tower's instructions did not make sense given what little he could see? The aircraft had no cockpit voice recorder, so this will remain an area for conjecture.
Linate, says the report, "had no functional safety management system, the aerodrome did not comply with International Civil Aviation Organisation Annex 14 [standards for aerodromes], no recurrent training for ATC personnel had been provided, [and] no aerodrome operations manual was established".
Airports were the last frontier for Eurocontrol, the JAA and now EASA. If Linate has been found wanting to such a severe extent, how many other European airports would be similarly judged if they suffered a serious surface accident today? Do some airport operators still think it is their role simply to provide facilities - the runways, taxiways, parking, passenger processing facilities and basic air traffic control? The Linate report should be compulsory reading for all airport operators. It is a strident, alarming wake-up call.
Source: Flight International
