1. Milano-Linate Runway Incursion 8th October 2001
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2. Runway 36R incursion and collision between
Overview
Runway 36R incursion and collision between
Cessna Citation - 2 pilots and 2 passengers
MD 87 – 6 Crew members and 104 passengers
0810 local, the Citation entered the active runway during the takeoff rotation of the MD87
MD 87 airborne for 12 seconds & crashed into a baggage handling building with 4 addition deaths
Both A/C destroyed and all 114 occupants died
Why did this accident occur?
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3. Divergent Taxiway Markings of R5 & R6
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4. The Final Impact of MD 87
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5. Sequence of Events
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6. Sequence of Events
Flight SK686 taxied to the holding point for runway 36R. Heavy fog had delayed the flight by more than one hour
While the visibility was improving, RVR was still only 225 metres
The Cessna Citation parked at the West Apron was cleared to taxi via taxiway Romeo 5 and to report reaching the first holding point
The pilot read the clearance back correctly, but entered taxiway Romeo 6
The Cessna Citation’s pilot called for clearance to proceed from the Romeo 5 holding point though it was in fact at the Romeo 6 holding point
Flight SK686 was cleared for take-off
The Cessna Citation crossed the holding point for runway 36R-18L
The two aircraft collided
The stricken MD-87 skidded off the runway into a baggage handling building adjacent to the passenger terminal.
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7. Immediate Causes
Citation crew used wrong taxiway & entered active runway without specific clearance
R/T not performed using standard phraseology (readback) or not consistently adhered to - untraced misunderstandings
R/T performed in Italian and English languages
Failure to check Citation crews qualification to operate in Low Vis
Pressure on Citation crew to commence flight despite the weather
ATC personnel did not realize Citation was on taxiway Romeo 6 -Controller issued taxi clearance toward main apron although reported position S4 did not have any meaning to him
Inadequate visual aids for Low Visibility conditions.
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8. Systemic Causes High volume of ground movements allowed by procedures
Instructions, training and the prevailing environment prevented ATC from having full control over the aircraft ground movements
Official documentation failed to report presence of unpublished markings (S4, S5, etc) that were unknown to air traffic managers
Citation crew not aided properly with correct publications (AIP Italy-Jeppesen) for lights, non standard markings and signs to enhance their situational awareness
The aerodrome standard was not compliant with ICAO Annex 14 -required markings, lights and signs absent or in dismal order
No functional Safety Management System (SMS) in operation.
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