AGENZIA NAZIONALE PER LA SICUREZZA DEL VOLO (Istituita Con Decreto Legislativo 25 Febbraio 1999, N

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AGENZIA NAZIONALE PER LA SICUREZZA DEL VOLO (istituita con decreto legislativo 25 febbraio 1999, n. 66) Via A. Benigni, 53 - 00156 Rome - Italy tel. +39 0682078219-0682078200, fax +39 068273672 SECOND INTERIM FACTUAL REPORT (ANSV Board decision of July 9th 2002) ACCIDENT INVOLVED AIRCRAFTS BOEING MD-87 REG. MARKS SE-DMA AND CESSNA 525A REG. MARKS D-IEVX Milano Linate Airport October 8, 2001 INDEX INDEX . I PURPOSE OF THE INVESTIGATION . III FOREWORD . IV GLOSSARY . V CHAPTER I - FACTUAL INFORMATION. 1 1. SUMMARY . 1 1.1. FACTUAL INFORMATION . 1 1.2. INJURIES TO PERSONS . 5 1.3. DAMAGE TO AIRCRAFTS . 5 1.4. DYNAMICS OF AIRCRAFTS COLLISION. 5 1.4.1. Significant parameters recorded on Boeing MD-87 DFDR at collision point . 5 1.4.2. Boeing MD-87 DFDR significant recordings seconds after the collision point . 6 1.4.3. Boeing MD-87 CVR-sound extract . 6 1.4.4. Preliminary analysis of collision scenario . 6 1.4.5. First point of contact . 6 1.4.6. Second point of contact . 7 1.4.7. Third point of contact . 7 1.5. ANALYSIS OF THE POST COLLISION SCENARIO . 8 1.5.1. The Cessna 525A. 8 1.5.2. The Boeing MD-87 . 8 1.5.3. Final impact with airport baggage building . 9 1.6. OTHER DAMAGES . 9 1.7. INFORMATION ON PERSONNEL . 9 1.7.1. Pilots . 9 1.7.2. Pilots pre-accident duty time . 10 1.7.3. Air traffic controller. 11 1.7.4. Air traffic controller’s duty time . 12 1.8. AIRCRAFT INFORMATION . 12 1.8.1. The Boeing MD-87 . 12 1.8.2. The Cessna 525A. 12 1.9. WEATHER INFORMATION. 13 1.10. NAVIGATION AIDS . 13 1.11. COMMUNICATIONS . 13 1.12. AIRPORT CONFIGURATION AND ASSOCIATED CHARTS AND MAPS INFORMATION . 13 1.12.1. Airport information . 13 1.12.2. Airport charts and maps . 14 1.13. FLIGHT RECORDERS . 14 1.13.1. DFDR Boeing MD-87 . 14 1.13.2. QAR Boeing MD-87 . 15 1.13.3. CVR Boeing MD-87 . 15 1.13.4. Cessna 525A . 15 1.14. WRECKAGE FINDINGS . 15 1.14.1. The Boeing MD-87 . 15 1.14.2. The Cessna 525A. 17 ANSV I 1.15. FORENSIC INFORMATION. 18 1.15.1. The Boeing MD-87 occupants . 18 1.15.2. The Cessna 525A occupants . 18 1.16. FIRE. 18 1.17. SURVIVALASPECTS . 18 1.18. TESTS AND FURTHER ANALYSIS . 18 1.19. OPERATIONAL INFORMATION. 18 CHAPTER II - ANALYSIS. 19 2. ANALYSIS . 19 2.1. GENERAL ASPECTS . 19 2.2. HUMAN FACTOR . 19 2.2.1. Analysis of the professional experience of the pilots . 19 2.2.2. Pilots working schedule. 20 2.2.3. Analysis of controllers background and professional preparation. 20 2.2.4. Controllers working schedule . 21 2.2.5. Communications analysis - glossary . 21 2.2.6. Preliminary information. 22 2.2.7. Communications analysis . 22 2.2.8. Pilots human factor . ..

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AGENZIA NAZIONALE PER LA SICUREZZA DEL VOLO (istituita con decreto legislativo 25 febbraio 1999, n. 66) Via A. Benigni, 53 - 00156 Roma - Italia tel. +39 0682078219 - 0682078200 - fax +39 068273672 FINAL REPORT (As approved by ANSV Board on the 20th of January 2004) ACCIDENT INVOLVED AIRCRAFT BOEING MD-87, registration SE-DMA and CESSNA 525-A, registration D-IEVX Milano Linate airport October 8, 2001 N. A/1/04 INDEX INDEX . I PURPOSE OF THE TECHNICAL INVESTIGATION. VII SYNOPSIS . VIII GLOSSARY. IX CHAPTER I - GENERAL INFORMATION . 1 1. GENERAL INFORMATION . 1 1.1. HISTORY OF THE EVENT . 1 1.1.1. Aircraft involved. 1 1.1.2. ATC situation . 4 1.1.3. Aircraft movement on the ground . 4 1.1.4. Collision. 7 1.1.5. MD-87 impact with the baggage building . 8 1.1.6. First alert . 9 1.2. INJURIES TO PERSONS . 11 1.3. DAMAGE TO AIRCRAFT . 11 1.3.1. Boeing MD-87 . 11 1.3.2. Cessna 525-A . 12 1.4. OTHER DAMAGE . 13 1.5. PERSONNEL INFORMATION . 13 1.5.1. Pilots . 13 1.5.1.1. Pilots of the Boeing MD-87 . 13 1.5.1.2. Pilots of the Cessna 525-A. 14 1.5.1.3. The status of the Milano Linate to Paris Le Bourget flight . 16 1.5.2. Cabin crew . 17 1.5.3. Air Traffic Controllers. 17 1.5.4. Fire brigade personnel . 20 1.5.5. Airport Civil Aviation Authority personnel (UCT-DCA) . 21 1.5.6. SEA station manager . 21 1.5.7.
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