SAFETY SENSE GROUND COLLISION ON THE ACTIVE The disaster remains ’s deadliest air accident, caused by a number of nonfunctioning and nonconforming safety standards and procedures at the airport. Michael R. Grüninger and Capt. Carl C. Norgren analyze the causes and general precautions for preventing runway incursions

n the morning of October 8th, IEVX proceeded on taxiway R6 to the D-IEVX reported “approaching 2001, was covered by a parking on the General Aviation Sierra 4,” as marked on the taxiway. I thick layer of dense fog. This is Apron located west of the runway. When the controller asked for clarifi- not uncommon in the lowlands of the The turn-around was expeditious. cation, the flight crew of D-IEVX river Po. After the engine start, the D-IEVX responded: “Approaching the run- The Cessna Citation Jet 525-A reg- received clearance to taxi. way…Sierra 4.” The Controller istered D-IEVX was taxiing through “DeltaVictorXray taxi north via assumed D-IEVX was holding short of dense fog at Milano Linate. It was Romeo 5, QNH 1013, call me back at runway 36R on R5. He did not ques- early in the morning and the crew the stop bar of the….main runway tion the designator Sierra 4 as this had arrived from Cologne to pick extension.” The crew read back: designator was not normally used by up two passengers for a short flight “Roger via Romeo 5 and …1013, and the ground controllers. D-IEVX was to Paris Le Bourget. Low visibility call you before reaching main run- in fact on R6. procedures were in place. The way.” After clarifying that no other traffic arrival and departure traffic was The controller did not react to the was a factor on the main apron, the heavy and the fog was slowing small, but critical omissions in the ground controller cleared D-IEVX to down operations during an already read-back. The word ‘north’ was “continue the taxi to the Main Apron, busy morning. missing as well as the word ‘exten- follow the Alpha Line.” The flight During the approach, the Runway sion’. Both of these words did proba- crew replied: “Roger continue the taxi Visual Range (RVR) reported that bly not fit the flight crew’s mental in the main apron, Alpha Line.” FATAL runway 36R was 175 / 200 / 225 model. Taxiing via R5 meant taxiing While on the ground frequency, D- A map of Linate meters at touchdown, mid-point and ‘the long way around’, not the short- IEVX proceeded to cross the active Airport showing stop-end respectively. Even though est and most expeditious route to the runway at the R6 intersection. At this the paths of the the crew were only qualified for threshold of the departure runway moment, the Cessna entered the two aircraft Instrument Landing System (ILS) 36R. active runway. A runway incursion (left). The Category (CAT) I operations, they D-IEVX left the General Aviation was the result. Cessna Citation had continued the approach and com- apron. But instead of following R5 to At the same time, on the tower fre- Jet and SAS pleted a successful landing. the north, the crew followed R6 to the quency, a Scandinavian Air Lines MD- MD-87 involved Finding their way along Linate’s east. This was the shortest route and 87 was given take-off clearance on run- in the crash taxiways was not an easy task. After it was also the same taxiway they had way 36R. The RVR readings were 225 (right). vacating runway 36R the crew of D- arrived on. / 200 / 175 meters respectively.

94 - BART: OCTOBER - NOVEMBER - 2018 As the MD-87 rotated, it struck D- Red stop bars were permanently on The European Action Plan for the IEVX with a speed of 146 knots. The and could not be turned off. Green Prevention of Runway Incursions Citation Jet was crushed and ripped taxiway centerline lights were perma- includes the following recommendations: into three parts as the right hand main nently on. These deficiencies reduced landing gear of the MD-87 sliced the effectiveness of communications ❍ Ensure that flight deck procedures contain a require- through the Citation Jet. The Citation and caused many clues to be missed ment for explicit clearances to cross any runway. was engulfed in fire and the two pilots both by the ground controller and the ❍ Promote best practices for pilots’ planning of as well as two passengers perished. flight crew. Each one could have ground operations. The MD-87 became airborne for a saved the day. But all of them togeth- ❍ Pilots must be made aware of current safety sig- short while, but having lost the right- er resulted in tragedy. nificant airport information. ❍ hand engine and ingested debris in If pilots have any doubts as to their exact position on the left-hand engine, the aircraft When Radio Sectors Make Us Deaf the surface of an aerodrome, they should contact ATC. ❍ could not remain airborne. It slid The separation of the ground con- Aerodrome charts should be displayed on the along the runway and crashed into a troller and the tower controller fre- flight deck during taxi. This includes when operating baggage handling building, causing it quencies left the crew of D-IEVX at the home aerodrome. ❍ to collapse. All 6 crew members, 104 ignorant of the take-off clearance of Implement, monitor and ensure the use of the passengers and 4 baggage handlers the MD-87. Had they been on the readback procedure. ❍ perished in the ensuing fire. same frequency, the crew of D-IEVX Where practicable, improve situational awareness How could such a tragic accident might have realized the danger and by implementing procedures whereby all communi- cations associated with runway operations are on a happen? There were no technical fail- questioned their perceived clearance common or cross-coupled frequency. ures. The investigation was long and to cross the runway. Source: detailed. This Safety Sense focuses on In addition to being blind due to the https://www.eurocontrol.int/publications/european- some aspects related to the runway fog, the crew of D-IEVX was partially action-plan-prevention-runway-incursions-eappri-v30 incursion. deaf because of the separation of radio frequencies in Linate. When Fog Makes Us Blind Without a ground movement radar, When Italian and English Runway Incursion the ATC controllers at Linate relied on are Spoken Together Must Be Prevented procedural separation of aircraft on the on the Same Frequency Presently, two runway incursions ground. The spectacular view from the Other aircraft were receiving taxi occur in Europe every day. The large windows in the tower was useless clearances in Italian. Such clearances European Aviation Safety Agency in foggy conditions. The controllers included reference to D-IEVX. For the (EASA) as well as all major stakehold- might as well have been below on the flight crew of D-IEVX, these instruc- ers of the aviation industry are aware ground or on the other side of the plan- tions were of little meaning. Had they of this aviation hazard and find that et. The radio was their only means of understood them, the crew might the related risks are unacceptable. controlling and tracking aircraft move- have questioned their actions, as they The European Stakeholders have ments. The controllers had to rely on did not match the instructions given launched an Action Plan to Prevent verbal communication with the flight to other aircraft. Runway Incursions (EAPPRI). crews. Position reports could not be In an international context, with It goes without saying that the verified. The fog made the controllers German crew members communicat- EAPPRI’s and other recommenda- blind, but not deaf, at least for the traf- ing with Italian ATC controllers in tions need to be taken seriously and fic on their frequency. English, transmissions in the local implemented by aircraft and aero- Although fog is not an unusual language removed one layer of safety. drome operators. Even more so when weather occurrence in Linate, the low low visibility prevails. visibility procedures were found to be When Commercial Pressures ✈ weak. When fog makes controllers Make Us Bend the Rules and pilots blind, the radio communi- Why the flight crew of D-IEVX decid- Michael R. Grüninger is Managing cation is the only way to coordinate ed to land in and planned to take-off Director of Great Circle Services (GCS) ground movements. Communications fromLinate that morning we will never Safety Solutions and Capt. Carl C. must be standardized and precise. know. The operator, the crew and the Norgren is a freelance contributor to Signals and signs must be clear and aircraft were limited to ILS CAT I oper- Safety Sense. GCS provides assistance on beyond doubt. The signage was found ations. With RVR values around 200 a range of planning and management to be incomplete, in bad condition meters, they were well below the 550 issues, offering customized solutions to and not conforming to ICAO stan- meters required for ILS CAT I. The air- strengthen the position of businesses in dards. Designators were painted on craft should not have landed and the aviation market. Its services include taxiways which were not known to should not have taken off in such training and auditing (IS-BAO, IOSA), the controllers and not published in weather conditions. Had the crew been consultancy, manual development and the AIP. Taxi instructions contained trained to operate in low visibility con- process engineering. GCS can be reached descriptions and names which were ditions, they might have acted differ- at www.gcs-safety.com and +41-41 460 not officially published in the AIP and ently. ‘Mission bias’ probably caused 46 60. The column Safety Sense has which were of no value to non-local them to bend the rules and they ended been appearing regularly in BART flight crews. up way outside their comfort zone. International since 2007.

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