Human error cited in Milan fatal collision

Aviation International News » April 2004
April 2, 2007, 5:58 AM

Italian accident investigators have concluded that human error on the part of two German pilots of a Cessna Citation CJ2 was the main cause of a fatal collision with a McDonnell Douglas MD-87 at Milan Linate Airport on Oct. 8, 2001. But the recently published accident report by the Agencia Nazionale per la Sicurezza del Volo also heaped strong criticism on airport and ATC authorities, blaming them for seriously inadequate safety procedures and taxiway signage.

A total of 118 people died when the CJ2–operated by German charter firm Air Evex–collided with a SAS MD-87 taking off from Runway 36R. All aboard both aircraft were killed, along with four airport workers in the baggage area of the airport’s main terminal, in which the MD-87 came to rest.

The CJ2 crew had mistakenly taxied onto the runway from taxiway R6, despite having been told to use taxiway R5. Poor communications between the pilots and local controllers failed to correct the error, and those in the Milan tower evidently had no idea that the CJ2 was on the wrong taxiway.

Due to thick fog, visibility at the time (8:10 a.m.) was between 160 and 330 feet. Both pilots had IFR ratings clearing them for flights in ILS Cat I conditions (1,800 feet runway visual range/200 feet decision height). The investigators found “no evidence” of either pilot having had training for RVR conditions of less than 1,300 feet, the conditions under which they landed about an hour before the accident.

Air traffic controllers were specifically criticized for not informing the Citation crew that lower-visibility ILS Cat III operations were required at the time and for failing
to ascertain whether the pilots were qualified to operate in such conditions.

Furthermore, the report suggests that although the Citation crew was permitted to taxi in the prevailing fog, they could nottake off with visibility less than 1,300 feet.
The Citation was on a sales demonstration flight to Paris Le Bourget Airport. The MD-87 was headed for Copenhagen, Denmark.

Eleven airport and ATC officials were on trial for criminal charges stemming from the accident. Prosecutors have called for eight-year jail terms for three senior executives charged with manslaughter, including Sandro Gualano, the former chief executive of Italy’s EBAV ATC agency, and Linate Airport director Vincenzo Fusco. Both have been held responsible for the persistent failure of authorities to complete the installation of a ground radar system at Linate, despite the fact that the equipment had been supplied several years earlier.   

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