Milano-Linate Runway Incursion 8th October 2001 © Global Air Training Limited 2010

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? © Global Air Training Limited 2010

Divergent Taxiway Markings of R5 & R6 © Global Air Training Limited 2010

The Final Impact of MD 87 © Global Air Training Limited 2010

Sequence of Events © Global Air Training Limited 2010

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. © Global Air Training Limited 2010

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. © Global Air Training Limited 2010

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ATC from having full control over the aircraft ground movements Official documentation failed to report presence of unpublished markings (S4, S5, etc) that were unknown to air traffic managers Citation crew not aided properly with correct publications (AIP Italy-Jeppesen) for lights,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. © Global Air Training Limited 2010