Milan Runway Collision Teaches Lessons

Condensed from Runway Incursions: reducing the risk, by Ruth King; published in “Flight Safety Australia,” January — February 2002 issue.

It’s your worst nightmare: you’re on short final, your checks are complete, and you’re mentally committed to the landing, you flare... and there, right in front of you, is another aircraft. “Go around! Go around!” The error processes involved in runway incursions — entering an active runway without a clearance — are essentially the same as for violations of controlled airspace or even controlled flight into terrain. They shouldn’t happen, but they do.

The above illustration indicates how the Cessna Citation taxied onto
taxiway R6 instead of taxiway R5, and later crossed the holding point of R6 to Runway 36R.

Milan, 8 October 2001:  A McDonnell Douglas MD-87 carrying 104 passengers and six crew is scheduled to depart Linate Airport for Copenhagen at 7:35 a.m. Heavy fog delays the flight some 45 min. At departure the visibility had improved slightly to a runway visual range of 225 m. Meanwhile, a Cessna Citation also waiting to depart is cleared onto taxiway R5. R5 does not cross either of Linate’s parallel runways. The Cessna pilot correctly reads back the clearance for taxiway R5, but mistakenly turns onto taxiway R6, which crosses the main runway, 18L-36R. Although ground radar is installed at Linate, it is not yet operational and the controller has no hope of seeing the Citation through the fog.

The Citation crosses the holding point as the MD-87 commences its take-off roll on Runway 36R. The airliner hits the Citation during rotation destroying the Cessna and killing its four occupants instantly. The airliner skids along the runway and starts veering right. Seconds later it crashes into a baggage hangar next to the main apron, killing all on board and four ground personnel. A slightly different trajectory would have sent it across the main apron into the passenger terminal.

Ground radar:  Following the Milan accident fierce criticism arose over delays in getting the airport’s ground radar operational. Had it been working at the time of the incident, it’s possible that air traffic control (ATC) would have corrected the Citation’s taxiing error well before the runway incursion. Nevertheless, the initial error was a very human one; disorientation at an unfamiliar airport in thick fog. Who could dare say it could not happen to them?

Runway incursions are not attributable to any one class of pilot; all licences and experience levels are represented. In other words, this is everybody’s problem. The majority of runway incursions identified in Australian occurrence reports involved a failure to follow ATC instructions. In just over 90% of incursions, ATC intervened before the incident became serious, providing a critical final safety barrier.

Solutions:  Runway incursions always involve an element of human error. While we cannot hope to eliminate error we can implement personal and system-wide strategies to make errors less likely and reduce the consequences of those errors that do occur.

Situational Awareness:  In a runway environment, situational awareness is largely about understanding and observing your clearances, knowing where you are, and where you are going in relation to the airport and other traffic. There are several things you can do to improve your situational awareness:

Planning:  During pre-flight plan, study the current aerodrome charts and familiarize yourself with any special procedures. If possible, obtain an informal briefing from someone with local knowledge.

Anticipation:  Take the time to consider the possibility of something going wrong and develop contingencies. For example, what would you do if an aircraft taxied onto the runway shortly after you landed?

Alertness:  Most of us have had the experience of being stopped at the traffic lights, thinking about something or other, sensing a change to “green” and moving forward, only to discover that it was the turn arrow that had changed and not the main light. Attention is actually indivisible. The human brain can only concentrate on one thing at a time and other tasks get demoted to “automatic” or reflexive programs, which are executed without conscious thought.

Entering a runway or commencing take-off can likewise be demoted to an automatic “program” that we execute when triggered inappropriately. Runway entry should be performed with at least the same caution as stepping off the curb onto a busy road, and given due conscious thought.

Refrain from anything but safety-related discussion during the departure and arrival phases. Using taxiing time to perform checks divides your attention and increases the likelihood of error. Where possible restrict pre-flight checks to those times when the aircraft is stationary.

Communication:  Ensure you understand all ATC instructions completely. If not, ask for clarification. Any controller would rather repeat a clearance than resolve a traffic conflict.

Think before you speak and use standard phraseology.

Physical environment:  Maintaining a good lookout is as important on the ground as it is in the air — perhaps even more so given that the traffic is condensed into a much smaller area.

Monitor airport communications to form a mental picture of where other aircraft are and what they are doing. When taxiing, align the aerodrome diagram to your direction of travel. Keep your eyes outside as much as possible and watch for signs, taxiway markings, other aircraft, vehicles and pedestrians. If you get lost, or believe you have inadvertently crossed a holding point, notify ATC immediately.

Conclusion:  Runway incursions present an unparalleled opportunity for aircraft collisions and loss of life. Vigilance on the part of each pilot will go a long way to prevent being at the wrong place at the wrong time.

Ruth King is a commercial pilot. She teaches commercial and ATPL Theory at the Australian College of Aviation.

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