Analisis Accidente Linate - Solucion Eurocontrol PDF
Analisis Accidente Linate - Solucion Eurocontrol PDF
Ground: “That is correct, and please call me back entering the main taxiway.”
D—IEVX: “I’ll call you on the main taxiway.”
The Cessna continued on R6, crossing a stop marking which was painted on the
asphalt, then an ICAO pattern B runway-holding position marking painted on the
taxiway, and a unidirectional lighted red stop bar alongside which was a lighted CAT III
holding position sign. Immediately before entering the runway by following the green
taxiway centerline lights, the Cessna crossed an ICAO pattern A runway-holding
position marking painted on the taxiway without communicating with a controller. As the
Cessna entered the active runway at the intersection with R6, the tower controller
cleared Flight SK 686 for take-off. At 0610:18, the aircraft communications addressing
and reporting system (ACARS) installed on the MD-87 communicated with the receiving
installation in Copenhagen, which registered the take-off signal. At 0610:21 the two
aircraft collided. At the time of collision, the MD-87 was performing a normal take-off
rotation. Approximately one second prior to the collision an additional large elevator
nose-up command was registered by the MD-87 digital flight data recorder. It is
probable that the crew of the MD-87 had a glimpse of the Cessna just prior to the
collision (this is suggested by an unintelligible exclamation recorded on the cockpit
voice recorder).
Conclusions
The accident investigation report cited a number of deficiencies that played a role in the
outcome. While the immediate cause of the accident was identified as the runway
incursion by the Cessna pilot, the report stated that this error must be weighed against a
range of systemic shortcomings. “The system in place at Milan Linate airport was not
geared to trap misunderstandings, let alone inadequate procedures, blatant human
errors and faulty airport layout” the report concluded. Among its findings, the report
stated that:
• The management and operation of Milan Linate Airport was complicated and
involved three major organizations. ENAC, the regulatory authority, also held
overall responsibility for the management and operations of the aerodrome;
• The aerodrome did not conform with ICAO Annex 14 standards regarding required
aerodrome markings, lights and signs;
• No functional safety management system was in place. Its absence prevented
each actor at the aerodrome from seeing the "overall picture" regarding safety
matters and may have caused: the lack of updates of official documents; the lack of
compliance with ICAO Annex 14 standards; the fact that no aerodrome operations
manual had been established; and the fact that an effective system for reporting
deviations was not in place;
• Fear of sanctions discouraged the self-reporting of incidents and individual
mistakes;
• Documentation provided by Aeronautical Information Publication (AlP) Italy and by
Jeppesen was not consistent with the Milan Linate Airport layout;
• SAS flight support documentation was not consistent with the airport layout;
• Taxiways had not been designated in a logical manner (in a clockwise direction
with north as the starting point, the taxiways had been designated R1, R2, R3, R4,
R6 and R5);
• Markings on the West apron dedicated for general aviation were insufficient and
not in conformity with ICAO provisions;
• The West apron was without signs: Published aerodrome documents were out of
date and inaccurate, so written taxi instructions available to Cessna flight crew
differed from verbal instructions issued by controller;
• Aerodrome tower controllers “declared that they ignored the existence” of markings
such as S4.
• There was no ground radar system in operation at the aerodrome. The aerodrome
had purchased a state of the art Norwegian ground radar system 6 years earlier
but the equipment had never been installed. The previous ground radar system
had been uninstalled and had been deactivated for many years;
• Documentation regarding TWY R5 and R6 movements was complex and
procedures were poorly described; and
• Required markings, lights and signs either did not exist in the case of Taxiway R6
or were “in dismal order and were hard to recognize especially in low-visibility
conditions (R5 and R6)”.
The report also states that equipment which had been installed near the intersection of
Runway 18L/36R and Taxiway R6 for the purpose of preventing runway incursions had
been deactivated several years previously. The ground controller had no control over
the fight cross bars located on Taxiways R5 and R6 and could not adjust taxiway
centreline lights to reflect the taxi clearance.
Radiotelephony phraseology used by controllers and pilots did not conform with ICAO
phraseologies and it was found that these deviations from standard phraseology were
common practice. Analysis indicated that internal quality insurance regarding
compliance with standard phraseology was not adequate in the Tower.
The investigation found that the taxi instructions issued to the Cessna by the ground
controller were correct, but the readback was incomplete, the controller did not detect
the error in the Cessna pilot's readback, and omissions by the pilot were left
uncorrected.
In citing causes for the accident, the report indicates that the Cessna crew's situational
awareness was diminished by inaccurate charts and a lack of visual aids. Evidence
came to light that the Cessna crew were not qualified to operate in conditions where
visibility was less than 400m.
The accident investigation report also points out that despite the low-visibility conditions,
ranging from 50 to 100 meters at the time of the accident, operational procedures
allowed a high volume of aircraft movements.
Controller workload was also very high, with radio communications conducted in more
than one language.
Table 7.1
Data Sorted using SHEL Model
Table 7.2
Absent or Failed Barriers Identified
44
Note that it is not essential to determine the type of barrier in each case. This information is provided here for instructional
purposes only.
Table 7.3
Human Involvement Identified
Controller did not detect error in Cessna pilot’s readback of Incorrect interpretation
(ATCO heard the readback but
initial taxi instruction did not interpret it as wrong)
Table 7.3 depicts the Contextual Conditions prevailing in the Linate accident:
Table 7.3
Contextual Conditions Identified
The final step under SOAM is to convert the analysis data generated above into a
SOAM Analysis Chart, as depicted in Figure 7.1 below.
PP/CG Operational
Heavy traffic and low Runway
procedures allowed Controller did
visibility meant high guard lights
high traffic volume not detect error
workload situation for not present
in reduced visibility in Cessna
controllers on any TWY
conditions pilot’s
readback of
AC Inadequate QA Common for initial taxi
re compliance controllers not to use instruction
with standard standard
phraseology phraseology
Figure 7.1
SOAM Analysis Chart for Milan Linate accident
As indicated above, two further worked examples of the SOAM analysis process are
included at Appendices B and C to this document.