Incident Involving an Embraer 170-200 at Milan Malpensa Airport

Incident Overview and Location On July 1, 2014, an incident occurred involving an Embraer 170-200 at the airport identified as MXP. The event was classified as an incident by the Polish State Commission for Aviation Accident Investigation (Państwowa Komisja Badania Wypadków Lotniczych), with the investigation supervised by Piotr Lipiec. The investigation was concluded on June 21, 2016. ## Sequence of Events During the engine start and pushback procedure at MXP, the aircraft likely began pushback without obtaining Air Traffic Control (ATC) clearance. The flight had a delayed departure due to an assigned departure slot. The crew reported readiness for engine start and pushback on the Delivery frequency 120.9 MHz, stating “FULLY READY.” In the crew’s perception, they received clearance for engine start and pushback and were subsequently transferred to the Ground frequency. However, the crew did not have complete certainty that they had received pushback clearance. After pushback commenced, the crew was called on the Ground frequency and asked to stop the pushback. They were informed that pushback had started without ATC authorization. Following clarifications, the pushback and taxiing continued in a normal manner. ## Investigation Findings and Cause Upon returning to Warsaw (WAW), the crew reported the event using an ASR report. After an explanatory discussion with the captain, the probable cause was identified as a human factor: the crew’s mental set to receive the specific clearances they had requested, under situational pressure caused by the delay and assigned departure slot. The incident was considered isolated. The official cause of the aviation incident was inattentive listening to radio communications, likely resulting from the crew’s mental set to receive a specific clearance under situational pressure from the delay and assigned departure slot. ## Safety Actions As a preventive measure, the incident was discussed during periodic theoretical pilot training. The Commission did not formulate safety recommendations, and no further comments were provided.