What happened
On April 27, 2004, at 07:10 UTC, a serious runway incursion occurred at Naples Capodichino airport involving two aircraft. An MD-82, registration I-DAVS, operating flight AZA 1211 toward Turin, entered runway 06 without authorization. At the same time, a Boeing 737, registration F-GKTA, operating flight ADH 49N, was performing its takeoff roll in the opposite direction on the same runway. The pilot of the Boeing 737 noticed the MD-82 entering the runway from the opposite end and aborted the takeoff, coming to a stop approximately 800 meters away from the other aircraft.
The investigation
The ANSV investigation examined radio communications, cockpit voice and flight data recorders, and air traffic control procedures. The investigation focused on the sequence of events leading to the unauthorized entry and the breakdown in communication between the flight crews and the tower controller. The inquiry also reviewed the airport's operational documentation, including the AIP Italia and NOTAMs, to evaluate the clarity of runway usage instructions.
Findings
- The primary cause of the incursion was the unauthorized entry of the I-DAVS onto runway 06.
- The pilot of flight AZA 1211 failed to use standard phraseology during the read-back, which led to significant misunderstandings in radio communications.
- The crew of the MD-82 failed to implement effective crew coordination and integration techniques, which prevented them from detecting the communication error.
- The crew of the MD-82 was not sufficiently attentive to the communications being made by the pilot of the Boeing 737.
- The tower controller failed to maintain critical attention when the pilot of the Boeing 737 signaled a discrepancy in the takeoff authorization exchange.
- The tower controller did not adopt a sufficiently cautious approach following the reported communication error.
- The crew of the MD-82 did not follow company procedures recommending the use of headsets for monitoring radio communications.