What happened
On November 24, 2001, an MD-82, registration I-DAWE, operating a scheduled flight from Tirana to Rome, landed on runway 16L at Rome Fiumicino airport. Although the crew had been cleared to land on runway 16C, the aircraft instead occupied runway 16L, which was closed to all traffic at the time due to ongoing maintenance work.
During the descent, the pilot in command requested a heading change to shorten the approach. After following instructions from Approach Control to intercept the ILS for runway 16C, the pilot manually disconnected the autopilot to continue the approach visually. The crew correctly read back the landing clearance for runway 16C. However, upon touchdown, the crew realized they had landed on the wrong runway. An airport surface movement radar alert notified the tower controller of the error, and a follow-me vehicle was dispatched to guide the aircraft to a taxiway.
The investigation
The ANSV investigation focused on the crew's performance and the flight planning process. Investigators examined the cockpit communications, radar tracks, and the NOTAMs in effect at the time. The investigation looked into the crew's use of onboard instrumentation and their adherence to company standard operating procedures regarding cross-checking and approach planning.
Findings
- The primary cause of the event was a loss of situational awareness and a breakdown in crew integration.
- The crew failed to maintain effective cross-checking of flight instruments, which would have identified the misalignment with the authorized runway.
- The approach planning was insufficient, as the crew did not adequately account for the NOTAM indicating that runway 16L was closed.
- Contributing factors included the pilot's request to shorten the approach path and the high level of familiarity with the airport, which, combined with excellent visibility, led the crew to rely on visual cues rather than continuous instrumental monitoring.
- The crew's reliance on visual references during a visual approach contributed to the error.