What happened
On September 22, 2004, at Milan Malpensa Airport, a serious runway incursion occurred involving two aircraft. The MD-87, registration LN-RMG, operating flight SAS 688, was positioned on runway 35L and had been cleared for takeoff. Simultaneously, an Airbus A330, registration I-LIVN, operating flight LDI 9330, was taxiing from Terminal 2 and was instructed by ground control to cross runway 35L.
As the MD-87 began its takeoff roll, the crew observed the Airbus A330 entering the runway from taxiway EM. The pilot immediately intervened, aborting the takeoff maneuver at a low speed of less than 20 knots. The aircraft came to a stop a few meters after the initial brake application. Once the crossing aircraft had cleared the runway, the tower controller re-issued the takeoff clearance, and the MD-8X successfully departed from its new position on the runway.
The investigation
The ANSV investigation focused on the coordination between the Tower (TWR) and Ground (GND) controllers during a shift change. Due to ongoing construction work on several taxiways, aircraft movements were diverted, requiring more complex taxi routes. To reduce operational workload and avoid frequent frequency changes for pilots, the controllers had agreed to a deviation from standard procedures. Specifically, the ground controller was authorized to permit the Airbus A330 to cross the runway via verbal coordination with the tower controller, without requiring the pilot to contact the tower frequency directly.
Findings
- The primary cause of the event was the issuance of takeoff clearance to flight SAS 688 before the crossing aircraft had fully cleared runway 35L.
- A failure to adhere to established procedures meant the crossing aircraft did not contact the tower frequency, which would have provided an extra layer of oversight.
- Ineffective coordination between the ground and tower controllers during the management of the operational situation contributed to the error.
- The pilot's quick reaction and high visibility conditions prevented a collision.