What happened
On October 8, 2001, a collision occurred on the ground at Milan Linate Airport involving two aircraft: a Boeing MD-87, registration SE-DMA, and a Cessna 525-A, registration D-IEVX. The incident took place during a period of low visibility at the airport. The Boeing MD-87 was involved in a movement that resulted in a collision with the Cessna 525-A, which subsequently led to the aircraft striking a baggage sorting building. The impact triggered a significant fire involving both aircraft.
The investigation
The ANSV investigation focused on the complex ground movements and the environmental conditions at the time of the accident. Investigators examined the airport's signage, specifically looking at unofficial markings (such as S1, S2, S4, and S5) and the taxiway configurations (R5 and R6). The probe also reviewed the accuracy of aeronautical documentation, including the AIP Italia, Jeppesen, and SAS Flight Support charts, against the actual physical state of the West apron.
Furthermore, the investigation scrutinized the Air Traffic Control (ATC) procedures during low-visibility operations, the effectiveness of the Aerodrome Surface Movement Indicator (ASMI) radar, and the communication between the Tower and ground units. The investigators also analyzed the technical data from the flight recorders (DFDR and CVR) of the Boeasting MD-87 and the ELT signals from the Cessna 525-A to reconstruct the sequence of events.
Findings
- The investigation identified significant discrepancies between the official airport charts and the actual ground markings and taxiway paths available to pilots.
- Inadequate or unofficial signage on the West apron contributed to confusion during ground maneuvers.
- There were deficiencies in the coordination and information flow between the Air Traffic Control Tower and the Fire Department (VVF) during emergency interventions.
- The investigation noted that the visibility conditions required strict adherence to low-visibility procedures, yet the physical infrastructure and signage did not support safe navigation during such periods.