What happened
On August 13, 2001, at 17:10 UTC, a serious runway incursion occurred on runway 35L/17R at Milan Malpensa Airport. The incident involved an Air Europe B777, registration EI-CRS, and an Egyptair B737, registration SU-GBH.
The Air Europe flight was cleared for an immediate takeoff. As the aircraft reached a speed of approximately 110 knots during its takeoff roll, the pilot observed the Egyptair aircraft approaching from the opposite direction on the same runway. The pilot immediately aborted the takeoff, bringing the aircraft to a stop safely without any technical damage or injuries to those on board.
The Egyptair aircraft had been requesting taxi instructions via the apron frequency. During this communication, the pilot's response was obscured by overlapping transmissions from another aircraft. While taxiing, the Egyptair crew mistakenly crossed taxiway BA, which led them onto runway 17R, placing them directly in the path of the departing Air Europe flight. Upon realizing the error, the Egyptair pilot quickly vacated the runway.
The investigation
The ANSV investigation examined several factors, including radio communications, airport signage, and air traffic control procedures. The investigation noted that the Egyptair pilot's initial taxi instruction was difficult to understand due to frequency congestion. Furthermore, the investigation looked into the maintenance and compliance of airport markings, noting that some signage at taxiway BA was not compliant with ICAO standards at the time of the event.
The inquiry also reviewed the operational procedures at Malpensa, specifically regarding the noise abatement procedures that involve alternating takeoff and landing runways, which can potentially cause pilot disorientation or increased workload for controllers. Additionally, the investigation found that the ground radar system (ASMGCS) being implemented at the time did not provide coverage for the North and West apron areas.
Findings
- The primary cause of the incursion was the Egyptair crew taxiing in the wrong direction after erroneously crossing taxiway BA.
- Communication interference occurred when the Egyptair pilot's response to taxi instructions was partially lost due to overlapping transmissions from another aircraft.
- Inadequate airport signage at certain intersections did not meet ICAO technical standards.
- The use of alternating runway procedures for noise abatement may have contributed to operational complexity.