What happened
On June 15, 2005, a Beech 36 N767CM, operating a private flight from Luxembourg to Milan Linate, performed an unintended landing on taxiway T. The aircraft was conducting an IFR approach to runway 36R. At the time, the ILS glide slope signal was inoperable due to maintenance, requiring the pilot to perform a non-precision approach.
As the aircraft descended, the pilot deviated approximately three degrees to the right of the localizer centerline. While the pilot was able to maintain visual contact with the ground, the lack of vertical guidance and presence of haze led to a loss of situational awareness. Upon reaching approximately 600 feet, the pilot misidentified taxiway T as the active runway 36R. Despite noticing the absence of standard runway markings, the pilot decided to continue the landing, believing the concrete surface was suitable for the aircraft's weight.
The investigation
The ANSV investigation examined the flight's radar track, radio communications, and the pilot's use of navigational aids. The investigation established that the pilot relied on a small 6-inch Garmin MX20 electronic display rather than paper charts. Radar data confirmed the lateral deviation began approximately 3 NM from the touchdown point.
Investigators also reviewed the airport's aeronautical information. While the primary runway 36R was the intended target, the airport also features a parallel runway, 36L, used for light aircraft. The investigation found that the pilot's approach profile was higher than optimal due to the lack of glide slope guidance, which contributed to the confusion when visual contact was established.
Findings
- The primary cause was inadequate flight planning, as the pilot failed to properly study the airport's layout, specifically the distinction between runways and taxiways.
- The pilot's reliance on a small electronic display made it difficult to discern the location of the shorter, parallel runway 36L.
- The absence of the ILS glide slope signal forced a non-precision approach, increasing the complexity of the descent.
- The pilot failed to request clarification from Air Traffic Control despite being uncertain about the runway's location.
- Contributing factors included insufficient graphical detail in certain Jeppesen and AIP charts regarding the location of runway 36L, and the lack of paper charts on board to assist in orientation.