What happened
On May 14, 2001, at 06:21 UTC, an Air Sicilia B737-300, registration TC-ESB, landed on runway 16L at Rome Fiumicino Airport. The aircraft was cleared for a "LAND AFTER" approach to runway 16C, following an Alitalia MD-80.
During the approach, the air traffic controller (ATC) confirmed the pilot had the preceding aircraft in sight and authorized the landing procedure for runway 16C. However, the pilot of flight SIC 2322 responded by confirming the landing for "the 16," and subsequently touched down on runway 16L. At the time, runway 16L was closed to daytime traffic due to scheduled grass mowing, though it remained physically usable.
Upon realizing the error, the controller instructed the crew to hold their position to avoid conflict with following traffic and informed them that the runway was closed. The crew acknowledged the instruction but did not initially realize they had landed on the wrong runway. The error was only addressed after the controller issued further instructions to follow a subsequent aircraft and repeated the runway closure information.
The investigation
The ANSV investigation examined radio communications, weather conditions, and airport infrastructure. The investigation found that weather conditions were excellent (CAVOK) and the aircraft was fully functional. The investigation also reviewed the use of the "LAND AFTER" procedure and the accuracy of the NOTAMs in effect.
Key points examined included the physical differences between the runways, such as the fact that the threshold of 16C is set back approximately 900 meters from the 16L threshold, and the difference in runway widths (45 meters for 16C versus 60 meters for 16L). The investigation also noted that the controller used inconsistent terminology, referring to the runway as both "16 Centre" and "16 Charlie," which may have contributed to confusion.
Findings
- The primary cause of the event was a misunderstanding of communications between the ATC and the flight crew, compounded by the crew's failure to follow ICAO-mandated readback procedures for critical instructions.
- The pilot's readback was imprecise, failing to specifically confirm the intended runway.
- The controller's use of non-standard or inconsistent runway identifiers (16 Centre vs. 16 Charlie) created uncertainty.
- A lack of specific NOTAM information regarding the temporary closure of runway 16L for maintenance contributed to the situation.
- The physical layout of the airport, specifically the offset thresholds and varying runway widths, made the error more likely during the landing phase.