What happened
On October 11, 1961, a Beechcraft Bonanza D-35, registration HB-EGI, departed Lugano-Agno for a flight to Milan Linate. The flight was being operated commercially by Aeroporto Lugano S.A., carrying one passenger. While conditions in Lugano were clear, heavy ground fog had reduced visibility at Linate to approximately 50 to 80 meters.
During the approach to runway 36 at Linate, the pilot attempted an instrument landing approach despite the lack of appropriate training or equipment. At approximately 09:53, the aircraft, flying at an altitude of about 12 meters, struck the rooftops of a group of buildings roughly 300 meters west of the runway centerline. The impact caused the aircraft to crash into an adjacent field, where it was destroyed by the impact and a subsequent fire. The two fatalities included the pilot and the passenger. Three individuals on the ground sustained minor injuries due to burning fuel debris.
The investigation
An investigation conducted by Italian authorities, with Swiss observers, established that the aircraft was not equipped for instrument flight rules (IFR), lacking a marker beacon or ILS receiver. The investigation also revealed that the pilot, while holding a private pilot license, had been performing commercial operations for Aeroporto Lugano S.A. without the required commercial ratings. Furthermore, the pilot had previously requested ILS and radar guidance during a landing in Düsseldorf just two weeks prior to the accident.
Findings
- The pilot attempted an instrument approach in dense fog without the necessary instrument flight training or certification.
- The Beechcraft Bonanza D-35 was not equipped with the required navigation aids, such as an ILS receiver, for such an approach.
- The pilot proceeded with the approach despite being explicitly warned by air traffic control about the extremely low visibility at Linate.
- There was no operational necessity to attempt the landing at Linate when much better weather conditions were available at nearby Milan Malpensa.
- The operator, Aeroporto Lugano S.A., assigned the pilot to commercial flights despite his lack of appropriate commercial licensing.