The worst aviation accident in Italy occurred in 2001 at Milano Linate airport, on the ground.
A taxiing Cessna Citation crossed the runway after a taxiway error, on a foggy day at the same time a MD-87 was taking off. The Citation pilot had taken R6 instead of R5 at this branch:
Source: ANSV Investigation report.
From the investigation report:
The obvious consideration is that the human factor related action of the Cessna crew – during low visibility conditions - must be weighted against the scenario that allowed the course of events that led to the fatal collision; equally it can be stated that the system in place at Milano Linate airport was not geared to trap misunderstandings, let alone inadequate procedures, blatant human errors and faulty airport layout.
The clearance was not long:
DeltaVictorXray taxi north via Romeo 5, QNH 1013, call me back at the stop bar of the…main runway extension.
But the readback was not compliant, neither mentioning north or the stopbar:
Roger via Romeo 5 and…1013 and call you back before reaching main runway.
This case was a concentratecombination of errors and technical failures, in spitedespite the airport isbeing one of the busiest in Italy. A visual path of some sort would have been sufficient to neutralize the problems and prevent the fatal consequences.
There is an episode of Air Crash Investigation about it: The Invisible Plane.
More about A-SMGCS and SMAN systems:
