Much as we all want to show sympathy to the crew involved an incident like this can only have one cause. Inattention by the crew to instructions given.
Talk of holes in the cheese strike me as being a bit by the by in this case. Holes require errors elsewhere and I don't see "errors" in the info given elsewhere.
We all know the shortcomings of Italian ATC in general and Pisa's in particular, we are also familiar with the layout of the airport and it's offset approach and if not regular visitors then we should be even more cautious to brief these punctiliously.
Perhaps they were "cleared" to land on a runway notified as closed by NOTAM (surmise at present, but possible) this should have instantly lit up a big red mental light and been queried as befits the extra level of caution and suspicion we should all be exercising in that particular environment. Even so, the standard level of caution we should exercise ought to prevent such an incident. I'm afraid the NOTAM looks perfectly clearly written to me.
Surely anywhere we find parallel runways or mistakeable parallel taxiways we check and doublecheck we are using the right one, and that process begins with punctilious reading of NOTAMS in flight as well as pre flight. Nice stands out as an example, apparently three landing strips visually. (another potential gotcha destination where all our antennae need to be out to spot traps)
Of course there will be factors that led the crew into this event but we are very familiar with all of them and therefore should routinely ensure that we do not fall foul of any of them, and one of the factors that should result in a much higher level of attention than usual is the Pisa factor. Unfortunately it got these guys.
Sure, there are far too many unfiltered NOTAMS, many are far too verbose and sorting the wheat from the chaff is nigh on impossible in a 5 minute briefing. All the more reason to refresh them in flight. Both of us...
We anticipate unintelligible RT and strange clearances at Pisa and should be all too aware of the possibility of a runway closure and ATC not responding correctly to it. And so on. Every clearance and instruction should be analysed for rationality, especially at Pisa as we all know and questioned if necessary. There are two of us up front partly to minimise missing such things. It doesn't look as though the crew queried the runway in use so one can only surmise that they were happy to land on the "usual" one regardless of what they were told to do. Where was the NOTAM in their minds?
We are Professional pilots and this is no more than our job requires. Occasionally - rarely two people simultaneously make the same genuine human error and hit the headlines. It's sad but it happens. I can't see any piece of swiss cheese in this incident apart from the one labeled "inattention" or perhaps "complacency" or "environmental capture" and my feeling is that this event, as far as we can tell at present has all the hallmarks of a tricky destination being treated as routine and of all places, as we know, Pisa is not the best place to do that.
Ultimately, (unless dramatic new info is presented) I can only see one cause for this; had the NOTAM been correctly read and understood this incident would simply not have happened. How else can you put it?
Anyone can say "There but for the Grace of God." but this wasn't just happenstance, we can minimise the risks and eliminate most of them by thorough application of our training and experience.
Last edited by Wageslave; 3rd Jan 2016 at 13:54.