Accident in LIN involving an SAS aircraft... continued

[Sick Squid]

The original thread on this topic, which can be found here (http://www.pprune.org/cgibin/ultimatebb.cgi?ubb=get_topic&f=1&t=016034&p=7) was closed when it reached the 100-post limit.

Please use this thread to continue any further debate.

Thank you,

[stickyb]

Milan airport runway closed

from the BBC (see the last few paras)

Italian authorities have ordered the closure of a connecting runway at Linate airport in Milan, where a collision on Monday led to the death of 118 people in Italy's worst aviation disaster.

The order from Milan's state attorney was issued after Italy's flight safety agency said that signals on some lanes feeding the main runway fell short of international standards.

The crash happened when a jet belonging to the Scandinavian airline, SAS, which was taking off, hit a smaller aircraft, ploughed into a hangar and exploded.

The smaller aircraft, a Cessna, was crossing the main runway at the time.


Preliminary investigations have indicated that the causes of the disaster appear to have been misunderstandings between Italian flight controllers and the Cessna's German pilots, poor signals on the connecting runway, and thick fog.

Some reports suggest that the Cessna's pilots may have believed they were on a different taxiway which did not cross the runway.

There has also been a heated debate about the busy airport's lack of a functioning ground radar system.

"The signalling on certain connecting runways at Milan-Linate airport did not meet international standards set down by the International Civil Aviation Organization," said spokesman Adalberto Pellegrino of the flight safety agency.

He said this fact had been discovered during a technical investigation and that the civil aviation authority had been immediately alerted.

The connecting runway was closed on Wednesday, the day the airport re-opened.

At least three investigations have been opened into the disaster.

Two "black boxes" from the SAS plane were recovered: the flight data recorder and an optional system that records equipment maintenance information.

All those killed were travelling on the SAS aircraft, except the four occupants of the Cessna, and four hangar workers, who were pinned under the plane.

Italy's Transport Minister, Pietro Lunardi, said a new ground radar system should be working "by the end of this year".

Norway's Aftenposten newspaper says a Norwegian team has arrived in Milan to install part of the new system, and that work should begin within a week.

It adds that the system has been in storage in Milan since 1995, alleging that Italian weapons industries disliked the fact that the contract was signed with a foreign manufacturer.

There have been reports that motion detectors at the end of the access taxiway were deactivated because traffic controllers could make little sense of them without a radar system.

[railwaysengineer]

German print media showed an airport diagram of the runway, the parallel taxiway and the entrances/highspeed exits (for landing from south) to/from the runway. It showed the german pilot taking the first entrance, coming from the nord. I do not know and do not remember the exact distance from that entrance to the northern end of runway, but it looked like, if not having collided with the SAS a/c, the Cessna couldn´t make a take off from that position (to the north) before the end of the runway.
Another sad day for aviation, condolences to all who lost beloved ones.

[DamienB]

Just a quickie to say ta to Nick for his response to my post, down to being thoughtful enough to explain things like V1 (already know this stuff but appreciated nonetheless). I'm not the type to need reassuring but a few months browsing this board has left this passenger (and future wannabe) to have a great deal more respect for the guys up the front with the best view.

[LimaNovember]

Anybody....what did the ATIS say prior to the accident?

[DoctorA300]

Gofer,
The reason it takes 10-15 seconds to transmit, is that the ACARS MU has to have a reception level from the ground station above a certain threshold for 10 secs, and it does not accuire the station, unles specially requested, on ground. I am SO impressed with your calculations, my humble experience with ACARS is only as a lowly engineer, and I KNOW that it takes 10-15 secs from the time you get the "message sent" cue on the cdu until the message apears on the reciver computer.
Anyway, it´s scary to reminiss about. It means that they had quite some time to think, 10 seconds is a long time to sit in a cockpit going 140 kts with no control.
God speed guys - RIP.
Brgds
Doc

[OVERTALK]

http://www.iasa-intl.com/dreadle.html

Linate runway layout would require max seven DREADLE treadles. Would have been a cheap solution. Cross an armed Dreadle-treadle and everyone gets an immediate VHF audio alert that "something" has illegally entered an "armed" runway. Better than finding out two seconds prior to a collision.

http://www.iasa-intl.com/images/dreadle1.gif

[Faulty]

Apologies if this point has already been made and I know one shouldn’t speculate…. I operate regularly from Linate, including today, and it was as bad as ever for non use
of English. Wouldn’t be surprised if this also had some bearing on the accident. Just what is it going to take to make English
mandatory.

[AEROVISION]

Overtalk,
Interesting reading, and yes I agree with you and Algy's earlier posting that efficient and cheaper surface surveillance systems are possible than the very expensive ones now being promoted.
This especially for airports with a simple runway layout, like Linate and airports which could not easely afford the expenditure for the high end ground movement monitoring radar systems.
Sometimes the KISS solution is (deliberately)overlooked.

Best regards
AV

[Nick Figaretto]

Wheat really beats me is that it seems like there are no responsible persons for anything at LIN. (And the whole italian CAA?)

The Ground radar was delivered in 1996, and it hasn't been mounted and nobody knows why!

Some of the taxiway marking signs on "R6" were reportedly run down during lawn mowing two years ago and nobody have taken the responsibility to put them back up!

Who is responsible for these things at LIN? Where is the quallity system that is supposed to detect and correct errors like these?

At what other Italian airports do we have the same kind of problems? I am shocked by the fact that taxiway marking signs have been down for two years, without anyone doing anything about it.

I'm not asking these questions to place the blame. The case is just that if no one is responsible, then things like these will happen. And it just shouldn't.

Nick.

[GEENY]

Today I passed through LIN as pax,first time after the event and again was amazed by the fact that the ESSO filling station was still there.It is situated roughly 200 meters on the extended RWY CL,northern side.I am sure that if SAS didn't hit where it did it would have hit the station.I guess it is going to wait for another occasion(overun,possibly by the pilots being given inaccurate braking action or a plain brake failure).Anyone who knows the situation care to comment?Obi?
Need expanded memory?
[ 16 October 2001: Message edited by: GEENY ]

[ 27 October 2001: Message edited by: GEENY ]

[GEENY]

Any news?
From MXP:another ground near miss in the recent fog(rumour).

[GotTheTshirt]

Overtalk,
interesting article !!

Of course it will never catch on - too simple, too foolproof and too cheap!! :) :)

[Flap40]

I don't know about you, but I was a little unsure how everyone was sadly killed in this accident given that the forward fuselage was so intact (see pic 1 (http://www.airdisaster.com/photos/sk686/photo.shtml)).

but if you look at this (http://www.airdisaster.com/photos/sk686/5.shtml) you can see where the aircraft has hit the building side on (ie entered the picture from the right with the tail towards the camera), and the reason for the plane going sideways??? (http://www.airdisaster.com/photos/sk686/7.shtml)

Poor blighters didn't stand a chance (in EITHER aircraft)

RIP

Flap40

[ 28 October 2001: Message edited by: Flap40 ]

[MrNosy]

Someone was telling me that a few years ago the very same thing nearly happened when an Alitalia MD80 just clipped an MU2 which was apparently entering the runway at R6. The wing tip of the MD80 reportedly struck the MU2 but it took off safely. No deaths or injuries and apparently little damage. Anyone got chapter and verse on this earlier event?

[Midnight Blue]

Could maybe somebody give us the content of the tapes in English if they are released for public? My Danish is not so good, unfortunately...

[flapsforty]

Rough translation of the above:

Researchers have put the blame for the worst crash in the history of SAS on the 2 ATCO’s in the tower at Linate, a report released on monday in Italy shows. In the oct 8th crash 118 people died.

SK686 was abou to take off when it hit a small cessna which by mistake crossed the SAS runway. The SAS ac the hit a luggage building 300 mtrs further on.

Initialy, the responsability for the tracig crash was put on the cessna pilots and the heavy fog and the bad sign-posting at the airport. After the accident it was obvious that the airport lacks sign-posting, there’s no electric sensors in the run & taxiways, the signal lights for both runways are totally identical, and the ground radar was not working.

But on monday the Italian paper “La Republicca” writes that “serious negligence” on the part of the ATCO’s contributed to the accident. This new info has come to light with a background in the taped conversations between the German cessna pilots and the tower, moments before the crash.

The ATCO’s should have realized that the cessna was on the wrong runway. This conclusion os drawn from the information the pilots gave the tower via radio.

On top of which the cessna pilots had an inkling that they were in the wrong place/lost and indicated as much to the tower. The tower did not react, writes La Republicca.

SAS waits for the Italian Authorities befor they will say anything about the guilt question.

[Midnight Blue]

Thanks, flapsforty!

[Faulty]

Well known about in Italian press ref the
SAS accident is that ATC unaware of the crash cleared a Lufthansa to takeoff.....
Lufty then asked ATC to clarify that SAS was
airborne as it was not painting on TCAS!!!
No contact with SAS made and the rest you know.
Sharp or what....earned the money that day.

[Saab 2000 Driver]

Why, ohh why am I not surprised ??? :( :( :( :( :(

[Saab 2000 Driver]

Which means...?? :confused: :confused: :confused: :confused: :confused:

[Shore Guy]

Faulty and all,
Could you post text or a link on the Lufthansa/TCAS situation following the Milan collision? I wrote a piece for our in house safety pub, and this would make a great follow up. Thanks.

[ATC Watcher]

I am very surprised with this latest news, if they are true indeed.
I was shown a transcript of the ATC tapes 2 weeks ago which did not contain any indications that the Cessna mentionned he was lost.(But I am not sure I was shown the complete transcript.)
Anyway, on what I read, the Cessna was on the GND freq, was told twice to taxi via R5, the controller even mentionned : "via the North " and the Cessna was requested to report at the stopbar ( before crossing extended centre line runway 36R )The Cessna pilot confirmed taxi via R5, adding : " I am familiar with the airport "
He then reported at the stopbar (without any number specification )He was then cleared to continue taxiyng to holding point 36R.(controller believing he was on R5)
the clearance was acknoldeged.
That was the last transmission from the Cessna on the transcript I saw.

As there are now 4 (!) separate investigations into that crash, I am sure the truth will come up soon.I will for one wait for it before starting blaming anyone.

[Airbubba]

Italians Blame Runway Crash on Human Error

By THE ASSOCIATED PRESS

Published: February 18, 2004

Filed at 10:36 a.m. ET

ROME (AP) -- A final report on Italy's worst civil aviation disaster -- the 2001 runway collision of a small jet and an SAS jetliner that killed 118 people -- placed the blame on human error, poor weather and faulty airport procedures, officials said Wednesday.

In a 182-page report Italy's national air safety agency said the crash happened after the small plane, a Cessna, veered into the wrong runway where the jetliner was accelerating for takeoff.

The report, however, said there were mitigating factors, especially a poor safety plan and runway directional system at the airport.

``The Cessna was instructed to follow a path with no adequate signage and markings to allow their identification,'' the report said.

The crash occurred Oct. 8, 2001, one of Linate's frequent foggy mornings. A Copenhagen-bound Scandinavian Airlines System jetliner was accelerating for takeoff when a Cessna business jet crossed its path. The planes collided, and the MD-87 jetliner slammed into a baggage hangar, killing all 110 people on board, as well as the four people on the Cessna and four ground crew.

The report said the inadequate procedures and poor layout at Linate included faulty and confusing lighting and pavement signals on the runway, miscommunication between air traffic controllers and the pilots, and the lack of ground radar.

``The Cessna was instructed to follow a path with no adequate signage and markings to allow their identification,'' the report said.

Ground radar at Linate had been pulled out of service to be replaced by a new system that only went into effect after the crash set off an outcry.

``The absence of radar monitoring capability and the absence of an anti-incursion efficient system allowed the aircraft to cover a path that the controller could not monitor,'' the report said.

Investigators also said the control tower and the Cessna communicated in Italian and English instead of the standard English-only. The Cessna pilot, taxiing around in the fog, was also never asked to read back the tower's instructions.

``With a functional safety management system the Linate accident would definitely not have happened,'' said Henrik Elinder, chief technical investigator at the Swedish Accident Investigation Board, at a press conference in Stockholm.

He criticized the fact that radio communication was conducted in both English and Italian.

``It's almost ridiculous that it's like this. If you could agree that all radio communication is done in English, it would have simplified a lot.''

The Italian air safety agency released similar findings in two preliminary reports over the past two years. But in a new element, Wednesday's report also faulted the response by firefighters after the crash, saying their reaction was poorly coordinated and slow.

However, the head of the air safety agency, Bruno Franchi, said a better response wouldn't have saved lives since the victims died on impact.

SAS chief executive Joergen Lindegaard said in a statement Wednesday that Swedish investigators fully agreed with the findings of the Italian report, and he welcomed its release.

The families of 70 people killed in the crash have sued Cessna and a Boeing subsidiary in Miami federal court for wrongful death, seeking $5.25 million in damages. Other lawsuits have been brought in Europe.

Several countries contributed to the investigation that produced Wednesday's final report, including Denmark, Germany, Norway, Sweden, and the United States, which was participating because the planes were manufactured by American companies.

http://www.nytimes.com/aponline/international/AP-Italy-Crash-Report.html

[Justforkix]

Here's a link to the report

Report (http://www.havkom.se/virtupload/news/FINALREPORTA-1-04Linate.pdf)

Devastating reading

[Daysleeper]

How the heck do you sue cessna and boeing for a badly designed airport system in Italy and the neglect of the ground radar?:confused:


Hang on I'll answer my own question, Cessna employee demo pilot flying, and jeppesen are a part of Boeing. Point about the airport still stands though.

[Capt H Peacock]

This is another opportunity to admire the airmanship of the Lufthansa crew who prevented the accident becoming even worse by applying an inquisitive and confirmatory mindset before accepting a clearance to take-off in Cat III.

An inspirational use of TCAS that has now become SOP for many companies.:ok:

[Tony_EM]

Capt H Peacock wrote;

This is another opportunity to admire the airmanship of the Lufthansa crew who prevented the accident becoming even worse by applying an inquisitive and confirmatory mindset before accepting a clearance to take-off in Cat III.

Where can I read more about this aspect? I briefly scanned the report but could find no reference to an LH aircraft.

[admiral ackbar]

Faulty stated earlier in the thread:

Well known about in Italian press ref the
SAS accident is that ATC unaware of the crash cleared a Lufthansa to takeoff.....
Lufty then asked ATC to clarify that SAS was
airborne as it was not painting on TCAS!!!
No contact with SAS made and the rest you know.
Sharp or what....earned the money that day.


So the LH chap was very sharp in not accepting the clearance.

[pinguino]

http://www.ansv.it/En/Detail.asp?ID=177

link to download it directly from the italian air safety agency web site.

[golfyankeesierra]

From page 132 of the report: "I-LUBI had been cleared to line up on runway 36R after the MD-87 departure".
No LH here.

[azdriver]

LH? I read all the report and LH is not mentioned even once. Go figures hoe this things get spreads out.

Anyway, the reading is really impressive.

Ciao

[RRAAMJET]

Very sad....

The last 2 paragraphs of chapter 2.4.2 are the kind of epitaph I think all professional aviators would like to have.

This SAS crew set a high standard.

[ATC Watcher]

First : Admiral , Shore guy and Faulty :

You se how false stories and rumours grow ?
Look at page 113 of the report ( it lists all aircraft on the various frequencies at the time ) : no LH involved .
In fact the next aircraft lined up for take of after the SAS was I-LUBI and he was told by ATC to vacate runway.

Second :
There are some (minor) differences between the preliminary reports we saw and this final one.
But taking my ATC hat on , I feel like giving a big apology to all pilots operating in such an Airport at the time. Failure of management at all levels and unprofessionalism all around.
Do not say : Its is Italy, the same also occurs on many airports worldwide.
Individuals were led into some situations by a system that did not learn from its mistakes. Many previous runway incursions occurred without being reported , or when they were , were not acted upon..
Of course the main causes are : the Cessna pilot mistakenly taken R6 for R5 ( we knew this from the beginning ) the incomplete read back not being challenged ( but we all do this regurlarly , you hear what you want to hear remember ?) the airport markings being below standard ( like in 80 % of airports worldwide ) . The report is very illustrative of a system apparently being driven by costs rather than safety .

Now taking on my pilot hat :

The operator of the Cessna does not come out very good either. Cowardice and disdain for its own employees perhaps an illustration of our times. It is the first time I see "Commercial pressure " apply to a purely "private flight " ....

The SAS crew actions are worth praising , but what it is worth on an epitaph ?

This report, together with the Ueberlingen one ( collision between 757 and Tu154 in July 2001 ) which is due in the next 2 or 3 months ( and which bears very similar conclusions as to the failure of the ATC system as a whole ) should serve a basic training material for every ATC and Airport manager everywhere.

We owe this to all those that lost their lives in these 2 accidents.

[Bletchley]

Guys,

I am a railwayman not a pilot.

I cannot understand how such incompetence and systematic failures were allowed and not detected.

Yes we do have our accidents but we also have safety management systems that highlight near misses and trends are (normally) identified early on.

We also have the Regulatory people and our own Industry safety people crawling all over us all the time.

Any views?