Italians call for long prison sentences after Linate SAS accident

[WHBM]

Italian prosecutors have called for prison sentences of 8 years for the leading officials from the ATC and airport authorities, and controllers on duty, following the Linate SAS/Citation collision.

http://news.bbc.co.uk/1/hi/world/europe/3543353.stm

Really, this is what you would expect from a banana republic. How can the leaders of the public bodies be said to have "killed" those involved. And presumably if any of the unfortunate pilots had survived they would want them jailed as well.

[tom de luxe]

If found guilty in a court of law of criminal negligence or other offences that carry a jail sentence unter Italian law, then why should they not go to jail? Mind you, whether or not the prosecution will get its way is certainly not for me to decide.

However, lots of people here like to point the finger to the "bosses" when something goes wrong and pilots or other front line staff get to carry the blame. Read that story about the charter airline (Italian, by the way) where the owner allegedly fires pilots on duty who refuse to take off due security concerns? So if one of these aircraft goes down one day, are you saying that the boss should be able to walk away because he's "just the Boss"? And why should that not apply to those responsible for LIN (infrastructure and ATC) to have been in the state described rather accurately in the accident report?

[C-47]

Hey Flowman,

have you ever heard of NOTAMS? Or, actually, do you refer to a 2 years old news from BBC for your "safe" and "foggy" flights to Northern Italy?

Let me understand: would you really fly down to 75 mt. on a CAT 1 ILS?

The ENAV decision to degrade ILS procedures in many Italian airports from CAT 3 to CAT 1 was a simple way to make sure that airports were REALLY ready to face with low visibility conditions.

After a few weeks almost all ILS returned to normal CAT 3 operations including LIN (again, refer to NOTAMS...much more reliable than BBC...).

Need other updates?

[flowman]

That'll teach me not to check the dates.
Ta very much.:O

[maxy101]

Isn´t it called corporate manslaughter in the UK? Nice to know that responsibility doesn´t stop at the sharp end.....

[brownstar]

WHBM

i may be covering old ground here, but were the authories at the airport not guilty of gross negligence,( I'm not refering to the controllers) .The airport authorities ordered and had delivery of a high tec state-of-the-art ground movement tracking system which actually sat in it's packing case for a couple of years, the airport authorities failing to install it, relying on the old faulty system. After the crash i believe the system was installed within 6 weeks.

Someone is responsible for the decision not to install it, this crash wouldn't have happened if it had been installed as the GMC would have spotted the citation going the wrong way.

I think the actual person responsible for the decision not to install the new system, not the controllers, should face the full force of the law.

i shall put my soap box away now.

[Mark Lewis]

As far as I understand it the airport authorities bought the wrong radar, and it was unsuitable for installation in Linate due to some frequency issue?
However the point is that many airports don't use ground movement radars and still manage to conduct a safe operation. Blaming it on the radar is just as pertinant as blaming it on the weather.

[ATC Watcher]

Once again the journalists at their best !

quote from the BBC site mentionned above :
____________________________________________________
She has also asked for a sentence of three years and 10 months for air traffic controller Paolo Zacchetti, who was on duty on the day of the crash.


Relatives of some of the victims have also expressed their dissatisfaction.

"To think that those who killed 118 people should get eight years makes us a little angry," the president of the victims' association, Paolo Pettinaroli,
________________________________________________

As 99,99% of the readers of that Press news bulletin will never read the full accident report, they have the cause of the crash as they believe the BCC is a serious organisation .
Again by naming the controller and by putting these sentences next to each other , one gets the impression that this controller really is responsible for killing 118 persons ! Exactly like the Ueberlingen collision press coverage, with the consequences that we all know.

I do not know if I should be mad or just extremely sad.

We are not going to improve safety with this.

:(

[Bletchley]

ATC Watcher.

Whilst I have no time for journalists of any sort in general (there are one or two 'good ones' but they are the exception to the rule), and I don't seek to defend the BBC, I would make the following point which is I think a salient one.

The fault must rest with the Prosecution authorities in this case. You can hardly blame the BBC for reporting effectively what the Prosecutor has said albeit no doubt possible simplified.

I admit that I speak from a basis of little knowledge of all the facts but I have read the accident report.

Anyone with a modicum of commonsense (I do not include the Police or Judiciary generally in this) would appreciate that there is not normally any one person to blame in any accident.

Accidents of this nature tend to result from a number of failures. Some of these will be failures of individuals but generally they will only affect the outcome of any incident.

The basic (root) cause of nearly almost every accident can be traced back to system (i.e. Management) failures.

Such a shame that the Prosecution authorities in Italy seem to have opted for the classic scapegoat and are dealing with the symptoms rather than the cause.

Why oh why is it that the legal system is unable to understand the concept of system failure but always go for the poor devil at the sharp end?

[scambuster]

:( the ground controllers are still terrible....giving clearances in high speed barely intelligible english over crackly radios.

[ATC Watcher]

Bletchley :
I agree with what you say up to a point : what does the journalist ( and the editor above him ) want to achieve by publishing the exact name of the controller in this case ?

Following your reasoning, These journalist must also know that no-one willfully "killed "118 pax. so why reporting the words said by the victim rep without commenting on it ?

I find both of these irresponsible , and sad to see this coming from the BBC, which I normally respect a lot.

The whole Airport structure and safety system failed in Linate.
The controllers gave clear taxi clearances but accepted very poor read backs. The ground signs were inappropriate and some apparently unknown to the ATC staff on duty. It took 30 minutes for the fire rescue to find the Citation hull despite a functioning ELB that could not be heard in the TWR.
These are points that will need very serious review.

The airport had no functioning safety management system in place, and this is seen by the investigators as the main contributing factor.. The report place great emphasis in non-punitive incident reporting to learned from past errors as a basis to improve Safety. .
Sending them to jail will certainly improve the reporting in the future!
I hate to think what they would have done with the Citation pilots if they would have survived the crash...

And I fully endorse your last sentence. Indeed.

[Bletchley]

ATC Watcher

Thank you for an interesting response.

Pardon my lack of knowledge in this area.

It would seem to me that the primary fault lies with the Airport management and I would anticipate also with the Regulatory authorities in respect of lack of supervision?.

What I wonder do the Prosecution authorities seek to do as to this element.

I feel uncomfortable that ALL the blame be shouldered by one or two individuals, who whilst their personal performance may have been below acceptable levels, should presumably have been under some sort of higher level supervision.

When this sort of major failure is detected what do the wider International authorities do (or can do) to put things right?

[Eva San]

I admit that I speak from a basis of little knowledge of all the facts but I have read the accident report.

Is the accident report available somewhere on the net ?
If yes, thanks in advance for the link...

[ATC Watcher]

Bletchley , you asked :
____________________________________________________
quote : When this sort of major failure is detected what do the wider International authorities do (or can do) to put things right?
____________________________________________________

This has been the real issue in fact. Investigations Offices, and / or ICAO are publishing reports and recommendations. But it is up to the States authorities to implement those recommendations.
Very often , in a lot of cultures ( and in our case in Linate, the Latin culture is a good example ) acting on the recommendations is seen as an admission that something was wrong before, in areas where the same people having the power to act were responsible. Therefore they try to make the accident a human error and by blaming individuals they think they can avoid blame on areas for which they were in charge.

The only way out of this paradox is to get away from the " blame game " and enter the area of " just culture " where people making errors (or even mistakes) can report them in a non-punitive way , and actions to prevent thoses mistakes from happenning again are seen as an improvement , or a " good " thing to do, having a positive impact on one's carreer.

Only very few States have put such a system in place , Denmark for instance is one of them, if not the only one ,at the moment.
But we are working on doing someting similar in many States right now.

But what is happenning in Milan at the moment is setting the clock back further, as the start of any "just culture " system is based on TRUST.

[Flap 5]

The report gives a concise and accurate account. As an airline captain the following is clear to me:

The Citation pilots were an accident waiting to happen. Their arrival in to Linate in Cat lll conditions without being Cat lll rated should not have been made. Having done so it should have been queried by the airport authorities and their departure not have been allowed until the visibility improved, with an investigation as to why they made the approach.

The controllers were under a high work load. However in Cat lll conditions both controllers and (qualified) pilots are aware of giving greater separation between aircraft, in the air and on the ground. The controllers should have asked the Citation pilots to report passing specific taxiway signs. However these signs were themselves inadequate.

The airport authorities were also allowing the airport to be operated in Cat lll conditions with inadequate taxiway signs and without a ground radar which had been available for installation for many months but was still boxed up, presumably to save money. Certainly the ground radar is not essential as long as the other factors in this accident were not there. In this case the ground radar would probably have prevented the accident, but only if it was being operated correctly.

It will be interesting to see where the investigating authorites put the blame for this tragedy.

[Bletchley]

ATC Watcher.

Thank you

[amanoffewwords]

Italian press (Corriere della Sera (http://www.corriere.it/Primo_Piano/Cronache/2004/04_Aprile/16/linate.shtml)) reports the court verdict:

The controller was sentenced to 8 years in prison, Linate's director to 6, 6.5 years to the ex-director of ENAV and 6.5 years to another director of the Milan Airports.

I would have thought the managers were more at fault for not ensure the kit they already had was installed, but that is my opinion only.


amofw

[Avman]

If true that the controller is to get 8 years I wouldn't be surprised if industrial action will soon follow by controllers throughout Europe. Furthermore, controllers should no longer accept working with inferior or unserviceable equipment.

[shortfinals]

That the controller has been caned harder than anyone else is unbelievable. As an earlier posting said, his errors were not active - he gave correct clearances in correct language. His errors were mostly of omission - failing to question pilot responses that were vague.

The airport signage and taxiway markings were almost all non-ICAO and in poor condition, but the red lighted stop bar that the Cessna pilot taxied across to kill himself and more than a hundred other people was fully serviceable and active. That stop-bar was the last warning, and taxiing across it was like intentionally shooting red lights at a major road junction. And now the controller is going to get the biggest hit for this.

I can't imagine his lawyers won't appeal, and I wish him luck. As for the management, while I believe they deserve to be punished, I was surprised at the length of their sentences. This is definitely "pour encourager les autres", but I don't think hitting people this hard is the best way to do it. It's negligence, yes, but these sentences are the kind that people get when they knew positively that they were risking people's lives. I think that these people are a product of the existing Italian civil service culture, which is laissez faire and whose errors are of omission rather than commission. This is a classic scapegoating action, intended to bury the Linate tragedy so the system can expunge its guilt and go on being they way it was before.

The report is good and thorough. I wish I could believe that Italy's aviation system will learn from what it says, rather than from the court's message, which is loud and clear: "Don't get found out".

shortfinals

[Flap 5]

I too am surprised that the controller got a longer sentence than the airport authorities. The controller was only involved in one of the many factors contributing to this accident. The airport authorities were involved in all of the factors by their lack of supervision.

1. Not preventing the Citation crew from departing in conditions they were not qualified to fly in after ariving in those conditions.

2. Not ensuring the airport signs were at least adequate for cat lll operations.

3. Not having installed the ground radar which had been available for some months.

We have all crossed red stop bars but have always queried them with ATC, only to be told they are on for 'test', and NEVER in cat lll conditions. But then the Citation crew were not cat lll qualified were they? Although not crossing red stop bars is pretty basic stuff.

[amanoffewwords]

Now the Corriere (http://www.corriere.it/ultima_ora/agrnews.jsp?id={2310DA52-E471-4D2D-8EC2-03CEC6522EFD}) is reporting that the controller received a death-threat earlier this evening when he returned home.

Worryingly reminiscent of the Swiss controller incident in Zurich a few months back.

[LatviaCalling]

A death threat to Paulo? Really? I don't think the Swedes or the Danes are up to that kind of action.

Switching subject a bit, I do find that the report emphasizes the point at least four times by my count, that English should be spoken at all times. We've had reaction on that before.