Accident in LIN involving an SAS aircraft... continued
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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.
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.
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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.
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.
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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/inte...sh-Report.html
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/inte...sh-Report.html
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How the heck do you sue cessna and boeing for a badly designed airport system in Italy and the neglect of the ground radar?
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.
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.
Last edited by Daysleeper; 19th Feb 2004 at 03:31.
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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.
An inspirational use of TCAS that has now become SOP for many companies.
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Capt H Peacock wrote;
Where can I read more about this aspect? I briefly scanned the report but could find no reference to an LH aircraft.
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.
Faulty stated earlier in the thread:
So the LH chap was very sharp in not accepting the clearance.
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.
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.
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http://www.ansv.it/En/Detail.asp?ID=177
link to download it directly from the italian air safety agency web site.
link to download it directly from the italian air safety agency web site.
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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.
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.
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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?
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?
