Original subtitles

NARRATOR: A Boeing MD-87 cuts through the morning fog.

The accident was inevitable.

They were doomed.

NARRATOR: The plane, carrying 110 people,

erupts in flames at Milan's Linate Airport.

This is the most serious accident

in the history in Italy.

NARRATOR: Incredibly, no one at the airport

has noticed the catastrophe.

TOWER CONTROLLER: Hello. This is Tower. No, nothing.

NARRATOR: Valuable minutes pass.

It was astonishing.

Air traffic control still doesn't know what happened.

NARRATOR: Only when the wounded come looking for help...

PILOT (OVER RADIO): There's a red streak of fire at the end of the runway.

NARRATOR: ...do authorities begin to realize

that something is seriously amiss...

My God!

NARRATOR: ...at one of Europe's busiest airports.

Mayday! Mayday!

NARRATOR: Milan.

Fashion capital of Europe

and Italy's economic and financial heart.

Milan is served by three international airports.

Only one, Linate Airport, lies within city limits.

It handles nine million passengers a year

on short flights all across Europe.

AIR TRAFFIC CONTROLLER (OVER RADIO): Alitalia 226, airborne, 05.

NARRATOR: On the morning of October 8th, 2001,

dense fog shrouds the airport.

CATINO: The fog that day was very bad,

and the general visibility was about 50 and 100 meters.

NARRATOR: In the tower,

controllers have a heavy workload.

There are nearly two dozen aircraft

to get off the ground in the next 60 minutes.

AIR TRAFFIC CONTROLLER: Alitalia 2120, buongiorno, start up.

NARRATOR: They handle nearly 500 radio communications every hour.

PILOT (OVER RADIO): Linate, Buongiorno.

Delta, India, Echo, Victor, X-ray. Requesting startup.

Delta, Victor, X-ray. You are clear to start your engines.

Ground, Scandinavian 686, request taxi from 13.

Scandinavian 686, taxi to your holding position, CAT III.

HYLLANDER: Scandinavian 686, taxi to holding position, CAT III.

NARRATOR: One of today's flights is Scandinavian Airlines Flight 686.

The Boeing MD-87 is scheduled for a routine flight

to Copenhagen, Denmark.

There are 110 people onboard.

Taxi holding point, CAT III.

NARRATOR: The captain is Joakim Gustafsson.

He has been with SAS for more than a decade.

ZACCHETTI: Scandinavian 686, your position, please.

We still haven't reached the main taxiway. Scandinavian 686.

NARRATOR: First Officer Anders Hyllander

has been flying for the airline for the past four years

and has clocked 2000 hours on the MD-87.

The SAS crew were very highly experienced pilots,

so couldn't ask more for two qualified pilots.

NARRATOR: With thick fog blanketing the airport,

the pilots have almost no visibility.

They must rely entirely on instructions from air traffic controllers

as they navigate their way to the runway.

CATINO: There are a lot of taxiways,

one runway for commercial aviation,

and there are a lot of many different types of airplanes at Linate,

so it's a very busy airport.

NARRATOR: High above the runway,

air traffic controllers normally have a clear view of the airport,

but not today.

ZACCHETTI: Air 1937, where are you?

PILOT (OVER RADIO): Between 18 and Delta.

ZACCHETTI (OVER RADIO): So you're practically in front of the tower, right?

NARRATOR: Paolo Zacchetti is the ground controller

responsible for guiding flights to the start of the runway

where planes take off every two minutes.

ZACCHETTI (OVER RADIO): Taxi north via Romeo Five.

Call me back at the stop bar of the main runway extension.

NARRATOR: With Linate fogbound, he's got his hands full.

Scandinavian 686, your position, please.

GUSTAFSSON: Now we are on the main taxiway.

Yes. Now we're entering the main taxiway. Scandinavian 686.

NARRATOR: At 8:01 a.m.,

Zacchetti hands SAS 686 over to the tower controller

for final takeoff instructions.

Tower, buongiorno. Scandinavian 686, sequence to 36 Right.

Ciao, Scandinavian 686, line up and wait, 36 Right.

Line up and wait, 36.

NARRATOR: The SAS crew must wait behind other planes

taking off from Linate's main runway, 36 Right.

ZACCHETTI (OVER RADIO): Alitalia 226, cleared for takeoff, 36.

Report when rolling.

Low visibility is not a problem in air.

It's a very big problem on the ground

because the pilots depend completely upon the air traffic controller.

Delta, Victor, X-ray. Confirm your position.

PILOT: Approaching Sierra 4.

Roger.

Maintain the stop bar. I'll call you back.

Takeoff data.

57 tons, and it is checked.

Checklist complete.

TOWER CONTROLLER: Scandinavian 686, Linate.

The wind is calm. Report rolling.

When airborne, squawk ident.

NARRATOR: Once the plane ahead has taken off,

Flight 686 begins its takeoff roll

down the airport's 2400-meter-long runway.

And we are rolling. Scandinavian 686.

GUSTAFSSON: Auto-throttle on.

Set thrust.

HYLLANDER: V1.

NARRATOR: At a speed of 140 knots...

HYLLANDER: Rotate.

NARRATOR: ...the pilots lift the plane off the ground.

GUSTAFSSON: What's that?

Come on, come on.

Come on.

(PASSENGERS SCREAMING)

(EXPLOSION)

NARRATOR: Something catastrophic has happened to Flight 686,

but because of the thick fog,

no one in the control tower has any idea.

CATINO: It was astonishing.

It's so close to the tower, and nobody was aware about this.

NARRATOR: Out on the tarmac,

ground workers have heard a series of loud noises.

(PHONE RINGING)

TOWER CONTROLLER: Hello. This is Tower.

We heard a number of bangs like an engine.

We heard it too, but we don't know what it was.

Seemed, uh, as if somebody was climbing the steps.

You don't have anything abnormal?

NARRATOR: A passenger jet has been in flames for nearly a minute

at one of Europe's busiest airports,

but so far no one knows.

No, nothing.

This was incredible to believe

that this big accident happened,

and nobody, uh, could see what was happening in that moment.

NARRATOR: The crash site goes undiscovered

until a customs officer spots an injured baggage handler

stumbling from the wreckage.

CATINO: It took a while to figure out

that, uh, they had a big disaster on their hands.

NARRATOR: The officer alerts emergency crews,

but the controllers still don't know there's been an accident.

Incredibly, Linate air traffic control

still doesn't know what happened.

NARRATOR: Only now does the tower controller check

for the SAS flight on his radar.

He can't find it.

The radar does not show the plane flying away from Linate.

NARRATOR: Then, they get a radio call from another plane.

PILOT (OVER RADIO): There's a red streak of fire at the end of the runway.

NARRATOR: Finally, almost three minutes after the accident,

Linate air traffic control raises the general alarm.

(ALARM BLARING)

They ground all departing planes and close the airport to incoming traffic.

Scandinavian Airlines Flight 686

has crashed and exploded on takeoff,

but no one yet knows the true scope of this disaster.

NARRATOR: Ten tons of jet fuel feed a massive fire

where a Boeing MD-87 has collided with an airport building.

Awful, terrible devastation.

The collapse of a roof of the hangar

and the SAS airplane completely destroyed in many different parts

and, unfortunately, the dead bodies.

The rescue people had problems to enter the cargo building

to rescue, uh, victims

because the airplane was blocking the entrance.

NARRATOR: Some 14 minutes have passed since the crash.

As emergency crews battle the fire,

Linate air traffic controllers

frantically try to understand what just happened.

There are two aircraft unaccounted for.

NARRATOR: Paolo Zacchetti discovers a private Cessna Citation

did not return to its parking position after all planes were grounded.

The main attention was focused on the SAS airplane

so nobody thought that there was another airplane.

A private aircraft is missing, a Cessna 525.

NARRATOR: Ground crews search for the missing plane.

Finally, 26 minutes after the crash,

they find the Cessna burning and in pieces

halfway down runway 36R.

It appears there's been a collision.

It's hard to believe that after half an hour,

people became aware about the fact

that the Cessna was, uh, on the main runway.

There is another aircraft in the accident near Romeo Six.

NARRATOR: Air traffic controllers are mystified.

How did these two planes end up on the same runway at the same time?

GUSTAFSSON: What's that?

Come on.

NARRATOR: Two planes are destroyed. A hangar is in ruins.

The scope of the tragedy is overwhelming.

It's soon clear that no one from either plane has survived.

The crash has killed 110 people on the SAS flight...

and four onboard the Cessna.

Inside the collapsed hangar, four more people have died.

118 fatalities in all.

This is the most serious accident in the history in Italy.

You can't imagine. I haven't taken it all in.

I heard three explosions, boom, boom, boom.

And then a huge flame, a long one.

First, there was a crash,

then this hot air that was inside...

this extremely hot air that burned my head.

My God!

NARRATOR: Mario Pica is the lead investigator

for Italy's National Agency for Flight Safety, the ANSV,

but he's not in command of the crash site.

It took me a few hours to get access to the scene of the accident.

NARRATOR: Unlike most countries, Italy treats aviation accidents as crimes.

The police get priority at the scene.

After an air crash in Italy,

the criminal investigation automatically begins,

and the police is involved in analyzing this event.

NARRATOR: Pica has a different goal.

PICA: It was mandatory to find out really what happened

and find the reasons that could help us to avoid it happening again.

Grazie.

First thing I remember was to have a look at the baggage hangar

where the rescue workers were still busy

taking out pieces of rubble of the aircraft

and looking for bodies and possibly survivors.

I decided to go and have a look at the Cessna

that was still on the runway.

I just sketched the first map of the position

of the various pieces of the debris

to reconstruct the dynamics of impact.

And there were intermingled pieces from the Cessna and pieces from the MD-87.

NARRATOR: As lead investigator and a pilot,

Pica knows the most valuable information in any air disaster

comes from the black boxes.

But the Cessna was not equipped with either a cockpit voice recorder

or a flight data recorder.

PICA: The absence of the flight recorders were really a drawback

'cause they are very helpful in any investigation

to precisely define what happened.

NARRATOR: The Swedish Accident Investigation Board

sends a team to Milan.

It includes technical specialist Tom Zollner

and lead investigator Frank Kristensen from SAS.

They will work with Pica to unravel the accident.

We were called to be part of the investigation

as it was a Scandinavian Airlines plane.

I guess we'll have to wait for authorization.

We realized that the investigation in Italy

was different from what we learned.

In Italy, they conduct it as a criminal investigation

and we, as investigators, have to wait.

Damn.

We were not happy about that.

We would like to see what the planes look like,

how the accident site looked like.

We were not allowed to be near the accident site.

The media worldwide attention was on the Linate disaster.

REPORTER: The SAS airliner headed for Copenhagen slammed into the private...

CATINO: And so what happened at Linate?

What were the main causes of this accident?

What were the main responsibilities for this?

NARRATOR: Investigators soon make a troubling discovery

about Linate Airport.

So you're telling me there have been a lot of these incidents before?

Air traffic controllers reported

we have an average of nearly one runway incursion per week.

NARRATOR: It appears the nine million people

who use this airport every year

have been in danger for some time.

ZOLLNER: There had been other runway incursions.

This was shocking.

NARRATOR: Less than a month before the collision,

a near miss on the same runway.

PICA: With an aircraft entering the runway

while another aircraft was taking off.

It was really a big shock for us

that it happened that often at Linate Airport.

NARRATOR: Clearly, something is very wrong at Linate.

The morning after the crash,

investigators face national and international pressure

to figure out what it is.

REPORTER: Meanwhile, there were prayers for victims of the crash,

Italy's worst ever civil aviation disaster.

NARRATOR: Finally, the entire investigative team

is given access to the crash site.

KRISTENSEN: All of us were trained investigators,

and we knew what we were going to investigate

and how to do it.

NARRATOR: But authorities have thrown a major obstacle in their path.

So where's the plane?

NARRATOR: The police have ordered airport workers

to move the debris off the runway and away from the baggage hangar.

We got very angry.

The removal of the debris actually removed a lot of valid information,

which we now never could see.

NARRATOR: Debris from both planes

has been piled on a concrete helicopter pad.

Locating Flight 686's voice recorder will be a huge challenge.

We couldn't find the cockpit voice recorder.

ZOLLNER: The importance to find the CVR

was to check if the crew realized

the collision was actually going to take place

and to see how well they were trying to avoid it.

KRISTENSEN: We can't know what the crew were doing without the CVR.

We had to learn about the possible takeoff clearance

and, uh, if there were crew errors.

Did they receive takeoff clearance or did they not?

Here's what we know so far.

The MD-87.

Measuring the distance, we are certain that the MD-87

had traveled for about 40 seconds

and gone 1500 meters before striking the Cessna.

It was clear that the collision had occurred on the main runway

at the interception from taxiway.

The MD-87 had continued its run, deviating slightly to the right,

until hitting the baggage hangar.

Here.

NARRATOR: Weather reports show that visibility

was only 50 meters at the time of the collision.

PICA: With the heavy fog that morning,

it was clear that environmental factor

was a contributing cause of the event.

HYLLANDER: V1. Rotate.

Imagine an aircraft traveling at 72 meters per second.

What reaction time would they have needed to avoid the collision?

NARRATOR: The SAS pilots would not have been able

to see the Cessna on the runway

until a split second before impact.

What's that?

NARRATOR: But fog should not cripple a major airport like Linate.

Modern airports use a system of regulations and safety equipment

when operating in low visibility.

ZOLLNER: Airports avoid incursions

by having defined low-visibility operating rules.

These rules can be augmented by technology,

ground radars, alarm systems, and other things.

NARRATOR: Airport runways and taxiways

are broken down into a series of checkpoints

known as stop bars.

Aircraft must always wait for authorization before passing,

like a car must wait for a green light.

The system is designed to keep planes from colliding.

KRISTENSEN: Planes can avoid each other at night.

So why should it be any different in fog?

We have to consider this right off the bat.

One of the first thoughts that came to mind was...

Pilot error.

...the possibility of a pilot error.

NARRATOR: One of the pilots was not where he was supposed to be.

Investigators need to know which one.

NARRATOR: The worst air disaster in history

occurred under eerily similar conditions.

On the island of Tenerife in 1977,

583 people died when two Boeing 747s

collided on the runway in heavy fog.

In comparison with the Tenerife accident,

they were both in dense fog.

Taxiing on the wrong taxiway was involved.

Communication was also involved,

as the KLM captain thought he heard a takeoff clearance,

but he didn't.

NARRATOR: Investigators wonder

if the Linate disaster is a case of history repeating itself.

They learn that the brand new Cessna Citation jet

had arrived in Milan following a flight from Germany.

The German crew was now taking two passengers to Paris.

Since the Cessna was not equipped with a cockpit voice recorder

and the CVR from SAS Flight 686 has not yet been found,

investigators have only one record of what happened,

the air traffic control recordings.

ZOLLNER: We had to listen to the facts.

Our expectation was that the ATC recording would reveal

what actually was being said that morning.

NARRATOR: Investigators pay close attention

to Paolo Zacchetti's conversations with the Cessna,

call sign Delta, Victor, X-ray.

ZACCHETTI: Delta, Victor, X-ray. Taxi north via Romeo Five.

Call me back at the stop bar of the main runway extension.

PILOT: Roger. Via Romeo Five.

Call you back before reaching main runway.

NARRATOR: The Cessna was instructed to go north from the apron,

along taxiway Romeo Five,

to a taxiway that runs parallel to runway 36R.

The route should have kept the Cessna off the runway.

PICA: But he ended up here instead.

NARRATOR: Investigators make a shocking discovery.

The Cessna went south from the apron, not north as instructed.

It now appears the pilots made the fatal error that caused the accident.

PILOT: Call you back before reaching main runway.

NARRATOR: The control tower recording makes it clear.

The Cessna pilots got lost on the way to the runway.

The Cessna didn't follow the taxiway Romeo Five,

which had been authorized,

but took, instead, taxiway Romeo Six.

NARRATOR: The revelation leads to an important question.

So why didn't anyone notice, hmm?

Delta, Victor, X-ray. Continue to taxi on the main apron.

Roger. Continue to taxi on main apron. Delta, Victor, X-ray.

That is correct and please call me back entering the main taxiway.

PICA: Main apron? Main taxiway?

NARRATOR: The recording reveals

that the air traffic controller did not clearly distinguish

between aprons and taxiways.

His choice of words may have led the Cessna pilots

to believe they were headed the right way.

NARRATOR: An apron is a restricted section of an airport where planes park,

are loaded or refueled.

Taxiways are roads from the apron to the runway.

ZOLLNER: The communication with the tower and the pilots

that morning of the accident was inconsistent.

They used the word "main" for different things,

main runway, main apron, main taxiway.

ZACCHETTI: And please call me back entering the main taxiway.

NARRATOR: But Linate Airport has several aprons and taxiways,

none of them designated as main.

ZOLLNER: That was a communication below acceptable standards.

Play that again.

NARRATOR: Investigators also hear a puzzling transmission from the Cessna.

PILOT: Approaching Sierra Four.

KRISTENSEN: I don't see it anywhere.

It's not here.

Listening to the communications,

I was baffled when I heard the pilot reporting a Sierra Four.

NARRATOR: The controllers' maps don't show S4 at all.

Investigators are beginning to suspect the error goes beyond

the poor communications between Zacchetti and the Cessna.

PILOT: Approaching Sierra Four. Sierra Four.

I asked him if he knew where Sierra Four was.

Where is Sierra Four?

I have no idea.

PICA: That was very simple.

He confessed he didn't know where Sierra Four was.

NARRATOR: Pica finds that Zacchetti's managers

never gave him a tour of the taxiways as part of his training.

PILOT: Approaching Sierra Four.

ZACCHETTI: Delta, Victor, X-ray. Roger.

Maintain the stop bar. I'll call you back.

NARRATOR: He had no way of knowing where Sierra Four was.

The Cessna now has to cross the runway to get to the apron.

He keeps going past several signs that he's approaching an active runway.

Air traffic controller didn't stop the Cessna.

ZACCHETTI: Delta, Victor, X-ray.

NARRATOR: At that moment, the tower clears the MD-87 for takeoff.

TOWER CONTROLLER: Scandinavian 686, Linate, cleared for takeoff.

Continue your taxi on the main apron.

He should have stopped the Cessna but unfortunately...

Roger. Continue to taxi on main apron.

...he thought that the Cessna was on R5 taxiway.

NARRATOR: The Cessna pilot makes a fatal mistake.

With the MD-87 now traveling at 260 kilometers an hour,

he taxis across the runway.

Suspicions about procedures at Linate Airport deepen

as investigators learn that the exact same mistakes

that led to the deadly collision

were made by another plane less than 24 hours earlier.

Frank, Frank, come. Come and look at this.

I was shocked to find out that only the previous afternoon...

Same thing, 24 hours before.

...an aircraft had been cleared by the air traffic controller

to taxi onto Romeo Five.

Twenty-four hours... It happens here all the time.

The aircraft taxied really onto Romeo Six.

NARRATOR: Because there was no fog that day,

the two planes saw each other and did not collide.

Investigators are beginning to suspect that something about the airport,

not bad pilots, may be the cause of the Linate crash

and the frequent runway incursions there.

When we found out

that the Cessna pilot had taken the wrong taxiway,

first question was to explain what did he see

that brought him so much off course.

Okay, this is where they started.

KRISTENSEN: The taxiway we went on was Romeo Six,

and we walked the whole length of the taxiway.

We wanted to put ourselves in the shoes of the pilot

to understand his actions.

NARRATOR: They look for route identification signs

that are supposed to help guide the pilots.

KRISTENSEN: The status of those markings were in very poor condition.

It was, uh, surrounded by high grass,

and there was only a very few of those markings.

NARRATOR: The markings painted directly onto the tarmac are also vital for pilots.

PICA: When we came to the intersection between Romeo Five and Romeo Six,

we could see that the markings on the ground

were... so badly painted

that even in good visibility, it was difficult to read them.

Which made us understand

that for a pilot not familiar with the place

it would have been difficult to understand

where was Romeo Five, where was Romeo Six.

NARRATOR: The faded markings help explain why the Cessna turned right

when it should have turned left to avoid the runway.

They also come upon the reason

the Cessna pilot referred to the unknown position, Sierra Four.

PILOT: Approaching Sierra Four.

Uh, there's Sierra Four

but it's not on the map.

Actually, Sierra Four was the marking on the Romeo Six taxiway

going towards the runway,

but was not reported on any official map.

PILOT (OVER RADIO): Approaching Sierra Four.

ZACCHETTI: Delta, Victor, X-ray. Roger.

NARRATOR: Had the controller known where Sierra Four was,

he would have realized the Cessna was headed the wrong way

and approaching the runway.

But inadequate markings and maps still don't explain the collision.

Linate, like all modern airports, is equipped with motion sensor alarms

to guard against runway incursion.

Even with the failures of all other systems,

the acoustic alarm should have worked and we wondered why it didn't work.

PICA: Reading the ATC communication recordings,

we couldn't find any alarm going on

when the Cessna aircraft crossed the stop bars and entered the runway.

NARRATOR: Pica decides to test the runway incursion sensors himself.

PICA: I was told that, possibly, they didn't work

but we wanted to be certain.

Okay, commencing test of the motion sensor alarm

on taxiway Romeo Six.

So, one night when the airport was closed,

we made an experiment going over and over through the sensors.

But we had a man on the tower

just to make sure that the alarm didn't go.

Anything?

MAN: No, nothing.

Again.

Eventually, we found out that those alarms had been deactivated years before

to avoid unnecessary alarms

that were triggered eventually by an animal crossing

or a car doing an inspection during the night.

NARRATOR: One week after the accident,

investigators still have not located the cockpit voice recorder

amid the aircraft wreckage.

Finding the CVR was crucial

in order to establish that there was no problems prior to impact.

So I decided to search through this giant pile of rubble...

and concrete and steel,

and eventually, we did find the CVR.

The CVR of the MD-87 was carefully analyzed

to find out what had been said onboard,

what kind of procedures had been done.

TOWER CONTROLLER: Scandinavian 686, Linate.

Cleared for takeoff, 36.

NARRATOR: The recording shows

that the SAS crew did receive the proper clearance

to proceed down runway 36R.

HYLLANDER: Cleared for takeoff, 36, set.

NARRATOR: The SAS crew played no role in causing the accident.

They were the victims of the airport's failings.

The investigation has identified one final factor

that underlines how dangerous conditions at Linate had become.

No.

There is no ground radar at Linate.

We have not had it in years.

The ground radar at Linate, the old one, was dismantled.

The new one was in boxes.

Had been there for years and not yet installed.

Why? I don't know.

NARRATOR: Airport ground radar systems

detect movement of all aircraft and vehicles,

a vital piece of safety equipment at a busy airport.

KRISTENSEN: If you have ground radar,

it's a good tool to establish what's going on in the airport,

even in low visibility conditions.

We can certainly say

that if the ground movement control radar had been in place,

the ground controller would have had the opportunity

to see the aircraft crossing the stop bars.

And possibly then would have stopped the aircraft

before the collision happened.

ZACCHETTI: Delta, Victor, X-ray. Confirm your position.

NARRATOR: The Cessna took the wrong path due to flawed taxiway markings.

Without ground radar,

controllers couldn't properly monitor the movement of the Cessna.

Add fog into the mix and disaster was inevitable.

When the Cessna and the SAS aircraft started moving,

they were both doomed.

The accident was now inevitable.

TOWER CONTROLLER: Scandinavian 686, Linate.

Cleared for takeoff, 36.

Delta, Victor, X-ray. Continue to taxi on the main apron.

And we are rolling. Scandinavian 686.

Roger. Continue to taxi on main apron.

HYLLANDER: V1.

Rotate.

What's that?

NARRATOR: The cockpit voice recorder gives investigators a detailed picture

of what happened at the moment of impact.

ZOLLNER: Noises in the cockpit

will also tell us the different controls being moved.

And the ambient noise from the area mic would give us information

on some of the sounds during the collision.

GUSTAFSSON (OVER CVR): What's that?

(AIRPLANE CRASHING)

We realized that the impact was more than one collision.

It was actually several collisions in half a second.

NARRATOR: When that half second of audio is analyzed more closely,

investigators discover it contains several distinct sounds.

(AIRPLANE CRASHING)

ZOLLNER: So we exposed this data over a schematic of the aircraft

showing the travel of the sound.

By doing that, we could analyze

that we have several points of impact during the collision.

NARRATOR: The painstaking research gives investigators a better understanding

of how the two planes came together on the runway.

The MD-87 first hit the Cessna

with its nose landing gear at the Cessna's stabilizer.

And then, in short order of time,

the left hand main landing gear of the MD-87

hit the outer part of the right hand wing of the Cessna.

And then the biggest impact

was the right hand main landing gear of the MD-87

cutting through the cabin of the Cessna.

NARRATOR: Investigators conclude the MD-87 lost its right engine after the impact.

The plane would have been almost impossible to fly.

But, remarkably, the pilots almost managed to do just that.

GUSTAFSSON: Come on, come on.

After the collision, the MD-87 actually got into the air.

According to the flight data recorder,

the aircraft was airborne almost nine seconds.

The captain, uh, made a heroic attempt to fly the airplane.

GUSTAFSSON: Come on, come on, come on.

He tried to accelerate the left hand engine and use it,

but it, uh, had ingested too much debris.

And the pilot did an amazing work...

trying to control it.

Up to the last minute, he tried to avoid impact.

(EXPLOSION)

The pilots could not have done anything to avoid this accident

because the aircraft was traveling too fast.

Such a big aircraft cannot respond on a dime.

It's impossible.

I believe that both crew and both airplanes

think they did everything right, right until the moment of impact.

NARRATOR: It's now clear

that a badly flawed control system at Linate Airport

led directly to the crash.

What's more, it's beginning to look like organizational failures

may also have prevented rescue personnel from saving lives.

Grazie.

How long was it before the general alarm was sounded?

NARRATOR: The investigation begins to uncover evidence

of how failures at the airport made a bad situation...

Please call me back, entering the main taxiway.

NARRATOR: ...even worse.

TOWER CONTROLLER: Hello, this is Tower.

The wreckage of the Cessna

was found only about 25 minutes after the accident.

And by the time the fire brigade arrived on the scene,

all the occupants were dead.

NARRATOR: Post mortem exams confirm that three people in the Cessna

had high concentrations of smoke in their lungs.

They were still alive after being hit by the MD-87.

They were burned alive.

ZOLLNER: After the collision,

the Cessna burned for more than 20 minutes.

PICA: If the rescue to the Cessna had arrived earlier,

certainly the two pilots would have survived the accident.

NARRATOR: After more than six months of painstaking investigation,

Mario Pica delivers his findings.

Though runway incursion by the Cessna

is listed as the immediate cause of the accident,

Pica does not entirely blame the Cessna pilot.

Instead, he points to the lack of proper signage

and taxiway markings at Linate

as well as to the airport's failings overall.

KRISTENSEN: A fairly simple airport like Linate, with only one main runway,

it should be easy to, uh, to cover this with signs

and with paintings and so forth.

But, apparently, everything which could go wrong

did go wrong at that airport.

Delta, Victor, X-ray. Taxi north via Romeo Five.

Call me back at the stop bar of the main runway extension.

NARRATOR: And for some of the people involved,

the fallout is especially harsh.

Ground controller Paolo Zacchetti,

along with high-ranking officials from the agencies which oversee Linate,

are handed prison sentences.

The judgment sparked intense debate.

Should human error in air accidents be considered a criminal act?

I define the ground controller as the 119th victim of the case.

I didn't have the equipment

that could have made me aware of what was happening.

Delta, Victor, X-ray. Continue to taxi on the main apron.

PILOT (OVER RADIO): Roger.

PICA: Yes, it is true, he did make a mistake,

but it is the result of a system that failed.

NARRATOR: Because of the tragedy,

Linate Airport underwent a major overhaul

designed to improve safety.

ZOLLNER: Linate improved the airport by installing the ground radar.

Some of the markings and signage was repainted.

CATINO: The runway incursion alarms are functioning now.

(ALARM BUZZING)

GROUND CONTROLLER: Alitalia 212, hold your position.

You are crossing an active runway.

Repeat, hold your position, Alitalia 212.

The biggest lesson learned in this accident, in my opinion,

is that people are prone to get used to failures.

There is no ground radar at Linate.

Accepting latent conditions,

getting used to a system that doesn't work,

and by time, actually getting the whole system

more and more dangerous.

An airport is a highly complicated place.

There's the vehicles, there's the airplanes,

baggage lorries, cargo lorries,

all sorts of activities going around at the same time.

There has to be a very high level of safety in an airport.

NARRATOR: The reforms ushered in following the collision on 36R

have made runway incursions far less likely

and made Linate a much safer airport.