Original subtitles

When a plane crashes...

What the hell?

What the hell?

...the shock is profound.

But when two planes are found in the wreckage...

The runway was occupied, and that's something

The runway was occupied, and that's something

that should never happen.

...the extent of the tragedy is multiplied.

Oh god, Oh god!

Oh god, Oh god!

It's up to investigators...

727's wings sliced right through the fuselage.

...to solve multiple mysteries.

...to solve multiple mysteries.

Why would he lie?

What's that?

My God.

Three collisions raise the same question...

Three collisions raise the same question...

how did two planes end up on the same runway...

Oh no.

...at the same time?

...at the same time?

For an airplane to be on an active runway

when they shouldn't, somebody did something wrong.

when they shouldn't, somebody did something wrong.

Ladies and gentlemen,

we are starting our approach.

We lost both engines.

We lost both engines.

Put the mask over your nose.

Emergency.

Mayday, mayday.

FLIGHT ATTENDANT (ON PA): Brace for impact!

He's going to crash!

Detroit Metropolitan Airport.

In the tower...

Man, I don't think I've ever seen fog this bad.

Man, I don't think I've ever seen fog this bad.

...controllers are dealing with fog that's

blanketed the entire airport.

blanketed the entire airport.

It's so thick, they can't see the planes they're guarding.

Northwest 299, ready to taxi.

Northwest 299, ready to taxi.

Northwest 299, metro ground, taxi to runway 3 center

via Oscar 6, Fox, and X-ray.

via Oscar 6, Fox, and X-ray.

The ground controller is directing Northwest

flight 299 to the runway.

flight 299 to the runway.

It's a Boeing 727 bound for Memphis

with 146 passengers on board.

with 146 passengers on board.

Only way they could know where the aircraft were

on the airport was to have the pilots give them positions

on the airport was to have the pilots give them positions

as to where they were.

Northwest 299, what's your position now?

OK, we just turned down onto X-ray 299.

OK, we just turned down onto X-ray 299.

Roger.

Switch to tower control 118.4.

Switch to tower control 118.4.

After reaching the runway threshold,

control of a 727 passes from the ground controller

control of a 727 passes from the ground controller

to the tower controller.

Northwest 299, metro tower, runway 3 center, clear

Northwest 299, metro tower, runway 3 center, clear

for takeoff.

Roger.

80 knots.

Suddenly, midway down the runway,

the 727 encounters the unexpected...

A DC-9 with 40 passengers on board.

A DC-9 with 40 passengers on board.

In its cockpit...

Oh no.

Oh no.

...there's nothing the pilots

can do to prevent a collision.

Oh God.

Oh God!

Oh God!

Northwest 299 aborting.

There's an aircraft on the runway, and we struck his,

uh, right wing.

The 727 wing has sliced

through the DC-9's fuselage.

Inside the DC-9, there's chaos.

Firefighters and emergency response

teams rush to the scene.

teams rush to the scene.

No one on the 727 is injured, but the same

is not true of the DC-9.

The aircraft

was virtually burned out.

The passenger compartment was gutted.

The passenger compartment was gutted.

The pilots of the DC-9 survive the collision,

but eight of the 44 people on board are killed.

but eight of the 44 people on board are killed.

The DC-9 is identified as another Northwest Airlines

The DC-9 is identified as another Northwest Airlines

plane, flight 1482 bound for Pittsburgh.

The National Transportation Safety Board

The National Transportation Safety Board

launches an investigation into the accident.

launches an investigation into the accident.

The 727's wing sliced right through the fuselage.

We obviously knew what happened in a gross sense.

Two aircraft came together and...

and a tragic event occurred.

and a tragic event occurred.

How did the DC-9 end up in the path

of the oncoming 727?

of the oncoming 727?

Investigators immediately suspect the thick fog played

a major part in the accident.

a major part in the accident.

Visibility was 3/4 of a mile an hour before the accident.

But then it drops to a 1/4 mile.

But then it drops to a 1/4 mile.

1/4 mile is the minimum.

Did the DC-9 get lost in the fog on the way

Did the DC-9 get lost in the fog on the way

to the runway?

Visibility was at least 1/4 mile.

Visibility was at least 1/4 mile.

That would allow operations to continue.

That would allow operations to continue.

Before the accident, every other aircraft that took off

had no problem at all finding the end of the proper runway

had no problem at all finding the end of the proper runway

and departing.

But our men in the DC-9 didn't do this.

But our men in the DC-9 didn't do this.

Why did the DC-9 lose its

way when other aircraft didn't?

Investigators wonder if ground control is at fault.

Investigators wonder if ground control is at fault.

I cleared them to use, uh, Oscar 6, foxtrot,

and X-ray to runway 3 center.

and X-ray to runway 3 center.

The ground controller tells investigators

he gave the DC-9's crew, First Officer Jim Schifferns

he gave the DC-9's crew, First Officer Jim Schifferns

and Captain Bill Lovelace, specific instructions

to get to the runway.

to get to the runway.

Northwest 1482, taxi to Oscar 6

to foxtrot, report making a right turn on X-ray.

to foxtrot, report making a right turn on X-ray.

Oscar 6 to foxtrot, report X-ray.

Beginning on taxiway Oscar 6,

the aircraft was to take foxtrot and then X-ray

the aircraft was to take foxtrot and then X-ray

to the start of the runway.

Northwest 1482, what's your position now?

Northwest 1482, what's your position now?

But when asked for an update on their progress...

We're headed eastbound on Oscar 6 here.

We're headed eastbound on Oscar 6 here.

Uh, eastbound on Oscar 6?

Uh, eastbound on Oscar 6?

The crew's response didn't make sense.

The crew's response didn't make sense.

They announced that they were eastbound on Oscar

6, which was an impossibility.

It's a northwest-southeast oriented taxiway.

It's a northwest-southeast oriented taxiway.

OK, I think we might have missed Oscar 6.

OK, I think we might have missed Oscar 6.

I see a sign here that says, uh...

the arrow's to Oscar 5.

the arrow's to Oscar 5.

The folks in the tower realized that the pilots

in the dc9 were probably becoming a little confused

in the dc9 were probably becoming a little confused

about where they were.

Instead of remaining straight on Oscar 6,

the aircraft turned left and past taxiway Oscar five.

the aircraft turned left and past taxiway Oscar five.

I realized they had made a wrong turn,

I realized they had made a wrong turn,

so I gave them directions to get them back on track.

Northwest 1482 at Oscar 4, make the right turn onto X-ray,

Northwest 1482 at Oscar 4, make the right turn onto X-ray,

report crossing 927.

The DC-9 was then directed to continue straight

The DC-9 was then directed to continue straight

to Oscar 4, turn right onto X-ray,

cross inactive runway 927, and then follow X-ray

cross inactive runway 927, and then follow X-ray

back to the runway for takeoff.

back to the runway for takeoff.

Roger.

At Oscar 4, make the right turn onto X-ray.

At Oscar 4, make the right turn onto X-ray.

The DC-9 radioed back, OK, I understand,

or something to that effect.

And everybody calmed down and thought that they had

And everybody calmed down and thought that they had

straightened everything out.

But somehow, five minutes later, the DC-9

But somehow, five minutes later, the DC-9

ended up on the active runway.

Somebody did something wrong.

Somebody did something wrong.

Investigators need to find out who and why.

Investigators need to find out who and why.

We hoped we would

find out, why did you miss all this

and wind up on an active runway?

and wind up on an active runway?

Investigators interview

the DC-9's crew, starting with Captain Bill Lovelace.

The captain was kind of a mild-mannered fellow.

The captain was kind of a mild-mannered fellow.

He loved to fly.

I wasn't familiar with the layout

of the taxiways and runways.

of the taxiways and runways.

He recently returned to flying

after a six-year medical leave and was unfamiliar

after a six-year medical leave and was unfamiliar

with the airport in Detroit.

So I asked my first officer...

So I asked my first officer...

Where have you been flying out of?

Memphis and Detroit.

Memphis and Detroit.

Good, you can help me find my way around these taxiways

here in Detroit.

I sure can.

I sure can.

The first officer who bragged about his knowledge

of the airport, that would have enhanced the likelihood

that the captain would have trusted the first officer

to help navigate in Detroit.

I thought, great, someone in the copilot seat

I thought, great, someone in the copilot seat

who knows where he's going.

But, uh, we still got lost somehow.

But, uh, we still got lost somehow.

The NTSB next questions First Officer Jim

Schifferns, a former military pilot who joined

Schifferns, a former military pilot who joined

Northwest earlier that year.

He was a little brash, perhaps a little cocky.

I wouldn't say a know-it-all, but he'd been around the horn.

I wouldn't say a know-it-all, but he'd been around the horn.

Captain Lovelace misunderstood.

What I meant was I knew the procedures

What I meant was I knew the procedures

for pushing back from the gate, not the physical layout

of the airport.

of the airport.

Investigators conclude the first officer,

whether deliberately or not, misled the captain about

whether deliberately or not, misled the captain about

his knowledge of the airport.

Our DC-9 crew was really not familiar

Our DC-9 crew was really not familiar

with the Detroit Airport.

And then you bring in all the other things,

like low visibility, it all comes together to create

like low visibility, it all comes together to create

a dangerous situation.

Still, investigators wonder

how two professional pilots could

become so dangerously lost.

OK, let's see where they go.

OK, let's see where they go.

And let's confirm any directional changes

with the FDR data.

To trace their route, investigators

To trace their route, investigators

combine the plane's heading changes captured

by the flight data recorder with the conversation

recorded in the cockpit.

recorded in the cockpit.

Before the plane starts to taxi, the team

hears something on the tape that gets their attention.

hears something on the tape that gets their attention.

I've always flown with an ejection seat.

I've used it twice.

At the departure gate, the first officer

At the departure gate, the first officer

began to boast about his military service.

I got shot down once over Southeast Asia.

I got shot down once over Southeast Asia.

I didn't have time to get scared.

Ooh.

Is that right?

Is that right?

And then, uh, when I was flying T-38S one time,

I had an engine fire.

The tower controller said, you are on fire, eject.

The tower controller said, you are on fire, eject.

Bam! I...

- Wow. - Shh.

Wow.

At that time in the NTSB, a lot of us

had military backgrounds.

He and I were in the same place at nearly the same time,

He and I were in the same place at nearly the same time,

so my ears perked up.

Is he some kind of war hero?

Sounds like it.

Sounds like it.

To bailout or eject out of two different airplanes,

well, that's very rare.

well, that's very rare.

Investigators review the first officer's military

record to verify his story.

record to verify his story.

Check this out.

He's clearly embellishing.

It turns out that he didn't bail out

It turns out that he didn't bail out

of any aircraft at any time.

We even have a phrase for that... stolen valor.

We even have a phrase for that... stolen valor.

Why would he lie?

That's a good question.

The NTSB needs to know why first officer Jim

Schifferns lied to the captain about his military record

Schifferns lied to the captain about his military record

just minutes before Northwest 1482

strayed onto an active runway.

strayed onto an active runway.

Investigators check his employment record

for an answer.

He was still on probation.

So he needed the captain to give him a good report.

So he needed the captain to give him a good report.

I think the first officer was bringing to impress

the captain because a bad mark would

be tantamount to not getting a career with Northwest Airlines.

be tantamount to not getting a career with Northwest Airlines.

But did the first officer's boasting influence

decision-making in the cockpit?

decision-making in the cockpit?

3 center, exit the ramp at Oscar 6.

Did you get all that?

Did you get all that?

Yeah, but I'm going to need you to have...

Kind of wind around here, and Oscar 6

is going to be right around the corner here.

is going to be right around the corner here.

OK.

The CDR reveals that, as the plane begins to taxi,

the dynamic in the cockpit changed.

the dynamic in the cockpit changed.

The first officer was correct in offering

up help to the captain.

This is just the way things should work.

This is just the way things should work.

Uh, left turn or right turn?

Yeah, well, this is the inner taxiway here.

Yeah, well, this is the inner taxiway here.

We're still going for Oscar 6.

So... left turn?

Yeah.

The first officer was

kind of taking on a bit more responsibility,

kind of taking on a bit more responsibility,

a bit more, a bit more.

And then he started to direct the taxi itself.

And then he started to direct the taxi itself.

Seems like the first officer is calling the shots.

We're headed eastbound on Oscar 6

We're headed eastbound on Oscar 6

here.

Just as the controller said, you can't go east on Oscar 6.

Just as the controller said, you can't go east on Oscar 6.

Oscar 6 runs north-south.

Northwest 1482, at Oscar 4 take the right turn on X-ray,

Northwest 1482, at Oscar 4 take the right turn on X-ray,

report crossing 927.

report crossing 927.

As their predicament worsened...

So what do we do here.

So what do we do here.

You make the right turn and report crossing 27.

The captain became completely reliant on

The captain became completely reliant on

the first officer's guidance.

This role reversal was pretty total.

This role reversal was pretty total.

There's Oscar 4.

And this is X-ray.

OK, so the last instruction was at Oscar 4,

OK, so the last instruction was at Oscar 4,

turn right onto X-ray.

Right over here then.

Yeah, that way.

Yeah, that way.

I think we... we're on X-ray here now.

There is no way they're on X-ray.

There is no way they're on X-ray.

They never make it on to X-ray.

The captain suddenly realized

they missed the taxiway and were now on a runway.

they missed the taxiway and were now on a runway.

What runway is this?

Turn left over there.

Turn left over there.

No, wait, wait, that's a runway too.

They are totally disoriented.

They are totally disoriented.

Tell them we're out here, we're stuck.

We can't see anything, but I believe we're on a runway.

We can't see anything, but I believe we're on a runway.

Somehow, they've made it here.

Somehow, they've made it here.

And we've got two planes facing

each other on the same runway.

But there's signs and surface markings all along here.

I don't get it.

I don't get it.

When an aircraft gets lost on the airfield,

usually, the pilots will spot signs or something like that,

usually, the pilots will spot signs or something like that,

help clarify the position in the controller's mind of where

the aircraft is exactly.

Investigators are baffled.

Investigators are baffled.

Why didn't the airport signs and runway markings prevent

the pilots from getting lost?

the pilots from getting lost?

To better understand what happened...

To better understand what happened...

Let's do this.

...investigators retrace their route.

The only way to fix this in our minds

was to perform what we call a taxi demonstration.

was to perform what we call a taxi demonstration.

Wow.

Will you look at that?

The team discovers that the yellow taxi

markings were badly faded.

markings were badly faded.

I can barely see it on a bright day.

It was obvious that if we

It was obvious that if we

got confused in broad daylight with no fog,

perfect visibility, that the issue was more acute when

perfect visibility, that the issue was more acute when

you could barely see your hand in front of your face

out there.

out there.

Investigators continue to the Oscar 4 intersection

where the DC-9 failed to make the critical right turn.

where the DC-9 failed to make the critical right turn.

So which way is the Oscar 4 sign

pointing, right or straight ahead?

pointing, right or straight ahead?

They discover that the signage at the intersection

They discover that the signage at the intersection

is confusing.

The only way for pilots to really be certain of where they

are is to have unmistakable signs

are is to have unmistakable signs

that offer pilots clear and readily

that offer pilots clear and readily

interpretable information.

Investigators finally think they know what happened

on the day of the collision.

on the day of the collision.

Now, what runway is this?

This is a runway.

This is a runway.

A dysfunctional and disoriented DC-9 crew

mistakenly taxied onto an active runway,

mistakenly taxied onto an active runway,

at the same time as the Boeing 727 was cleared for takeoff.

80 knots.

Oh no.

Oh no.

Oh god, oh god!

In the aftermath of the crash,

In the aftermath of the crash,

Detroit Metropolitan Airport improved signage

and now uses highly visible reflective paint

and now uses highly visible reflective paint

for all airfield markings.

Ground radar with audible and aural warnings,

Ground radar with audible and aural warnings,

as well, to tell controllers of an impending collision

is in place at most major airports at this point in time.

is in place at most major airports at this point in time.

That's gone a long ways to preventing actual collisions

from happening.

The high volume of daily traffic

poses a constant challenge for both pilots and controllers.

poses a constant challenge for both pilots and controllers.

It can become overwhelming, with devastating consequences.

It can become overwhelming, with devastating consequences.

It's just before sunset on America's West Coast.

It's just before sunset on America's West Coast.

US air Flight 1493 out of Columbus, Ohio, cruises

toward Los Angeles International Airport.

toward Los Angeles International Airport.

There are 89 passengers and six crew on board the Boeing 737.

There are 89 passengers and six crew on board the Boeing 737.

Just confirm the visual approach

for US Air 1493 is 24-Left.

for US Air 1493 is 24-Left.

That's correct, US Air 1493.

That's correct, US Air 1493.

48-year-old Captain Colin Shaw has logged

more than 16,000 flying hours.

more than 16,000 flying hours.

First Officer David Kelly is 32 with 4,300 hours

of flying experience.

of flying experience.

In the control tower...

In the control tower...

246 heading 270, contact Los Angeles departure.

246 heading 270, contact Los Angeles departure.

Goodnight.

...Robin Wascher is handling two runways,

including runway 24 left.

including runway 24 left.

Like all controllers, she uses flight

strips to keep track of all planes arriving and departing.

strips to keep track of all planes arriving and departing.

SkyWest 569, taxi into position, hold runway 24 left.

Traffic will cross downfield.

Traffic will cross downfield.

Roger.

Eight miles from LAX, the pilots

Eight miles from LAX, the pilots

radio for landing instructions.

US Air 1493, inside Roman.

US Air 1493, inside Roman.

But there's no response.

Wascher is busy with other planes on the ground.

Sundance 518, taxi across Runway 24-Left.

Sundance 518, taxi across Runway 24-Left.

Contact ground 0.65 when you're off the runway.

Flight 1493 can't land until it

receives Wascher's clearance.

receives Wascher's clearance.

US Air 1493 for the left side, 24-Left.

The 737 is only one minute from the runway.

The 737 is only one minute from the runway.

Out of 1,000 feet.

Out of 1,000 feet.

Thank you, US Air 1493.

Thank you, US Air 1493.

You're cleared to land, 24-Left.

Cleared to land, 24-Left, 1493.

Cleared to land, 24-Left, 1493.

Looks real good.

What the hell!

US Air 1493 bursts into flames

upon landing at LAX.

upon landing at LAX.

It skids across the tarmac and slams

It skids across the tarmac and slams

into an abandoned building.

Firefighters hurry to the scene.

20 people on the fly are dead.

Two more will succumb to their injuries

Two more will succumb to their injuries

in the days that follow.

As rescue efforts continue, a shocking discovery is made.

Firefighters pull a propeller from the wreckage.

Firefighters pull a propeller from the wreckage.

As soon as we found out that information,

As soon as we found out that information,

we started actively looking to see what aircraft, if any,

were missing.

were missing.

So we started looking at the flight strips

that were already departed.

And then we looked at the ones that were still pending.

And then we looked at the ones that were still pending.

Uh, what about SkyWest 569?

No, we haven't heard from them.

SkyWest 569, a 19-seat twin engine plane

SkyWest 569, a 19-seat twin engine plane

bound for Palmdale, California, isn't

responding to radio calls.

Emergency crews eventually find the wrecked commuter plane

Emergency crews eventually find the wrecked commuter plane

beneath the 737.

beneath the 737.

It was a horrific scene.

The front end of the airplane was

The front end of the airplane was

impaled against the building.

We could see parts of another aircraft underneath.

We could see parts of another aircraft underneath.

There were 12 people on board.

Rescuers find no survivors.

Rescuers find no survivors.

The National Transportation Safety Board dispatches

The National Transportation Safety Board dispatches

a team of investigators to LAX.

The scenario of the accident

resulted in two planes being on the runway at the same time.

The runway was occupied.

The runway was occupied.

And that's something that should never happen when

a landing clearance is granted.

a landing clearance is granted.

Which one of these planes was cleared for 24-Left?

Recordings of Robin Wascher's communications in the

tower might provide an answer.

tower might provide an answer.

SkyWest 569, taxi up and hold short of Runway 24-Left.

Roger, hold short.

Roger, hold short.

Moments before the accident, Wascher

was prepping the SkyWest commuter plane for takeoff.

46, affirmative.

46, affirmative.

SkyWest 569, taxi into position

and hold Runway 24-Left.

Traffic will be crossing downfield.

Traffic will be crossing downfield.

The pilots, as instructed, taxied to takeoff

position and stopped so that Wascher could

position and stopped so that Wascher could

clear a third aircraft to taxi across the runway in front

of them.

of them.

OK, 24-Left, position and hold, SkyWest 569.

OK, stop right there.

OK, stop right there.

SkyWest 569 followed Wascher's directions.

SkyWest 569 followed Wascher's directions.

All right, let's keep going.

ROBIN WASCHER (ON RADIO): Wings West 5006,

ROBIN WASCHER (ON RADIO): Wings West 5006,

taxi cross Runway 24-Left.

Next, Wascher instructs

the plane in front of SkyWest 569 to cross the runway.

the plane in front of SkyWest 569 to cross the runway.

Wings West 5006, taxi across runway 24-Left.

But there's no response from that plane.

Wings West 5006, grou...

Wings West 5006, grou...

tower.

It takes nearly a minute for Wascher

to reestablish radio contact.

to reestablish radio contact.

Wings West 5006 on frequency again.

Wings West 5006 on frequency again.

Changed radios.

Sorry about that.

They advised her they had inadvertently

They advised her they had inadvertently

been on another frequency.

5006, you're back with me.

5006, you're back with me.

Yeah, we didn't mean to switch radios.

We're on now.

And that created a distraction for the local controller.

And that created a distraction for the local controller.

And that's when US Air Flight

1493, still a minute from touchdown,

1493, still a minute from touchdown,

requests clearance to land.

US Air 1493 for the left side, 24-Left.

US Air 1493 for the left side, 24-Left.

Thank you, US Air 1493.

You're cleared to land, 24-Left.

You're cleared to land, 24-Left.

US Air 1493 was cleared

to land on the same runway during the time

that SkyWest 569 was still sitting in position

that SkyWest 569 was still sitting in position

on that same runway.

Cleared to land, 24-Left, 1493.

Cleared to land, 24-Left, 1493.

It's a mistake that cost 34 lives.

It's a mistake that cost 34 lives.

The team now needs to find out from Robin

Wascher what went wrong.

Wascher what went wrong.

I couldn't find the flight progress strip.

Wascher explains that, as SkyWest 569 waited

Wascher explains that, as SkyWest 569 waited

on the runway for permission to take off,

she was distracted by a third plane

she was distracted by a third plane

requesting clearance to depart.

Tower, Wings West 5072 is ready for takeoff.

Tower, Wings West 5072 is ready for takeoff.

Wings West 5072?

Wings West 5072?

I need a strip for Wings West 5072.

I need a strip for Wings West 5072.

I couldn't find the strip, so I asked my supervisor to help me.

While Wascher looked for the strip for Flight 5072,

While Wascher looked for the strip for Flight 5072,

she forgot she had already moved Sky West 569 onto the runway.

she forgot she had already moved Sky West 569 onto the runway.

US Air 1493 for the left side.

And then she cleared Flight 1493 to land.

And then she cleared Flight 1493 to land.

Thank you, US Air 1493.

You're cleared to land, 24-Left.

What the hell!

This is a situation that no controller wants to go through.

This is a situation that no controller wants to go through.

You train your whole career for this not to happen.

But the NTSB isn't ready to close the case

of the LAX collision yet.

of the LAX collision yet.

Anytime that you do an investigation,

it's easy to point the blame at one individual.

it's easy to point the blame at one individual.

What you want to do is to say, why did this occur,

and what can we do to prevent a reoccurrence?

and what can we do to prevent a reoccurrence?

Documents provided by lax air traffic controllers

Documents provided by lax air traffic controllers

have revealed that the tower was understaffed in the months

before the deadly collision on Runway 24-Left,

before the deadly collision on Runway 24-Left,

and that some sections of the runway

and that some sections of the runway

are invisible to controllers.

We went up in the tower

and asked the air traffic controllers

to step aside while we sat in their chairs

to step aside while we sat in their chairs

and looked out the window.

The view that the air traffic controller was presented with

The view that the air traffic controller was presented with

had an obstruction, a light pole that produced a glare.

had an obstruction, a light pole that produced a glare.

The investigation also discovers that ground radar

The investigation also discovers that ground radar

systems used to track planes while taxiing

weren't operational on the day of the accident.

weren't operational on the day of the accident.

You're holding short.

Is that correct, sir?

Yes, ma'am, we're holding short.

It was in constant out of service, in service,

It was in constant out of service, in service,

out of service, in service, and gave the management

out of service, in service, and gave the management

a lot of trouble.

Los Angeles airport has always been known as one of the number

one runway incursion airports in the system.

one runway incursion airports in the system.

And changes were overdue.

In the months and years following the accident,

improvements were made to air traffic facilities to make

the airport a safer place.

The equipment we're using at Los Angeles

The equipment we're using at Los Angeles

tower today gives the controllers

the tools they need to make sure that the runways are clear.

the tools they need to make sure that the runways are clear.

Without those safety measures in place,

Robin Wascher lost track of the situation,

Robin Wascher lost track of the situation,

something that should never happen at a control tower.

Linate Airport, Milan, Italy...

it's just after 8:00 AM.

The runways and taxiways are shrouded in a dense fog,

The runways and taxiways are shrouded in a dense fog,

similar to that which covered Detroit

Airport 11 years earlier.

Airport 11 years earlier.

Alitalia 226 cleared for takeoff, 36.

Report when rolling.

Even so, planes take off every two minutes.

Even so, planes take off every two minutes.

Linate, buongiorno.

Linate, buongiorno.

Delta India Echo Victor X-ray requesting startup.

Delta Victor X-ray, you are cleared to start your engines.

Delta Victor X-ray, you are cleared to start your engines.

Paolo Zacchetti is the ground

controller responsible for guiding flights

controller responsible for guiding flights

to the start of the runway.

Taxi via Romeo 5.

Taxi via Romeo 5.

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

Scandinavian 606, taxi to your holding position, Cat 3.

Scandinavian 606, taxi to your holding position, Cat 3.

Scandinavian 686, taxi to holding position, Cat 3.

On the way to the runway

On the way to the runway

is Scandinavian Airlines Flight 686,

a Boeing MD-87 bound for Copenhagen

a Boeing MD-87 bound for Copenhagen

with 110 people on board.

Taxi holding point Cat 3.

Taxi holding point Cat 3.

The captain is Joakim Gustafsson.

He's been with SAS for more than a decade.

He's been with SAS for more than a decade.

Scandinavian 686, your position please.

We still haven't reached the

main taxiway, Scandinavian 686.

main taxiway, Scandinavian 686.

First Officer Anders Hyllander

has been flying for the airline for the past four years.

has been flying for the airline for the past four years.

The SAS crew were very highly experienced pilots,

The SAS crew were very highly experienced pilots,

so couldn't ask more for two qualified pilots.

In such thick fog, the pilots rely on Zacchetti

In such thick fog, the pilots rely on Zacchetti

to guide them to the runway.

to guide them to the runway.

Scandinavian 686, your position please.

Now you are on the main taxiway.

Yes, now we are entering the main taxiway, Scandinavian 686.

Yes, now we are entering the main taxiway, Scandinavian 686.

Flight 686 turns off the taxiway

Flight 686 turns off the taxiway

and onto the runway.

Zacchetti hands the flight off to the tower controller.

Tower, buongiorno.

Tower, buongiorno.

Scandinavian 686, sequence to 36-Right.

Ciao, Scandinavian 686.

Ciao, Scandinavian 686.

The wind is calm.

Report rolling.

When airborne, squawk ident.

The flight is cleared for takeoff at 8:09 AM.

The flight is cleared for takeoff at 8:09 AM.

And we are rolling, Scandinavian 686.

And we are rolling, Scandinavian 686.

Auto throttle on.

Auto throttle on.

Set thrust.

V1.

Rotate.

Rotate.

What's that?

What's that?

Come on, come on.

Come on.

Scandinavian Airlines Flight 686

has been struck by catastrophe.

But because of the thick fog, no one is aware of it.

But because of the thick fog, no one is aware of it.

Until a severely burned baggage handler emerges from the fog.

Until a severely burned baggage handler emerges from the fog.

We want to know what happened on the runway.

10 tons of jet fuel feed a massive fire

10 tons of jet fuel feed a massive fire

where the Boeing MD-87 has collided with one

of Linate airport's hangars.

of Linate airport's hangars.

Awful, terrible devastation, the collapse

of a roof over the hangar, and the SAS

of a roof over the hangar, and the SAS

airplane completely destroyed.

airplane completely destroyed.

While emergency crews battle the fire...

There are two aircraft unaccounted for.

There are two aircraft unaccounted for.

...ground controller Paola

...ground controller Paola

Zacchetti realizes a four-seat Cessna

Citation is unaccounted for.

The main attention was focused on the SAS airplane,

The main attention was focused on the SAS airplane,

so nobody thought that there was another airplane.

so nobody thought that there was another airplane.

A private aircraft is missing, a Cessna 525.

Ground crews immediately organize a search.

26 minutes after the crash, they find what's left of the Cessna

26 minutes after the crash, they find what's left of the Cessna

midway down the runway where the accident occurred.

The disaster has claimed the lives of all 110 people

The disaster has claimed the lives of all 110 people

on the MD-87, along with four onboard the Cessna.

Four more were killed inside the hangar.

This is the most serious accident

This is the most serious accident

in the history in Italy.

My God.

My God.

Mario Pica is the lead investigator

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

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

It was mandatory to find out really what happened

and find the reasons that could help

and find the reasons that could help

us to avoid it happening again.

The Swedish accident investigation board

also sends a team to Milan.

We were called to be part of the investigation

We were called to be part of the investigation

as it was in the Scandinavian Airlines plane.

Here's what we know so far.

Here's what we know so far.

The MD-87...

Measuring the distance,

we are certain that the MD-87 had traveled

we are certain that the MD-87 had traveled

for about 40 seconds and gone 1,500 meters

for about 40 seconds and gone 1,500 meters

before striking the Cessna.

- ACTOR AS MARIO - ...and go here.

Ah.

Did the SAS pilots have

any warning that another plane was on the runway?

any warning that another plane was on the runway?

Weather, weather.

Weather reports show visibility was only 160 feet

Weather reports show visibility was only 160 feet

at the time of the collision.

V1.

V1.

Rotate.

That means SAS pilots wouldn't

That means SAS pilots wouldn't

have been able to see the Cessna until just before impact.

What's that?

What's that?

With the heavy fog that morning

it was clear that environmental factor was contributing

it was clear that environmental factor was contributing

cause of the event.

But modern airports like Linate operate safely

But modern airports like Linate operate safely

in low visibility every day.

Planes can avoid each other at night,

so why should it be any different in fog?

What went wrong the morning of the accident?

What went wrong the morning of the accident?

We have to consider this right off the bat.

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

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

Pilot error.

...the possibility of a pilot error.

One of the pilots was not

One of the pilots was not

where he was supposed to be.

The question is, which one?

Investigators turn to control tower recordings for answers.

Investigators turn to control tower recordings for answers.

We have to listen to the facts.

Our expectation was that the ATC recording

would reveal what actually was being said that morning.

would reveal what actually was being said that morning.

They pay close attention to ground controller

Paolo Zacchetti's conversations with the Cessna,

call sign Delta Victor X-ray.

call sign Delta Victor X-ray.

Delta Victor X-ray, taxi north via Romeo 5.

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

Roger.

Via Romeo 5, call you back before reaching main runway.

Via Romeo 5, call you back before reaching main runway.

Zacchetti instructed the Cessna to go north

from the apron along taxiway Romeo 5

from the apron along taxiway Romeo 5

to a taxiway that runs parallel to Runway 36R.

The route should have kept the Cessna off the runway.

But he ended up here instead.

But he ended up here instead.

Investigators make a shocking discovery.

The Cessna didn't follow the taxiway Romeo 5

The Cessna didn't follow the taxiway Romeo 5

for which it had been authorized but took

instead taxiway Romeo 6.

instead taxiway Romeo 6.

It seems that the Cessna

pilots made the fatal error that caused the crash.

pilots made the fatal error that caused the crash.

Call you back before reaching

the main runway.

But the revelation raises an important question.

But the revelation raises an important question.

So why didn't anyone notice?

It's ground controls job

It's ground controls job

to monitor the movement of all aircraft across the airport.

That morning, it was Paolo Zacchetti's responsibility.

That morning, it was Paolo Zacchetti's responsibility.

Delta Victor X-ray, continue your taxi on the main apron.

Roger.

Roger.

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

That is correct.

And please call me back entering the main taxiway.

And please call me back entering the main taxiway.

Main apron, main taxiway?

But Linate airport has several aprons and taxiways,

But Linate airport has several aprons and taxiways,

none of them designated as main.

none of them designated as main.

Investigators now want to know how Zacchetti

lost track of the Cessna.

lost track of the Cessna.

Air traffic control recordings reveal that Paolo Zacchetti

failed to clearly differentiate aprons from taxiways

failed to clearly differentiate aprons from taxiways

when giving directions to the Cessna

that collided with an MD-87.

that collided with an MD-87.

Please call me back entering the main taxiway.

The communication with the tower and the pilots

The communication with the tower and the pilots

that morning of the accident was inconsistent.

It used the word main for different things...

It used the word main for different things...

main runway, main apron, main taxiway.

The controllers choice of words

may have led the Cessna pilots to believe

may have led the Cessna pilots to believe

they were on the correct route.

So that it was a communication below acceptable standard.

So that it was a communication below acceptable standard.

Play that again.

Investigators also hear a transmission

from the Cessna...

Approaching Sierra 4.

Approaching Sierra 4.

...that puzzles them further.

I don't see it anywhere.

I don't see it anywhere.

It's not here.

Listening to the communications,

I was baffled when I heard pilot reporting a Sierra 4.

I was baffled when I heard pilot reporting a Sierra 4.

The controller's maps don't show S4 at all.

The controller's maps don't show S4 at all.

Investigators are beginning to suspect the error goes

beyond the poor communications between Zacchetti

beyond the poor communications between Zacchetti

and the Cessna's pilot.

I asked him if he knew where Sierra 4 was.

I asked him if he knew where Sierra 4 was.

What is Sierra 4?

What is Sierra 4?

I have no idea.

That was very simple.

He confessed he didn't know where Sierra 4 was.

He confessed he didn't know where Sierra 4 was.

Pica learns that Zacchetti's managers

never gave him a tour of the taxiways

as part of his training.

as part of his training.

Approaching Sierra 4.

Delta Victor X-ray, roger.

Maintain the stop bar.

Maintain the stop bar.

I'll call you back.

Had he received proper training,

Zacchetti would have realized the Cessna wasn't on

Zacchetti would have realized the Cessna wasn't on

taxiway Romeo 5 as instructed.

Instead, it was on Romeo 6 and about to cross

Instead, it was on Romeo 6 and about to cross

the active runway.

Air traffic controller didn't stop the Cessna.

Air traffic controller didn't stop the Cessna.

Delta Victor X-ray.

And at that moment, the tower

clears the MD-87 for takeoff.

clears the MD-87 for takeoff.

Scandinavian 686 Linate cleared for takeoff.

Delta Victor X-ray,

continue your taxi on the main apron.

continue your taxi on the main apron.

He should have stopped the Cessna.

But unfortunately...

Roger, continue to taxi on main apron.

Roger, continue to taxi on main apron.

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

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

It's a fatal series of errors.

And we are rolling, Scandinavian 686.

And we are rolling, Scandinavian 686.

Just as the MD-87 reaches

a speed of 145 knots, or 160mph, the Cessna crosses the runway.

a speed of 145 knots, or 160mph, the Cessna crosses the runway.

Come on, come on.

Come on.

Investigators now have a picture of the events

leading up to the disaster.

leading up to the disaster.

But they still wonder, why didn't taxiway direction signs

But they still wonder, why didn't taxiway direction signs

alert the Cessna pilots that they were

heading in the wrong direction?

heading in the wrong direction?

The team looks at guidance signs at Linate airport

that are supposed to help guide the pilots.

that are supposed to help guide the pilots.

The status of those markings

were in very poor condition.

It was surrounded by high grass, and there was only a very few

It was surrounded by high grass, and there was only a very few

of those markings.

The markings painted directly onto the tarmac

The markings painted directly onto the tarmac

are also vital for pilots.

When we came to the intersection between Romeo 5

When we came to the intersection between Romeo 5

and Romeo 6, we could see that the markings on the ground

and Romeo 6, we could see that the markings on the ground

were so badly painted that even in good visibility

were so badly painted that even in good visibility

it was difficult to read them.

The faded markings helped

to explain why the Cessna turned right

to explain why the Cessna turned right

when, to avoid the runway, it should have turned left.

But investigators know Linate airport

But investigators know Linate airport

should have yet another tool to prevent this kind of disaster...

ground radar that can detect the movement

ground radar that can detect the movement

of all aircraft and vehicles on the surface of an airport.

of all aircraft and vehicles on the surface of an airport.

Delta Victor X-ray, confirm your position.

But when the team talks to controllers...

No, there is no ground radar in Linate.

No, there is no ground radar in Linate.

We have not had it in years.

...they discover another deficiency at Linate.

...they discover another deficiency at Linate.

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

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

The new one was in boxes.

It had been there for years and not yet installed.

Why?

I don't know.

I don't know.

Everything which could go wrong

Everything which could go wrong

did go wrong at that airport.

In the aftermath, Linate

In the aftermath, Linate

underwent a major overhaul to improve safety.

GROUND CONTROLLER (ON RADIO): Alitalia 212,

GROUND CONTROLLER (ON RADIO): Alitalia 212,

hold your position.

You are crossing an active runway.

Repeat, hold your position, Alitalia 212.

Repeat, hold your position, Alitalia 212.

Oh god, oh god!

Changes brought in after three catastrophic runway

Changes brought in after three catastrophic runway

collisions...

What the hell!

...have made the chance of a runway disaster

...have made the chance of a runway disaster

far less likely.

What's that?

Right now, air traffic controllers

have a tremendous amount of resources

available to them versus what they did even 10, 20 years ago.

available to them versus what they did even 10, 20 years ago.

And I think the safety record that we have in the industry

shows their abilities.

shows their abilities.

The air traffic control world has

grown so much, for the better.