1 00:00:03,103 --> 00:00:06,507 NARRATOR: A Boeing MD-87 cuts through the morning fog. 2 00:00:07,274 --> 00:00:09,676 The accident was inevitable. 3 00:00:10,244 --> 00:00:11,345 They were doomed. 4 00:00:17,417 --> 00:00:19,804 NARRATOR: The plane, carrying 110 people, 5 00:00:19,887 --> 00:00:22,823 erupts in flames at Milan's Linate Airport. 6 00:00:24,224 --> 00:00:26,527 This is the most serious accident 7 00:00:26,660 --> 00:00:27,812 in the history in Italy. 8 00:00:27,895 --> 00:00:30,080 NARRATOR: Incredibly, no one at the airport 9 00:00:30,163 --> 00:00:31,749 has noticed the catastrophe. 10 00:00:31,832 --> 00:00:33,584 TOWER CONTROLLER: Hello. This is Tower. No, nothing. 11 00:00:33,667 --> 00:00:35,702 NARRATOR: Valuable minutes pass. 12 00:00:35,836 --> 00:00:37,104 It was astonishing. 13 00:00:37,237 --> 00:00:41,175 Air traffic control still doesn't know what happened. 14 00:00:41,808 --> 00:00:43,627 NARRATOR: Only when the wounded come looking for help... 15 00:00:43,710 --> 00:00:47,398 PILOT (OVER RADIO): There's a red streak of fire at the end of the runway. 16 00:00:47,481 --> 00:00:49,467 NARRATOR: ...do authorities begin to realize 17 00:00:49,550 --> 00:00:51,852 that something is seriously amiss... 18 00:00:52,686 --> 00:00:54,421 My God! 19 00:00:54,555 --> 00:00:57,379 NARRATOR: ...at one of Europe's busiest airports. 20 00:01:01,361 --> 00:01:02,462 Mayday! Mayday! 21 00:01:23,150 --> 00:01:24,151 {\an8}NARRATOR: Milan. 22 00:01:26,453 --> 00:01:28,155 Fashion capital of Europe 23 00:01:28,288 --> 00:01:30,924 and Italy's economic and financial heart. 24 00:01:32,526 --> 00:01:35,729 Milan is served by three international airports. 25 00:01:36,330 --> 00:01:40,634 Only one, Linate Airport, lies within city limits. 26 00:01:43,370 --> 00:01:45,806 It handles nine million passengers a year 27 00:01:45,939 --> 00:01:48,108 on short flights all across Europe. 28 00:01:49,243 --> 00:01:52,949 AIR TRAFFIC CONTROLLER (OVER RADIO): Alitalia 226, airborne, 05. 29 00:01:53,146 --> 00:01:56,149 {\an8}NARRATOR: On the morning of October 8th, 2001, 30 00:01:56,283 --> 00:01:58,318 {\an8}dense fog shrouds the airport. 31 00:01:58,986 --> 00:02:01,172 CATINO: The fog that day was very bad, 32 00:02:01,255 --> 00:02:05,726 {\an8}and the general visibility was about 50 and 100 meters. 33 00:02:07,227 --> 00:02:08,580 NARRATOR: In the tower, 34 00:02:08,996 --> 00:02:11,031 controllers have a heavy workload. 35 00:02:11,732 --> 00:02:13,584 There are nearly two dozen aircraft 36 00:02:13,667 --> 00:02:16,220 to get off the ground in the next 60 minutes. 37 00:02:16,303 --> 00:02:18,722 AIR TRAFFIC CONTROLLER: Alitalia 2120, buongiorno, start up. 38 00:02:18,805 --> 00:02:22,460 NARRATOR: They handle nearly 500 radio communications every hour. 39 00:02:22,543 --> 00:02:23,761 PILOT (OVER RADIO): Linate, Buongiorno. 40 00:02:23,844 --> 00:02:27,214 Delta, India, Echo, Victor, X-ray. Requesting startup. 41 00:02:27,347 --> 00:02:30,468 Delta, Victor, X-ray. You are clear to start your engines. 42 00:02:30,551 --> 00:02:34,688 Ground, Scandinavian 686, request taxi from 13. 43 00:02:34,821 --> 00:02:37,975 Scandinavian 686, taxi to your holding position, CAT III. 44 00:02:38,058 --> 00:02:41,706 HYLLANDER: Scandinavian 686, taxi to holding position, CAT III. 45 00:02:43,397 --> 00:02:47,501 NARRATOR: One of today's flights is Scandinavian Airlines Flight 686. 46 00:02:48,735 --> 00:02:52,005 {\an8}The Boeing MD-87 is scheduled for a routine flight 47 00:02:52,139 --> 00:02:53,707 to Copenhagen, Denmark. 48 00:02:57,277 --> 00:02:59,479 There are 110 people onboard. 49 00:03:03,483 --> 00:03:05,419 Taxi holding point, CAT III. 50 00:03:06,386 --> 00:03:08,857 NARRATOR: The captain is Joakim Gustafsson. 51 00:03:10,357 --> 00:03:12,887 He has been with SAS for more than a decade. 52 00:03:15,662 --> 00:03:18,604 ZACCHETTI: Scandinavian 686, your position, please. 53 00:03:19,967 --> 00:03:23,770 We still haven't reached the main taxiway. Scandinavian 686. 54 00:03:24,638 --> 00:03:26,991 NARRATOR: First Officer Anders Hyllander 55 00:03:28,775 --> 00:03:31,979 has been flying for the airline for the past four years 56 00:03:32,112 --> 00:03:35,249 and has clocked 2000 hours on the MD-87. 57 00:03:38,218 --> 00:03:42,556 The SAS crew were very highly experienced pilots, 58 00:03:42,689 --> 00:03:46,727 so couldn't ask more for two qualified pilots. 59 00:03:48,328 --> 00:03:51,093 NARRATOR: With thick fog blanketing the airport, 60 00:03:53,033 --> 00:03:55,569 the pilots have almost no visibility. 61 00:03:57,304 --> 00:04:01,441 They must rely entirely on instructions from air traffic controllers 62 00:04:01,575 --> 00:04:03,987 as they navigate their way to the runway. 63 00:04:06,747 --> 00:04:08,432 CATINO: There are a lot of taxiways, 64 00:04:08,515 --> 00:04:11,652 one runway for commercial aviation, 65 00:04:11,785 --> 00:04:15,856 and there are a lot of many different types of airplanes at Linate, 66 00:04:15,989 --> 00:04:18,425 so it's a very busy airport. 67 00:04:21,728 --> 00:04:23,380 NARRATOR: High above the runway, 68 00:04:23,463 --> 00:04:27,287 air traffic controllers normally have a clear view of the airport, 69 00:04:27,401 --> 00:04:28,535 but not today. 70 00:04:30,938 --> 00:04:32,997 ZACCHETTI: Air 1937, where are you? 71 00:04:34,474 --> 00:04:36,886 PILOT (OVER RADIO): Between 18 and Delta. 72 00:04:36,977 --> 00:04:41,330 ZACCHETTI (OVER RADIO): So you're practically in front of the tower, right? 73 00:04:43,317 --> 00:04:47,054 NARRATOR: Paolo Zacchetti is the ground controller 74 00:04:47,187 --> 00:04:50,540 responsible for guiding flights to the start of the runway 75 00:04:50,724 --> 00:04:53,193 where planes take off every two minutes. 76 00:04:54,228 --> 00:04:56,413 ZACCHETTI (OVER RADIO): Taxi north via Romeo Five. 77 00:04:56,496 --> 00:04:58,849 Call me back at the stop bar of the main runway extension. 78 00:04:58,932 --> 00:05:02,436 NARRATOR: With Linate fogbound, he's got his hands full. 79 00:05:04,037 --> 00:05:06,673 Scandinavian 686, your position, please. 80 00:05:07,307 --> 00:05:09,593 GUSTAFSSON: Now we are on the main taxiway. 81 00:05:09,676 --> 00:05:13,313 {\an8}Yes. Now we're entering the main taxiway. Scandinavian 686. 82 00:05:14,014 --> 00:05:15,367 {\an8}NARRATOR: At 8:01 a.m., 83 00:05:16,250 --> 00:05:20,320 Zacchetti hands SAS 686 over to the tower controller 84 00:05:20,888 --> 00:05:22,890 for final takeoff instructions. 85 00:05:23,023 --> 00:05:28,095 Tower, buongiorno. Scandinavian 686, sequence to 36 Right. 86 00:05:28,695 --> 00:05:32,332 Ciao, Scandinavian 686, line up and wait, 36 Right. 87 00:05:32,933 --> 00:05:34,368 Line up and wait, 36. 88 00:05:35,602 --> 00:05:38,602 NARRATOR: The SAS crew must wait behind other planes 89 00:05:38,705 --> 00:05:42,476 taking off from Linate's main runway, 36 Right. 90 00:05:44,711 --> 00:05:47,331 ZACCHETTI (OVER RADIO): Alitalia 226, cleared for takeoff, 36. 91 00:05:47,414 --> 00:05:48,591 Report when rolling. 92 00:05:50,817 --> 00:05:53,887 Low visibility is not a problem in air. 93 00:05:54,021 --> 00:05:55,840 It's a very big problem on the ground 94 00:05:55,923 --> 00:06:00,260 because the pilots depend completely upon the air traffic controller. 95 00:06:00,394 --> 00:06:03,163 Delta, Victor, X-ray. Confirm your position. 96 00:06:03,297 --> 00:06:04,998 PILOT: Approaching Sierra 4. 97 00:06:05,132 --> 00:06:06,166 Roger. 98 00:06:06,300 --> 00:06:08,771 Maintain the stop bar. I'll call you back. 99 00:06:10,204 --> 00:06:11,205 Takeoff data. 100 00:06:12,639 --> 00:06:15,075 57 tons, and it is checked. 101 00:06:17,044 --> 00:06:18,162 Checklist complete. 102 00:06:19,046 --> 00:06:21,198 TOWER CONTROLLER: Scandinavian 686, Linate. 103 00:06:21,281 --> 00:06:23,717 The wind is calm. Report rolling. 104 00:06:23,851 --> 00:06:25,499 When airborne, squawk ident. 105 00:06:26,920 --> 00:06:29,509 NARRATOR: Once the plane ahead has taken off, 106 00:06:30,257 --> 00:06:32,926 Flight 686 begins its takeoff roll 107 00:06:33,060 --> 00:06:36,029 down the airport's 2400-meter-long runway. 108 00:06:36,930 --> 00:06:39,466 And we are rolling. Scandinavian 686. 109 00:06:41,535 --> 00:06:43,241 GUSTAFSSON: Auto-throttle on. 110 00:06:44,771 --> 00:06:46,073 Set thrust. 111 00:06:58,585 --> 00:06:59,586 HYLLANDER: V1. 112 00:07:00,053 --> 00:07:02,039 NARRATOR: At a speed of 140 knots... 113 00:07:02,122 --> 00:07:03,190 HYLLANDER: Rotate. 114 00:07:03,323 --> 00:07:06,441 NARRATOR: ...the pilots lift the plane off the ground. 115 00:07:11,565 --> 00:07:12,977 GUSTAFSSON: What's that? 116 00:07:15,469 --> 00:07:16,470 Come on, come on. 117 00:07:18,105 --> 00:07:19,106 Come on. 118 00:07:19,239 --> 00:07:21,074 (PASSENGERS SCREAMING) 119 00:07:24,144 --> 00:07:25,812 (EXPLOSION) 120 00:07:28,482 --> 00:07:32,085 NARRATOR: Something catastrophic has happened to Flight 686, 121 00:07:32,986 --> 00:07:34,692 but because of the thick fog, 122 00:07:35,055 --> 00:07:37,724 no one in the control tower has any idea. 123 00:07:38,992 --> 00:07:40,377 CATINO: It was astonishing. 124 00:07:40,460 --> 00:07:44,965 It's so close to the tower, and nobody was aware about this. 125 00:07:49,102 --> 00:07:50,750 NARRATOR: Out on the tarmac, 126 00:07:51,004 --> 00:07:53,858 ground workers have heard a series of loud noises. 127 00:07:53,941 --> 00:07:56,510 (PHONE RINGING) 128 00:07:58,178 --> 00:07:59,497 TOWER CONTROLLER: Hello. This is Tower. 129 00:07:59,580 --> 00:08:02,051 We heard a number of bangs like an engine. 130 00:08:02,282 --> 00:08:04,988 We heard it too, but we don't know what it was. 131 00:08:05,719 --> 00:08:08,602 Seemed, uh, as if somebody was climbing the steps. 132 00:08:09,256 --> 00:08:11,198 You don't have anything abnormal? 133 00:08:16,663 --> 00:08:20,017 NARRATOR: A passenger jet has been in flames for nearly a minute 134 00:08:20,100 --> 00:08:22,218 at one of Europe's busiest airports, 135 00:08:22,970 --> 00:08:25,372 but so far no one knows. 136 00:08:26,874 --> 00:08:27,975 No, nothing. 137 00:08:29,409 --> 00:08:31,211 This was incredible to believe 138 00:08:31,345 --> 00:08:33,680 that this big accident happened, 139 00:08:33,814 --> 00:08:39,853 and nobody, uh, could see what was happening in that moment. 140 00:08:43,056 --> 00:08:45,476 NARRATOR: The crash site goes undiscovered 141 00:08:45,559 --> 00:08:48,862 until a customs officer spots an injured baggage handler 142 00:08:48,996 --> 00:08:50,644 stumbling from the wreckage. 143 00:08:50,764 --> 00:08:52,941 CATINO: It took a while to figure out 144 00:08:53,066 --> 00:08:57,070 that, uh, they had a big disaster on their hands. 145 00:08:59,540 --> 00:09:02,129 NARRATOR: The officer alerts emergency crews, 146 00:09:05,746 --> 00:09:09,335 but the controllers still don't know there's been an accident. 147 00:09:12,286 --> 00:09:15,222 Incredibly, Linate air traffic control 148 00:09:15,355 --> 00:09:18,325 still doesn't know what happened. 149 00:09:19,526 --> 00:09:22,012 NARRATOR: Only now does the tower controller check 150 00:09:22,095 --> 00:09:24,331 for the SAS flight on his radar. 151 00:09:24,464 --> 00:09:25,732 He can't find it. 152 00:09:26,934 --> 00:09:31,104 The radar does not show the plane flying away from Linate. 153 00:09:32,105 --> 00:09:35,192 NARRATOR: Then, they get a radio call from another plane. 154 00:09:35,275 --> 00:09:39,570 PILOT (OVER RADIO): There's a red streak of fire at the end of the runway. 155 00:09:40,147 --> 00:09:42,867 NARRATOR: Finally, almost three minutes after the accident, 156 00:09:42,950 --> 00:09:46,553 Linate air traffic control raises the general alarm. 157 00:09:46,687 --> 00:09:49,189 (ALARM BLARING) 158 00:09:49,790 --> 00:09:54,143 They ground all departing planes and close the airport to incoming traffic. 159 00:09:59,566 --> 00:10:02,369 Scandinavian Airlines Flight 686 160 00:10:02,503 --> 00:10:04,905 has crashed and exploded on takeoff, 161 00:10:06,807 --> 00:10:10,477 but no one yet knows the true scope of this disaster. 162 00:10:19,019 --> 00:10:22,256 NARRATOR: Ten tons of jet fuel feed a massive fire 163 00:10:22,389 --> 00:10:26,059 where a Boeing MD-87 has collided with an airport building. 164 00:10:31,832 --> 00:10:34,568 Awful, terrible devastation. 165 00:10:34,701 --> 00:10:37,938 {\an8}The collapse of a roof of the hangar 166 00:10:38,071 --> 00:10:42,676 {\an8}and the SAS airplane completely destroyed in many different parts 167 00:10:43,076 --> 00:10:45,846 and, unfortunately, the dead bodies. 168 00:10:50,184 --> 00:10:54,288 The rescue people had problems to enter the cargo building 169 00:10:54,421 --> 00:10:56,990 to rescue, uh, victims 170 00:10:57,124 --> 00:11:00,327 because the airplane was blocking the entrance. 171 00:11:12,873 --> 00:11:16,443 NARRATOR: Some 14 minutes have passed since the crash. 172 00:11:16,577 --> 00:11:18,712 As emergency crews battle the fire, 173 00:11:19,213 --> 00:11:20,978 Linate air traffic controllers 174 00:11:21,081 --> 00:11:23,905 frantically try to understand what just happened. 175 00:11:26,153 --> 00:11:28,455 There are two aircraft unaccounted for. 176 00:11:30,991 --> 00:11:34,512 NARRATOR: Paolo Zacchetti discovers a private Cessna Citation 177 00:11:34,595 --> 00:11:38,654 did not return to its parking position after all planes were grounded. 178 00:11:39,800 --> 00:11:44,204 The main attention was focused on the SAS airplane 179 00:11:44,338 --> 00:11:47,975 so nobody thought that there was another airplane. 180 00:11:49,076 --> 00:11:51,645 A private aircraft is missing, a Cessna 525. 181 00:11:53,347 --> 00:11:56,347 NARRATOR: Ground crews search for the missing plane. 182 00:11:59,953 --> 00:12:03,056 Finally, 26 minutes after the crash, 183 00:12:03,190 --> 00:12:06,093 they find the Cessna burning and in pieces 184 00:12:06,226 --> 00:12:08,529 halfway down runway 36R. 185 00:12:10,197 --> 00:12:12,315 It appears there's been a collision. 186 00:12:12,466 --> 00:12:15,435 It's hard to believe that after half an hour, 187 00:12:15,569 --> 00:12:18,338 people became aware about the fact 188 00:12:18,472 --> 00:12:23,177 that the Cessna was, uh, on the main runway. 189 00:12:24,378 --> 00:12:27,673 There is another aircraft in the accident near Romeo Six. 190 00:12:28,282 --> 00:12:31,047 {\an8}NARRATOR: Air traffic controllers are mystified. 191 00:12:31,151 --> 00:12:35,689 How did these two planes end up on the same runway at the same time? 192 00:12:37,157 --> 00:12:38,569 GUSTAFSSON: What's that? 193 00:12:39,826 --> 00:12:40,827 Come on. 194 00:12:46,366 --> 00:12:49,903 NARRATOR: Two planes are destroyed. A hangar is in ruins. 195 00:12:50,037 --> 00:12:52,449 The scope of the tragedy is overwhelming. 196 00:12:56,743 --> 00:13:00,347 It's soon clear that no one from either plane has survived. 197 00:13:03,750 --> 00:13:07,788 The crash has killed 110 people on the SAS flight... 198 00:13:11,024 --> 00:13:13,160 and four onboard the Cessna. 199 00:13:14,995 --> 00:13:18,632 Inside the collapsed hangar, four more people have died. 200 00:13:19,233 --> 00:13:21,935 118 fatalities in all. 201 00:13:27,107 --> 00:13:30,777 This is the most serious accident in the history in Italy. 202 00:13:33,580 --> 00:13:36,450 You can't imagine. I haven't taken it all in. 203 00:13:37,351 --> 00:13:40,521 I heard three explosions, boom, boom, boom. 204 00:13:40,654 --> 00:13:42,654 And then a huge flame, a long one. 205 00:13:43,223 --> 00:13:46,527 First, there was a crash, 206 00:13:46,660 --> 00:13:48,746 then this hot air that was inside... 207 00:13:48,829 --> 00:13:51,398 this extremely hot air that burned my head. 208 00:13:56,103 --> 00:13:57,604 My God! 209 00:13:58,505 --> 00:14:01,742 NARRATOR: Mario Pica is the lead investigator 210 00:14:01,875 --> 00:14:05,812 for Italy's National Agency for Flight Safety, the ANSV, 211 00:14:05,946 --> 00:14:08,265 but he's not in command of the crash site. 212 00:14:08,348 --> 00:14:12,172 {\an8}It took me a few hours to get access to the scene of the accident. 213 00:14:12,319 --> 00:14:16,040 NARRATOR: Unlike most countries, Italy treats aviation accidents as crimes. 214 00:14:16,123 --> 00:14:18,358 The police get priority at the scene. 215 00:14:19,126 --> 00:14:21,128 After an air crash in Italy, 216 00:14:21,261 --> 00:14:24,698 the criminal investigation automatically begins, 217 00:14:25,232 --> 00:14:30,571 and the police is involved in analyzing this event. 218 00:14:30,704 --> 00:14:32,822 NARRATOR: Pica has a different goal. 219 00:14:33,207 --> 00:14:36,610 PICA: It was mandatory to find out really what happened 220 00:14:37,177 --> 00:14:41,181 and find the reasons that could help us to avoid it happening again. 221 00:14:41,949 --> 00:14:43,016 Grazie. 222 00:14:43,150 --> 00:14:46,920 First thing I remember was to have a look at the baggage hangar 223 00:14:47,054 --> 00:14:49,456 where the rescue workers were still busy 224 00:14:49,590 --> 00:14:52,492 taking out pieces of rubble of the aircraft 225 00:14:52,626 --> 00:14:56,029 and looking for bodies and possibly survivors. 226 00:15:03,237 --> 00:15:05,973 I decided to go and have a look at the Cessna 227 00:15:06,106 --> 00:15:07,941 that was still on the runway. 228 00:15:10,143 --> 00:15:13,914 I just sketched the first map of the position 229 00:15:14,548 --> 00:15:16,783 of the various pieces of the debris 230 00:15:16,917 --> 00:15:19,786 to reconstruct the dynamics of impact. 231 00:15:20,621 --> 00:15:26,326 And there were intermingled pieces from the Cessna and pieces from the MD-87. 232 00:15:27,461 --> 00:15:29,932 NARRATOR: As lead investigator and a pilot, 233 00:15:30,397 --> 00:15:33,717 Pica knows the most valuable information in any air disaster 234 00:15:33,800 --> 00:15:35,435 comes from the black boxes. 235 00:15:36,136 --> 00:15:39,423 But the Cessna was not equipped with either a cockpit voice recorder 236 00:15:39,506 --> 00:15:41,375 or a flight data recorder. 237 00:15:42,075 --> 00:15:46,380 PICA: The absence of the flight recorders were really a drawback 238 00:15:46,513 --> 00:15:49,883 'cause they are very helpful in any investigation 239 00:15:50,017 --> 00:15:52,819 to precisely define what happened. 240 00:15:57,057 --> 00:15:59,243 NARRATOR: The Swedish Accident Investigation Board 241 00:15:59,326 --> 00:16:01,328 sends a team to Milan. 242 00:16:01,461 --> 00:16:04,164 It includes technical specialist Tom Zollner 243 00:16:04,631 --> 00:16:07,868 and lead investigator Frank Kristensen from SAS. 244 00:16:08,902 --> 00:16:12,005 They will work with Pica to unravel the accident. 245 00:16:12,573 --> 00:16:14,725 {\an8}We were called to be part of the investigation 246 00:16:14,808 --> 00:16:17,161 {\an8}as it was a Scandinavian Airlines plane. 247 00:16:18,545 --> 00:16:20,998 {\an8}I guess we'll have to wait for authorization. 248 00:16:21,081 --> 00:16:23,167 {\an8}We realized that the investigation in Italy 249 00:16:23,250 --> 00:16:25,169 {\an8}was different from what we learned. 250 00:16:25,252 --> 00:16:28,072 {\an8}In Italy, they conduct it as a criminal investigation 251 00:16:28,155 --> 00:16:30,450 and we, as investigators, have to wait. 252 00:16:30,991 --> 00:16:32,092 Damn. 253 00:16:32,226 --> 00:16:34,061 We were not happy about that. 254 00:16:34,194 --> 00:16:37,731 We would like to see what the planes look like, 255 00:16:37,865 --> 00:16:40,267 how the accident site looked like. 256 00:16:40,400 --> 00:16:43,704 We were not allowed to be near the accident site. 257 00:16:45,138 --> 00:16:49,710 {\an8}The media worldwide attention was on the Linate disaster. 258 00:16:49,843 --> 00:16:53,297 {\an8}REPORTER: The SAS airliner headed for Copenhagen slammed into the private... 259 00:16:53,380 --> 00:16:55,533 CATINO: And so what happened at Linate? 260 00:16:55,616 --> 00:16:58,485 What were the main causes of this accident? 261 00:16:59,019 --> 00:17:02,055 What were the main responsibilities for this? 262 00:17:02,589 --> 00:17:05,209 NARRATOR: Investigators soon make a troubling discovery 263 00:17:05,292 --> 00:17:06,960 about Linate Airport. 264 00:17:07,094 --> 00:17:11,094 So you're telling me there have been a lot of these incidents before? 265 00:17:12,165 --> 00:17:14,668 Air traffic controllers reported 266 00:17:14,801 --> 00:17:18,972 we have an average of nearly one runway incursion per week. 267 00:17:20,774 --> 00:17:22,993 NARRATOR: It appears the nine million people 268 00:17:23,076 --> 00:17:25,012 who use this airport every year 269 00:17:25,145 --> 00:17:27,414 have been in danger for some time. 270 00:17:30,083 --> 00:17:31,836 ZOLLNER: There had been other runway incursions. 271 00:17:31,919 --> 00:17:33,287 This was shocking. 272 00:17:35,622 --> 00:17:37,908 NARRATOR: Less than a month before the collision, 273 00:17:37,991 --> 00:17:40,227 a near miss on the same runway. 274 00:17:42,996 --> 00:17:45,182 {\an8}PICA: With an aircraft entering the runway 275 00:17:45,265 --> 00:17:47,801 while another aircraft was taking off. 276 00:17:50,404 --> 00:17:52,506 It was really a big shock for us 277 00:17:52,639 --> 00:17:55,375 that it happened that often at Linate Airport. 278 00:17:56,043 --> 00:17:59,102 NARRATOR: Clearly, something is very wrong at Linate. 279 00:17:59,513 --> 00:18:01,098 The morning after the crash, 280 00:18:01,181 --> 00:18:04,384 investigators face national and international pressure 281 00:18:04,518 --> 00:18:05,989 to figure out what it is. 282 00:18:06,620 --> 00:18:09,340 REPORTER: Meanwhile, there were prayers for victims of the crash, 283 00:18:09,423 --> 00:18:12,626 Italy's worst ever civil aviation disaster. 284 00:18:14,561 --> 00:18:17,181 NARRATOR: Finally, the entire investigative team 285 00:18:17,264 --> 00:18:19,366 is given access to the crash site. 286 00:18:19,499 --> 00:18:21,652 KRISTENSEN: All of us were trained investigators, 287 00:18:21,735 --> 00:18:24,605 and we knew what we were going to investigate 288 00:18:24,738 --> 00:18:25,973 and how to do it. 289 00:18:27,207 --> 00:18:31,061 NARRATOR: But authorities have thrown a major obstacle in their path. 290 00:18:31,144 --> 00:18:32,363 So where's the plane? 291 00:18:32,446 --> 00:18:34,765 NARRATOR: The police have ordered airport workers 292 00:18:34,848 --> 00:18:38,731 to move the debris off the runway and away from the baggage hangar. 293 00:18:39,119 --> 00:18:40,254 We got very angry. 294 00:18:41,021 --> 00:18:45,080 The removal of the debris actually removed a lot of valid information, 295 00:18:45,692 --> 00:18:47,661 which we now never could see. 296 00:18:50,030 --> 00:18:51,515 NARRATOR: Debris from both planes 297 00:18:51,598 --> 00:18:54,368 has been piled on a concrete helicopter pad. 298 00:18:55,068 --> 00:19:00,073 Locating Flight 686's voice recorder will be a huge challenge. 299 00:19:01,542 --> 00:19:04,678 We couldn't find the cockpit voice recorder. 300 00:19:09,750 --> 00:19:12,002 ZOLLNER: The importance to find the CVR 301 00:19:12,085 --> 00:19:14,254 was to check if the crew realized 302 00:19:14,388 --> 00:19:16,841 the collision was actually going to take place 303 00:19:16,924 --> 00:19:19,748 and to see how well they were trying to avoid it. 304 00:19:20,427 --> 00:19:24,310 KRISTENSEN: We can't know what the crew were doing without the CVR. 305 00:19:25,599 --> 00:19:29,803 We had to learn about the possible takeoff clearance 306 00:19:29,937 --> 00:19:32,239 and, uh, if there were crew errors. 307 00:19:33,440 --> 00:19:36,382 Did they receive takeoff clearance or did they not? 308 00:19:36,844 --> 00:19:38,745 Here's what we know so far. 309 00:19:39,880 --> 00:19:41,114 The MD-87. 310 00:19:41,648 --> 00:19:46,053 Measuring the distance, we are certain that the MD-87 311 00:19:46,186 --> 00:19:48,589 had traveled for about 40 seconds 312 00:19:48,722 --> 00:19:52,025 and gone 1500 meters before striking the Cessna. 313 00:19:55,562 --> 00:20:00,300 {\an8}It was clear that the collision had occurred on the main runway 314 00:20:00,434 --> 00:20:02,469 at the interception from taxiway. 315 00:20:02,603 --> 00:20:07,841 {\an8}The MD-87 had continued its run, deviating slightly to the right, 316 00:20:07,975 --> 00:20:10,377 until hitting the baggage hangar. 317 00:20:11,211 --> 00:20:12,246 Here. 318 00:20:14,214 --> 00:20:16,200 NARRATOR: Weather reports show that visibility 319 00:20:16,283 --> 00:20:19,048 was only 50 meters at the time of the collision. 320 00:20:21,788 --> 00:20:24,024 PICA: With the heavy fog that morning, 321 00:20:24,124 --> 00:20:27,094 it was clear that environmental factor 322 00:20:27,227 --> 00:20:30,964 was a contributing cause of the event. 323 00:20:33,567 --> 00:20:35,636 HYLLANDER: V1. Rotate. 324 00:20:38,739 --> 00:20:43,544 Imagine an aircraft traveling at 72 meters per second. 325 00:20:44,211 --> 00:20:47,976 What reaction time would they have needed to avoid the collision? 326 00:20:48,148 --> 00:20:50,034 NARRATOR: The SAS pilots would not have been able 327 00:20:50,117 --> 00:20:52,019 to see the Cessna on the runway 328 00:20:52,953 --> 00:20:55,422 until a split second before impact. 329 00:20:55,556 --> 00:20:56,557 What's that? 330 00:20:58,192 --> 00:21:01,995 NARRATOR: But fog should not cripple a major airport like Linate. 331 00:21:05,799 --> 00:21:09,505 Modern airports use a system of regulations and safety equipment 332 00:21:09,603 --> 00:21:11,545 when operating in low visibility. 333 00:21:14,508 --> 00:21:16,494 ZOLLNER: Airports avoid incursions 334 00:21:16,577 --> 00:21:20,280 by having defined low-visibility operating rules. 335 00:21:21,048 --> 00:21:23,434 These rules can be augmented by technology, 336 00:21:23,517 --> 00:21:26,223 ground radars, alarm systems, and other things. 337 00:21:28,055 --> 00:21:30,141 NARRATOR: Airport runways and taxiways 338 00:21:30,224 --> 00:21:32,409 are broken down into a series of checkpoints 339 00:21:32,492 --> 00:21:34,161 known as stop bars. 340 00:21:35,462 --> 00:21:39,099 Aircraft must always wait for authorization before passing, 341 00:21:39,967 --> 00:21:42,262 like a car must wait for a green light. 342 00:21:43,070 --> 00:21:46,129 The system is designed to keep planes from colliding. 343 00:21:48,909 --> 00:21:50,895 KRISTENSEN: Planes can avoid each other at night. 344 00:21:50,978 --> 00:21:53,390 So why should it be any different in fog? 345 00:22:00,521 --> 00:22:02,992 We have to consider this right off the bat. 346 00:22:03,490 --> 00:22:06,343 One of the first thoughts that came to mind was... 347 00:22:06,426 --> 00:22:07,494 Pilot error. 348 00:22:07,628 --> 00:22:09,746 ...the possibility of a pilot error. 349 00:22:10,831 --> 00:22:14,351 NARRATOR: One of the pilots was not where he was supposed to be. 350 00:22:14,434 --> 00:22:17,004 Investigators need to know which one. 351 00:22:21,608 --> 00:22:23,561 NARRATOR: The worst air disaster in history 352 00:22:23,644 --> 00:22:26,280 occurred under eerily similar conditions. 353 00:22:27,981 --> 00:22:30,951 On the island of Tenerife in 1977, 354 00:22:36,256 --> 00:22:40,394 583 people died when two Boeing 747s 355 00:22:40,527 --> 00:22:43,897 collided on the runway in heavy fog. 356 00:22:44,031 --> 00:22:46,733 In comparison with the Tenerife accident, 357 00:22:46,867 --> 00:22:48,702 they were both in dense fog. 358 00:22:48,836 --> 00:22:51,538 Taxiing on the wrong taxiway was involved. 359 00:22:51,672 --> 00:22:53,574 Communication was also involved, 360 00:22:53,707 --> 00:22:57,878 as the KLM captain thought he heard a takeoff clearance, 361 00:22:58,011 --> 00:22:59,079 but he didn't. 362 00:23:00,614 --> 00:23:01,999 NARRATOR: Investigators wonder 363 00:23:02,082 --> 00:23:05,612 if the Linate disaster is a case of history repeating itself. 364 00:23:07,554 --> 00:23:10,591 They learn that the brand new Cessna Citation jet 365 00:23:10,724 --> 00:23:13,783 had arrived in Milan following a flight from Germany. 366 00:23:15,095 --> 00:23:18,498 The German crew was now taking two passengers to Paris. 367 00:23:21,568 --> 00:23:24,955 Since the Cessna was not equipped with a cockpit voice recorder 368 00:23:25,038 --> 00:23:29,243 and the CVR from SAS Flight 686 has not yet been found, 369 00:23:30,043 --> 00:23:33,347 investigators have only one record of what happened, 370 00:23:33,480 --> 00:23:35,549 the air traffic control recordings. 371 00:23:37,084 --> 00:23:38,803 ZOLLNER: We had to listen to the facts. 372 00:23:38,886 --> 00:23:42,689 Our expectation was that the ATC recording would reveal 373 00:23:42,823 --> 00:23:45,294 what actually was being said that morning. 374 00:23:48,829 --> 00:23:50,714 NARRATOR: Investigators pay close attention 375 00:23:50,797 --> 00:23:53,767 to Paolo Zacchetti's conversations with the Cessna, 376 00:23:53,901 --> 00:23:56,036 call sign Delta, Victor, X-ray. 377 00:23:57,204 --> 00:24:00,616 ZACCHETTI: Delta, Victor, X-ray. Taxi north via Romeo Five. 378 00:24:00,741 --> 00:24:03,194 Call me back at the stop bar of the main runway extension. 379 00:24:03,277 --> 00:24:04,929 PILOT: Roger. Via Romeo Five. 380 00:24:05,012 --> 00:24:07,483 Call you back before reaching main runway. 381 00:24:07,814 --> 00:24:11,001 NARRATOR: The Cessna was instructed to go north from the apron, 382 00:24:11,084 --> 00:24:13,187 along taxiway Romeo Five, 383 00:24:13,887 --> 00:24:17,591 to a taxiway that runs parallel to runway 36R. 384 00:24:18,292 --> 00:24:21,351 The route should have kept the Cessna off the runway. 385 00:24:22,696 --> 00:24:25,032 PICA: But he ended up here instead. 386 00:24:26,500 --> 00:24:29,220 NARRATOR: Investigators make a shocking discovery. 387 00:24:29,303 --> 00:24:33,273 The Cessna went south from the apron, not north as instructed. 388 00:24:33,774 --> 00:24:38,312 It now appears the pilots made the fatal error that caused the accident. 389 00:24:41,315 --> 00:24:44,139 PILOT: Call you back before reaching main runway. 390 00:24:45,285 --> 00:24:48,272 NARRATOR: The control tower recording makes it clear. 391 00:24:48,355 --> 00:24:51,425 The Cessna pilots got lost on the way to the runway. 392 00:24:53,727 --> 00:24:56,864 {\an8}The Cessna didn't follow the taxiway Romeo Five, 393 00:24:56,997 --> 00:24:59,600 {\an8}which had been authorized, 394 00:24:59,733 --> 00:25:02,469 but took, instead, taxiway Romeo Six. 395 00:25:03,804 --> 00:25:07,040 {\an8}NARRATOR: The revelation leads to an important question. 396 00:25:07,941 --> 00:25:10,611 So why didn't anyone notice, hmm? 397 00:25:12,246 --> 00:25:15,541 Delta, Victor, X-ray. Continue to taxi on the main apron. 398 00:25:15,849 --> 00:25:19,720 Roger. Continue to taxi on main apron. Delta, Victor, X-ray. 399 00:25:19,853 --> 00:25:23,607 That is correct and please call me back entering the main taxiway. 400 00:25:23,690 --> 00:25:25,893 PICA: Main apron? Main taxiway? 401 00:25:28,662 --> 00:25:29,747 NARRATOR: The recording reveals 402 00:25:29,830 --> 00:25:32,950 that the air traffic controller did not clearly distinguish 403 00:25:33,033 --> 00:25:35,102 {\an8}between aprons and taxiways. 404 00:25:35,936 --> 00:25:38,756 {\an8}His choice of words may have led the Cessna pilots 405 00:25:38,839 --> 00:25:41,310 to believe they were headed the right way. 406 00:25:44,511 --> 00:25:48,666 {\an8}NARRATOR: An apron is a restricted section of an airport where planes park, 407 00:25:48,749 --> 00:25:50,784 are loaded or refueled. 408 00:25:51,351 --> 00:25:54,488 Taxiways are roads from the apron to the runway. 409 00:25:55,055 --> 00:25:57,007 ZOLLNER: The communication with the tower and the pilots 410 00:25:57,090 --> 00:26:00,327 {\an8}that morning of the accident was inconsistent. 411 00:26:00,460 --> 00:26:02,813 They used the word "main" for different things, 412 00:26:02,896 --> 00:26:05,766 main runway, main apron, main taxiway. 413 00:26:06,867 --> 00:26:10,397 ZACCHETTI: And please call me back entering the main taxiway. 414 00:26:12,539 --> 00:26:16,109 NARRATOR: But Linate Airport has several aprons and taxiways, 415 00:26:17,544 --> 00:26:19,513 none of them designated as main. 416 00:26:20,347 --> 00:26:23,534 ZOLLNER: That was a communication below acceptable standards. 417 00:26:23,617 --> 00:26:24,651 Play that again. 418 00:26:24,785 --> 00:26:28,672 NARRATOR: Investigators also hear a puzzling transmission from the Cessna. 419 00:26:28,755 --> 00:26:30,624 PILOT: Approaching Sierra Four. 420 00:26:33,060 --> 00:26:35,178 KRISTENSEN: I don't see it anywhere. 421 00:26:36,563 --> 00:26:37,598 It's not here. 422 00:26:37,731 --> 00:26:39,416 Listening to the communications, 423 00:26:39,499 --> 00:26:43,604 {\an8}I was baffled when I heard the pilot reporting a Sierra Four. 424 00:26:43,737 --> 00:26:47,541 {\an8}NARRATOR: The controllers' maps don't show S4 at all. 425 00:26:49,943 --> 00:26:53,130 {\an8}Investigators are beginning to suspect the error goes beyond 426 00:26:53,213 --> 00:26:56,508 the poor communications between Zacchetti and the Cessna. 427 00:26:57,885 --> 00:27:00,415 PILOT: Approaching Sierra Four. Sierra Four. 428 00:27:00,921 --> 00:27:04,424 I asked him if he knew where Sierra Four was. 429 00:27:04,892 --> 00:27:06,128 Where is Sierra Four? 430 00:27:07,761 --> 00:27:08,795 I have no idea. 431 00:27:08,929 --> 00:27:10,697 PICA: That was very simple. 432 00:27:10,831 --> 00:27:13,714 He confessed he didn't know where Sierra Four was. 433 00:27:16,136 --> 00:27:18,422 NARRATOR: Pica finds that Zacchetti's managers 434 00:27:18,505 --> 00:27:22,109 never gave him a tour of the taxiways as part of his training. 435 00:27:22,242 --> 00:27:24,066 PILOT: Approaching Sierra Four. 436 00:27:24,344 --> 00:27:26,780 ZACCHETTI: Delta, Victor, X-ray. Roger. 437 00:27:27,381 --> 00:27:29,850 Maintain the stop bar. I'll call you back. 438 00:27:30,551 --> 00:27:33,846 NARRATOR: He had no way of knowing where Sierra Four was. 439 00:27:36,423 --> 00:27:39,927 The Cessna now has to cross the runway to get to the apron. 440 00:27:41,962 --> 00:27:47,267 He keeps going past several signs that he's approaching an active runway. 441 00:27:53,207 --> 00:27:55,855 {\an8}Air traffic controller didn't stop the Cessna. 442 00:27:55,943 --> 00:27:57,194 ZACCHETTI: Delta, Victor, X-ray. 443 00:27:57,277 --> 00:28:01,548 NARRATOR: At that moment, the tower clears the MD-87 for takeoff. 444 00:28:01,682 --> 00:28:05,136 TOWER CONTROLLER: Scandinavian 686, Linate, cleared for takeoff. 445 00:28:05,219 --> 00:28:07,037 Continue your taxi on the main apron. 446 00:28:07,120 --> 00:28:10,457 He should have stopped the Cessna but unfortunately... 447 00:28:10,591 --> 00:28:12,710 Roger. Continue to taxi on main apron. 448 00:28:12,793 --> 00:28:16,230 ...he thought that the Cessna was on R5 taxiway. 449 00:28:18,232 --> 00:28:20,885 NARRATOR: The Cessna pilot makes a fatal mistake. 450 00:28:20,968 --> 00:28:25,572 With the MD-87 now traveling at 260 kilometers an hour, 451 00:28:25,706 --> 00:28:27,841 he taxis across the runway. 452 00:28:35,382 --> 00:28:38,986 Suspicions about procedures at Linate Airport deepen 453 00:28:39,119 --> 00:28:42,039 as investigators learn that the exact same mistakes 454 00:28:42,122 --> 00:28:43,841 that led to the deadly collision 455 00:28:43,924 --> 00:28:47,828 were made by another plane less than 24 hours earlier. 456 00:28:47,961 --> 00:28:50,373 Frank, Frank, come. Come and look at this. 457 00:28:51,298 --> 00:28:54,902 I was shocked to find out that only the previous afternoon... 458 00:28:55,035 --> 00:28:57,704 Same thing, 24 hours before. 459 00:28:57,838 --> 00:29:02,176 ...an aircraft had been cleared by the air traffic controller 460 00:29:02,309 --> 00:29:04,444 to taxi onto Romeo Five. 461 00:29:05,345 --> 00:29:07,131 Twenty-four hours... It happens here all the time. 462 00:29:07,214 --> 00:29:10,350 The aircraft taxied really onto Romeo Six. 463 00:29:11,652 --> 00:29:14,105 NARRATOR: Because there was no fog that day, 464 00:29:14,188 --> 00:29:17,257 the two planes saw each other and did not collide. 465 00:29:21,795 --> 00:29:25,816 Investigators are beginning to suspect that something about the airport, 466 00:29:25,899 --> 00:29:29,903 not bad pilots, may be the cause of the Linate crash 467 00:29:30,037 --> 00:29:32,449 and the frequent runway incursions there. 468 00:29:33,841 --> 00:29:34,875 When we found out 469 00:29:35,008 --> 00:29:39,613 that the Cessna pilot had taken the wrong taxiway, 470 00:29:39,746 --> 00:29:43,917 first question was to explain what did he see 471 00:29:44,051 --> 00:29:46,220 that brought him so much off course. 472 00:29:48,188 --> 00:29:50,858 Okay, this is where they started. 473 00:29:52,860 --> 00:29:55,863 KRISTENSEN: The taxiway we went on was Romeo Six, 474 00:29:55,996 --> 00:30:00,167 {\an8}and we walked the whole length of the taxiway. 475 00:30:01,001 --> 00:30:04,037 We wanted to put ourselves in the shoes of the pilot 476 00:30:04,171 --> 00:30:06,006 to understand his actions. 477 00:30:09,843 --> 00:30:12,630 NARRATOR: They look for route identification signs 478 00:30:12,713 --> 00:30:15,184 that are supposed to help guide the pilots. 479 00:30:18,018 --> 00:30:21,672 KRISTENSEN: The status of those markings were in very poor condition. 480 00:30:21,755 --> 00:30:24,157 It was, uh, surrounded by high grass, 481 00:30:24,291 --> 00:30:27,427 and there was only a very few of those markings. 482 00:30:28,495 --> 00:30:33,260 NARRATOR: The markings painted directly onto the tarmac are also vital for pilots. 483 00:30:35,502 --> 00:30:41,341 PICA: When we came to the intersection between Romeo Five and Romeo Six, 484 00:30:41,875 --> 00:30:44,411 we could see that the markings on the ground 485 00:30:44,545 --> 00:30:46,713 were... so badly painted 486 00:30:46,847 --> 00:30:50,318 that even in good visibility, it was difficult to read them. 487 00:30:52,986 --> 00:30:56,557 Which made us understand 488 00:30:56,690 --> 00:31:00,460 that for a pilot not familiar with the place 489 00:31:00,594 --> 00:31:03,047 it would have been difficult to understand 490 00:31:03,130 --> 00:31:06,300 where was Romeo Five, where was Romeo Six. 491 00:31:07,835 --> 00:31:11,835 NARRATOR: The faded markings help explain why the Cessna turned right 492 00:31:11,939 --> 00:31:14,939 when it should have turned left to avoid the runway. 493 00:31:17,778 --> 00:31:19,263 They also come upon the reason 494 00:31:19,346 --> 00:31:23,650 the Cessna pilot referred to the unknown position, Sierra Four. 495 00:31:24,218 --> 00:31:26,042 PILOT: Approaching Sierra Four. 496 00:31:27,754 --> 00:31:29,456 Uh, there's Sierra Four 497 00:31:30,724 --> 00:31:32,593 but it's not on the map. 498 00:31:32,726 --> 00:31:37,497 Actually, Sierra Four was the marking on the Romeo Six taxiway 499 00:31:37,631 --> 00:31:38,816 going towards the runway, 500 00:31:38,899 --> 00:31:42,503 but was not reported on any official map. 501 00:31:43,070 --> 00:31:45,289 PILOT (OVER RADIO): Approaching Sierra Four. 502 00:31:45,372 --> 00:31:47,941 ZACCHETTI: Delta, Victor, X-ray. Roger. 503 00:31:48,075 --> 00:31:51,328 {\an8}NARRATOR: Had the controller known where Sierra Four was, 504 00:31:51,411 --> 00:31:54,764 he would have realized the Cessna was headed the wrong way 505 00:31:55,816 --> 00:31:57,405 and approaching the runway. 506 00:32:02,656 --> 00:32:06,539 But inadequate markings and maps still don't explain the collision. 507 00:32:09,863 --> 00:32:13,981 Linate, like all modern airports, is equipped with motion sensor alarms 508 00:32:14,935 --> 00:32:17,004 to guard against runway incursion. 509 00:32:18,872 --> 00:32:21,025 Even with the failures of all other systems, 510 00:32:21,108 --> 00:32:25,344 the acoustic alarm should have worked and we wondered why it didn't work. 511 00:32:27,381 --> 00:32:31,018 PICA: Reading the ATC communication recordings, 512 00:32:31,151 --> 00:32:34,788 we couldn't find any alarm going on 513 00:32:34,922 --> 00:32:39,927 when the Cessna aircraft crossed the stop bars and entered the runway. 514 00:32:43,263 --> 00:32:47,205 NARRATOR: Pica decides to test the runway incursion sensors himself. 515 00:32:47,501 --> 00:32:50,321 PICA: I was told that, possibly, they didn't work 516 00:32:50,404 --> 00:32:52,052 but we wanted to be certain. 517 00:32:53,373 --> 00:32:56,410 Okay, commencing test of the motion sensor alarm 518 00:32:56,543 --> 00:32:58,478 on taxiway Romeo Six. 519 00:32:59,379 --> 00:33:02,015 So, one night when the airport was closed, 520 00:33:02,149 --> 00:33:07,087 we made an experiment going over and over through the sensors. 521 00:33:07,654 --> 00:33:09,623 But we had a man on the tower 522 00:33:10,424 --> 00:33:13,894 just to make sure that the alarm didn't go. 523 00:33:16,630 --> 00:33:17,631 Anything? 524 00:33:18,699 --> 00:33:19,900 MAN: No, nothing. 525 00:33:22,336 --> 00:33:23,370 Again. 526 00:33:23,504 --> 00:33:28,942 Eventually, we found out that those alarms had been deactivated years before 527 00:33:29,776 --> 00:33:32,846 to avoid unnecessary alarms 528 00:33:33,347 --> 00:33:36,233 that were triggered eventually by an animal crossing 529 00:33:36,316 --> 00:33:39,653 or a car doing an inspection during the night. 530 00:33:41,455 --> 00:33:43,757 NARRATOR: One week after the accident, 531 00:33:43,891 --> 00:33:47,694 investigators still have not located the cockpit voice recorder 532 00:33:47,828 --> 00:33:49,463 amid the aircraft wreckage. 533 00:33:51,532 --> 00:33:53,767 Finding the CVR was crucial 534 00:33:53,901 --> 00:33:57,704 in order to establish that there was no problems prior to impact. 535 00:34:00,440 --> 00:34:04,811 So I decided to search through this giant pile of rubble... 536 00:34:05,646 --> 00:34:08,315 and concrete and steel, 537 00:34:08,448 --> 00:34:11,051 and eventually, we did find the CVR. 538 00:34:14,988 --> 00:34:18,959 The CVR of the MD-87 was carefully analyzed 539 00:34:19,426 --> 00:34:21,995 to find out what had been said onboard, 540 00:34:22,129 --> 00:34:24,048 what kind of procedures had been done. 541 00:34:24,131 --> 00:34:26,417 TOWER CONTROLLER: Scandinavian 686, Linate. 542 00:34:26,500 --> 00:34:28,402 Cleared for takeoff, 36. 543 00:34:28,535 --> 00:34:29,620 NARRATOR: The recording shows 544 00:34:29,703 --> 00:34:32,706 that the SAS crew did receive the proper clearance 545 00:34:32,840 --> 00:34:35,275 to proceed down runway 36R. 546 00:34:36,143 --> 00:34:37,762 HYLLANDER: Cleared for takeoff, 36, set. 547 00:34:37,845 --> 00:34:41,448 NARRATOR: The SAS crew played no role in causing the accident. 548 00:34:43,150 --> 00:34:45,915 They were the victims of the airport's failings. 549 00:34:47,955 --> 00:34:50,991 The investigation has identified one final factor 550 00:34:51,124 --> 00:34:54,895 that underlines how dangerous conditions at Linate had become. 551 00:34:55,896 --> 00:34:56,930 No. 552 00:34:57,531 --> 00:34:59,590 There is no ground radar at Linate. 553 00:34:59,933 --> 00:35:01,581 We have not had it in years. 554 00:35:02,069 --> 00:35:05,405 The ground radar at Linate, the old one, was dismantled. 555 00:35:05,539 --> 00:35:07,207 The new one was in boxes. 556 00:35:07,341 --> 00:35:10,047 Had been there for years and not yet installed. 557 00:35:10,277 --> 00:35:11,411 Why? I don't know. 558 00:35:12,412 --> 00:35:14,365 NARRATOR: Airport ground radar systems 559 00:35:14,448 --> 00:35:17,417 detect movement of all aircraft and vehicles, 560 00:35:18,285 --> 00:35:21,355 a vital piece of safety equipment at a busy airport. 561 00:35:22,556 --> 00:35:23,874 KRISTENSEN: If you have ground radar, 562 00:35:23,957 --> 00:35:26,977 it's a good tool to establish what's going on in the airport, 563 00:35:27,060 --> 00:35:30,430 even in low visibility conditions. 564 00:35:31,565 --> 00:35:32,900 We can certainly say 565 00:35:33,033 --> 00:35:37,538 {\an8}that if the ground movement control radar had been in place, 566 00:35:37,671 --> 00:35:40,874 {\an8}the ground controller would have had the opportunity 567 00:35:41,008 --> 00:35:44,478 to see the aircraft crossing the stop bars. 568 00:35:45,212 --> 00:35:47,731 And possibly then would have stopped the aircraft 569 00:35:47,814 --> 00:35:49,583 before the collision happened. 570 00:35:49,716 --> 00:35:52,893 ZACCHETTI: Delta, Victor, X-ray. Confirm your position. 571 00:35:54,688 --> 00:35:58,865 NARRATOR: The Cessna took the wrong path due to flawed taxiway markings. 572 00:36:01,828 --> 00:36:02,980 Without ground radar, 573 00:36:03,063 --> 00:36:06,828 controllers couldn't properly monitor the movement of the Cessna. 574 00:36:08,669 --> 00:36:12,439 Add fog into the mix and disaster was inevitable. 575 00:36:13,540 --> 00:36:18,478 When the Cessna and the SAS aircraft started moving, 576 00:36:19,112 --> 00:36:20,447 they were both doomed. 577 00:36:21,682 --> 00:36:24,551 The accident was now inevitable. 578 00:36:25,519 --> 00:36:27,872 TOWER CONTROLLER: Scandinavian 686, Linate. 579 00:36:27,955 --> 00:36:29,456 Cleared for takeoff, 36. 580 00:36:30,457 --> 00:36:33,794 Delta, Victor, X-ray. Continue to taxi on the main apron. 581 00:36:37,331 --> 00:36:39,867 And we are rolling. Scandinavian 686. 582 00:36:40,901 --> 00:36:43,137 Roger. Continue to taxi on main apron. 583 00:36:44,671 --> 00:36:45,706 HYLLANDER: V1. 584 00:36:46,440 --> 00:36:47,474 Rotate. 585 00:36:55,048 --> 00:36:56,083 What's that? 586 00:36:58,719 --> 00:37:02,406 NARRATOR: The cockpit voice recorder gives investigators a detailed picture 587 00:37:02,489 --> 00:37:04,901 of what happened at the moment of impact. 588 00:37:07,060 --> 00:37:08,412 ZOLLNER: Noises in the cockpit 589 00:37:08,495 --> 00:37:11,348 will also tell us the different controls being moved. 590 00:37:11,431 --> 00:37:14,685 And the ambient noise from the area mic would give us information 591 00:37:14,768 --> 00:37:17,638 on some of the sounds during the collision. 592 00:37:19,673 --> 00:37:20,758 GUSTAFSSON (OVER CVR): What's that? 593 00:37:20,841 --> 00:37:22,609 (AIRPLANE CRASHING) 594 00:37:23,310 --> 00:37:27,080 We realized that the impact was more than one collision. 595 00:37:27,214 --> 00:37:30,214 It was actually several collisions in half a second. 596 00:37:31,785 --> 00:37:35,609 NARRATOR: When that half second of audio is analyzed more closely, 597 00:37:35,856 --> 00:37:39,459 investigators discover it contains several distinct sounds. 598 00:37:40,827 --> 00:37:43,297 (AIRPLANE CRASHING) 599 00:37:43,430 --> 00:37:47,668 ZOLLNER: So we exposed this data over a schematic of the aircraft 600 00:37:47,801 --> 00:37:49,803 showing the travel of the sound. 601 00:37:50,771 --> 00:37:52,840 By doing that, we could analyze 602 00:37:52,973 --> 00:37:56,410 that we have several points of impact during the collision. 603 00:37:57,044 --> 00:38:00,498 NARRATOR: The painstaking research gives investigators a better understanding 604 00:38:00,581 --> 00:38:03,517 of how the two planes came together on the runway. 605 00:38:04,318 --> 00:38:07,654 The MD-87 first hit the Cessna 606 00:38:07,788 --> 00:38:11,391 with its nose landing gear at the Cessna's stabilizer. 607 00:38:12,059 --> 00:38:14,228 And then, in short order of time, 608 00:38:14,361 --> 00:38:16,781 the left hand main landing gear of the MD-87 609 00:38:16,864 --> 00:38:20,167 hit the outer part of the right hand wing of the Cessna. 610 00:38:20,300 --> 00:38:22,836 And then the biggest impact 611 00:38:22,970 --> 00:38:26,106 was the right hand main landing gear of the MD-87 612 00:38:26,240 --> 00:38:29,243 cutting through the cabin of the Cessna. 613 00:38:30,744 --> 00:38:35,549 NARRATOR: Investigators conclude the MD-87 lost its right engine after the impact. 614 00:38:38,986 --> 00:38:41,928 The plane would have been almost impossible to fly. 615 00:38:43,590 --> 00:38:48,061 But, remarkably, the pilots almost managed to do just that. 616 00:38:48,729 --> 00:38:50,347 GUSTAFSSON: Come on, come on. 617 00:38:50,430 --> 00:38:55,969 After the collision, the MD-87 actually got into the air. 618 00:38:57,571 --> 00:38:59,256 According to the flight data recorder, 619 00:38:59,339 --> 00:39:01,987 the aircraft was airborne almost nine seconds. 620 00:39:05,946 --> 00:39:09,383 The captain, uh, made a heroic attempt to fly the airplane. 621 00:39:09,516 --> 00:39:11,001 GUSTAFSSON: Come on, come on, come on. 622 00:39:11,084 --> 00:39:14,288 He tried to accelerate the left hand engine and use it, 623 00:39:17,324 --> 00:39:20,627 but it, uh, had ingested too much debris. 624 00:39:23,664 --> 00:39:25,782 And the pilot did an amazing work... 625 00:39:26,967 --> 00:39:28,203 trying to control it. 626 00:39:30,204 --> 00:39:33,574 Up to the last minute, he tried to avoid impact. 627 00:39:33,707 --> 00:39:35,209 (EXPLOSION) 628 00:39:37,044 --> 00:39:40,164 The pilots could not have done anything to avoid this accident 629 00:39:40,247 --> 00:39:42,700 because the aircraft was traveling too fast. 630 00:39:42,783 --> 00:39:46,119 Such a big aircraft cannot respond on a dime. 631 00:39:46,253 --> 00:39:47,421 It's impossible. 632 00:39:47,955 --> 00:39:51,191 I believe that both crew and both airplanes 633 00:39:51,325 --> 00:39:55,495 think they did everything right, right until the moment of impact. 634 00:39:59,766 --> 00:40:00,818 NARRATOR: It's now clear 635 00:40:00,901 --> 00:40:04,037 that a badly flawed control system at Linate Airport 636 00:40:04,438 --> 00:40:06,373 led directly to the crash. 637 00:40:07,274 --> 00:40:11,144 What's more, it's beginning to look like organizational failures 638 00:40:11,278 --> 00:40:15,215 may also have prevented rescue personnel from saving lives. 639 00:40:21,755 --> 00:40:22,789 Grazie. 640 00:40:23,423 --> 00:40:26,593 How long was it before the general alarm was sounded? 641 00:40:27,327 --> 00:40:29,647 NARRATOR: The investigation begins to uncover evidence 642 00:40:29,730 --> 00:40:32,933 {\an8}of how failures at the airport made a bad situation... 643 00:40:34,134 --> 00:40:36,487 Please call me back, entering the main taxiway. 644 00:40:36,570 --> 00:40:37,982 NARRATOR: ...even worse. 645 00:40:38,972 --> 00:40:40,591 TOWER CONTROLLER: Hello, this is Tower. 646 00:40:40,674 --> 00:40:42,126 The wreckage of the Cessna 647 00:40:42,209 --> 00:40:45,512 was found only about 25 minutes after the accident. 648 00:40:46,613 --> 00:40:49,850 And by the time the fire brigade arrived on the scene, 649 00:40:50,450 --> 00:40:52,452 all the occupants were dead. 650 00:40:54,254 --> 00:40:57,541 NARRATOR: Post mortem exams confirm that three people in the Cessna 651 00:40:57,624 --> 00:41:00,661 had high concentrations of smoke in their lungs. 652 00:41:01,195 --> 00:41:04,631 They were still alive after being hit by the MD-87. 653 00:41:06,667 --> 00:41:08,402 They were burned alive. 654 00:41:11,805 --> 00:41:13,023 ZOLLNER: After the collision, 655 00:41:13,106 --> 00:41:15,192 the Cessna burned for more than 20 minutes. 656 00:41:15,275 --> 00:41:19,980 PICA: If the rescue to the Cessna had arrived earlier, 657 00:41:20,113 --> 00:41:23,466 certainly the two pilots would have survived the accident. 658 00:41:27,521 --> 00:41:31,242 NARRATOR: After more than six months of painstaking investigation, 659 00:41:31,325 --> 00:41:33,627 Mario Pica delivers his findings. 660 00:41:37,764 --> 00:41:39,583 Though runway incursion by the Cessna 661 00:41:39,666 --> 00:41:42,636 is listed as the immediate cause of the accident, 662 00:41:42,769 --> 00:41:45,572 Pica does not entirely blame the Cessna pilot. 663 00:41:48,475 --> 00:41:51,195 Instead, he points to the lack of proper signage 664 00:41:51,278 --> 00:41:53,380 and taxiway markings at Linate 665 00:41:54,281 --> 00:41:57,184 as well as to the airport's failings overall. 666 00:42:00,721 --> 00:42:05,659 KRISTENSEN: A fairly simple airport like Linate, with only one main runway, 667 00:42:05,792 --> 00:42:09,830 it should be easy to, uh, to cover this with signs 668 00:42:09,963 --> 00:42:12,533 and with paintings and so forth. 669 00:42:12,666 --> 00:42:16,103 But, apparently, everything which could go wrong 670 00:42:16,236 --> 00:42:18,038 did go wrong at that airport. 671 00:42:19,606 --> 00:42:22,910 Delta, Victor, X-ray. Taxi north via Romeo Five. 672 00:42:23,043 --> 00:42:25,963 Call me back at the stop bar of the main runway extension. 673 00:42:26,046 --> 00:42:27,998 NARRATOR: And for some of the people involved, 674 00:42:28,081 --> 00:42:30,217 the fallout is especially harsh. 675 00:42:31,451 --> 00:42:33,620 Ground controller Paolo Zacchetti, 676 00:42:33,754 --> 00:42:38,225 along with high-ranking officials from the agencies which oversee Linate, 677 00:42:38,358 --> 00:42:40,360 are handed prison sentences. 678 00:42:40,494 --> 00:42:42,996 The judgment sparked intense debate. 679 00:42:43,130 --> 00:42:47,234 Should human error in air accidents be considered a criminal act? 680 00:42:49,169 --> 00:42:55,742 I define the ground controller as the 119th victim of the case. 681 00:42:57,377 --> 00:42:59,112 I didn't have the equipment 682 00:42:59,246 --> 00:43:02,246 that could have made me aware of what was happening. 683 00:43:03,050 --> 00:43:06,345 {\an8}Delta, Victor, X-ray. Continue to taxi on the main apron. 684 00:43:06,687 --> 00:43:08,105 PILOT (OVER RADIO): Roger. 685 00:43:08,188 --> 00:43:11,191 PICA: Yes, it is true, he did make a mistake, 686 00:43:11,325 --> 00:43:16,063 but it is the result of a system that failed. 687 00:43:17,164 --> 00:43:19,106 NARRATOR: Because of the tragedy, 688 00:43:19,967 --> 00:43:22,736 {\an8}Linate Airport underwent a major overhaul 689 00:43:22,870 --> 00:43:24,605 {\an8}designed to improve safety. 690 00:43:27,374 --> 00:43:30,694 ZOLLNER: Linate improved the airport by installing the ground radar. 691 00:43:30,777 --> 00:43:33,580 {\an8}Some of the markings and signage was repainted. 692 00:43:35,883 --> 00:43:39,286 CATINO: The runway incursion alarms are functioning now. 693 00:43:40,053 --> 00:43:41,054 (ALARM BUZZING) 694 00:43:41,188 --> 00:43:42,873 GROUND CONTROLLER: Alitalia 212, hold your position. 695 00:43:42,956 --> 00:43:44,241 You are crossing an active runway. 696 00:43:44,324 --> 00:43:46,793 Repeat, hold your position, Alitalia 212. 697 00:43:48,061 --> 00:43:51,473 The biggest lesson learned in this accident, in my opinion, 698 00:43:51,732 --> 00:43:56,136 is that people are prone to get used to failures. 699 00:43:56,270 --> 00:43:58,329 There is no ground radar at Linate. 700 00:43:58,705 --> 00:44:01,041 Accepting latent conditions, 701 00:44:02,009 --> 00:44:04,428 getting used to a system that doesn't work, 702 00:44:04,511 --> 00:44:07,481 {\an8}and by time, actually getting the whole system 703 00:44:07,614 --> 00:44:09,026 more and more dangerous. 704 00:44:11,518 --> 00:44:14,388 An airport is a highly complicated place. 705 00:44:14,521 --> 00:44:18,225 There's the vehicles, there's the airplanes, 706 00:44:18,358 --> 00:44:20,561 baggage lorries, cargo lorries, 707 00:44:20,694 --> 00:44:24,464 all sorts of activities going around at the same time. 708 00:44:24,598 --> 00:44:28,702 There has to be a very high level of safety in an airport. 709 00:44:30,604 --> 00:44:34,252 {\an8}NARRATOR: The reforms ushered in following the collision on 36R 710 00:44:35,843 --> 00:44:38,545 have made runway incursions far less likely 711 00:44:39,580 --> 00:44:42,549 and made Linate a much safer airport.