Very foggy at Milan's Lenate Airport and the controllers in the tower are very busy and hampered by the fact that they can't see the runways. A big Swissair Boeing rolls down for a takeoff and at the last minute creams a four-passenger Cessna who has made what's called a runway incursion. It takes almost half an hour to organize the emergency responders because at first no one realizes an accident has taken place.
Air crash investigators arrive quickly, to be joined by experts from Swissair, but they're held up because in Italy each aircraft accident is initially treated as a crime. The local police are in charge and know little about the kinds of data investigators need. That's the arrangement in Japan too and in the U. S. military. If a crime is committed on an American military base, the MPs are called in first to examine the scene and they know not what they do. In the case of Jeffrey MacDonald, the ex green beret who murdered his wife and children in Fort Bragg, North Carolina, the MPs walked heedlessly about the scene, stepping on bloody footprints, rearranging the furniture that had been upset during the crime, and someone found MacDonald's wallet and stole the bills from it. At Milan, the police carelessly jumbled all the wreckage together and piled it on an empty concrete slab. All this leaves the team of investigators "unhappy" as one of them puts it.
The air traffic controller was found to have used ambiguous terms in giving directions to the two aircraft, referring for example to "the main runway" when no runway was so named. The ATC also ignored curious transmissions from the Cessna -- "Approaching Sierra Five." The ATC had never heard of it because he'd never been given a tour of the runways. And it develops that the airport has routinely had such close calls -- one less than 24 hours earlier, when the pilots were able to see one another and avoid a collision. Transmissions with the tower indicate that the Swissair flight had followed directions and acted correctly. If it's not pilot error or some other obvious source of error, might it be something about Linate Airport itself? The team walks the entire route of the Cessna, putting themselves in the pilot's shoes, looking for location signs or other clues. They found few location marking and the ones they found were ill attended, with grass obscuring part of the sign. When they reach the point at which the Cessna made the wrong turn, they note that there are location markers painted on the pavement that distinguish between two routes at the intersection, but the paint is so weathered that it's hard to read the markers even in clear daylight.
The Cessna's signal, "Approaching Sierra Four" became clear as well. S/4 was painted on the taxiway but didn't appear on any maps of the airport. There should have been alarms triggered by the Cessna's error but the alarm system had been shut down because it was too often triggered by a car or an animal. Neither did Linate have any ground radar to keep track of the airplanes. The obsolete system had been dismantled years earlier when upgraded replacements arrived but the replacements had never been installed. Without ground radar, the ATC couldn't follow the movements of the Cessna. "Add fog into the mix and disaster was inevitable." The accident is reconstructed in incredible detail, which I won't describe here. It's also found that at least two of the four occupants of the Cessna had smoke in their lungs, meaning that they could have been saved if rescue services had not been delayed for almost half an hour. As it was, they were burned alive. The Ground Controller and several managers were subjected to a criminal trials and received prison sentences. The deficiencies at Linate have been corrected.
And, as usual, the narrative is clear and concise. The reenactments are just enough and the technical details are reduced in complexity so that an ordinary high schooler could grasp them. A nice job.
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