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  • 6/20/2025

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00:01When a plane crashes, the shock is profound.
00:10But when two planes are found in the wreckage,
00:14the runway was occupied, and that's something that should never happen.
00:18the extent of the tragedy is multiplied.
00:20It's up to investigators
00:29727's wing sliced right through the fuselage.
00:32to solve multiple mysteries.
00:34Why would he lie?
00:37What's that?
00:41My god.
00:43Three collisions raise the same question.
00:46How did two planes end up on the same runway?
00:49Oh, no.
00:50At the same time?
00:52An airplane to be on an active runway when they shouldn't.
00:56Somebody did something wrong.
00:58E.D. E.D. E.D.
01:03Up!
01:19Detroit Metropolitan Airport.
01:27Watch wow.
01:28In the tower.
01:30Man, I don't think I've ever seen fog this bad.
01:31Controllers are dealing with fog that's blown.
01:34that's blanketed the entire airport it's so thick they can't see the planes
01:39they're guiding
01:41I'm ready to taxi
01:43Northwest 299 Metro ground taxi to runway 3 Center via Oscar 6 Fox and x-ray
01:48the ground controller is directing Northwest flight 299 to the runway it's
01:54a Boeing 727 bound for Memphis with a hundred and forty six passengers on
01:59board only way they could know where the aircraft were on the airport was to
02:04have the pilots give them positions as to where they were Northwest 299 what's
02:09your position now okay we just turned down on to x-ray tonight Roger switch to
02:14tower control 118.4 after reaching the runway threshold control of the 727
02:21passes from the ground controller to the tower controller Northwest 299 Metro
02:27tower runway 3 Center clear for takeoff
02:4180 knots suddenly midway down the runway the 727 encounters the unexpected
02:49a DC-9 with 40 passengers on board in its cockpit oh no there's nothing the
02:58pilots can do to prevent a collision
03:00oh god oh god
03:03the 727's wing has sliced through the DC-9's fuselage
03:18inside the DC-9 there's chaos
03:23firefighters and emergency response teams rush to the scene no one on the 727 is
03:40injured but the same is not true of the DC-9 the aircraft was virtually burned out
03:47the passenger compartment was gutted the pilots of the DC-9 survived the collision but eight of the
03:5444 people on board are killed the DC-9 is identified as another Northwest Airlines plane flight 1482 bound for
04:04Pittsburgh the National Transportation Safety Board launches an investigation into the accident
04:10727's wing sliced right through the fuselage
04:14we obviously knew what happened in a gross sense two aircraft came together and and a tragic event occurred
04:24how did the DC-9 end up in the path of the oncoming 727
04:29investigators immediately suspect the thick fog played a major part in the accident
04:36visibility was three quarters of a mile an hour before the accident but then it drops to a quarter mile
04:41quarter mile is the minimum
04:44did the DC-9 get lost in the fog on the way to the runway
04:49visibility was at least one quarter mile that would allow operations to continue
04:56before the accident every other aircraft that took off had no problem at all finding the end of the
05:03proper runway and departing but our men in the DC-9 didn't do this
05:08why did the DC-9 lose its way when other aircraft didn't
05:15investigators wonder if ground control is at fault I could them to use Oscar six
05:25Foxtrot and x-ray to runway three center the ground controller tells investigators he gave the DC-9's crew
05:33first officer Jim Schiffens and Captain Bill Lovelace specific instructions to get to the runway
05:40north was 1482 taxi to Oscar six to Foxtrot report making the right turn on x-ray
05:45Oscar six to Foxtrot report x-ray
05:48beginning on taxiway Oscar six the aircraft was to take Foxtrot and then x-ray to the start of the runway
05:58north was 1482 what's your position now
06:00but when asked for an update on their progress
06:04the crew's response didn't make sense they announced that they were eastbound on Oscar six
06:22which was an impossibility it's a northwest southeast oriented taxiway okay I think we might have missed
06:29Oscar six see a sign here that says the arrows to Oscar five the folks in the tower realized that the
06:38pilots in the DC-9 were probably becoming a little confused about where they were instead of remaining
06:44straight on Oscar six the aircraft turned left and past taxiway Oscar five I realized they had made a
06:53wrong turn so I gave them directions getting back on track north was 1482 at Oscar four make the right
06:59turn on to x-ray report crossing nine to seven the DC-9 was then directed to continue straight to Oscar
07:05four turn right onto x-ray cross inactive runway nine to seven and then follow x-ray back to the runway for
07:15takeoff roger at Oscar four make the right turn on to x-ray the DC-9 radio back okay I understand or
07:25something to that effect and everybody calmed down and thought that they had straightened everything
07:29out but somehow five minutes later the DC-9 ended up on the active runway somebody did something wrong
07:40investigators need to find out who and why we hoped we would find out why did you miss all this and
07:48wind up on an active runway investigators interview the DC-9's crew starting with Captain Bill Lovelace the
07:56captain was kind of a mild-mannered fellow he loved to fly I wasn't familiar with the layout of the taxiways
08:03and runways he recently returned to flying after a six-year medical leave and was unfamiliar with the
08:09airport in Detroit so I asked my first officer where you been flying out of Memphis and Detroit good
08:21you can help me find my way around these taxiways here in Detroit I sure can first officer who bragged
08:27about his knowledge of the airport that would have enhanced the likelihood that the captain would
08:32have trusted the first officer to help navigate in Detroit I thought great someone in the co-pilot
08:38seated knows where he's going but we still got lost somehow the NTSB next questions first officer Jim
08:48Shiffens a former military pilot who joined Northwest earlier that year he's a little brash perhaps a
08:56little cocky I wouldn't say a know-it-all but he'd been around the horn captain Lovelace misunderstood what
09:05I meant was I knew the procedures for pushing back from the gate not the physical layout of the airport
09:11investigators conclude the first officer whether deliberately or not misled the captain about his
09:18knowledge of the airport our DC 9 crew was really not familiar with the Detroit airport and then you
09:25bring in all the other things like low visibility it all comes together to create a dangerous situation
09:31still investigators wonder how two professional pilots could become so dangerously lost okay let's see
09:39where they go and let's confirm any directional changes with the FDR data to trace their route
09:45investigators combined the plane's heading changes captured by the flight data recorder with the
09:50conversation recorded in the cockpit before the plane starts to taxi the team hears something on
09:57the tape that gets their attention I'm always flown with an ejection seat and used it twice at the
10:03departure gate the first officer began to boast about his military service I got shot down once over
10:09Southeast Asia I didn't have time to get scared oh is that right and then when I was flying t-38s one
10:17time I had an engine fire tower controller said you were on fire eject bam like wow wow at that time in
10:27the NTSB a lot of us had military backgrounds he and I were in the same place at nearly the same
10:33time so my ears perked up is he some kind of war hero sounds like it to bail out or reject out of
10:40two different airplanes you know that's very rare investigators review the first officer's military
10:47record to verify his story check this out it's clearly embellishing it turns out that he didn't bail
10:56out of any aircraft at any time we even have a phrase for that stolen valor why would he lie
11:02that's a good question the NTSB needs to know why first officer Jim Schiffen's lied to the captain
11:10about his military record just minutes before Northwest 1482 strayed onto an active runway
11:17investigators check his employment record for an answer
11:21he was still on probation so he needed the captain give him a good report I think the first officer was
11:33bragging to impress the captain because a bad mark would be tantamount to not getting a career with
11:40Northwest Airlines but did the first officer's boasting influence decision-making in the cockpit
11:46three center exit the ramp at Oscar six did you get all that yeah but I'm gonna need you to have
11:54kind of wind around here and Oscar six is gonna be right around the corner here okay the CVR reveals
12:00that as the plane begins to taxi the dynamic in the cockpit changed the first officer was correct in
12:06offering up help to the captain this is just the way things should work uh left turn or right turn
12:13yeah well this is the inner taxiway here we're still going for Oscar six so left turn yeah
12:20first officer was kind of taken on a bit more responsibility a bit more a bit more and then he
12:30started to direct the taxi itself seems like the first officer is calling the shots
12:35we're headed eastbound on Oscar six here just as the controller said you can't go east on Oscar six
12:45Oscar six runs north-south northwest 1482 at Oscar four take the right turn on x-ray report crossing nine
12:54two seven as their predicament worsened so what do we do here you make the right turn report crossing
13:03two seven the captain became completely reliant on the first officer's guidance this role reversal
13:11was it was pretty total there's Oscar four this is x-ray okay so the last instruction was at Oscar four
13:21turn right on the x-ray right over here then yeah that way I think we were on x-ray here now
13:32there is no way they're on x-ray they never make it on the x-ray the captain suddenly realized they
13:40missed the taxiway and we're now on a runway what runway is this turn left over there now wait wait that
13:49that's a runway two they are totally disoriented tell them we're out here we're stuck we can't see
13:57anything but I believe we're on a runway somehow they've made it here we've got two planes facing
14:06each other on the same runway but there's signs and surface markings all along here I don't get it
14:15when an aircraft gets lost on the airfield usually the pilots will spot signs or something like that
14:21help clarify the position in the controller's mind where the aircraft is exactly investigators are
14:28baffled why didn't the airport signs and runway markings prevent the pilots from getting lost
14:34to better understand what happened let's do this investigators retrace their route
14:43the only way to fix this in our minds was to perform what we call a taxi demonstration wow will you look
14:52at that the team discovers that the yellow taxi markings were badly faded I could barely see it on a bright day it was obvious that if we got confused in broad daylight with no fog perfect visibility that the issue was more acute when you could barely see your hand in front of your face out there
15:18investigators continue to the Oscar 4 intersection where the DC 9 failed to make the critical right turn
15:32so which way is the Oscar 4 sign point right or straight ahead
15:38they 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 that offer pilots clear and readily interpretable information investigators finally think they know what happened on the day of the collision
16:05now what runway is this this is a runway a dysfunctional and disoriented DC 9 crew mistakenly taxied onto an active runway
16:19at the same time as the Boeing 727 was cleared for takeoff
16:23in the aftermath of the crash Detroit metropolitan airport improved signage and now uses highly visible
16:51reflective paint for all airfield markings
16:55ground radar with audible and oral warnings as well to tell controllers of an impending collision
16:59is in place at most major airports at this point in time
17:03and that's going a long ways to preventing actual collisions from happening
17:07the high volume of daily air traffic poses a constant challenge for both pilots and controllers
17:13it can become overwhelming with devastating consequences
17:17it's just before sunset on America's west coast
17:21it's just before sunset on America's west coast
17:25U.S. Air flight 1493 out of Columbus Ohio cruises towards Los Angeles International Airport
17:31there are 89 passengers and 6 crew on board the Boeing 737
17:35just confirm the visual approach for U.S. Air 1493 is 2-4 left
17:45that's correct U.S. Air 1493
17:4748 year old captain Colin Shaw has logged more than 16,000 flying hours
17:53first officer David Kelly is 32 with 4300 hours of flying experience
17:59in the control tower
18:05246 heading 270 contact Los Angeles departure
18:11nice
18:13Robin Washer is handling two runways including runway 24 left
18:17like all controllers she uses flight strips to keep track of all planes arriving and departing
18:23Sky West 569 taxi to position hold runway 24 left
18:278 miles from LAX the pilots radio for landing instructions
18:37U.S. Air 1493 inside row
18:41but there's no response
18:45Washer is busy with other planes on the ground
18:49Sundance 518 taxi cross runway 24 left
18:51Sundance 518 taxi cross runway 24 left
18:53contact ground 0.65 when you're off the line
18:59Flight 1493 can't land until it receives Washer's clearance
19:03U.S. Air 1493 for the left side
19:052-4 left
19:07The 737 is only one minute from the runway
19:11Out of a thousand feet
19:13Thank you U.S. Air 1493 you're cleared to land 24 left
19:23Clear to land 24 left
19:251493
19:27Looks real good
19:37What the hell
19:39U.S. Air 1493 bursts into flames upon landing at LAX
19:51It skids across the tarmac
19:53And slams into an abandoned building
19:57Firefighters hurry to the scene
20:0720 people on the flight are dead
20:0920 people on the flight are dead
20:11Two more will succumb to their injuries in the days that follow
20:17As rescue efforts continue
20:19A shocking discovery is made
20:23Firefighters pull a propeller from the wreckage
20:29As soon as we found out that information we started actively looking to see
20:33What aircraft if any were missing
20:35So we started looking at the flight strips that were already departed
20:39And then we looked at the ones that were still pending
20:41What about Skywest 569?
20:43No, we haven't heard from them
20:45Skywest 569
20:47A 19-seat twin-engine plane bound for Palmdale, California
20:51Isn't responding to radio calls
20:53Emergency crews eventually find the wrecked commuter plane beneath the 737
21:07It was a horrific scene
21:09The front end of the airplane was impaled against the building
21:13We could see parts of another aircraft underneath
21:17There were 12 people on board
21:21Rescuers find no survivors
21:25The National Transportation Safety Board
21:27Dispatches a team of investigators to LAX
21:31The scenario of the accident
21:33Resulted in two planes being on the runway at the same time
21:37The runway was occupied
21:39And that's something that should never happen
21:41When a landing clearance is granted
21:43Which one of these planes was cleared for 2-4 left?
21:47Recordings of Robin Washer's communications in the tower
21:51Might provide an answer
21:53Skywest 569 taxi up and hold short of runway 2-4 left
21:57Roger, hold short
21:59Roger, hold short
22:01Moments before the accident
22:03Washer was prepping the Skywest commuter plane for takeoff
22:07Skywest 569 taxi into position and hold runway 2-4 left
22:11Traffic crossing downhill
22:13The pilots as instructed
22:17Taxied to takeoff position and stopped
22:19So that Washer could clear a third aircraft to taxi across the runway in front of them
22:23Okay, 2-4 left position and hold Skywest 569
22:27Skywest 569
22:29Okay, stop right there
22:31Skywest 569 followed Washer's directions
22:37Alright, let's keep going
22:39Wings West 5006 taxi across runway 2-4 left
22:43Next, Washer instructs the plane in front of Skywest 569 to cross the runway
22:49Wings West 5006 taxi across runway 2-4 left
22:55But there's no response from that plane
22:57Wings West 5006 ground tower
23:01It takes nearly a minute for Washer to re-establish radio contact
23:07Wings West 5006 on frequency again, change radios, sorry about that
23:13They advised her, they had inadvertently been on another frequency
23:195006, you're back with me
23:21Yeah, we didn't mean to switch radios, we're on now
23:25And that created a distraction for the local controller
23:29And that's when US Air Flight 1493, still a minute from touchdown, requests clearance to land
23:36US Air 1493 for the left side, 2-4 left
23:41Thank you US Air 1493, you're cleared to land 2-4 left
23:45US Air 1493 was cleared to land on the same runway during the time that Skywest 569 was still sitting in position on that same runway
23:55Cleared to land 2-4 left
23:571493
23:59It's a mistake that cost 34 lives
24:03The team now needs to find out from Robin Washer what went wrong
24:09I couldn't find the flight progress strip
24:12Washer explains that as Skywest 569 waited on the runway for permission to take off
24:18She was distracted by a third plane requesting clearance to depart
24:22Tower Wings West 5072 is ready for take off
24:28Wings West 5072?
24:34I need a strip for Wings West 5072
24:36I couldn't find the strip so I asked my supervisor to help me
24:40While Washer looked for the strip for Flight 5072
24:44She forgot she had already moved Skywest 569 onto the runway
24:49US Air 1493 for the left side
24:52And then she cleared Flight 1493 to land
24:55Thank you US Air 1493, you're cleared to land 2-4 left
25:02What the hell?
25:14This is a situation that no controller wants to go through
25:22You train your whole career for this not to happen
25:30But the NTSB isn't ready to close the case of the LAX collision yet
25:35Any time that you do an investigation
25:37It's easy to point the blame at one individual
25:40What you want to do is to say
25:43Why did this occur?
25:45And what can we do to prevent a reoccurrence?
25:54Documents provided by LAX air traffic controllers
25:57Have revealed that the tower was understaffed
25:59In the months before the deadly collision on runway 2-4 left
26:03And that some sections of the runway are invisible to controllers
26:14We went up in the tower
26:16And asked the air traffic controllers to step aside
26:19While we sat in their chairs and looked out the window
26:22The view that the air traffic controller was presented with
26:26Had an obstruction
26:29A light pole that produced a glare
26:38The investigation also discovers that ground radar systems
26:42Used to track planes while taxiing
26:44Weren't operational on the day of the accident
26:45You're holding short, is that correct sir?
26:47Yes ma'am, we're holding short
26:48It was in constant out of service, in service, out of service, in service
26:57And gave the management a lot of trouble
27:00Los Angeles airport has always been known as one of the number one runway incursion airports in the system
27:06And changes were overdue
27:09In the months and years following the accident
27:16Improvements are made to air traffic facilities
27:19To make the airport a safer place
27:21The equipment we're using at Los Angeles tower today
27:24Gives the controllers the tools they need
27:26To make sure that the runways are clear
27:28Without those safety measures in place
27:31Robin Washer was able to lose track of the situation
27:34Something that should never happen in a control tower
27:37Linate airport, Milan, Italy
27:42It's just after 8am
27:44The runways and taxiways are shrouded in a dense fog
27:48Similar to that which covered Detroit airport 11 years earlier
27:51Alitalia 226, cleared for takeoff
27:5436, report when rolling
27:56Even so, planes take off every 2 minutes
28:01Linate Buongiorno, Delta India Echo Victor X-Ray
28:05Requesting starter
28:06South Victor X-Ray
28:07You are cleared to start your engines
28:11Paolo Zacchetti is the ground controller
28:13Responsible for guiding flights to the start of the runway
28:18Taxi North Vero Mail 5
28:19Calling me back at the stop part of the main runway extension
28:24Scandinavian 686
28:25Taxi to holding position Cat 3
28:27Scandinavian 686
28:28Taxi to holding position Cat 3
28:30On the way to the runway is Scandinavian Airlines Flight 686
28:35A Boeing MD 87 bound for Copenhagen
28:38With 110 people on board
28:41Taxi holding point Cat 3
28:43The captain is Joachim Gustafsson
28:45He has been with SAS for more than a decade
28:49Scandinavian 686, your position please
28:51We still haven't reached the main taxiway Scandinavian 686
28:56First officer Anders Highlander has been flying for the airline for the past 4 years
29:02The SAS crew were very highly experienced pilots
29:06So couldn't ask more for 2 qualified pilots
29:09In such thick fog, the pilots rely on Zacchetti to guide them to the runway
29:16Scandinavian 686, your position please
29:20Now you are on the main taxiway
29:22Yes, now we are entering the main taxiway, Scandinavian 686
29:27Flight 686 turns off the taxiway and onto the runway
29:30Zaccetti hands the flight off to the tower controller
29:37Tower, buongiorno, Scandinavian 686, sequence to 3-6 right
29:44Ciao, Scandinavian 686
29:46The wind is calm, report rolling when airborne squawk ident
29:51The flight is cleared for takeoff at 8.09am
29:54And we are rolling Scandinavian 686
29:59Auto-throttle on
30:02Set thrust
30:05V1
30:18Rotate
30:21What's that?
30:31Come on, come on
30:33Come on
30:34Come on
30:36Come on
30:37Scandinavian 686
30:38Flight 686 has been struck by catastrophe
30:50But because of the thick fog, no one is aware of it
30:54Until a severely burned baggage handler emerges from the fog
31:01And we want to know what happened on the runway
31:14Ten tons of jet fuel feed a massive fire where the Boeing MD-87 has collided with one of Linate airport's hangars
31:22Awful, terrible devastation, the collapse of the roof of the hangar and the disaster plane completely destroyed
31:37While emergency crews battle the fire
31:41There are two aircraft unaccounted for
31:45Ground controller Paolo Zacchetti realizes a four-seat Cessna Citation is unaccounted for
31:54The main attention was focused on the Sasser plane
31:58So nobody thought that there was another plane
32:02A private aircraft is missing, a Cessna 525
32:09Ground crews immediately organize a search
32:1226 minutes after the crash
32:17They find what's left of the Cessna
32:19Midway down the runway where the accident occurred
32:22The disaster has claimed the lives of all 110 people on the MD-87
32:33Along with four on board the Cessna
32:36Four more were killed inside the hangar
32:41This is the most serious accident in the history in Italy
32:49My God
32:53Mario Pica is the lead investigator for Italy's National Agency for Flight Safety, the ANSV
33:00It was mandatory to find out really what happened
33:04And find the reasons that could help us to avoid it happening again
33:10The Swedish Accident Investigation Board also sends a team to Milan
33:15We were called to be part of the investigation as it was in the Scandinavian Airlines plane
33:20Here's what we know so far
33:22The MD-87
33:24Measuring the distance we asserted that the MD-87 had traveled for about 40 seconds
33:31And gone 1500 meters before striking the Cessna
33:36Here
33:37Huh
33:38Did the SAS pilots have any warning that another plane was on the runway?
33:47Weather, weather
33:48Weather reports show visibility was only 160 feet at the time of the collision
33:56V1
33:59Rotate
34:00That means SAS pilots wouldn't have been able to see the Cessna until just before impact
34:05What's that?
34:08With the heavy fog that morning it was clear that the environmental factor was a contributing cause of the event
34:18But modern airports like Linate operate safely and low visibility every day
34:26Planes can avoid each other at night so why should there be any difference in fog?
34:29What went wrong the morning of the accident?
34:34We have to consider this right off the bat
34:38One of the first thought that came to mind there was
34:42Pilot error
34:43The possibility of a pilot error
34:46One of the pilots was not where he was supposed to be
34:50The question is, which one?
34:53Investigators turned to control tower recordings for answers
34:59We have to listen to the facts
35:01Our expectation was that the ATC recording would reveal what actually was being said that morning
35:06They pay close attention to ground controller Paolo Zacchetti's conversations with the Cessna
35:13Call sign Delta Victor X-ray
35:18Delta Victor X-ray, taxi north via Romeo 5, call me back at the stop bar of the main runway extension
35:24Roger, via Romeo 5, call you back before reaching main runway
35:28Zacchetti instructed the Cessna to go north from the apron along taxiway Romeo 5
35:36To a taxiway that runs parallel to runway 36R
35:40The route should have kept the Cessna off the runway
35:43But he ended up here instead
35:46Investigators make a shocking discovery
35:49The Cessna didn't follow the taxiway Romeo 5 which had been authorized
35:54But took instead taxiway Romeo 6
35:58It seems that the Cessna pilots made the fatal error that caused the crash
36:04Call you back before reaching main runway
36:06But the revelation raises an important question
36:09So why didn't anyone notice?
36:11It's ground control's job to monitor the movement of all aircraft across the airport
36:19That morning, it was Paolo Zacchetti's responsibility
36:21Delta Victor X-ray, continue your taxi on the main apron
36:25Roger, continues the taxi on main apron, Delta Victor X-ray
36:29That is correct, and please call me back entering the main taxiway
36:33Main apron, main taxiway?
36:36But Linate airport has several aprons and taxiways
36:41None of them designated as main
36:44Investigators now want to know how Zacchetti lost track of the Cessna
36:49Air traffic control recordings revealed that Paolo Zacchetti failed to clearly differentiate aprons from taxiways
36:57When giving directions to the Cessna that collided with an MD-87
37:02Please call me back entering the main taxiway
37:05The communication with the tower and the pilots that morning of the accident was inconsistent
37:11They used the word main for different things, main runway, main apron, main taxiway
37:15The controller's choice of words may have led the Cessna pilots to believe they were on the correct route
37:22That was a communication below acceptable standard
37:25Play that again
37:27Investigators also hear a transmission from the Cessna
37:30Approaching Sierra 4
37:32That puzzles them further
37:34I don't see it anywhere
37:35It's not here
37:36Listening to the communications, I was baffled when I heard pilot reporting a Sierra 4
37:44The controller's maps don't show S4 at all
37:48Investigators are beginning to suspect the error goes beyond the poor communications between Zacchetti and the Cessna's pilot
37:56I asked him if he knew where Sierra 4 was
38:02Where is Sierra 4?
38:04I have no idea
38:06That was very simple
38:08He confessed they didn't know where Sierra 4 was
38:11Pika learns that Zacchetti's managers never gave him a tour of the taxiways as part of his training
38:16Approaching Sierra 4
38:18Delta V direction
38:20Roger
38:21Maintain the stop part
38:23I'll call you back
38:25Had he received proper training, Zacchetti would have realized the Cessna wasn't on taxiway Romeo 5 as instructed
38:32It was instead on Romeo 6 and about to cross the active runway
38:37Air traffic controller didn't stop the Cessna
38:40Delta V direction
38:42And at that moment the tower clears the MD-87 for takeoff
38:46Scandinavian 686 Linade cleared for takeoff
38:49Dr. V direction
38:52Continue taxi on the main apron
38:53He should have stopped the Cessna but unfortunately
38:56Roger, continue the taxi on main apron
38:58He thought that Cessna was on R5 taxiway
39:03It's a fatal series of errors
39:06And we are rolling Scandinavian 686
39:09Just as the MD-87 reaches a speed of 145 knots
39:16Or 160 miles per hour
39:18The Cessna crosses the runway
39:23Come on, come on
39:25Come on
39:26Come on
39:36Investigators now have a picture of the events leading up to the disaster
39:40But they still wonder, why didn't taxiway direction signs alert the Cessna pilots that they were heading in the wrong direction
39:47The team looks at guidance signs at Linate airport that are supposed to help guide the pilots
39:55The status of those markings were in a very poor condition
39:59It was surrounded by high grass and there was only a very few of those markings
40:04The markings painted directly onto the tarmac are also vital for pilots
40:10When we came to the intersection between Romeo 5 and Romeo 6
40:17We could see that the markings on the ground were so badly painted that even in good visibility it was difficult to read them
40:25The faded markings help to explain why the Cessna turned right
40:30When to avoid the runway it should have turned left
40:33But investigators know Linate airport should have yet another tool to prevent this kind of disaster
40:39Ground radar that can detect the movement of all aircraft and vehicles on the surface of an airport
40:46Delta Victor airspace, confirm your position
40:49But when the team talks to controllers
40:51No, there is no ground radar at Linate
40:55We have not had it in years
40:57They discover another deficiency at Linate
41:01The ground radar of Linate, the old one was dismantled, the new one was in boxes
41:06It had been there for years and not yet installed
41:08Why? I don't know
41:14Everything which could go wrong, did go wrong at the airport
41:17In the aftermath, Linate underwent a major overhaul to improve safety
41:24Alitalia, 212, hold your position, you are crossing an active runway, repeat, hold your position, Alitalia, 212
41:35Changes brought in after three catastrophic runway collisions
41:39What the hell?
41:42Have made the chance of a runway disaster far less likely
41:45What's that?
41:53Right now, air traffic controllers have a tremendous amount of resources available to them
41:58Versus what they did even 10, 20 years ago
42:02And I think the safety record that we have in the industry shows their abilities
42:07The air traffic control world has grown so much for the better
42:10For the better