A Perfect Storm of Mistakes! And how Heroic Pilots Almost solved it.

[@MentourPilot]

Go to curiositystream.thld.co/mento... and use the code MENTOURPILOT to save 25% off today, that's only $14.99 a year. Thanks to Curiosity Stream for sponsoring today's video!

[@goldreserve]

Amazing channel. Thanks. I will never fly on an MD-87.

[@ScottB05]

Thanks I will never fly, we're not meant to be up there.!! I Enjoy the videos though and thinking how lucky I am that shit won't happen to me. Enjoy Dubai.

[@MrCaiobrz]

I think its time we get such indepth view on JAL 123, the worst single-aircraft accident in history. Also show incredible intelligence and professionalism by the crew.

[@naifalotaibi6865]

Could you do a video on the Charkhi Dadri mid-air collision?

[@nadernowzadi1]

Thanks for your videos. Isn't this why English is the international standard for aviation language so all pilots are aware of their surroundings! Over the last 48 hours I heard air France 011 jfk to cdg which has to go around because the controls were not responsive and the entire conversation was in French as well as DHL emergency landing in Costa Rica and once again not a single word of English was spoken. There was an aircraft who was trying to depart and had no idea there was an emergency

[@Hartbreak1]

These kinds of accidents hit the hardest, where a crew was operating by the book and still got doomed because of stuff outside of their control.

[@MentourPilot]

Yeah, that’s exactly what I thought.

[@NicolaW72]

Yes, indeed.

[@oldschoolman1444]

Broken ground radar and poor taxiway lights and markings with bad visibility was a recipe for disaster. Sad thing is this could have been prevented.

[@trouty7947]

And then even flying the damaged aircraft, it was just system failure after system failure. Even the reverse thrust, the last thing they had available, was actively failing on them. It was incredibly quick thinking to use it that way, and shows how good of a pilot they were.

[@catbriggs8362]

No ground radar is criminal neglect, IMO.

[@salernolake]

This accident is a direct result of "normalizing deviance". A facility that requires workers to violate safety norms (in this case cross a red line), has set their workers up to have an accident.

[@anna_in_aotearoa3166]

Absolutely. It's unfortunately a pretty common problem in way too many workplaces, particularly where safety systems are not regularly reviewed and where employees haven't been actively consulted in designing and maintaining them?

[@Huntracony]

Yeah. Occasional deviance is fine, as long as everyone is hyperaware of what's happening and the associated risks, but normalizing it is not.

[@darkprose]

“Normalizing deviance” and violation of safety norms are _not_ synonyms. There is considerable confusion about Diane Vaughn’s concept and how she used it in her book on the _Challenger_ disaster. If it was merely another way of describing when individuals or groups don’t follow the rules of their organization, she wouldn’t have had to write a book about such a commonsensical description. When you read her book, deviance and normalization emerged from her study of the unique history and particular set of circumstances of NASA’s shuttle program. I know you’ve probably read it yourself, but I recommend her book to anyone else reading this.

[@darkprose]

This is from the 2016 preface to her book (italics mine): “Based on additional Commission findings, I began this research with the hypothesis that the Challenger accident was not caused by amorally calculating individual managers, as the report suggested, but was an example of organizational misconduct. All the classic signs were there: production pressures, risk taking and violation of rules in pursuit of organizational goals, and regulatory failure. Initially, I envisioned a short article. However, once I got beyond the readily available information and deep into the supplemental volumes of the Commission’s report, I found information that contradicted most of my starting assumptions about what had happened. _No rules had been violated on the eve of the launch. Instead managers had conformed to NASA’s rules and procedures._ More incredible, in the years preceding Challenger, despite worsening O-ring damage, managers _and_ engineers alike repeatedly assessed the O-ring damage as an “acceptable risk” in engineering documents. How was this possible? As the complexity of what happened materialized, the short article I imagined at the outset was reimagined as a chapter in a book and then grew into a book in its own right.” Vaughan, Diane. _The Challenger Launch Decision_ (p 9). University of Chicago Press. Kindle Edition.

[@Lucien86]

@@Huntracony In a safety critical environment even very occasional deviance can be lethal.. What they would need is a systematic plan to deal with situations where normal procedures needed to be modified. Making people cross the red line though - insanity.

[@MrGyngve]

I work as a train driver, and I have learned the hard way how respect for the signals basic color and meaning is of utmost importance. The infrastructure developer where I once worked, had to rebuild the signals on the entire freight train terminal which used to be my base, many years ago. To get it done quicker, they cut corners and got my company to agree on doing things differently than the rule books said. Usually when you build a new signaling system, once installed but not in use yet, you turn the signals away from the drivers view and put a large "X" on them, clearly marking them as "not in service". With my companies blessing, the infrastructure developer skipped these steps, turned the signals on 24/7 during the construction period (for testing etc.), and told us drivers to ignore them (pass them even if they say "stop"). Having done the EASA ATPL-H exams, I knew from the syllabus of Human Factors, that this was a bad idea, so I protested, but to no avail. We had some bad mishaps because of it, derailments and what not, once the signaling system was put to use. Cutting corners has never been good for safety.

[@filanfyretracker]

that seems really bad, Like on the road if traffic signal is malfunctioning default is to treat as a all ways stop and not blow through. Would think in an RR they would say stop and radio whatever the train version of a control tower is.

[@casedistorted]

That old saying “safety regulations are written in blood”.

[@tomriley5790]

That's almost unbelieveable - I'm surprised Unions were okay with it and failing that the safety inspectors.

[@LordInter]

@@tomriley5790in guessing it's in the usa where the rail unions aren't as powerful as elsewhere (?)

[@LittleJimmyR]

People can get fired for passing signal at danger, right? I like trains, so I hope that is correct.

[@Boyso5407]

It’s incredible that the pilots of the MD-87 were smart enough to not only input their controls seconds after the collision but they also made the correct inputs and kept that plane from hitting the terminal. They probably didn’t even have enough time to register what had actually happened but we’re still able to make clear and correct decisions in the few seconds they had left. Unbelievable piloting. I can’t even begin to imagine how many people would’ve been killed if that plane hit the terminal at that speed.

[@GilbertdeClare0704]

your comment brought tears to me eyes. Those BRAVE and highly skilled pilots !

[@kylieharrison3782]

Muscle memory is everything when it comes to disasters. Which is why in part the pilots trained by the armed services are so competent and incredible at piloting.

[@kay9549]

Jasonboisseau409 absolutely they did an wonderful job, in a short time of span, veering the plane away from the passenger terminal/other planes. Even through it all, they knew that this was no recoverability.

[@NoNameAtAll2]

were* extra apostrophe there

[@danielkarlsson9326]

@@kylieharrison3782 Sas pilots tended to be former Swedish and Danish royal airforce fighter pilots. and Especially the Swedish Airforce fighter pilots flew in a way we other Nato forces was not allowed to do due to safety concerns and rightfully so. it meant dlying at the speed of sound between five meters and 20 meters above ground during regular training at mach 0.95 during all weather conditions. this made them extreamly well versed in extreme conditions but it also came with a high cost of lives. Now i dont know if any of the two pilots who lost their lives was in any airforce before joining SAS, but the chance was quite high. the one thing we do know is that they flew that plane even when i wasnt able to fly anymore, And that is something that few can do no matter who they were before that dreadfull day. In gottröra the fantastic crew had the Margins and a spare senior captain with them and that saved them all. Sadly the Crew on the Linate Flight had no such margin.

[@PokeMaster22222]

I can't believe how much of a shitshow this was - the tower not being informed of runway/taxiway markings, leading to major confusion around a plane's location, then the tower not activating 'emergency mode' after a phone call about an explosion and injured people, then the tower not being made aware of fire trucks racing to the baggage -building fire. What the hell, Italy?!

[@RavenMobile]

I couldn't believe it took them half an hour to identify a burning plane on the runway!

[@dahliacheung6020]

All of this, everything you said. I was absolutely blown away at the failures and shocking carelessness on the ground. Even as someone who has never been more than an airline passenger I can't fathom how they thought the abundance of errors and lack of proper information/procedure regarding the runways would somehow magically not cause a serious accident.

[@EK-gr9gd]

Look up the episode from Mayday Air Crash Investigation Series 11 Episode 12) There the accident is shown from all points of views and both investigators, Italian and Swedish are interviewed.

[@atranotte8154]

@@RavenMobile It reminds me about the moby prince ferry disaster, in wich the ferry collided with an oil tanker, both started burning inside Leghorn port during an allegedly foggy night, and the ferry flee and then went adrift to the open see. Since everyone was watching at the enourmous tanker burning and rescue and civil ships maked hurry to extinguish the fire before the ships explosion or collision with the docks, it took half an hour before a little boat of volunteer rescuer saw the ferry adrift, and it took hours before the rescuers. A bad mix of disorganization, fog, panic.

[@alaeus2310]

@@RavenMobile In their defense, fog in late autumn in the Po valley can be absolutely horrible. I have been there during some days where the visibility is under 100 meters, no joke. This likely made ATC even less alert, since this level of fog during autumn mornings is normal there.

[@NicolaW72]

This was not the failure of the safety management - this was the complete absence of a safety management. Thank you very much for bringing up this tragic story!

[@sharoncassell9358]

I worked as a signal maintainer in NY subway system and safety was paramount. But I saw many things that were not done properly. I corrected what I could like putting lightbulbs in traffic signals and fuses in electric switches to change tracks. There were occasional derailments in the train yards frozen switches men getting electrocuted or run over. All transportation means can be dangerous and unexpected. Try to report or fix the problem. Not be part of it.

[@NicolaW72]

@@sharoncassell9358 Yes.

[@johndasalty111]

Italy in a nutshell. Welcome to criminal negligence, the country.

[@flagmichael]

Worse yet, as mentioned at 27:49 safety processes were essentially forbidden.

[@AnoNym-zi5ty]

This is the most iconic Italian thing. Complete absence of safety 😂

[@newoldbrain]

I have personally lost friends and colleagues in that perfectly avoidable accident. I still remember the unreal atmosphere at work that fateful morning. My blood boils every time I hear the amount of carelessness and sloppiness that managed to kill 118 persons. A big thank you to Mentour Pilot for his clear and always tactful description of the events.

[@stevencooke6451]

My heart goes out to you and their families. I cannot imagine ever being to shelve the anger you and they feel. Sometimes people die tragically, but you can't really put the blame anywhere. Then there is this inevitable disaster, one presaged by countless warning signs that were all ignored.

[@LVLouisCyphre]

My condolences for your loss. This must have been a difficult video for you to watch.

[@Yamyatos]

I'm so sorry to hear that. This one really made me angry when i watched it too. I hope something like that never happens again.

[@Dowlphin]

My blood boils every time I see cringy dumbfuckery in what claims to be top-notch safety standards. Stuff that absolutely could and should be predictable before people die, and only needs someone with good creative imagination and logical system analysis. But the most important thing to change is the basic societal system that relativizes people with profits and creates situations of artificial scarcity. My standards are high, meaning I even consider Lauda Air having made blunders, but those blunders were industry standard, based on profit, efficiency and thus business survivability calculations in a competitive environment. (Ideally an airplane with a mysterious error warning absolutely should not be flown with passengers in hopes of eventually finding out what the problem is. To me that is insane.)

[@socialaction680]

@@Yamyatos ff%%%%%

[@HomebrewHorsepower]

The quality and detail in these videos are unmatched. I'm an engineer by trade, and the detailed, factual approach to these investigations and reports speaks directly to my engineering brain.

[@MentourPilot]

I’m so happy to hear that! Welcome to the channel.

[@gloriajackson2021]

@@MentourPilot It's true! You are very good at making these videos! They are just exceptional!

[@gorillaau]

The narration of these videos is very information dense, but easy to listen to and comprehend. Well done to all that had input into this video, as well as others.

[@Southwest_923WR]

WOW. Just plain wow. Didn't hear of this one, wow. SO many red flags. Thanks for your good work and info. No opinion about content,... just wow.

[@Southwest_923WR]

Oh and thanks for explaiming taxiway maneing system, but is it the same general systrm here in the U.S.? Say at DAL, we have "A"-"C#" and DAL is a medium size airport.( SOUTHWEST AIRLINES home!😍)

[@Night_Stary]

When u mentioned the stop light, it made my blood boil. I've seen something simmilar happen before on a train station, where the sound signal sometimes wouldn't play on train approaching and sometimes play out when there was no train approaching at all. So ppl were used to ignoring the signal, which led to death of a young boy. What is more outrageous, is that this issue wasn't fixed even after the incident.

[@thewhitefalcon8539]

Normalization of deviance as someone called it

[@hari4406]

That is worse than having no signal

[@koharumi1]

Where was this??

[@crazyguy32100]

So many similarities to Tenerife. Limited visibility, confusion of taxi directions, lack of ground radar, non-standard communication language/phrases, complacency with non-regulation procedures and everybody thought things were fine until a shape comes looming out of the fog. However at Tenerife both sets of pilots knew there was another plane on the runway and it was a case of pilot error assuming the runway was clear, disaster could have been averted with a single additional radio call or better CRM. Here the pilots did everything right, having no indication whatsoever of any issues but still payed the ultimate price. The technology was there, it used to work, but was never repaired after failing, a simple taxiway sign could have prevented tragedy, cost cutting and complacency at its worst. The events of 24 years earlier were lost on the airport management, who did not learn from history and were doomed to repeat it.

[@mikekeenan8450]

Tenerife, plus a dash of Zagreb with the use of Italian on ATC frequencies.

[@giulia480]

Well the cessna pilots didn't do everything right... they confirmed romeo 5 and went on romeo 6

[@LordOfSweden]

Yep but in tenerife it was both planes fault right? In this case it was only one planes fault, the cessna + air traffic control and saftey management of the airrport.

[@giulia480]

@LordOfSweden yeah but my response was to op who said that the pilots did everything right (which is true for the bigger aircraft, but the cessna did so many things wrong)

[@18robsmith]

In the late 1990s & early 2000s I used to fly in and out of Linate fairly regularly. Twice we were just starting the take-off run along the runway when we stopped very suddenly, on one of those aborted take-offs I could see another aircraft crossing the runway ahead of us. Scary or what.

[@MentourPilot]

Indeed! Like I said in the video, it was fairly common apparently.

[@chaimbar1171]

Wow, unbelievable!

[@marhawkman303]

@@MentourPilot The way you explained the airport layout... I was thinking it was inevitable for a disaster like this to happen. :/

[@NicolaW72]

@@MentourPilot I readed in a report of this accident that the Tower even cleared a Lufthansa Flight for Take-Off after the crash happened - the Lufthansa Pilot´s negated the Take-Off-clearance because they weren´t able to recognize that the SAS flight in front of them had started. According to this report this was the only reason why not a second aircraft at this morning crashed into the Cessna.

[@kavinskysmith4094]

this is why if you see a situation like this you play hell and get stuff changed, my dad when he was working out of pureto rico was being flown to and from an island as part of his job regularly with a shot transport plane that was always having trouble with an aileron getting stuck and on one of the last times he flew on it the engine started having trouble and sparking, the pilot brushed it off and my dad when he got off that plane that day said to his boss, you either get rid of that plane or I'm done, as I am NOT flying on that aircraft ever again. and they did, a brand new cesna citation, which he was not happy about as this guy was always pulling deals, and the plane, the bad one, which had been used as a transport in africa of all things, got sold and put on mail duty flying to and from the islands of puerto rico, till a few weeks latter with a 20 something pilot flying it, the engine caught fire midflight, an aleron got stuck, and crashed with him in it like when you see crap with that, I dont care if your boss is the highest general in the land, YOU PULL HIS TAG and tell him what's up as if my dad hadnt done that, him and his coworkers would have been at the bottom of the ocean, all because of some cheapskate boss running a deal with a stupid transport plane like my pops actually saved lives that day by telling that SOB whats up, and dont hesitate to do the same, as aircraft are not the kind of things you screw around with, like they demand respect and to be looked after, if you cant do that, pull it from service as the risk is too great if even one system is working incorrectly on it also one of his pieces of advice is never fly on an aircraft with two engines, always one, three or four, as the two engines you cant tell what engine failed and if they get unbalanced and dont know they go in, with one you can still fly the aircraft just with reduced power and every since he told that every single damn time a crash has happened, I look and sure enough, every single time, its a two engined aircraft, like if you ever meet me and wonder why I get ansy about 2 engine aircraft, and the always crashing DC10 that's why lol sad part is as an aviation enthusiast I really like alot of the two engined aircraft from WW2 too as well but each and every single one of them, engine failure and go ins from an engine failing........... even with experienced pilots behind them too, like its just, yeah you really have to be damn careful with dual engine setups as theirs still no cameras to tell you what engine quit to this day as mentour mentioned in one of this debrief videos here awhile back.

[@Mark-oj8wj]

As a fellow pilot I also feel so deeply for the sas crew. I can't imagine anything worse than being given no chance because of another person's mistakes.

[@MentourPilot]

True.. my thoughts exactly

[@lucassteen4050]

Like the DHX 611 pilots in the Uberlingen mid air collision

[@NicolaW72]

@@lucassteen4050 Yes.

[@andrew_koala2974]

SAS not sas You are NOT paying attention to detail Slap yourself in the face for your failure When you L00K at something - be sure to see exactly what it is you are looking at.

[@lodnisroub]

If only mistakes, it is pure negligence.

[@ellicel]

Considering the conditions and practices at the airport, it is a wonder that an accident didn’t happen sooner. Such a tragedy, but it’s clear that without a major incident all these improprieties would simply have continued. As a very nervous flyer, I would never have believed it if someone had told me a year ago that this channel would become my favorite and most consistently consumed form of media. But everything from the production values to the writing and presentation is top notch. I have learned so much and even feel better about flying.

[@zippymk13]

It really was a matter of when not if an accident would occur.

[@606Jelly]

I'm a nervous flyer too, and these videos have made me much calmer. They really bring home that disasters are almost never the result of one thing going wrong - there has to be multiple failures/issues. And the near miss videos where skill and professionalism wins out are so reassuring.

[@Warhaawk]

@@606Jelly As well seeing how the accidents that do happen so often bring about changes in practices and procedures that increase safety.

[@brianwest2775]

Interesting because I'm not a nervous flyer but these videos make me realize how reliant we passengers are on everyone doing their job conscientiously and correctly. Ex. I just watched the one where a pilot let his children fly the plane. We can only trust that our pilots won't be so irresponsible. Of course, the vast majority are very responsible and the chances of a serious incident are very low, but we are completely in their hands.

[@SonnyKnutson]

@@brianwest2775 that was also many years ago

[@JoeyFlyBoy]

About the Cessna Citation, 3 of the 4 occupants initially survived after being struck by the MD-87, but due to the delayed emergency response, it took firefighters 25 minutes to reach the Cessna, by the time they arrived, all 4 occupants in the Cessna were killed. Autopsy showed that the 3 initial survivors had high traces of smoke in their lungs, meaning that they were burned alive

[@221b-l3t]

That's aweful. If they did have a lot or smoke in their lungs they may likely have passed before being burned. The thick toxic smoke of a burning jet can knock you out in just a few breaths and death soon follow as it's so rich in monoxide and dioxide.

[@dk2428]

Aircraft engineer here. The total lack of safety measures and bad practices that lead to this accident are just beyond me. I can not overstate just how important it is to have a mental map of the airport you're operating on as well as being crystal clear in communication with ground control. I remember back in the day when taxiing an RJ to the tech platform for an engine run up i got clearance to cross the runway yet the stop bar was lit. It was a super foggy morning and this was an active runway. I read back "unable to cross, lit stop bar, (AC registration)" followed by a much faster speaking controller who acknowledged and corrected his mistake. One 5 sec read back to clarify the situation was all it took to avoid a possible disaster. Listening to both air and ground, having a clear map of the field, check with crew, ask for confirmation...everything that can build a bigger situational awareness is and always will be absolutely essential.

[@thomasfriberg225]

I will never forget 8th of October 2001... My girlfriend and I was flying from CDG to CPH with SAS, but on the way to the airport, we heard on the radio that a SAS aircraft had crashed in Milano, and they were unsure if it was due to a terrorist attack. Remember this was shortly after 9/11. The ground crew in CDG were obviously chocked, our plane was cancelled and everything was chaos, After 5-6 hours of wait, we were booked on a SAS flight from CDG to ARN, and from there we flew ARN to CPH. The atmosphere on these flights were very depressed, and seeing the crew keeping up their duties was impressive in every way, considering they had lost some of their colleagues earlier that day. RIP all onboard SK686.

[@metalgearsolidsnake6978]

Spiderman into SPIDERVERSE< yes SAS is bad

[@sharoncassell5273]

I was a signal maintainer for NYC subway system. I had already been an aircraft mechanic for USAF. Safety 🦺 was my middle name. I corrected many negligence events. I didn't blow whistles because I knew that did not work from a previous job in mechanical HVAC. I taught new guys the same way. I'm retired & hope they carry on that way. Good luck.

[@vinslungur]

​@@sharoncassell5273 I appreciate people like you who aren't pig headed enough to ignore safety protocols and cause death and destruction. Following safety regulations isn't always easy but it's only the difficult things that give life meaning. Taking the easy road isn't meaningful, ever. I have a role in keeping people safe in my country's biggest warehouse. It doesn't sound dangerous but that's why people get hurt. They never see it coming. The statistics speak for themselves. I love my coworkers and never want to see them injured.

[@Richardincancale]

I was working in Stockholm at this time on the design of a new 3G mobile network, commuting from France each week. One of my radio planning colleagues commuted from Milan. He was on this plane, and never made it. We later had a memorial plaque for him in our office. Operating an airport in fog with no ground control radar was criminal.

[@lassehaggman]

Especially when the radar was there, but no one bothered to install it.

[@NicolaW72]

@@lassehaggman Exactly.

[@stevencooke6451]

My condolences. That colleague should still be there living their life.

[@annedavis3340]

@@andreypetrov4868 found the racist. "What do you expect from Italians" 🙄 holy shit dude You knew a guy who was 2nd generation, so based on what he said as an offhand comment, 'all Italians" are like this. Wtf. This is exactly like having "a friend who's black" so now you can say all sorts of shifty stuff. Get that crap out of here. This was one airport. There was miscommunication and people who were used to the area. It shouldn't have happened like this but it's not cause they were Italians. Shit like this happens all over the place. Go watch a video about nuclear accidents where workers got complacent and stopped following safety procedures. Russia. Brazil. America. People getting complacent is a humanity thing, not an Italian thing.

[@andreypetrov4868]

@@annedavis3340 I was not talking about nationalities but Italian engineering culture or management style instead. It is nothing to do with what kind of blood is in your veins but more related to location. I work with engineers from India, Nigeria, Pakistan, Vietnam (some of them are extremely smart and talented) - ask them why they left their countries - it is all about local management style and engineering culture. I don't know if it can be clearer than that.

[@jamesengland7461]

It took 36 minutes for the fire crew to reach the fire, and then they quickly put the fire out. Yeah, because it had probably consumed most of the fuel by then.

[@Dowlphin]

This was also a powerful statement on the power of fog and how we should treat it accordingly. As a pilot I'd double- and triple-check to make sure everything is communicated clearly before entering a runway that I cannot see along. You are almost literally moving about blind, trusting an ATC who has no visual either, and all based on radio comms with complex terminology easy to confuse. Imagine if the Cessna pilot at some point had simply given a status update to the ATC, stating clearly where exactly he is right now. Like: "About to enter runway soandso from access point soandso, please verify that runway is free."

[@jamesengland7461]

@@Dowlphin absolutely! Even driving a car, I've many times suddenly come upon fog so thick I can't safely maintain 30 mph.

[@nomore6167]

@@Dowlphin "Imagine if the Cessna pilot at some point had simply given a status update to the ATC, stating clearly where exactly he is right now" - He did. In the video at time index 15:43, the Cessna Citation pilot told the ground controller he was approaching Sierra 4. The controller was unaware of that marking, so he didn't know what the pilot meant and thus asked the pilot to confirm position. The pilot replied "Approaching the runway...Sierra 4". At that point, the controller knew that either 1) he aurally didn't understand what the pilot said, or 2) he didn't know how to interpret/process what the pilot said. Despite that, he simply disregarded what the pilot said and told the pilot to continue on the main apron rather than telling the pilot to hold position until the controller could determine exactly where he was.

[@Dowlphin]

@@nomore6167 Thanks for pointing that out. I got a little confused by all the explanations of markings myself. Or maybe I wanted the pilot to ask for confirmation right before entering. Probably that; not sure now. Entering a runway is the most crucial during bad visibility and should always have a separate confirmation.

[@nomore6167]

@@Dowlphin I had to rewind and re-watch quite a bit of the video multiple times to process/understand everything because my brain kept saying "that doesn't make sense" or "how is that possible?!?" It's astounding that an active airport was so deficient and lax regarding safety. Also, to me, someone not involved in aviation in any way, it's difficult to imagine any valid reason for anyone to cross an active runway, especially in poor visibility.

[@umpbumpfiz]

This is the sort of situation that still makes me anxious, with the benefit of having watched a bunch of videos posted by pilots. Even with amazingly skilled pilots and meticulously engineered planes, even with crackdowns on bogus parts and better understanding of weather phenomena like icing and microbursts... shocking sloppiness in the ATC tower (which must be rare) and lack of maintenance on the runways kills people.

[@claudiuspulcher2440]

I'm confused that ground control kept planes moving when they knew there had been a severe incident yet didn't know what was going on... why not order everyone to hold position??

[@TheStephan262]

I think one of the most damning things about this disaster was the fact that the airport had bought a new ground radar system but not installed it, citing 'technical reasons'. The new system was installed not long after the accident.

[@californiahiker9616]

Funny, how fast you can solve “technical issues” when “no can do” is not a choice! Glad some of these folks ended up with jail time!

[@marhawkman303]

@@californiahiker9616 and technical "issues" are often just "we don't know how to do it right".

[@Sinvare]

They couldn't install a light switch for the stop bar. It probably did take them the 5-6 years to figure out how to open the box the radar parts came in.

[@Aikisbest]

Us humans in a nutshell, we really really dont like doing things that take more effort than we are comfortable with, even if said thing is absolutely vital.

[@marhawkman303]

@@Aikisbest and people will use selective logic in deciding if something really "needs" to be done.

[@vishakhk8156]

Pilot in the md 87 pulling the left engine reverses, such fast reaction in such a critical condition, its just outstanding and mind blowing. They did everything the could. However this is a sad news.

[@NicolaW72]

Yes, indeed.

[@lightwalker222]

I bet they pulled both engine reversers to try and slow the aircraft, only the right engine was not exactly responding

[@itellyouforfree7238]

@@lightwalker222 exactly

[@marhawkman303]

@@lightwalker222 I suspect this reaction was part of their "Oh Shi---" when they saw the other plane. They knew they had 0% chance of takeoff, and that there was two possible outcomes. flaming wreck... and worse flaming wreck. Limiting the damage done was their only viable option.

[@Julia-nl3gq]

@@marhawkman303 No, it wasn't their only viable option. They could have easily simply not cared which type of flaming wreck it was, since, either way, they'd be dead. The most common reaction would be to not care. But they cared. On the verge of their own deaths, they still though of others. They chose to care. They chose, even at that moment, to think of others. That's amazing. They saved lives. It is very sad that they died, but hopefully their loved ones took some consolation in the amazing thing they did.

[@Shadowfax-1980]

This reminded me of the TF Greene Airport runway incursion that occurred many years ago. In that instance, it was a foggy night and a plane got lost and ended up back on an active runway, but what compounded the situation was an impatient tower controller that was clearing other planes for takeoff despite the lost plane saying they were on an active runway. Thankfully another pilot stood his ground when given takeoff clearance which probably saved many lives. It would be a good topic for a future episode.

[@Powerranger-le4up]

That occurred two years before the Linate disaster.

[@metalgearsolidsnake6978]

Spiderman into SPIDERVERSE< yes SAS is bad

[@J-Rod91]

Damn! The way you explained how the pilots avoided killing so many more innocent people, in the terminal and loading onto planes, with their final inputs hit me in the emotions. Got my eyes watering thinking how they saved so many yet couldn’t save their own lives or those on the flight with them.

[@daffidavit]

The work that went into the production of this video was "first class". It's absolutely amazing how these sad events were so accurately depicted in such a professional way. Honestly, as a GA pilot for over 50 years, it boggles my mind to consider the complexity of what professional pilots must go through on a daily basis. It's not always an easy and glamorous job.

[@kommandantgalileo]

god, the flight crew of the SAS flight did all they could do, die and still saved lives, at least their deaths were not in vain, what a way to go. God bless their souls.

[@MentourPilot]

Absolutely true!

[@tomriley5790]

Yes they did everything they could. So sad.

[@randyogburn2498]

Absolutely terrible that what amounts to neglect played a huge role in this tragedy. The Cessna crew obviously paid the ultimate price. But I can't help feeling the poor decisions by the airport authorities should result in some jail time at least.

[@liamkiney4124]

From Wiki: "On 16 April 2004, a Milan court found four persons guilty for the disaster. Airport director Vincenzo Fusco and air-traffic controller Paolo Zacchetti were both sentenced to eight years in prison. Francesco Federico, former head of the airport, and Sandro Gualano, former head of the air traffic control agency, received sentences of six and a half years. In the appeal trial (7 July 2006), Fusco and Federico were discharged. Another four people were sentenced. The pardon law issued by the Italian Parliament on 29 July 2006 reduced all convictions by three years. On 20 February 2007 the Court of Cassation upheld the decision of the Appeal Court."

[@probusexcogitatoris736]

This is what happens when you let corruption into your society. Many parts of Italy are hopelessly corrupt. This is not a "single bad apple" situation. This is a matter of a rotten society.

[@natashamilosavljevic6458]

The Cessna crew made as many mistakes as the airport and shouldn't even have landed there if they followed the rules. The ultimate price was payed by Scandinavian Airlines passengers and crew, who had done everything by the book and then died because of the insane amount of mistakes and negligence done by both the airport and the Cessna crew.

[@tomriley5790]

@@liamkiney4124 so the airport directors served 2 years? That stinks of corruption.

[@randyogburn2498]

@@natashamilosavljevic6458 yes the Cessna crew used exceedingly bad judgment. They also paid for their errors with their lives.

[@nutsbutdum]

It's as if everybody at this airport were doing everything they could in order for an accident to happen. Nothing was left to chance.

[@MattyEngland]

Welcome to Italy lol

[@CiaranMaxwell]

I have to agree. If they tried to cause an accident any harder, it would've become a purpose and not an accident.

[@NicolaW72]

Yes, indeed.

[@tatianasusu5468]

GirbCs cancel today I will be at this point today

[@stevencooke6451]

That is the one thing they worked hard at doing.

[@cryzz0n]

I remember this vividly. As with any accident involving SAS, this was major headline news here in Denmark (and all of Scandinavia I suspect) for weeks after it happened. People were properly mad at Linate Airport and the Italian authorities for a while.

[@Sunsmasher1]

I love your very informative videos and the value of your comments from the viewpoint of a professional pilot. Thank you very much!

[@dranze2020]

I am an Anesthesiologist. The importance of communication and a universal language and signs for every field is made crystal clear in this video. Your efforts at animation are awesome sir

[@70AD-user45]

Unusual word, anesthesiologist. It is to with using anaesthetics in intensive care?

[@dranze2020]

@@70AD-user45 It's a very common word in world of modern medicine.yes it means those who use Anesthesia techniques in anywhere, be it operation theatre , critical care, etc

[@70AD-user45]

@@dranze2020 I recognise the word from the Greek, meaning "without feeling". I know some Greek which I believe is the language of medicine.

[@marhawkman303]

@@70AD-user45 Well yeah, that's the point of Anesthesia. To prevent patients from feeling pain while a medical procedure is done.

[@Strathclydegamer]

@anz s There’s a very good video called “just a routine operation” that shows how aviation CRM can be applied to medicine. I was shown it as part of my Ambulance Technician training, well worth a watch.

[@robotportachiavi2507]

this episode is particularly important to me. I'm Italian and I fly in the skies over Milan a lot. When the accident happened I wasn't even born, but a neighbor of mine died that day. It is pretty shocking just thinking about it

[@MentourPilot]

Thanks for viewing.

[@quasimoto4424]

@@MentourPilot How can your neighbor die if you are not even born?

[@jackielinde7568]

@@quasimoto4424 If I had to guess, the poster's family (not Mentour Pilot's) was living next to the family of one of the victims. And, it's possible the poster's mother was pregnant with the poster at the time of the accident.

[@philhughes3882]

@@quasimoto4424 - That’s a bit pedantic mate, - unless he’d been fiddling about with The Space Time Continuum, we all understood what the OP meant.

[@donaldstanfield8862]

@@philhughes3882 Wankers everywhere!

[@PilotBlogDenys]

New video! Yay! Safe Flights to everyone! Stay Awesome ❤✈

[@MentourPilot]

Thanks for being here Denys! I hope you too are safe and well.

[@cupofjoen]

Just came from Denys' video on DHL incident.

[@PriHL]

Same here, from the DHL incident :) Comes just right as I'm just binge watching your videos, there's another one and on an accident I wanted you to analyse! Keep up the great work, your videos are awesome!

[@Joostdw]

Team up with Denys for a aviation related video ? Stay safe Denys

[@NicolaW72]

All the best wishes, too!!!

[@autumnleaves2766]

Thanks for another excellent presentation. I was living in Italy when this crash happened and remember it well. Astonishing that Linate didn't have a ground radar system in an area of Italy which is often very foggy in winter. Sounds like there had already been near misses due to runway incursions. This really was an accident waiting to happen. The SAS pilots are heroes for still managing to steer their stricken plane away from the terminal building and apron.

[@mediocreman2]

This tragedy reminds me of a phrase I have heard many times over the years from various people. Well it's more of a concept than a phrase, but it's basically that since nothing bad has happened yet, that there is no reason to change what we're doing. For example, someone that never wears a seatbelt in a car might say "I haven't died yet!", or someone that texts and drives that says they haven't had a crash yet. They associate a lack of catastrophe with safety. There are plenty of other examples that aren't safety related. It has always seemed odd to me that people assume they'll always be the statistical anomaly. But the odds are working against them.

[@vk2ig]

During my career I've had people try the "nothing bad has happened therefore there's no reason to change what we're doing" excuse for not doing anything. My response is "Have you conducted a hazard analysis followed by a risk assessment, and identified if the existing controls mitigate the risk So Far As Reasonably Practicable (SFARP)?", which is the law in my country. One particular case comes to mind, where the response was "We have 1,000 of these out in the field for five years and no-one's dead yet", to which I asked "OK, how many were actually operating for the full five years, as opposed to sitting in storage or powered down, being rotated through the maintenance pipeline, etc?" They couldn't answer that, which immediately blew a hole in their "no accidents in 5,000 operating years" statistic underpinning their safety argument.

[@puellanivis]

What blows my mind is that people still tend to not learn from the close calls that they experience either. As noted in the video these sorts of incidents were a regular occurrence at the field, but no one bothered to treat any of them as a full incident and follow an investigation with recommendations to resolve the issue. In a similar way, when I first started riding in an automobile with my now-ex, at-the-time-boyfriend, I kept getting _really_ upset about how close we were following other cars. One time, he even had to drive out onto the apron to avoid a collision, and he was like, “wow, if you had not been harping on me about following too close, we would have been in an accident!” And I was like _we actually did just have an incident!_ I tried to explain to him that he was still following too closely, and that his driving out onto the apron to avoid a collision demonstrated conclusively that he had been driving too close. Ahead of all of this, I had been riding a motorcycle for 5+ years in all weather conditions (yes, in snow, five times, I highly don’t recommend it) and so I had a habit of safety drilled into my head, because almost _any_ crash would have been a disaster for me.

[@Shadowsearcher64]

Safety regulations are written in blood.

[@insertcognomen]

would the phrase you're looking for be if it ain't broke don't fix it?

[@fuzzblightyear145]

Cost cutting, laziness and arrogance - perfect recipe for a disaster

[@MatecaCorp]

I think it’s absurd that they don’t have universal protocols to just immediately halt all non-emergency movements in the airports the moment a severe emergency occurs in the airport area

[@PascalBrax]

Protocols? In Italy?!

[@bratpive6955]

I watched all accident analysis of this channel, because they are so well done as to expose the facts in a simple and chronological order with a careful although respectful method. As a scientist, this appeals to me and I regarded this work as a little jewel in the internet "diversity". I never thanked you and the makers of these videos before, but today I must react on the huge and excellent work on this one, for fitting the numerous facts to the official report conclusion and also on the incredible visual plans and 3D scenes. Aviation documentaries scenarized for the television are so bad compared to your work, in which you enrich the intelligence of your audience in a humble way. This respect bears a touching tribute to the unfortunate victims and will also contribute to improve the security of flying.

[@MentourPilot]

Thank you! It really means a lot to hear that from a member of the scientific community, a community who always strives for the highest standards. We do our best to make sense of the unthinkable and to show just how much it takes for these horrible accidents to happen.

[@bigbrownbagofcash]

I agree 100%. I am not a scientist, but work in construction and have done airside work, including being involved in the planning and execution of airside building extensions and lighting upgrades. Having experienced proper systems and controls for our work, the approach of this airport is hard to believe. The way these videos are put together, the calm and factual presentation and the depth of knowledge is a testament to the team who works on them. I will listen to a knowledgeable working pilot/captain discussing his industry from a point to knowledge any day over any “influencers”

[@marc-andreservant201]

Any workplace where you're responsible for thousands of lives per day, and your boss threatens to fire you if you complain against unsafe procedures, is an accident waiting to happen. We wouldn't accept such a culture of silence in heart surgery wards or in highway engineering, yet a mistake in such fields can only kill people one at a time.

[@aesaphyr]

I agree with you however unfortunately I have to point out that in the UK where I live (and work as a doctor) we have no whistleblowing protections if we see unsafe practices in hospital. Look up Chris Day (ICU doctor) or Claire Connolly (paediatric A&E doctor), they lost their jobs after speaking out about unsafe working conditions - but unlike most others they fought back - so that's why we know of them. Chris Day is still in a court case over this and it's been nearly 9 years. But if you want to see situations where the whistleblowers were just fired and malpractice continued, look at the many, many reports out there on units that have been doing this for decades. Shrewsbury maternity scandal (1400 mothers and babies dead or permanently disabled), Gosford Scandal (400 killed by inappropriate painkiller prescriptions), Bristol Inquiry (dozens of babies dying because of dangerous conditions in a surgical cardiac unit), Morecambe Bay Scandal (multiple babies dying due to institutionally poor care) and so on. You get the picture: unfortunately it is the same in hospitals (in the UK at least) as it is in airports. There is no safe whistleblowing culture. Junior doctors have been begging for this to change for years now. We'll be taking industrial action again soon over this. (We did in 2016.)

[@Matt_Barnes]

"No matter what, fly the damn plane." And that's what those MD-87 pilots did. Airmen to the very end. Tragic, but I'm grateful there's as much emphasis as there is in the industry on making the best decision possible, even when there aren't really any good options to be had.

[@bmjpdx9222]

And the MD-87 might had made it, but the left engine power dropped due to debris ingestion.

[@sacrilegiousboi978]

It’s mind boggling that an accident like this was even possible at a busy airport in a first world country as late as 2001.

[@papegoja4]

Italy hardly classifies as one, it’s a third world experience at first world prices. That they hadn’t fixed the issues for years is very on brand, it is the same in Italy today in 2024 at least outside of airports.

[@giulia480]

​@@papegoja4if you think Italy is third world you haven't seen much of the world

[@TJTurnage]

I am pausing here at just four and a half minutes into the video and shaking my head over the sheer number of contributing factors that already seem to be in place.

[@seriouscat2231]

A sure sign of Italian inefficiency. Many other nationalities could have done the accident with far fewer contributing factors.

[@itellyouforfree7238]

@@seriouscat2231 nice one

[@MikkoRantalainen]

6:00 Did I understand this correctly? The red stop bar lighting was diagnosed broken in 1998 and it was still not fixed at the time of the accident? I would understand such problems to exists for a couple weeks in worst case. And in case of broken lights, I would expect the airport to be automatically closed in case of fog because of being unable to execute the tasl safely. If the airport were closed every time there was fog, maybe they would have considered fixing those lights a bit more important?

[@AlessandroGenTLe]

I used to work (for 2 years) as a project manager (private, consultant) for an important public institution. I ran away from them as there was constantly no "due date", no "action" if the time was not respected (and reported to managers), and situations like "So, have you did the meeting with the project sponsors? - No, they were a bit busy, so we rescheduled it in ONE MONTH...". So I'm not surprised at all of this crazy behavior. I've worked for private companies too, big ones, and such behavior would mean being fired within 3 months... But that's public, and none is ever been fired, so everyone does the absolute minimum and "who cares"...

[@jwenting]

@@AlessandroGenTLe Correct. Even worse, nobody can get fired and they all get automatic promotions based on the number of years of employment in most government agencies. All part of the juicy union controlled contracts. No accountability, no incentive to go beyond the bare minimum to be seen to be doing your job, no consequences for messing up. And if someone does mess up, it gets blamed on some contractor brought into the team to do the actual work.

[@mangos2888]

@@jwenting That only happens in law enforcement union contracts, not anywhere else.

[@jwenting]

@@mangos2888 nope, it happens in most all government employee contracts. Here it certainly does, and in other countries as well.

[@knuckleburger]

Yah, I had to rewind and hear that a second time, in disbelief that I 'thought' I'd heard nineteen ninety eight.

[@fredashay]

Using terms like "main runway" and "main taxiway" is problematic as well.

[@itellyouforfree7238]

not if you start your sentence with "buongiorno"

[@rolandbogush2594]

How very sad. A colleague of mine died aboard the SAS jet. A completely avoidable accident. Thank you for explaining it so clearly.

[@CzechMirco]

That was not an airport, that was a circus.

[@papaquonis]

I remember this vividly. As with any accident involving SAS, this was major headline news here in Denmark (and all of Scandinavia I suspect) for weeks after it happened. People were properly mad at Linate Airport and the Italian authorities for a while.

[@tomriley5790]

Quite justifiably.

[@itellyouforfree7238]

and what about the two Kartoffeln I pilots operating below minima?

[@NicolaW72]

@@itellyouforfree7238 I think you mean the two German Pilots of the Cessna. I have my own theory of what was going on in the Cessna Cockpit and I published it here somewhere in a comment. But unfortunately the Cessna wasn´t equipped with a CVR , so we will never KNOW what exactly happened inside of this Cockpit.

[@HattoriHanzo62]

An ex colleague of mine was supposed to be on the SAS flight, but he was required in office to deal with a situation and didn't show. He was shocked...

[@MentourPilot]

I can imagine..

[@Hans-gb4mv]

Sometimes, a situation like that can also become very taxing on people who have experienced such an event, feeling guilty about surviving something that they shouldn't have.

[@atzuras]

That's a lifetime worth of luck.

[@IceHax]

@@Hans-gb4mv final destination

[@larryroyovitz7829]

Yeah, I'd say he'd be shocked. Shocked might not be strong enough of a word.

[@getyoursupervisor8519]

At the time I was flying the first CJ2 in Europe, just 10 serial numbers ahead of D-IEVX (26 vs. 36) and I knew the pilots. I was asked to do this flight, but couldn´t as our aircraft was already chartered that day. I also was - and still am - a regular to Linate... I have complaint many times about the signage on what is now K taxiway. Often the signs are half overgrown by grass. As one consequence, K (former R6) is an exit only taxiway (oneway) now and we always have to taxi northbound first with a follow me (which leaves as soon as one is on the R taxiway) That accident gets to me every time I see it mentioned...

[@californiahiker9616]

Isn’t there an entity that inspects airports and their procedures? I’m not aviation connected, so I really don’t know.

[@getyoursupervisor8519]

@@californiahiker9616 That would be the national aviation authorities - most countries (if not all) have signed with the ICAO and more or less mirror what is laid out in ICAOs manuals. National differences (eg. in signage) are published in the national AIPs. BUT: having procedures and manuals does not guarantee that these procedures are followed. I have my own little theory here: we have so much overboarding stuff in our regs, that people just can't and won´t cope, thus the really important stuff sometimes slips. Plus - in this case - I regard Italy as not as a country were following rules and regs is the most important thing. Live and let live is practiced a lot. Has its pros and cons.

[@mangos2888]

@@getyoursupervisor8519 Consumer Protections are never the problem. As is the case in many industries, those rules are written in [victims'] blood.

[@NicolaW72]

I can imagine this.

[@nandoorru6002]

I had flown for 39 years as pilot (16 Italian Air Force an 23 commercial airline). I don't understand because the Cessna Crew continue the approach and landed with weather condition below CAT I and they departed in the same condition.

[@wazeFPS]

This story hits really close to home because growing up one of my best friends, his father was the customer in the plane and he passed away. It feels really morbid watching this knowing the victims family so closely

[@cancan-wq9un]

This reminds me a great quote from another great Captain: “Sometimes you can do everything right and still lose. That’s now weakness, that’s life.” - Captain Jean-Luc Picard

[@mrpbia]

I remember very well this tragedy: at that time was flying back and forth to Milan twice a week and quite always from Linate early in the morning. I could have been on that SAS flight. Thank you for bringing back this to our memory. Not an expert here, but have always asked to myself how has it been possible that such a foggy airport has been cleared to handle traffic in such low visibility conditions without having clear runaway indications, fully functional lights and a ground working radar! This, out of all, is imho the main cause of this accident!

[@NicolaW72]

Yes, indeed.

[@samin_taekwondo_pilot]

I love this video dear captain 😍💝 And I'm samin and I'm girl and I'm 13 years old and I'll be pilot 🥰 I very very love pilot job and i hope i can be one good and famous pilot ♥♥♥

[@ceebeegeegee8293]

You don’t have to be famous to be appreciated as a pilot, Samin. Being a safe pilot will be enough. Best wishes to you.

[@samin_taekwondo_pilot]

@@ceebeegeegee8293 Thanks for your comment

[@ashleyc8373]

Doubtful. Very doubtful.

[@kunalsingh4418]

​@@ashleyc8373 never got this. Why do women enjoy pushing down each other. Shouldn't u be motivating this girl? So pathetic.

[@angelapuzzle]

I hope you can be a great pilot :3

[@d8889]

I have been working for almost 25 years in the civil aviation field in Italy. Even today, after such a tragedy, it's unbeliavable the amateur management, the lack of knowledge of the english language and the arrogance of believing themselves fully capable of managing situations of great responsibility shown everyday by whoever preside over air traffic in my country. Because of my job I had several occasions to deal with realities of foreign countries. Inno case have I ever encountered such a low level of professionalism as in Italy, but if you try to criticize certain situations you are either marginalized or worse, fired. Does anybody know that the mandatory minimum number of qualified personnel assigned in any main airport to fire-fighting vehicles is only 2 units??? The remaining needs can be covered by volunteer personnel who have received only a very limited training on the management of airport emergencies!!Geez, a short time ago I was kind of joking with a colleague of mine: should my plane crash, I hope it'll happen somewhere else. Kudos to the SAS pilots.

[@materliliorum]

sorry to tell you that it's not the case in Italy only, but in most countries, especially but not only of the former Warsaw treaty area. I can't help remembering Eschede in Germany and Grayrigg in the UK. I thought they had improved processes in Germany at least but then came Schäftlarn.

[@pepplund1]

Thank you @davide for pointing that out

[@piwex69]

I lived for several years in Italy and quite frequently (3times a month) I had to fly from Trieste to Linate and back, for work. I have never heard about this incident before, had I known I would have requested to book Malpensa more often. When deviated, it gave me +1 hour and 120 EUR to the morning trip to work once.

[@sweetcarbine]

@@materliliorum it is the case in italy only, we you land in Italy you expect European professionalism and infrastructure but what you get is complete mess. Responsibility is a word that doesn't mean anything there. I am sure people would be blaming passengers for buying flight tickets and then getting into an accident.

[@materliliorum]

@@sweetcarbine just as they do in Poland and in Britain

[@BillMikeKenya]

Amazing story! You have no idea how the lessons I take from these stories are impacting my work and the work I do is nothing near the aviation sector

[@Aircraft1606.]

0:01 Intro 0:30 The Central Airport 2:53 Unorthodox Taxiway 4:24 Taxiway Lighting 7:08 Incoming Cessna 9:20 MD - 87 Requests Start - Up 10:53 Both Aircraft Underway 13:36 Miscommunications 15:01 Another Witness 15:43 Perceptions 16:38 Recap 17:20 Not Where They Should Be 19:41 Cleared For Takeoff 22:03 The Inevitable Happens 24:29 It Sounded Like An Explosion 25:53 Delayed Response 27:29 Initial Findings 29:17 Closing Statements

[@bepowerification]

Watched a disaster breakdown video about this the other day and it was good and interesting. But then I see this and I know I am gonna watch the best video one can create about this incident.

[@gerryino]

I was just thinking about it this morning. I live near Linate and I just passed by the memorial of the victims

[@youtubestolemyusername3419]

I have watched all your videos and this is by far the most disturbing. The amount of mistakes in the airport is mind-blowing and to them it wasn't even mistakes, just normal procedure. Wow.

[@mkgvlc4]

Italy...

[@marcobassini3576]

@@mkgvlc4 Yes, like the GERMAN pilots of the CESSNA that were NOT authorized to fly in foggy weather and nonetheless decided to ignore their incompetence and fly anyway...... They were also incompetent to taxi on the ground since they took the wrong taxi way, ignored a red light and crossed the main air strip ..... Germany .......

[@Davide0033]

as an italian, italy in a nutshell

[@icksv5529]

I'm Italian and I remember very well that day and the news on TV. I would like to add some extra to this tragic event: - Investigations found out that Linate Airport didn't have a "land radar". According to the news this would have avoided the incident (not sure if is true, just what the news stated) - There was one survivor, Pasquale Padovano, a SEA airport employee. He was in a coma for 4 months and underwent 108 surgeries - Viviana and Simone, 30 years old, were a newly wed couple. Originally they had planned a travel in Egypt, but changed their minds cause they thought Egypt was not safe. Just two days before their wedding celebration, they were traveling to Copenhagen for their honeymoon. - Court verdict. The fourth criminal section presided over by Mariano Battisti confirmed the acquittal against Vincenzo Federico, former director of the Milan airports area, and Francesco Fusco, director of Linate airport. Instead, the sentences for Sandro Gualano (6 years and 6 months), former CEO of ENAV (air traffic management), and radar man Paolo Zacchetti (3 years) become final. The one who risked the most with the court's decision was Fabio Marzocca, former ENAV general director who plea-bargained 4 years and 4 months on appeal and asked for foster care. Confirmed 3 years' imprisonment for Antonio Cavanna and Lorenzo Grecchi, former SEA development and maintenance manager and airport resource management manager, respectively.

[@alice20001]

Everything that happened sounds exactly like trying to do business in Spain. 80 different people having overlapping responsibilities that everyone assumes the other group will do so it is never done... This time it actually cost lives.

[@tepan]

When you feel constantly obliged to compensate for the dysfunctionality of the others and the architecture you have to work with, you become sooner or later part of the problem, until you literally cross a red line. Very sad story. Thanks for the video. Good work, as always.

[@mapleext]

Yes, Dysfunctional is the correct word for this - so sad

[@materliliorum]

Exactly so, but it's not about feeling obliged, but being obliged to do so. I'm admirative of people that keep complying and doing their best in order to avoid a catastrophe

[@sweetcarbine]

@@mapleext this is the normal way of working, repairing something would need paperwork which is so boring for some.

[@NicolaW72]

@@mapleext Yes.

[@nirppa100]

Can't believe this airport was allowed to operate like this for so long... Great video!

[@georghaupftink7372]

Great as ever. Couple of thoughts: - shouldn't there be some sort of worldwide airport police, which flies around randomly and everywhere reporting on egregious and just dodgy features in airports, i.e. in this case the red stop bar lights? - And what about all the pilots who went along with this red stop bar lights thing? I presume they just had no-one (i.e. no authority) to report to. What would happen now if something similar was spotted by a pilot when flying into and out of an airport in a country with very poor regulatory standards?

[@larnregis]

Looks like Pilots have a better chance to enforce a change by making a social media post than actually finding an authority to which they could report the problem.

[@MGower4465]

Many countries have something like a civil aviation administration, but many have no real teeth to enforce anything, and others are corrupt. You already have a team of rovjng experts - the pilots. They just know if they bother to say anything, the best they can hope for is nothing happens. If the airport bosses are connected, the pilot(s) could be retaliated against. Janes Gordon, in Batman Begins: "In a town this bent, sho is there to rat to, anyway?"

[@tomriley5790]

There kind of already is as I understand it for countries to operate international flights between each other they have to satisfy each other's equivalent of the FAA/CAA/EASA, if they don't they're not accepeted, the standards required are set by those bodies - for this reason there are no direct flights between some countries (IIRC Pakistan is one) and Europe or the US.

[@cortex333]

@@larnregis nope...they would be pushed out ..just like any job where if you say something they hate u out...I think there should be an International Airport Police just as he said! Independent from all airlines and airports, so they can feel safe to report!

[@giftofthewild6665]

There are regulators. I don't know how thorough their checks are or whether they do unannounced visits to airports. The regulators should have noticed the situation in Linata before this accident happened but I guess they weren't doing their job correctly either

[@LawpickingLocksmith]

I had an offer of a free flight out of Linate. My inner voice told me to reject it. Malpensa is the large international business airport of Italy. Unfortunally they are struggling to handle what others call average. Thanks but no thanks, I drive my car in Italy!

[@ChaJ67]

That is some tremendous restraint when talking about what happened at this airport. The sad thing is I can totally see this happening in Italy. This is just the time it ended in disaster. I am sure you have been in Italy many times, especially with your job, so you know what I am talking about, yet you maintain your professionalism about it.

[@TimothyChapman]

TL;DR: Corrupt airport management created a ticking time bomb. I would like to think that one whistleblower could have prevented this from happening, but I know from other instances of corruption that whistleblowers are often not given a platform to speak on. Was anyone ever held accountable for this criminal negligence?

[@DERP_Squad]

Airport director Vincenzo Fusco and air-traffic controller Paolo Zacchetti were both sentenced to eight years in prison. Francesco Federico, former head of the airport, and Sandro Gualano, former head of the air traffic control agency, received sentences of six and a half years. On appeal Fusco and Federico were found not guilty. Four others received minor sentences for their involvement. It strikes me that those who put the holes in the Swiss cheese didn't have to answer for their negligence, and those who were a cog in a broken machine ended up being held responsible. That isn't to say the ATC did nothing wrong, but that the accident was able to happen wasn't his failure alone, and that it could happen was the failure of the airport management and government inspection agencies.

[@levanataylor790]

@@DERP_Squad That's enraging. :-[

[@stomponpie]

@@DERP_Squad i agree. It's hard to understand how the air traffic controller contributed enough to justify prison. The mistakes made were understandable ones, and at any other airport wouldn't have lead to a crash.

[@tomriley5790]

@@DERP_Squad it sounds to me very like the airport management and the government wanted to be able to move things in and out of the airport without anyone having too much notice taken (a bit like the cessna).

[@itellyouforfree7238]

@@DERP_Squad this is the typical italian culture of systemically breaking the law at a high level and let poor workers pay the price

[@EpicJoshua314]

Great video! Completely messed up system at one of Europe's busiest airports and the fact that runway incursions had been going on for so long is unbelievable. Some people involved were criminally charged for this crash. Just one thing to mention, after the collision, the pilots and one passenger of the Citation remained alive but were trapped and died of burns and smoke inhalation. Had the Citation been found much sooner then they likely would have survived.

[@marcoliguori879]

Thank you for the video Petter! I was one of the people who asked you to make a video about this tragedy. As italian I am simply embarrassed. Such an avoidable accident! I well remember it. And you are right, the SAS pilots were absolute heroes! And great video from your side... As always!

[@maryeckel9682]

That makes this even worse. Damn

[@williamsstephens]

My God, that's horrifying.

[@filanfyretracker]

even worse is that the tower on someone reporting they heard explosions probably should have hit the oh shit button and ordered the FD to the runway without question or pause.

[@NicolaW72]

Indeed, exactly.

[@vvforme]

Wow! By the way, I’m neither a pilot nor an aspiring pilot, but I really appreciate your channel. I’m merely a (once) fearful flyer. But my work requires me to travel a lot, and your channel has taught me that every disaster comes with lessons that make aviation safer. And that makes me feel much more confident every time I board a plane. So, thank you! Keep up the amazing work!

[@Eyeofthemourning]

The ones who ran the airport IMO are fully responsible. They made the decision to still keep the airport open despite no ground radar or properly working taxi lights. They were essentially being cheap and had everything together with "duct tape". Those decision makers should've gone to prison.

[@giulia480]

They did get prison time. The cessna shouldn't have landed nor restarted though and additionally took the wrong taxiway eventhough they knew the airport well

[@anthonyglee1710]

I remember flying into Linate shortly after this incident. The baggage handling building destruction was chilling to see as we arrived. On a side note my company’s daily internal paper mail was routed from London to Linate and was often delayed by fog at Linate.

[@bluesfun]

As an Italian I sadly remember this accident very well. I just would like to add that not only all passengers and crew members perished in this accident, but also four airport workers inside the building. Only one man survived, Pasquale Padovano, who suffered extreme burns all over his body. Thank you Petter for your great videos, they help to understand how these terrible accidents always lead to improvements to the safety of the aviation world.

[@thatLukeKneller]

it was mentioned in the video that 4 workers also perished

[@tedwalford7615]

The Citation should not have even been there. Had the Citation's pilots not violated rules, landing below their qualified minimums, they and the others would have lived. Yes, there were a multiplicity of factors, but this one was a willful violation.

[@tomriley5790]

Yes it makes me wonder about a couple of things, whether the crew knowing they shouldn't have been there kept quiet and didn't question things that they might have done leading to persistence of their mental model, or alternatively whether the airport was poorly maintained for a reason - either corruption or smuggling, it does seem to have been a place you could get in and out of without too many questions being asked.

[@MentourPilot]

Correct, that’s where the chain started

[@MatthijsvanDuin]

At the same time, it's not obvious this accident would have been avoided if the aircraft and crew were qualified for cat.III operations. The same confusion could still have occured, and indeed the final report discovered multiple recent runway incursions due to pilots confusing taxiways R5 and R6. The situation at this airport was simply a ticking time-bomb.

[@NicolaW72]

@@MatthijsvanDuin Yes.

[@perry4003]

I remember the horror I felt when on the telly was shown 'breaking news'. Los Rodeos tragedy came to my mind straight away mainly because of the fog. Of course it wasn't just that. As usual the chain of events it's the cause of it all. So sad. As ever, great video Captain ✈️

[@MentourPilot]

This is very true.

[@russlehman2070]

Both accidents featured fog, miscommunication and a runway collision involving a plane taking off. Lots of similarities, though the details differ.

[@rahulnair3463]

What amazing quality of video and explanations you have given Sir.. Hats off !!!🙌🙌 Scandinavian pilots showcased an amazing skill of quick thinking, quick action in just few seconds and they tried all their ways to protect the people. It is very sad that, those amazing pilot’s efforts couldn’t save their passengers. Yes it’s very true that the accident would have been more extreme without those pilot’s efforts,,,

[@GabelhelmSogarbraten]

This enrages me as a mechanic/electrician those airport lighting faults could have probably been fixed in a day by a motivated guy who just looked up how its all wired and where the issues came from I havent watched on so far but my guess is he probably wouldnt even have had to leave the tower for it because this sounds like faulty or defective wiring in some kind of control board for the operator since the actual lights seemed to work fine So if my guess is right id say i need about half a day to fix sth like that and yet theese people just let dangerous conditions carry on in a place where mistakes can cost lives? Thats why i dont like working around lazy people, it doesnt just cost them...

[@aneeshbarracuda]

Goodness, there is absolutely nothing else the SAS crew could have done. Lives snuffed out due to unnecessary and horrible mistakes! RIP I applaud you, Capt. Your videos just get better and better. Cheers!

[@TheLastPhoen1x]

This is what happens when you keep malfunctioning equipment in use and just say "it's fine". Especially in such critical area as aviation where failure is not an option. The human error is a factor, but the whole system that was designed to catch and prevent such error was basically neutered.

[@Teh_Random_Canadian]

That entire airport was a gongshow. Only a matter of time before an accident happened with that lack of professionalism and maintenance.

[@NicolaW72]

@@Teh_Random_Canadian Yes.

[@NicolaW72]

It was not a failure of the system, it was the absence of a system.

[@johnstudd4245]

That is a frequent factor in many work place accidents of all different types. Then employees are blamed because they "should have remembered that was not working".

[@Boyso5407]

Exactly. They put all of these systems in place in order to avoid an accident yet when the equipment fails no one bothers to fix the problem. It’s just common sense

[@wobblybobengland]

I read that they had a ground radar system at Linate when this happened, in a cardboard box in a store room.

[@lassehaggman]

Yes. This report was pretty scathing, but still too kind. The whole criminal, hapless airport should have closed down.

[@talesfromunderthemoon]

@@lassehaggman closed down, torn down, and replace in somewhere else where fog won't bother that much anymore.

[@francomccarnevali]

Unfortunately it condenses in one short, tragic video, the state of Italian affairs ... Corruption, fear, lack of control, all contributed to this very avoidable incident ... Sad to see how a bunch of politicians have transformed a nation of Artis and skilled worker into an abomination.... And sad to see that things get rectified only after lives are lost (see Morandi bridge collapse) 😔😔

[@baldrian22]

i watched an episode on aircrash investigators (The name of the program in Norway is Flyhavari kommisjonen) your method to tell about the accident is quite different than how they do it. on their episode on the accident we dident realise how bad thing was that quickly but your way of seying in these storys makes red flags pop up ALL over the place specialy on this one.

[@IceHax]

My parents were returning from their honeymoon that day. They ended up stuck in paris for two days where they had a connecting flight to Linate, which was obviously shut down after the accident. Nowadays linate is the smallest of the three airports serving milan, Malpensa and Il Caravaggio intl. Are much more serviced.

[@NightMotorcyclist]

I remember this being pretty big news since it was almost a month after the events of 9/11 and then American Airlines 587 happened at JFK...

[@moneyfalcon267]

Sad thing is, this happened again in japan's Haneda airport

[@jenjenjennyful]

This was horrifying. I have heard of too many incidents, here at LAX, that were too close to being something like this. It’s amazing sometimes how everything just lines up horribly for these disasters to happen… but it’s also not surprising since there are so so many flights.

[@221b-l3t]

Almost exactly the same did happen at LAX. Landing 737 plowed through a regional jet. Surprisingly 2/3 made it out alive but the aircraft didn't crash into a building and it wasn't taking off, so easier to stop.

[@gmalcolms]

As an Italian I am both thoroughly enraged by the tragic and easily avoidable loss of life and also completely unsurprised. Like with everything in Italy.

[@seanmcerlean]

All good Petter. As i already commented on Patreon,i can see no problems here. Dreadful state of affairs, you can really see the holes lining up. Also understand this would be one close to home given the crew and passengers were swedish nationals. A clear case of never assume everything is the same, always check especially by the german guys. It also shows the importance of one standard language & phraseology for all RTF comms. RIP and condolences to all affected by this. Class complete.

[@MentourPilot]

Thanks Sean!

[@NicolaW72]

Yes, indeed. RIP.

[@gglovato]

One things are holes lining up on the accident model, what the Italians did is bulldoze through the cheese with a tunnel boring machine

[@seanmcerlean]

@@gglovato I guess that is one way of looking at it. A general lack of attention to internationally accepted standards and housekeeping. This accident forced them to put things in order.

[@Glegh]

Congrats on 1 million subscribers Petter 🎉🎉

[@MentourPilot]

Thank you!

[@nicatnight1777]

Hello, I have a question. Why don't commercial aircraft have small cameras mounted in the fuselage looking back at the engines? I have seen several videos of crashes where this would have been very beneficial.

[@johngerard4676]

This airport was a disaster waiting to happen - they had dodged the bullet a few times, but you will never dodge it forever. I find it incredible that an airport could be in such a horrendous state in the 21st Century.

[@ReikoTennosaar]

I love watching these videos on saturdays after going to the sauna.

[@kilozulu9990]

Looking at current satellite images of Linate it appears R6 is now one way traffic into west apron beyond 36L with a number of NO ENTRY signs and vertical signalization and GA aircraft need to taxi through north apron if they need to use 36R... It also appears 36L is now 35.

[@itellyouforfree7238]

correct

[@theagentsmith]

I live nearby Milan and remember the news very well. How a fog-prone airport could operate without a working ground radar?

[@lassehaggman]

I think the radar had been ordered and delivered and was there at the airport, but no one thought of getting it operational. The incompetence and negligence at the airport was staggering. The whole country should have been closed from international air traffic for ten years.

[@cowsgoloka]

@@lassehaggman The elected representatives are corrupt in most part of the world. By hook or crook they win. They never go in disguise in public places to check the competency of the public service or anything. But when they pass everything is made to look green by public servants. They should pass in public without announcements and protection convoy. Only Lord Ramachandra did the checking of the country in disguise.

[@jonathanparry9505]

Dear Mentour, thank you for your insightful explanation of these incidents. I find them very interesting.

[@jussikuusela7345]

From the point of view of an electrician... the problem with the taxiway lights and the red stop lights being unable to turn on or off separately, was likely caused by two wires being shorted together somewhere. Maybe a crushed conduit or an arc flashover form a lightning strike. And thinking of how much wiring there must be all over the place... I know it can be a hell of a job to troubleshoot, and really expensive to repair.

[@peregrina7701]

Thanks for the video Captain. I'm continually impressed that you can provide a very balanced account of these incidents. I hope this one gets regularly used as a case study for the Swiss cheese model. Further - hearing these stories of flight crews who use up their last moments in this life minimizing casualties always gets me right in the feels and makes me bawl. RIP.

[@Raymondgogolf]

Hi Beth 👋 I hope my comment didn't sound as a form of privacy invasion your comment tells of a wonderful woman with a beautiful heart which led me to comment I don't normally write in the comment section but I think you deserve this complement. If you don’t mind can we be friends? You can text me with my gmail on my profile Thanks God bless you….🌹

[@Highentaker]

from my point of view you reached TV - quality in your videos! keep the great work up!

[@MentourPilot]

Thank you for the kind comments. We always aim to raise the bar!

[@michaelbaron288]

Actually, this surpasses TV quality by FAR as this is a true documentary - not just made for entertainment purposes, like its "competitors."

[@strik3r2000]

Literally was refreshing youtube for this video!! Always something I look forward to on Saturdays.

[@MentourPilot]

Thanks for being here! 😃

[@waynemgtregear7228]

Any airport that won't upgrade their ground radar should be banned by all airlines until upgrade or replacement

[@fnkfauzan]

Bruh Is like Tenerife 1977 Airport Disaster Boeing 747 (PAM Am) & Boeing 747 (KLM) But different