WHAT caused these Aircraft to COLLIDE?!

the pilots of this md-87 is just lining their aircraft up for an early morning departure in milan the fog outside of the cockpit window is dense as they set take off trust and start accelerating down the runway as the aircraft start rotating they suddenly see a black shadow and an anti-collision light appearing straight ahead how was this possible a huge thank you to for sponsoring this video the terrible chain of events that led up to the lenota airport disaster on the 8th of october 2001 actually started many many years earlier and in order for us to understand it we have to go way back in the history of the airport where it happened there are three main airports that serving the city of milan in northern italy one is milan bergamo the other one is milan malpensa and the third one is milan lenot of which we're going to be talking about today milondinata is the most central situated out of this airport and it started its story back in the 1930s and then after the second world war it became more and more popular as the tourism industry increased in italy this meant that the airport went through several upgrades during the 1960s 1970s and also in the 1990s there are two runways in milondonate the main runway 36 right which serves all commercial traffic and larger business jets and then the much smaller runway 36 left which is only 600 meters long and only serves general aviation aircraft to the right of the main runway there is the north apron and the north apron is where all the commercial flights are parked that's connected to the passenger terminal and the other apron is called the west apron which is just to the west of the smaller runway 36 left now on the west apron all private jets and all general aviation aircraft are normally parked as i mentioned before there had been major upgrades to leonardo airport over the years but most of those upgrades had happened on the main runway 36 right and on the north apron and connected taxiways the western part of the airport had been largely neglected in these upgrades and that meant that taxiway markings and taxiway signs had started to degrade a bit but that wasn't a big problem because aircraft and most pilots that were operating out of the western apron were mostly very familiar with the airport that had also started to develop a kind of complacency without traffic control where air traffic control maybe wasn't listening too carefully to what aircraft that was going out on that part of the airplane was saying and there was also frequently use of italian as a language mixed up with english from the commercial side of the airport so you had a frequent mix of two languages going on and that's going to play a bit of a role in this accident one upgrade that had happened to the western side of the airport was the addition of a new taxiway called romeo 6. this taxiway was built back in the 1960s when the airport started to recognize that a lot of the private jets that were operating from the western apron needed access to the main runway runway 36 right because they were just becoming too big to use the smaller runway because this taxiway was a later addition it meant that it didn't follow the standard icao marking system the way that normally works is that if you put a needle down in the main runway and you start from 12 o'clock position then you start marking the taxiways romeo one romeo two romeo three roman four number five and romeo six in a clockwise movement but in this case they were marked romeo 1 romeo 2 romeo 3 romeo 4 romeo 6 and then romeo 5. from where the romeo 6 taxiway intersected the main runway 36 right and all the way to the west apron there was not a single vertical sign that showed that this taxiway was actually called romeo6 however there were some other markings that were written on the taxiway surface called sierra 4 and sera 5. those markings had been put there after a meeting with the airport where they thought that they had to expand the parking capability of the west apron but that never really came to fruition which meant that the tower was not made aware of these markings and that's going to become very important soon another thing that happened during the mid 1990s was that the taxiway lighting system was upgraded generally if an airport is supposed to work during low visibility conditions you need these green center taxi line lights and they were added to most of the airport that included taxiway romeo 6 from runway 36 towards the west apron initially the lighting was alternating yellow and green and then you had a red stop bar that's the cat 3 holding position at romeo 6 and then these green center line lights continued all the way to the start of the west apron coming from the other direction from the west apron towards the runway you could see the green centerline light and then you had the red stop bar and then the green texan lights continued now these type of tack slide lights need to be controlled by the tower so that the tower can for example illuminate a section of the green taxon light up to the red stop bar and then remove the green lights beyond the stop bar that way giving a very clear indication to taxing aircraft that they have to stop but something happened to this taxi line system around 1998 where all of a sudden the tower was unable to control these lights they can either have them all on or all off which meant that if the green taxi light was going to be used you would always have the red stop bar illuminated as well this led to a situation where pilots who were familiar with the airport we're also familiar with having to cross that red stop bar in order to enter the runway after receiving clearance from our traffic control and i cannot overemphasize how important of a detail this is because as a pilot we are taught to never ever ever cross a red stop bar so to have as a standard operating procedure at an airport that you have to cross a illuminated red stop bar in order to comply with a further taxi clearance that is in my ears complete insanity and if you put on top of that that the taxiway holding point guard system which is a laser beam that is supposed to monitor all active holding points to make sure that no aircraft or vehicle inadvertently enters into an active runway without adc clearance was also inoperative since back in 1998 now you're starting to see that all of the latent threats in dr reese's swiss cheese model is starting to add up and we haven't even gotten to the worst point yet because in 1994 the uh lenote airport management started talking about replacing the ground radar on the northern but for some reason these plans were never implemented so that meant that in 1999 when the old ground radar system stopped working it was never replaced in the very early morning of the 8th of october 2001 a cessna citation 525 took off from cologne in germany and made its way down towards milan de notte the aircraft was owned by a private german citizen but he had started up an aoc recently and was in the process of moving this aircraft ownership over towards this aoc this company but on this day the flight plan indicated that this was a private flight and the aircraft was supposed to land in milan leonardo pick up another passenger and then fly up to paris both of these flights were going to be paid for by the cessna company because the person that was being picked up in lenota was a potential cessna citation customer the citation was flown by two experienced pilots but both the citation itself and these pilots were limited to fly down to category 1 limitations this meant that the worst visibility that they could land an aircraft in was 550 meters and the worst visibility they can take off with was 400 meters but as they started to get closer to lenot and they took the weather they realized that the weather was way worse than that the wind was calm visibility was only about 100 meters with overcast clouds at 100 feet and rvr which is the runway visual range was 175 200 and 225 meters which is well below category 1 minimums however the airport had not yet started to issue low visibility procedures and did not say on the 80s that the category 3 ils approaches for enforce now that doesn't really matter because as a pilot you need to keep track of what your lowest visibility is and if the weather is worse than that you're not able to land it's as easy as that however the crew of this citation started their approach anyway and at the time 04 59 and 34 seconds they touched down on runway 36 right in lenote after the landing the pilots asked if they could make a short back track on the runway and exit on taxiway raw music to tax it to their parking position on the west april air traffic control cleared them to do this and it showed that these two pilots they were quite familiar with the taxiway layout of lenota at the same time as this is happening as scandinavian airlines flight 686 was getting ready for departure over on the north apron the aircraft being used was an md-87 and in the cockpit there were two very experienced pilots both of them whose training records showed that they were above average skill together with them there were four cabin crew members and 104 passengers being boarded at time 05 41 and 39 seconds the first officer of the scandinavian flight requests startup clearance the air traffic controller on the ground frequency gives them the startup clearance and also advises them that they have a slot restriction at time 0616 now a slot restriction is basically a defined time window when an aircraft is allowed to depart in this case it's five minutes before and ten minutes after so between zero six one one two six zero six two six this is very common especially when there's low visibility procedures in use because there's a limitation on how many aircraft movements there can be on the airport at any given time the first officer read back the startup clearance and the slot time and the pilots now completed their final flight deck preparation at times 05 54 and 23 seconds the md-87 have started off both engines and the pilots are now ready for taxi they request taxi clearance and the ground controller responds and tells scandinavian 686 to taxi to hauling position runway 3-6 and to call him back when they enter the main taxiway this is then read back by the first officer and the md-87 slowly starts moving through the fog towards the holding position the airport is now beginning to get really busy with both a couple of aircraft arriving and quite a few aircraft departing for the first morning wave about four minutes off the scandinavian starch taxi the cessna citation on the western apron calls up the ground controller and asks for startup clearance the ground controller gives the aircraft their startup clearance and they also give them their departure ifr clearance and this departure clearance was incorrectly read back by the pilot which was picked up and corrected by the ground controller as part of the atc clearance the cessna citation pilots also get a slot restriction which is at zero 619 three minutes after the departure of the scandinavian aircraft as the clearance has been given to the system citation the md-87 from scandinavian airlines have been slowly moving their way down towards the main tax away just as the conversation finishes the md-87 pilot calls up the ground controller and tells them that they're now on the main taxiway abeam the fire station the ground-controlled response and tells the pilots to switch over to the tower controller on frequency 118 decimal one and this is normally the way that it works where you have the ground controller that is handling all the traffics on the taxiways and apron and then as the aircraft is getting ready to enter the active runway they will switch over to a tower controller which is a different frequency but this also means that this is the last time that the cessna citation and the scandinavian airlines md-87 are sharing the frequency after this these two aircraft are going to be talking on two different frequencies the scandinavian pilot checks in on the new frequency and the tower controller tells them to continue to watch the hauling position from with three six right and that they are number four in the queue for departure now before we get into the actual accident sequence i just want to share this short message from my sponsor now i know that you guys are watching my videos because you love learning new things and finding out the nitty-gritty nerdy details behind each story and if that's true you should seriously check out the sponsor of this episode which is curiosity stream curiosity stream is a high quality subscription streaming service with thousands of great non-fictional stories and documentaries from some of the best filmmakers in the world a video that i am watching right now is heavy lift the antonov dream about the anthem of 225 which obviously is really sad right now but still very important to watch if you think better that sounds really interesting well then consider supporting me by supporting my sponsor go down in the description click on the link which is curiositystream.com slash mentor pilot and the coupon code mentor pilot that will give you a whopping 25 off the annual subscription fee which is wait for it only 14.99 per year which is insane value for money now back to the video at time zero six zero five and 44 seconds the cessna citation calls up the ground controller once again this time asking for taxi clearance the ground controller responds with the following clearance delta victor x-ray taxi north via romeo 5 qnh1013 coming back at the stop bar of the main runway extension the citation pilot then responds roger via romeo 5 and 1013 and call you back before reaching the main runway now if you pay a bit of attention here you see that the read back does not match the actual clearance the actual clearance both tells the aircraft to turn towards the north taxaway romeo 5 and hauled before the runway extension the read back from the citation does include the correct tax way romeo 5 but it also says call you back before reaching the main runway so these are two different things and this is not picked up and not corrected by the ground controller this is very important because there is a chance right now that the pilot in the cessna citation have a mental picture of how they are going to taxi and they think that they are going to tax it back the same way as they tax it in which is the closest connection to the active runway however they do read back romeo 5 which is the noddly taxiway only 30 seconds after this another aircraft that was parked on the western apron lima x-ray papa romeo alpha also called up the ground controller and asked for taxi clearance this aircraft received the same tax instruction as the citation i just received with the additive that they had the whole position until the cessna citation taxed it in front of them before they could start taxi now if the citation pilots would have heard this taxi clearance it is likely that that would have updated their situational awareness a little bit knowing that they needed to taxi past another aircraft before they reached romeo 5. but unfortunately this whole conversation was made in italian so the german pilots in the citation would not have understood it two minutes later the citation pilot calls up the ground controller and tells him that he is approaching sierra iv the ground controller gets a little bit confused by this because he is not aware of any holding position named zera4 remember those are the markings that was put onto romeo 6 but no one ever told air traffic control about the ground controller just asked delta victor x-ray confirm your position and the citation delta vector x-ray response we're approaching the runway sierra 4. now this is another opportunity to solve this confusion the problem is that this only plays further into the perceived situation that the ground controller has in his head that the citation is indeed taxing via romeo 5 and that are holding short of the runway extension from the 36 right the ground control responds with delta victor x-ray roger maintained the stop bar i'll call you back so let's recap the situation as it stands right now because this is a very crucial part of this accident the ground controller is convinced that delta victor x-ray is holding at the holding position at the runway extension on romeo 5. the pilots in the cessna citation have just been told to hold at the stop bar to get further clearance now they are on romeo 6. that is the wrong taxiway they read back romeo 5 but it's also very likely that they have a mental model that they should be on romeo 6 and in any case during their taxes so far there have been no signs along the tax away that are actually on romeo 6 and not on romeo 5. after this conversation the ground controller calls up another aircraft which is on the north apron and the reason he's doing this is to make sure that the taxiway is clear for the cessna citation to continue taxing through the north apron and on to the main tax away for the holding point from the 36 right when he gets confirmation that this other aircraft has moved out of the way he calls up the cessna citation again the clearance that the ground controller now gives the cessna citation is deltavictor x-ray continued taxi on the main apron follow the alpha line the citation pilot responds with roger continue taxi in main apron alpha line the delta victor x-ray the ground controller then continues with yep that's correct and please come back entering the main taxiway now we will never really know exactly what conversations that took place inside of the cessna citation cockpit and the reason for that is that the cessna citation did not have a cockpit voice recorder it was not required on aircraft of that size but it is likely that this last clearance where the ground controller tells them to continue on to the north apron then onto the alpha line and then subsequently onto the main taxiway could be understood as a clearance to cross the active runway onto the north apron and then turning right onto the main taxiway because what happens next is that the assassin citation now taxes past a big white stop mark which is painted onto the taxiway they then continue past some holding point markings which are painted yellow on the taxiway and then they cross a red lit stop bar remember the one that we talked about in the beginning of the video the one that could not be turned off unless you wanted to turn off all of the taxon lighting yeah that one and since these pilots are familiar with lenot it is very possible that they have gotten the clearance to taxi paws red stop bars before at this airport next to the red stop bar there's also a cat tree holding point vertical sign and then they taxi past another holding point marking on the tax way before they enter the active runway 36 right this is all happening on the ground frequency and the scandinavian airlines flight 686 is on the tower frequency they've been in line but now they are getting a clearance to enter and line up the runway three six right at time zero six zero nine and twenty eight seconds the tower controller whilst he's talking to another aircraft ends off the transmission with giving the full take-off clearance for scandinavian airline flight 686 the pilots inside of the md87 reads back clear for takeoff from with 36 and when airborne squawk ident and we're rolling scandinavian 686. the captain now sets take off trust and the aircraft starts accelerating down the runway the visibility outside of the cop with windows is still really bad it's only about 200 meters which means that they can only see a few centerline lights ahead of them as they're accelerating the first officer calls out 130 knots which is checked by the captain he then calls out v1 rotate and the aircraft start rotating as the nose wheel comes off the ground as signal is automatically sent by the aircraft's a-car system to the scandinavian airlines headquarters in copenhagen saying that the aircraft has taken off only about 4.8 seconds after the initiation of the rotation a black shadow and an anti-collision light appears in front of the pilot of the md-87 half a second before the impact a unreadable word is said on the cockpit voice recorder indicating that the pilot did indeed see something then at times 0 6 10 and 21 seconds the md 87 collide with the cessna citation a beam the romeo 6 taxiway intersection the first point of impact is the nose gear of the md-87 who touches the horizontal stabilizer of the citation the second point of impact which is much more severe is the right hand main landing gear of the md-87 who first touches the right-hand wing and then slams into the body of the citation completely destroying the aircraft and most likely killing everyone on board the force of that impact is so severe that it cuts the right hand landing gear straight off the gear is then pushed backwards it damages the right hand flaps on the wing of the md-87 before it flies further back and jams itself between the engine pylon and the right-hand engine that impact causes the right-hand engine to immediately fail and then separate the aircraft that causes a number of electrical failures inside of the md-87 and after this follows numerous contacts between the two aircraft before the md-87 gets airborne inside of the cockpit the pilots are now struggling to maintain control of their badly damaged aircraft they get as high as 35 feet which is about 10 meters before the left-hand engine who has likely ingested a lot of debris from the collision now also starts failing without any of the engines functioning the aircraft cannot continue to fly and now starts descending back onto the runway it touches down towards the very end of runway 36 right at the speed of about 166 knots when it does so because it's now lacking its right hand landing gear the right hand wing touches the ground and starts to pivot the aircraft towards the right the pilots in the cockpit are now trying to maintain directional control of their aircraft we know this because they did select the left hand reversers to activate under now failing left-hand engine they did this likely to try to slow the aircraft down because all brakes had failed at this point because of the damage to the hydraulic systems during the impact but also the fact that they did this now caused a bit of asymmetrical trust on the left hand side which also helped them to slightly maintain control but since the right hand wing was touching the ground the whole aircraft continued to pivot up to an angle of about 45 degrees as the aircraft careered off the runway but it has been shown in tests after the disaster that if it weren't for these last heroic actions by the flight crew the trajectory of the aircraft would have been more towards the right where could have impacted parked aircraft that was being boarded for departure and also the terminal building potentially causing many many more people to lose their lives sadly there was nothing more the pilots could do the aircraft did not slow down instead it continued in a slight right-hand trajectory after it left the runway until it crashed into a baggage handling building when it crashed into the building it came to a complete stop from 149 knots and that caused the roof of the building to collapse down onto the aircraft and a violent fire to immediately break out [Music] this was a completely non-survivable event and all 110 passengers and crew plus four workers inside of the building immediately perished this was the second worst on-ground aircraft collision accident in history only second to the terrible tenerife disaster but the story does not end here because of the dense fog and because of the lack of situational awareness inside of the air traffic control tower the fact that this accident had even happened did not become clear to the tower controllers for several minutes after the disaster about 49 seconds after the crash the first phone call came into the tower the person who called said that he heard something that sounded like explosions from the runway but the tower controller didn't know exactly what he was talking about he didn't have any other indications of anything being wrong so he largely disregarded it the second thing that happened was that a police officer was stationed outside of the airport perimeter next to one of the airport gates called directly to the airport firefighting units and said that he could see fire coming off the baggage handling building and he could also see people who seem to have been hurt coming out of the building this caused the airport firefighters to immediately launch a couple of their fire fighting vehicles to watch the baggage handling building but this was never really communicated with air traffic control tower instead the tower controller about two minutes after the crash that happened was trying to reach the scandinavian aircraft on the radio remember they were supposed to squawk ident that would show them up on his radar screen but he couldn't see them instead he called to the other air traffic control sectors around to see if the scandinavian aircraft had called in on their sector instead but none of the others had heard anything about 20 seconds after the tower controller had made these calls a pilot from one of the aircraft that was still standing at the gate called up the tower and said that he had been speaking to his dispatcher and the dispatcher had said that he'd heard explosions and he'd seen something that looked like a fire that had streaked down the runway and disappeared into the fog now the air traffic controllers are starting to put two and two together at a time 06 13 and 30 seconds they push the alarm button in the tower after this follows a sequence of almost complete confusion in the tower where the air traffic controllers are trying to figure out what has happened they're also trying to control all of the aircraft that are still out there because so far they have no idea what has actually happened there's a huge lack of communication between the traffic controllers and the firefighting units so bad that when a traffic control tells the leading units of the firefighters that they need to send someone out to do a runway inspection to see if there's something on the runway this is not understood as a direct order and subsequently is not being done as a result of this it takes almost 30 minutes before an aircraft that is taxing along the main taxiway calls into tower and says that he can see that something is burning on the runway the traffic controller then contacts the firefighting services again and asks them whether or not they have completed that runway inspection which they say they haven't done now they send out the unit and they finally after 36 minutes find the wreckage of the cessna citation on the runway they quickly extinguish the fire and they report that back to our traffic control the investigation into this terrible accident resulted in one of the most skating reports that i've ever read against a airport and a national aviation authority the investigation basically said that there was a lack of organization at leonardo airport that stemmed from several different authorities not working well together there was a lack of a proper safety management system and a toxic reporting environment existed where people were afraid to report what they saw as potential safety issues out of fear of being fired it was found that the accident was directly caused by the poor visibility on the day then the lack of visual guidance aids and signatures on the taxiway most likely caused the assassin citation to take the wrong tax away there was no further signature that could indicate to the cessna that they were on the wrong taxiway and there was also a lack of situational awareness between the tower and the cessna citation that eventually caused them to enter the active runway and led up to the collision no one did at any point question the fact that the cessna citation landed in lower minima than they were allowed to do according to their flight plan and that they also tax it out in much worse condition than they were allowed to take off from the reason that the pilots of the citation actually did so we're never really going to know but it is likely that some commercial pressure was involved further to this the report also talked about the improper use of both english and italian on the same frequency the incorrect read back from the pilots that weren't properly caught by air traffic control and they also found that there wasn't any proper recurrent training being given to the air traffic controllers at leonardo airport it was also found that the lack of ground radar and the monitoring system at the holding point of romeo 6 also contributed to the accident all in all this led up to a stunning 18 different recommendations that had to be implemented in order to make leonardo more safe the investigators were stunned to realize that just 24 hours prior to this fatal runway incursion another runway incursion had happened and that this was a fairly common occurrence on the airport this accident has led to many improvements in the aviation business especially during low visibility procedures and how airports put up signs and how they conduct themselves in foggy conditions but to finish off when i read through this report i just felt so bad for the pilots in the md-87 they did everything right from when they pushed back the aircraft to the collision and even after the collision their skills and airmanship shone through throughout this horrible horrible story and it likely stopped this accident from becoming an even bigger disaster now if you want to see the video i did about the world's worst on-ground aircraft collision well then check out the video up here if you want to support me and the work that i do you can buy yourself some merch or you can take part in my patreon crew i know that you will like it in there and i'd love to see you in my next weekly hangout bye-bye [Music]

Channel: Mentour Pilot

Views: 494,004

Keywords: captain, mentour pilot, mentor pilot, crash investigation, full epsiodes, aviation, pilot, crash, air crash investigation, boeing, seconds from disaster, flight simulator, flight sim, 2020, airbus, piper, cessna, disaster, fatal crash, air incident, air disasters 2022, linate, italy, MD-87, Cessna citation, fireball, loss of life, runway excursion, milan

Id: xkrd3XFHDsc

Length: 30min 35sec (1835 seconds)

Published: Sat Apr 09 2022