An admirable series. 1991: A US Air heavy lands on a runway at Los Angeles International Airport and immediately collides with a smaller commuter airliner waiting for clearing to take off. The fuel explodes. Everyone on the commuter flight dies. Many on the larger airplane also die. One of the escapees is David Koch, of Koch brothers fame, who seems entirely human and a bit guilty about not having helped anyone else.
Okay, one airplane is line up, waiting to take off. Another lands pretty much on top of it. What happened? The crash is traced directly to an Air Traffic Controller, Robin Wascher, who was kept so busy maintaining communication with an entirely different airplane that she simply forgot about the commuter airplane. She was also distracted by the absence of an important paper record -- a "strip" -- that should have been sent to her.
And here's where the program excels. One of the talking heads comments that it's easy to point the finger at one person and blame her, but that's never the ultimate cause. An analyst has to overcome the impulse to let all the responsibility rest on one face and one name, and examine the causes of the mistake.
It's an impulse that few of us can resist. Who wants to delve into network dynamics when he can simply say, "SHE DID IT"? Of course she did do it. She left the trade at once and never worked as an ATC again. But why did the mistake happen? For one thing, Los Angeles is one of the busiest airports in the world, with about one near collision every months. Wascher couldn't see the Sky West commuter sitting on the runway because the line of sight was blocked by a pole with a bright light on it. The ground surface radar, which keeps track of who's where on the runways and intersections, was never reliable and was down that night. Requests for repair or replacement were overlooked.
So why didn't the pilots of the US Air see the smaller airplane? It had its navigation lights on but was not required to use the more salient strobe lights. The lights that were displayed resembled many other lights at the airport. The ATSB investigators placed an identical airplane on the runway, then took off at night in a helicopter and simulated the approach of US Air. They couldn't see the commuter plane.
Improvements in the technology were made and a new control tower built, but runway incursions continued with many near misses. The latest improvement is a series of lights resembling traffic lights than tell the pilot when he can go and when he can't.
Okay, one airplane is line up, waiting to take off. Another lands pretty much on top of it. What happened? The crash is traced directly to an Air Traffic Controller, Robin Wascher, who was kept so busy maintaining communication with an entirely different airplane that she simply forgot about the commuter airplane. She was also distracted by the absence of an important paper record -- a "strip" -- that should have been sent to her.
And here's where the program excels. One of the talking heads comments that it's easy to point the finger at one person and blame her, but that's never the ultimate cause. An analyst has to overcome the impulse to let all the responsibility rest on one face and one name, and examine the causes of the mistake.
It's an impulse that few of us can resist. Who wants to delve into network dynamics when he can simply say, "SHE DID IT"? Of course she did do it. She left the trade at once and never worked as an ATC again. But why did the mistake happen? For one thing, Los Angeles is one of the busiest airports in the world, with about one near collision every months. Wascher couldn't see the Sky West commuter sitting on the runway because the line of sight was blocked by a pole with a bright light on it. The ground surface radar, which keeps track of who's where on the runways and intersections, was never reliable and was down that night. Requests for repair or replacement were overlooked.
So why didn't the pilots of the US Air see the smaller airplane? It had its navigation lights on but was not required to use the more salient strobe lights. The lights that were displayed resembled many other lights at the airport. The ATSB investigators placed an identical airplane on the runway, then took off at night in a helicopter and simulated the approach of US Air. They couldn't see the commuter plane.
Improvements in the technology were made and a new control tower built, but runway incursions continued with many near misses. The latest improvement is a series of lights resembling traffic lights than tell the pilot when he can go and when he can't.
