The Linate Air Disaster: A Multilevel Model of Accident Analysis

This chapter uses a multilevel organizational model to analyse the Linate air disaster (8 October 2001 Milan, Italy), in which a SAS MD-87 and a Cessna collided with the loss of 118 lives. The cause of the accident was a mistake by the Cessna pilots, who took a taxiway different from the one authorized by the ground controller and moved their plane onto the runway from which the MD-87 was about to take off. But the disaster was not caused by human error alone. Analysis of the disaster reveals multiple failures in communication, coordination, and the technologies used. This chapter develops a relational and multilevel model for the analysis and prevention of accidents in complex organizational systems. This multilevel analysis model highlights the different levels of failure that provoked the disaster: individual (pilots and air-traffic controllers), organizational (Linate Airport), and inter-organizational (the various organizations involved in the air transport system). The analysis centres on the problem of coordination.