Last night I watched a program on Discovery Channel with my father. It was about the Linate airport disaster in 2001 – the deadliest aviation accident in Italian history.
This disaster was not the result of a computer system failure. But it is a good reminder of important lessons that apply in IT.
What happened at Linate
An MD-87 plane with over 100 people on board collided with a small private plane. In the dramatization, it looked as if the bigger plane drove over the Cessna that crossed its path. 118 people died, 8 people were prosecuted, and 5 people went to jail for their negligence.
An aviation investigation is complex and difficult. But the identified causes are easy to understand:
- The ground controller used imprecise terminology. The names he used for aprons and runways did not match the names on the ground. So it was possible that what he meant, and what the Cessna pilots understood, were different.
- The ground controller had not been properly trained. He had never seen the actual runways, and didn’t know what runway the Cessna pilots had referred to in one of the calls.
- The Cessna pilots were not certified for the poor visibility conditions.
- The ground radar system wasn’t working. It should have alerted the controllers to the problem. A new system had been commissioned and received, but not installed.
- The guidance signs along the taxiways (like road signs) were not well-maintained. So the Cessna pilots might not have been able to read them.
Take the matching quiz
A matching quiz consists of two columns of items. You need to connect items in the first column with the correct option in the second column.
While I was watching the program, I kept thinking that those are very real problems in the world of IT and systems. So let’s connect the findings of the aviation investigation with problems we deal with daily.
Terminology
Terminology is important. It might be difficult and annoying, but it is still important. Without a common understanding of terms, we will have communication problems.
The best example of this is the story of the NASA Mars Climate Orbiter. In 1999, the Mars Climate Orbiter burned and broke into pieces after 10 months of space travel. The project cost more than $300 million. What was the cause? One team used the metric system of millimeters and meters. The other team used the English system of inches, feet, and pounds.
Training
It’s easy to skimp on training. It’s easy to decide that the extra training isn’t really necessary. It’s easy to postpone training. Everybody looks at the cost of training. But do you ever think about the cost of not training?
The Cessna pilots both had thousands of flight hours. But neither were certified for landings with visibility less than 500 meters. On that day, visibility was less than 100 meters. Maybe they didn’t have any other options, and thought their experience was enough. They paid for their lack of training with their lives.
The air traffic controller also lacked adequate training. When the Cessna pilots reported the id of the taxiway they were on, he ignored it. It was not on his maps and was unknown to him. He went to jail for that.
Maintenance
Years ago I walked into the server room at a large client where I was consulting as a project manager. I noticed a new unconnected server on the floor. The server had been ordered and delivered a while before. But nobody had installed it.
Maybe the server wasn’t critical. But it reminds me of the DOJ’s failure to renew licences for anti-virus and monitoring software. Poor maintenance and poor training caused the Government Printing Works system crash in 2021 that led to massive data loss. You can think of more examples, and not just in government.
Maintenance is a management issue. That is why four other airport officials were also convicted and sentenced to jail.
Your work matters
Traffic controllers and pilots know that a mistake can be fatal. I hope they remember that every day when they do their job.
Programmers write the code that make our world work. Whether you are a manager or a developer, remember every day how important the work of a programmer is.
Please share your thoughts.