It is not rare for individuals to be punished for the sins of the system in which they work. This is what has happened in the Linate court case

An Italian court, in handing out lengthy prison sentences to four people as a result of the October 2001 fatal collision between two aircraft at Milan Linate airport, has certainly not served the cause of justice. As for the cause of aviation safety, the only good that may result is that the sentences have been so surprisingly severe that the publicity generated may serve to alert Europe's airport managers and air traffic service providers to their obligations as defined by the Eurocontrol safety regulatory requirements (ESARR).

But whenever punishment - especially on this scale - is meted out to individuals for the failures of a system, there is a danger that the message to other individuals is not so much "improve" as "keep your head down". The prison sentences were eight years for the duty tower controller and the airport manager, six and a half years for the official at Italy's National Agency for Civil Aviation (ENAC) responsible for Linate and Malpensa airports, and the same for the managing director of Italy's air traffic services provider ENAV. They were also ordered to pay court costs and compensate the victims, and the court called for them to be banned for life from public office. International lawyers say the severity of the penalties is unprecedented for this type of case.

To add to the many anomalies in the case, the court more than doubled the prison sentence recommended by the public prosecutor for the controller, which has baffled commentators in the Italian media and horrified air traffic controllers' associations locally and internationally. In fact all four parties are to appeal against the judgements, and they will remain free pending their appeal hearings, which may not happen for up to three years. By that time the blood of the Italian judiciary may, hopefully, have had time to cool.

The sentence passed on the air traffic controller is particularly extraordinary. He did not make any errors of commission. Such mistakes as he did make were errors of omission or of insufficient attention to detail, the accident report makes clear. The clearances he gave to the two aircraft that eventually collided were correct. His main mistakes were in failing to challenge some of the readback messages from the Cessna Citation CJ2 business jet pilot which were vague, incomplete and suggested uncertainty, and it was this pilot that had taken a wrong taxiway and eventually strayed across a stop-bar of red lights and fatally entered the runway without clearance to do so. But there was thick fog and the controller was busy. In fact the airport was too busy for the weather conditions; although operations had been slowed down they were not as slow as they should have been in those conditions given that Linate lacked a surface movement radar system. Another less-than-ideal practice by the controller was speaking in English to some pilots and Italian to others.

A crucial point not taken into account by a court judgement like this is that many of the faults for which Linate and the controller were criticised in the accident report - inadequate and non-standard signage, surface markings and lighting, non-standard ATC language, and the lack of a safety management system - are common at many other airports also. They are systemic faults in the sense that the system had either not noticed them, or it tolerated them, and a controller is a product of that systemic environment. All the people sentenced are Italian civil servants, and as such they are a product of the Italian civil service ethos. Leaving aside the defence's claims that the guilty verdict on the air traffic controller was legally unsound, the point is that the system needs fixing, not just individuals within it. There is a case for examining some serious accidents in court to determine whether people are guilty of professional negligence. But if negligence is indeed established, sentencing must take into account the environment in which the parties judged guilty were working, and how much of the negligence was system-induced. In the Linate, case, the controller's sentence is wildly inappropriate - indeed any penalty should not be custodial - and those of the administrators were unusually severe. Perhaps the appeal courts will right the excessive zeal of the lower court. It has meted out judgements that smack of scapegoating.

Meanwhile Europe's airports, which are an integral part of the air traffic management system, undoubtedly have a great deal of work to do to raise their safety and operational standards and safety management systems to the levels demanded in the relatively newly defined ESARRs. Standardisation itself would constitute an improvement.

Source: Flight International