Bashkirian Airlines Flight 2937
Encyclopedia
The 2002 Überlingen mid-air collision occurred at 23:35 UTC on 1 July 2002 between Bashkirian Airlines Flight 2937 (a Tupolev Tu-154
M passenger jet
carrying 57 passengersmostly childrenand twelve crew) and DHL Flight 611 (a Boeing 757-23APF cargo jet
manned by two pilots) over the towns of Überlingen
and Owingen
in southern Germany
. All 71 people on board the two aircraft were killed.
On 19 May 2004, the German Federal Bureau of Aircraft Accidents Investigation (BFU) published its determination that the accident had been caused by shortcomings in the Swiss
air traffic control
system supervising the flights at the time of the accident and by ambiguities in the use of TCAS, the on-board aircraft collision avoidance system.
Three months previously, on 24 February 2004, Peter Nielsen, the air traffic controller on duty at the time of the accident, was stabbed to death by Vitaly Kaloyev
.
Kaloyev, an architect, had lost his wife and two children in the accident.
, Russia
to Barcelona
, Spain
, carrying sixty passengers and nine crew. Forty-five of the passengers were Bashkortostan
schoolchildren on a school trip organized by the local UNESCO committee to the Costa Daurada area of Spain.
Most of the parents of the children were high-ranking officials in Bashkortostan.
The aircraft, a Tupolev Tu-154M registered as RA-85816, was piloted by a Russian crew. The captain
Alexander Mihailovich Gross (Александр Михайлович Гросс) and first officer Oleg Pavlovich Grigoriev (Олег Павлович Григорьев) flew the Tupolev. Grigoriev, the chief pilot of Bashkirian Airlines, used the trip to evaluate Gross's performance. Murat Ahatovich Itkulov (Мурат Ахатович Иткулов), normally the first officer, did not officially serve on duty because of this. The crew valued the opinions and guidance of Itkulov, who was slated to be promoted to captain. Sergei Kharlov, a navigator, and a flight engineer joined the three pilots.
DHL Flight 611, a Boeing 757-23APF cargo aircraft registered as A9C-DHL, had originated in Bahrain
and was being flown by two Bahrain-based pilots, British
captain Paul Phillips and Canadian
first officer Brant Campioni. At the time of the accident, it was en route from Bergamo
, Italy
to Brussels
, Belgium
.
360 (approximately 36000 feet (10,972.8 m) above Mean Sea Level) on a collision course. Despite being over Germany, the airspace was controlled from Zürich
, Switzerland by the private Swiss airspace control company Skyguide
.
The only air traffic controller
handling the airspace, Peter Nielsen, was working two workstations at the same time. He did not realise the problem in time and thus failed to keep the aircraft at a safe distance from each other. Only less than a minute before the accident did he realize the danger and contacted Flight 2937, instructing the pilot to descend by a thousand feet to avoid collision with crossing traffic (Flight 611). Seconds after the Russian crew initiated the descent, however, their traffic collision avoidance system
(TCAS) instructed them to climb, while at about the same time the TCAS on Flight 611 instructed the pilots of that aircraft to descend. Had both aircraft followed those automated instructions, it is likely that the collision would not have occurred.
Flight 611's pilots on the Boeing jet initially followed the TCAS instructions and initiated a descent, but could not immediately inform the controller due to the fact that he was dealing with Flight 2937. About eight seconds before the collision, Flight 611's descent rate was about 2400 ft/min, not as rapid as the 2500 ft/min range advised by TCAS. The Russian pilot on the Tupolev disregarded the TCAS instruction to climb and instead began to descend, as instructed by the controller, thus both planes were now descending.
Unaware of the TCAS-issued alerts, Nielsen repeated his instruction to Flight 2937 to descend, giving the Tupolev crew incorrect information as to the position of the DHL plane. Maintenance work was being carried out on the main radar system, which meant that the controllers were forced to use a slower system.
The aircraft collided at almost a right angle at an altitude of 34890 feet (10,634.5 m), with the Boeing's vertical stabilizer slicing completely through Flight 2937's fuselage just ahead of the Tupolev's wings. The Tupolev exploded and broke into several pieces, scattering wreckage over a wide area. The nose section of the aircraft fell vertically, while the tail section with the engines continued, stalled, and fell. As the nose section of the Tupolev fell at such speed, the flight deck crew soon lost consciousness. The crippled Boeing, now with 80% of its vertical stabilizer lost, struggled for a further seven kilometres (four miles) before crashing into a wooded area close to the village of Taisersdorf at a 70 degree downward angle. Each engine ended up several hundred metres away from the main wreckage, and the tail section was torn from the fuselage by trees just before impact. All 69 people on the Tupolev, and the two on board the Boeing, died.
In the minutes before the accident, Nielsen was occupied with an Airbus
on a delayed Aero Lloyd
Flight 1135 approaching Friedrichshafen Airport.page 16 Handling two workstations at once, Nielsen struggled with the malfunctioning phone system that he was trying to use to call the Friedrichshafen airport to announce the approaching Aero Lloyd. The main phone lines at Skyguide were down due to maintenance work, and the backup line was defective. This caused Nielsen to spend more time than he anticipated coordinating the Airbus late arrival into Friedrichshafen, and to miss several calls from aircraft. The faulty phone lines also prevented adjacent air traffic controllers at Karlsruhe
from phoning in a warning. Due to these distractions he did not spot the danger until about a minute before impact. Had he been aware of the dangerous situation earlier, he could have kept the aircraft at a safe distance from each other. They would have been separated and their collision avoidance systems would not have issued instructions.
Additionally, after Nielsen instructed the Russian crew to descend, he returned to the situation with the Airbus bound for Friedrichshafen, and did not hear the DHL aircraft TCAS report of its descent.
Another factor was that the ground-based optical collision warning system, which would have alerted the controller to imminent collisions early, had been switched off for maintenance; Nielsen was unaware of this. There still was an aural STCA
warning system, which released a warning addressed to workstation RE SUED at 21:35:00 (32 seconds before the collision); this warning was not heard by anyone present at that time, although no error in this system could be found in a subsequent technical audit; whether this audible warning is turned on or not, is not logged technically. Even if Nielsen had heard this warning, he might have misinterpreted it until the next radar update 12 seconds later became visible or until the TCAS descent notice by the DHL crew came in; at that time finding a useful resolution order by the air traffic controller
is difficult to impossible.page 89
, Switzerland and the Russian Federation did submit positions that were published with the official report. The USA did not submit deviating positions. The comments were published as an appendix to the report but were not commented upon by the German federal investigators
.
The statement by the Kingdom of Bahrain, the home country of the DHL plane, mostly agrees with the findings of the report. It says that the report should have put less emphasis on the actions of individuals and stressed the problems with the organisation and management more. Bahrain's statement also mentions the lack of crew resource management
in the Tupolev's cockpit as a factor in the crash.
The Russian Federation states that the Russian pilots were unable to obey the TCAS advisory to climb; the advisory was given when they were already at 35500 feet while the controller wrongly stated there was conflicting traffic above them at 36000 feet. Also, the controller gave the wrong position of the DHL plane (2 o'clock instead of the actual 10 o'clock). Russia asserts that the DHL crew had a "real possibility" to avoid a collision since they were able to hear the conversation between the Russian crew and the controller.
Switzerland notes that the Tupolev was about 33 metres below the flight level ordered by the Swiss controller, and still descending at 1900 feet per minute. The Swiss say that this was also a cause of the accident. The Swiss position also states that in spite of the false information given (position and phraseology) by the Swiss controller the TCAS advisories would have been useful if obeyed immediately.
The change in magnetic bearing of the Russian aircraft by cumulatively 20 degrees (from 254 to 274) during the upcoming conflict is not assessed in the official report.
Nielsen needed medical attention due to traumatic stress
caused by the accident. At Skyguide, his former colleagues maintained a vase with a white rose over Nielsen's former workstation. Skyguide, after initially having blamed the Russian pilot for the accident, accepted its share of the responsibility and asked relatives of the victims for forgiveness.
On 19 May 2004, the official investigators found that managerial incompetence and systems failures were the main cause for the accident, so that Nielsen was surely not the only one to be blamed for the disaster. As explained above, a series of coincidences of which Kaloyev and Nielsen were unaware precipitated the accident.
On 27 July 2006, a court in Konstanz
decided that the Federal Republic of Germany should pay compensation to Bashkirian Airlines. The court found that it was illegal for the state to allow a foreign private company to provide air traffic control in German airspace. The government appealed the ruling, and a final decision is still pending as of 2008.
In another case before the court in Konstanz, Skyguide's liability insurance is suing Bashkirian Airlines for 2.5 million euro in damages. The case was opened in March 2008; the legal questions are expected to be difficult, as the airline has filed for bankruptcy under Russian law.
A criminal investigation of Skyguide began . On 7 August 2006, a Swiss prosecutor filed manslaughter charges against eight employees of Skyguide. The Winterthur
prosecutor called for prison terms of 6 to 15 months, alleging "homicide by negligence". The verdict was announced in September 2007. Three of the four managers convicted were given suspended prison terms and the fourth was ordered to pay a fine. Another four employees of the Skyguide firm were cleared of any wrongdoing.
(ATC). The TCAS is programmed to assume that both crews will promptly follow the system's instructions. The operations manual clearly states that TCAS should always take precedence over any ATC commands: If an instruction to manoeuvre is received simultaneously from an RA (resolution advisory, the command issued by the TCAS) and from ATC, the advice given by RA should be followed.
It is not required to notify the ATC prior to responding to an RA. This manoeuvre does not require any ATC clearance since TCAS takes into account the position of all other aircraft with transponder
s in the surrounding area.
, two Japanese airliners nearly collided with each other in Japanese skies. Both aircraft had received conflicting orders from the TCAS and ATC; one pilot followed the instructions of the TCAS while the other did not. Disaster was only averted because one of the pilots made evasive manoeuvres based on a visual judgement. The aircraft missed each other by less than 100 metres (328.1 ft), and the abrupt manoeuvre necessary to avert disaster left about 100 occupants hurt on one aircraft, some seriously. As a consequence Japan called for measures to prevent similar incidents. However, the International Civil Aviation Organization
(ICAO) did not take action until after the crash over Germany. In addition four near misses in Europe occurred before the German disaster, because one set of pilots obeyed the air traffic controllers while the other obeyed TCAS. The ICAO decided to fulfill Japan's request 18 months after the Japan Airlines incident.
The same flight manual, on a different page, also contains a passage that strictly forbids manoeuvers contrary to the TCAS under any circumstances. Nevertheless, the official investigation found that the pilots seemed unaware that the TCAS RA should take precedence.page 103
Additionally, an automatic downlink for the TCAS - which would have alerted the air traffic controller - had not been deployed worldwide at the time of the accident.page 50
all died. Kaloyev would later go on to murder Nielsen.
home, near Zürich, on 24 February 2004. Police arrested Kaloyev at a local motel not long after the murder, and he was subsequently convicted of the crime in 2005. He was released on 8 November 2007 because his mental condition was not sufficiently considered in the initial sentence. After his release, Kaloyev was infamously dubbed a "hero" in North Ossetia. In January 2008, he was appointed deputy construction minister of North Ossetia.
featured this accident in the episode titled Deadly Crossroads, which was released in 2004.
The National Geographic Channel
documentary series Seconds From Disaster
featured this mid-air collision in the episode entitled Collision at 35,000 feet release in 26th September 2011.
"Flug in die Nacht - Das Unglück von Überlingen" (2009), ("Flight into the night - the accident at Überlingen") produced by German and Swiss TV stations SWR
and SF
, is a motion picture based on the crash and the subsequent killing of the air traffic controller.
Tupolev Tu-154
The Tupolev Tu-154 is a three-engine medium-range narrow-body airliner designed in the mid 1960s and manufactured by Tupolev. As the mainstay 'workhorse' of Soviet and Russian airlines for several decades, it serviced over a sixth of the world's landmass and carried half of all passengers flown...
M passenger jet
Jet airliner
A jet airliner is an airliner that is powered by jet engines. This term is sometimes contracted to jetliner or jet.In contrast to today's relatively fuel-efficient, turbofan-powered air travel, first generation jet airliner travel was noisy and fuel inefficient...
carrying 57 passengersmostly childrenand twelve crew) and DHL Flight 611 (a Boeing 757-23APF cargo jet
Cargo aircraft
A cargo aircraft is a fixed-wing aircraft designed or converted for the carriage of goods, rather than passengers. They are usually devoid of passenger amenities, and generally feature one or more large doors for the loading and unloading of cargo...
manned by two pilots) over the towns of Überlingen
Überlingen
Überlingen is a city on the northern shore of Lake Constance . After the city of Friedrichshafen, it is the second largest city in the Bodenseekreis , and a central point for the outlying communities...
and Owingen
Owingen
Owingen is a town in the district of Bodensee in Baden-Württemberg in Germany....
in southern Germany
Germany
Germany , officially the Federal Republic of Germany , is a federal parliamentary republic in Europe. The country consists of 16 states while the capital and largest city is Berlin. Germany covers an area of 357,021 km2 and has a largely temperate seasonal climate...
. All 71 people on board the two aircraft were killed.
On 19 May 2004, the German Federal Bureau of Aircraft Accidents Investigation (BFU) published its determination that the accident had been caused by shortcomings in the Swiss
Switzerland
Switzerland name of one of the Swiss cantons. ; ; ; or ), in its full name the Swiss Confederation , is a federal republic consisting of 26 cantons, with Bern as the seat of the federal authorities. The country is situated in Western Europe,Or Central Europe depending on the definition....
air traffic control
Air traffic control
Air traffic control is a service provided by ground-based controllers who direct aircraft on the ground and in the air. The primary purpose of ATC systems worldwide is to separate aircraft to prevent collisions, to organize and expedite the flow of traffic, and to provide information and other...
system supervising the flights at the time of the accident and by ambiguities in the use of TCAS, the on-board aircraft collision avoidance system.
Three months previously, on 24 February 2004, Peter Nielsen, the air traffic controller on duty at the time of the accident, was stabbed to death by Vitaly Kaloyev
Vitaly Kaloyev
Vitaly Konstantinovich Kaloyev is an architect and deputy minister of housing from North Ossetia, Russia, known for his 2004 murder of Peter Nielsen in the Swiss town of Kloten. Kaloyev's family died aboard Bashkirian Airlines Flight 2937, which collided with another aircraft over Germany in 2002...
.
Kaloyev, an architect, had lost his wife and two children in the accident.
Flights involved
Bashkirian Airlines Flight 2937 was a chartered flight from MoscowMoscow
Moscow is the capital, the most populous city, and the most populous federal subject of Russia. The city is a major political, economic, cultural, scientific, religious, financial, educational, and transportation centre of Russia and the continent...
, Russia
Russia
Russia or , officially known as both Russia and the Russian Federation , is a country in northern Eurasia. It is a federal semi-presidential republic, comprising 83 federal subjects...
to Barcelona
Barcelona
Barcelona is the second largest city in Spain after Madrid, and the capital of Catalonia, with a population of 1,621,537 within its administrative limits on a land area of...
, Spain
Spain
Spain , officially the Kingdom of Spain languages]] under the European Charter for Regional or Minority Languages. In each of these, Spain's official name is as follows:;;;;;;), is a country and member state of the European Union located in southwestern Europe on the Iberian Peninsula...
, carrying sixty passengers and nine crew. Forty-five of the passengers were Bashkortostan
Bashkortostan
The Republic of Bashkortostan , also known as Bashkiria is a federal subject of Russia . It is located between the Volga River and the Ural Mountains. Its capital is the city of Ufa...
schoolchildren on a school trip organized by the local UNESCO committee to the Costa Daurada area of Spain.
Most of the parents of the children were high-ranking officials in Bashkortostan.
The aircraft, a Tupolev Tu-154M registered as RA-85816, was piloted by a Russian crew. The captain
Pilot in command
The pilot in command of an aircraft is the person aboard the aircraft who is ultimately responsible for its operation and safety during flight. This would be the "captain" in a typical two- or three-pilot flight crew, or "pilot" if there is only one certified and qualified pilot at the controls of...
Alexander Mihailovich Gross (Александр Михайлович Гросс) and first officer Oleg Pavlovich Grigoriev (Олег Павлович Григорьев) flew the Tupolev. Grigoriev, the chief pilot of Bashkirian Airlines, used the trip to evaluate Gross's performance. Murat Ahatovich Itkulov (Мурат Ахатович Иткулов), normally the first officer, did not officially serve on duty because of this. The crew valued the opinions and guidance of Itkulov, who was slated to be promoted to captain. Sergei Kharlov, a navigator, and a flight engineer joined the three pilots.
DHL Flight 611, a Boeing 757-23APF cargo aircraft registered as A9C-DHL, had originated in Bahrain
Bahrain
' , officially the Kingdom of Bahrain , is a small island state near the western shores of the Persian Gulf. It is ruled by the Al Khalifa royal family. The population in 2010 stood at 1,214,705, including 235,108 non-nationals. Formerly an emirate, Bahrain was declared a kingdom in 2002.Bahrain is...
and was being flown by two Bahrain-based pilots, British
United Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...
captain Paul Phillips and Canadian
Canada
Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...
first officer Brant Campioni. At the time of the accident, it was en route from Bergamo
Bergamo
Bergamo is a town and comune in Lombardy, Italy, about 40 km northeast of Milan. The comune is home to over 120,000 inhabitants. It is served by the Orio al Serio Airport, which also serves the Province of Bergamo, and to a lesser extent the metropolitan area of Milan...
, Italy
Italy
Italy , officially the Italian Republic languages]] under the European Charter for Regional or Minority Languages. In each of these, Italy's official name is as follows:;;;;;;;;), is a unitary parliamentary republic in South-Central Europe. To the north it borders France, Switzerland, Austria and...
to Brussels
Brussels
Brussels , officially the Brussels Region or Brussels-Capital Region , is the capital of Belgium and the de facto capital of the European Union...
, Belgium
Belgium
Belgium , officially the Kingdom of Belgium, is a federal state in Western Europe. It is a founding member of the European Union and hosts the EU's headquarters, and those of several other major international organisations such as NATO.Belgium is also a member of, or affiliated to, many...
.
Accident
The two aircraft were flying at flight levelFlight level
A Flight Level is a standard nominal altitude of an aircraft, in hundreds of feet. This altitude is calculated from the International standard pressure datum of 1013.25 hPa , the average sea-level pressure, and therefore is not necessarily the same as the aircraft's true altitude either...
360 (approximately 36000 feet (10,972.8 m) above Mean Sea Level) on a collision course. Despite being over Germany, the airspace was controlled from Zürich
Zürich
Zurich is the largest city in Switzerland and the capital of the canton of Zurich. It is located in central Switzerland at the northwestern tip of Lake Zurich...
, Switzerland by the private Swiss airspace control company Skyguide
Skyguide
skyguide is the air navigation services company that controls Swiss airspace....
.
The only air traffic controller
Air traffic controller
Air traffic controllers are the people who expedite and maintain a safe and orderly flow of air traffic in the global air traffic control system. The position of the air traffic controller is one that requires highly specialized skills...
handling the airspace, Peter Nielsen, was working two workstations at the same time. He did not realise the problem in time and thus failed to keep the aircraft at a safe distance from each other. Only less than a minute before the accident did he realize the danger and contacted Flight 2937, instructing the pilot to descend by a thousand feet to avoid collision with crossing traffic (Flight 611). Seconds after the Russian crew initiated the descent, however, their traffic collision avoidance system
Traffic Collision Avoidance System
A traffic collision avoidance system or traffic alert and collision avoidance system is an aircraft collision avoidance system designed to reduce the incidence of mid-air collisions between aircraft...
(TCAS) instructed them to climb, while at about the same time the TCAS on Flight 611 instructed the pilots of that aircraft to descend. Had both aircraft followed those automated instructions, it is likely that the collision would not have occurred.
Flight 611's pilots on the Boeing jet initially followed the TCAS instructions and initiated a descent, but could not immediately inform the controller due to the fact that he was dealing with Flight 2937. About eight seconds before the collision, Flight 611's descent rate was about 2400 ft/min, not as rapid as the 2500 ft/min range advised by TCAS. The Russian pilot on the Tupolev disregarded the TCAS instruction to climb and instead began to descend, as instructed by the controller, thus both planes were now descending.
Unaware of the TCAS-issued alerts, Nielsen repeated his instruction to Flight 2937 to descend, giving the Tupolev crew incorrect information as to the position of the DHL plane. Maintenance work was being carried out on the main radar system, which meant that the controllers were forced to use a slower system.
The aircraft collided at almost a right angle at an altitude of 34890 feet (10,634.5 m), with the Boeing's vertical stabilizer slicing completely through Flight 2937's fuselage just ahead of the Tupolev's wings. The Tupolev exploded and broke into several pieces, scattering wreckage over a wide area. The nose section of the aircraft fell vertically, while the tail section with the engines continued, stalled, and fell. As the nose section of the Tupolev fell at such speed, the flight deck crew soon lost consciousness. The crippled Boeing, now with 80% of its vertical stabilizer lost, struggled for a further seven kilometres (four miles) before crashing into a wooded area close to the village of Taisersdorf at a 70 degree downward angle. Each engine ended up several hundred metres away from the main wreckage, and the tail section was torn from the fuselage by trees just before impact. All 69 people on the Tupolev, and the two on board the Boeing, died.
Other factors in the crash
Only one air traffic controller, Peter Nielsen of ACC Zurich, was controlling the airspace through which the aircraft were transitioning. The other controller on duty was resting in another room for the night. This was against the regulations, but had been a common practice for years and was known and tolerated by management. Due to maintenance work, Nielsen had a stand-by controller and system manager on call. Nielsen was either unaware of this or he chose not to use either of the two additional air traffic controllers available to him.page 84, section Air traffic situation 1st paragraph When Nielsen realised that the situation had subtly increased beyond his span of control, it was too late to summon assistance.In the minutes before the accident, Nielsen was occupied with an Airbus
Airbus
Airbus SAS is an aircraft manufacturing subsidiary of EADS, a European aerospace company. Based in Blagnac, France, surburb of Toulouse, and with significant activity across Europe, the company produces around half of the world's jet airliners....
on a delayed Aero Lloyd
Aero Lloyd
Aero Lloyd Flugreisen GmbH & Co was a charter airline based in Oberursel, Germany.- History :Aero Lloyd was originally founded on December 5, 1980. It was originally headquartered in Frankfurt. The airline start operation with 3 McDonnell Douglas DC-9-32 ex Garuda Indonesia.The airline ceased...
Flight 1135 approaching Friedrichshafen Airport.page 16 Handling two workstations at once, Nielsen struggled with the malfunctioning phone system that he was trying to use to call the Friedrichshafen airport to announce the approaching Aero Lloyd. The main phone lines at Skyguide were down due to maintenance work, and the backup line was defective. This caused Nielsen to spend more time than he anticipated coordinating the Airbus late arrival into Friedrichshafen, and to miss several calls from aircraft. The faulty phone lines also prevented adjacent air traffic controllers at Karlsruhe
Karlsruhe
The City of Karlsruhe is a city in the southwest of Germany, in the state of Baden-Württemberg, located near the French-German border.Karlsruhe was founded in 1715 as Karlsruhe Palace, when Germany was a series of principalities and city states...
from phoning in a warning. Due to these distractions he did not spot the danger until about a minute before impact. Had he been aware of the dangerous situation earlier, he could have kept the aircraft at a safe distance from each other. They would have been separated and their collision avoidance systems would not have issued instructions.
Additionally, after Nielsen instructed the Russian crew to descend, he returned to the situation with the Airbus bound for Friedrichshafen, and did not hear the DHL aircraft TCAS report of its descent.
Another factor was that the ground-based optical collision warning system, which would have alerted the controller to imminent collisions early, had been switched off for maintenance; Nielsen was unaware of this. There still was an aural STCA
Short Term Conflict Alert
Short Term Conflict Alert is an automated warning system for air traffic controllers . It is a ground-based safety net intended to assist the controller in preventing collision between aircraft by generating, in a timely manner, an alert of a potential or actual infringement of separation minima.-...
warning system, which released a warning addressed to workstation RE SUED at 21:35:00 (32 seconds before the collision); this warning was not heard by anyone present at that time, although no error in this system could be found in a subsequent technical audit; whether this audible warning is turned on or not, is not logged technically. Even if Nielsen had heard this warning, he might have misinterpreted it until the next radar update 12 seconds later became visible or until the TCAS descent notice by the DHL crew came in; at that time finding a useful resolution order by the air traffic controller
Air traffic controller
Air traffic controllers are the people who expedite and maintain a safe and orderly flow of air traffic in the global air traffic control system. The position of the air traffic controller is one that requires highly specialized skills...
is difficult to impossible.page 89
Deviating statements in the official report
All countries involved could add additional "deviating" statements to the official report. The Kingdom of BahrainBahrain
' , officially the Kingdom of Bahrain , is a small island state near the western shores of the Persian Gulf. It is ruled by the Al Khalifa royal family. The population in 2010 stood at 1,214,705, including 235,108 non-nationals. Formerly an emirate, Bahrain was declared a kingdom in 2002.Bahrain is...
, Switzerland and the Russian Federation did submit positions that were published with the official report. The USA did not submit deviating positions. The comments were published as an appendix to the report but were not commented upon by the German federal investigators
Bundesstelle für Flugunfalluntersuchung
The German Federal Bureau of Aircraft Accidents Investigation is the German federal agency responsible for air accident investigation.The purpose of BFU is to find out the causes of air accidents and how they can be prevented. The BFU facility is located in Braunschweig, Lower Saxony...
.
The statement by the Kingdom of Bahrain, the home country of the DHL plane, mostly agrees with the findings of the report. It says that the report should have put less emphasis on the actions of individuals and stressed the problems with the organisation and management more. Bahrain's statement also mentions the lack of crew resource management
Crew Resource Management
Crew resource management or Cockpit resource management is a procedure and training system in systems where human error can have devastating effects. Used primarily for improving air safety, CRM focuses on interpersonal communication, leadership, and decision making in the cockpit...
in the Tupolev's cockpit as a factor in the crash.
The Russian Federation states that the Russian pilots were unable to obey the TCAS advisory to climb; the advisory was given when they were already at 35500 feet while the controller wrongly stated there was conflicting traffic above them at 36000 feet. Also, the controller gave the wrong position of the DHL plane (2 o'clock instead of the actual 10 o'clock). Russia asserts that the DHL crew had a "real possibility" to avoid a collision since they were able to hear the conversation between the Russian crew and the controller.
Switzerland notes that the Tupolev was about 33 metres below the flight level ordered by the Swiss controller, and still descending at 1900 feet per minute. The Swiss say that this was also a cause of the accident. The Swiss position also states that in spite of the false information given (position and phraseology) by the Swiss controller the TCAS advisories would have been useful if obeyed immediately.
The change in magnetic bearing of the Russian aircraft by cumulatively 20 degrees (from 254 to 274) during the upcoming conflict is not assessed in the official report.
Consequences
Traumatic stress
Traumatic Stress is a commonly used term describing reactive anxiety . It is not a medical term and is not included in the Diagnostic and Statistical Manual of Mental Disorders . What is popularly referred to as Traumatic Stress is covered in DSM-IV by Adjustment Disorders...
caused by the accident. At Skyguide, his former colleagues maintained a vase with a white rose over Nielsen's former workstation. Skyguide, after initially having blamed the Russian pilot for the accident, accepted its share of the responsibility and asked relatives of the victims for forgiveness.
On 19 May 2004, the official investigators found that managerial incompetence and systems failures were the main cause for the accident, so that Nielsen was surely not the only one to be blamed for the disaster. As explained above, a series of coincidences of which Kaloyev and Nielsen were unaware precipitated the accident.
On 27 July 2006, a court in Konstanz
Konstanz
Konstanz is a university city with approximately 80,000 inhabitants located at the western end of Lake Constance in the south-west corner of Germany, bordering Switzerland. The city houses the University of Konstanz.-Location:...
decided that the Federal Republic of Germany should pay compensation to Bashkirian Airlines. The court found that it was illegal for the state to allow a foreign private company to provide air traffic control in German airspace. The government appealed the ruling, and a final decision is still pending as of 2008.
In another case before the court in Konstanz, Skyguide's liability insurance is suing Bashkirian Airlines for 2.5 million euro in damages. The case was opened in March 2008; the legal questions are expected to be difficult, as the airline has filed for bankruptcy under Russian law.
A criminal investigation of Skyguide began . On 7 August 2006, a Swiss prosecutor filed manslaughter charges against eight employees of Skyguide. The Winterthur
Winterthur
Winterthur is a city in the canton of Zurich in northern Switzerland. It has the country's sixth largest population with an estimate of more than 100,000 people. In the local dialect and by its inhabitants, it is usually abbreviated to Winti...
prosecutor called for prison terms of 6 to 15 months, alleging "homicide by negligence". The verdict was announced in September 2007. Three of the four managers convicted were given suspended prison terms and the fourth was ordered to pay a fine. Another four employees of the Skyguide firm were cleared of any wrongdoing.
TCAS and conflicting orders
The accident raised questions on how pilots must react when they receive conflicting orders from the TCAS and from air traffic controlAir traffic control
Air traffic control is a service provided by ground-based controllers who direct aircraft on the ground and in the air. The primary purpose of ATC systems worldwide is to separate aircraft to prevent collisions, to organize and expedite the flow of traffic, and to provide information and other...
(ATC). The TCAS is programmed to assume that both crews will promptly follow the system's instructions. The operations manual clearly states that TCAS should always take precedence over any ATC commands: If an instruction to manoeuvre is received simultaneously from an RA (resolution advisory, the command issued by the TCAS) and from ATC, the advice given by RA should be followed.
It is not required to notify the ATC prior to responding to an RA. This manoeuvre does not require any ATC clearance since TCAS takes into account the position of all other aircraft with transponder
Transponder (aviation)
A transponder is an electronic device that produces a response when it receives a radio-frequency interrogation...
s in the surrounding area.
Prior incidents
About a year before the Bashkirian-DHL collision there had already been another incident involving confusion conflicting TCAS and ATC commands. During the 2001 Japan Airlines mid-air incident2001 Japan Airlines mid-air incident
On Wednesday, January 31, 2001, Japan Airlines Flight 907, using a Boeing 747-446 Domestic bound from Tokyo International Airport in Ōta, Tokyo, Japan to Naha International Airport in Naha, Okinawa, Japan and Japan Airlines Flight 958, using a Douglas DC-10-40D bound from Gimhae International...
, two Japanese airliners nearly collided with each other in Japanese skies. Both aircraft had received conflicting orders from the TCAS and ATC; one pilot followed the instructions of the TCAS while the other did not. Disaster was only averted because one of the pilots made evasive manoeuvres based on a visual judgement. The aircraft missed each other by less than 100 metres (328.1 ft), and the abrupt manoeuvre necessary to avert disaster left about 100 occupants hurt on one aircraft, some seriously. As a consequence Japan called for measures to prevent similar incidents. However, the International Civil Aviation Organization
International Civil Aviation Organization
The International Civil Aviation Organization , pronounced , , is a specialized agency of the United Nations. It codifies the principles and techniques of international air navigation and fosters the planning and development of international air transport to ensure safe and orderly growth...
(ICAO) did not take action until after the crash over Germany. In addition four near misses in Europe occurred before the German disaster, because one set of pilots obeyed the air traffic controllers while the other obeyed TCAS. The ICAO decided to fulfill Japan's request 18 months after the Japan Airlines incident.
Unclear instructions for the Bashkirian crew
The Bashkirian pilots were using the Tu-154 Flight Operations Manual, which contained a section that emphasizes the role of the ATC and describes the TCAS as an additional aid:page 53The same flight manual, on a different page, also contains a passage that strictly forbids manoeuvers contrary to the TCAS under any circumstances. Nevertheless, the official investigation found that the pilots seemed unaware that the TCAS RA should take precedence.page 103
Technical solutions
Before this accident a change proposal (CP 112) for the TCAS II system had been issued. This proposal would have created a "reversal" of the original warning - asking the DHL plane to climb and the Tupolev crew to descend. According to an analysis by Eurocontrol this would have avoided the collision if the DHL crew had followed the new instructions and the Tupolev had continued to descend.page 35Additionally, an automatic downlink for the TCAS - which would have alerted the air traffic controller - had not been deployed worldwide at the time of the accident.page 50
Recommendations after the accident
The investigation report contains a number of recommendations concerning TCAS, calling for upgrades and for better training and clearer instructions to the pilots.Notable passengers on Flight 2937
Fourteen-year old Kirill Degtyarev created paintings from age 4 to his death and had held two public exhibitions. After his death, Ufa hosted one exhibition and Überlingen hosted another exhibition. The family of future deputy North Ossetian housing minister Vitaly KaloyevVitaly Kaloyev
Vitaly Konstantinovich Kaloyev is an architect and deputy minister of housing from North Ossetia, Russia, known for his 2004 murder of Peter Nielsen in the Swiss town of Kloten. Kaloyev's family died aboard Bashkirian Airlines Flight 2937, which collided with another aircraft over Germany in 2002...
all died. Kaloyev would later go on to murder Nielsen.
Murder of Peter Nielsen
Grieved by the loss of his family, Vitaly Kaloyev held Peter Nielsen responsible for their deaths. He stabbed Nielsen to death at his KlotenKloten
-External links:* -References:...
home, near Zürich, on 24 February 2004. Police arrested Kaloyev at a local motel not long after the murder, and he was subsequently convicted of the crime in 2005. He was released on 8 November 2007 because his mental condition was not sufficiently considered in the initial sentence. After his release, Kaloyev was infamously dubbed a "hero" in North Ossetia. In January 2008, he was appointed deputy construction minister of North Ossetia.
Dramatization
The Discovery Channel Canada documentary series MaydayMayday (TV series)
Mayday, also known as Air Crash Investigation in the United Kingdom, Australia and Asia and Air Emergency and Air Disasters in the United States, is a Canadian documentary television programme produced by Cineflix investigating air crashes, near-crashes and other disasters...
featured this accident in the episode titled Deadly Crossroads, which was released in 2004.
The National Geographic Channel
National Geographic Channel
National Geographic Channel, also commercially abbreviated and trademarked as Nat Geo, is a subscription television channel that airs non-fiction television programs produced by the National Geographic Society. Like History and the Discovery Channel, the channel features documentaries with factual...
documentary series Seconds From Disaster
Seconds From Disaster
-By original broadcast date:National Geographic Channel has broadcast many episodes under multiple titles. The title currently or most recently listed on the NGC Calendar is shown first...
featured this mid-air collision in the episode entitled Collision at 35,000 feet release in 26th September 2011.
"Flug in die Nacht - Das Unglück von Überlingen" (2009), ("Flight into the night - the accident at Überlingen") produced by German and Swiss TV stations SWR
Südwestrundfunk
The Südwestrundfunk is a public broadcasting company for the southwest of Germany, specifically the states of Baden-Württemberg and Rhineland-Palatinate. The company has main offices in three cities: Stuttgart, Baden-Baden and Mainz, with the director's office being in Stuttgart. It is an...
and SF
Schweizer Fernsehen
Schweizer Fernsehen is the German language division of SRG SSR, in charge of production and distribution of television programmes in German for German-speaking Switzerland...
, is a motion picture based on the crash and the subsequent killing of the air traffic controller.
Related Articles
- 2001 Japan Airlines mid-air incident2001 Japan Airlines mid-air incidentOn Wednesday, January 31, 2001, Japan Airlines Flight 907, using a Boeing 747-446 Domestic bound from Tokyo International Airport in Ōta, Tokyo, Japan to Naha International Airport in Naha, Okinawa, Japan and Japan Airlines Flight 958, using a Douglas DC-10-40D bound from Gimhae International...
- 1996 Charkhi Dadri mid-air collision
- TCAS
- 1986 Cerritos Mid-air collision
- Gol Transportes Aéreos Flight 1907Gol Transportes Aéreos Flight 1907Gol Transportes Aéreos Flight 1907 was a Boeing 737-8EH, registration PR-GTD, on a scheduled passenger flight from Manaus, Brazil, to Rio de Janeiro. On 29 September 2006, just before 17:00 BRT, it collided in midair with an Embraer Legacy business jet over the Brazilian state of Mato Grosso...
External links
- Final Report - German Federal Bureau of Aircraft Accidents Investigation (English)
- Final Report - German Federal Bureau of Aircraft Accidents Investigation - The German version is the version of record
- "Information regarding the air accident at Überlingen on 1 July 2002." SkyguideSkyguideskyguide is the air navigation services company that controls Swiss airspace....
. - District Court of Kostanz Bashkirian Airlines v. Federal Republic of Germany
- Photo documentary from Owingen Fire Dept. (German) - Official website from Owingen Fire Dept. with photos from a firefighter's perspective
- Identifying the factors that contributed to the Ueberlingen mid-air collision (PDF 322 KB) - University of Illinois
- Gallery of crash victim Kyrill Degtyarev's works
- 'The Uberlingen mid-air collision: Lessons for the management of control rooms in the process industries', Loss Prevention Bulletin issue 196, 2007, IChemE, UK.