2002 Überlingen mid-air collision

From Wikipedia, the free encyclopedia

This article needs additional citations for verification. Please help improve this article by adding reliable references. Unsourced material may be challenged and removed. (December 2009)

Bashkirian Airlines Flight 2937
DHL Flight 611

Bashkirian Airlines Flight 2937
Accident summary
Date	1 July 2002 (2002-07)
Type	Mid-air collision involving ATC error, TCAS ignorance and technical limitations, crew error (Bashkirian Airlines 2937)
Site	Überlingen, Germany 47°46′42″N 9°10′26″E / 47.77833°N 9.17389°E / 47.77833; 9.17389Coordinates: 47°46′42″N 9°10′26″E / 47.77833°N 9.17389°E / 47.77833; 9.17389
Total fatalities	71
Total survivors	0
First aircraft
Type	Tupolev Tu-154M
Operator	Bashkirian Airlines
Tail number	RA-85816
Flight origin	Domodedovo Int Airport[BFU 1][2]  Moscow, Russia
Destination	Barcelona Int'l Airport  Barcelona, Spain
Passengers	60
Crew	9
Second aircraft
Type	Boeing 757-23APF[1]
Operator	DHL International
Tail number	A9C-DHL
Flight origin	Bahrain Int'l Airport[3][4]
Stopover	Orio al Serio Airport  Bergamo, Italy
Destination	Brussels Airport, Belgium
Passengers	0
Crew	2

Bashkirian Airlines Flight 2937, registration RA-85816, was a Tupolev Tu-154M passenger jet en route from Moscow, Russia, to Barcelona, Spain. DHL Flight 611, registration A9C-DHL, was a Boeing 757-23APF cargo jet flying from Bergamo, Italy, to Brussels, Belgium. The two aircraft collided in mid-air on 1 July 2002, at 21:35 (UTC) over the towns of Owingen and Überlingen in Germany, (near Lake Constance), killing all 71 aboard both aircraft^[5]. The German Federal Bureau of Aircraft Accidents Investigation (BFU) determined on 19 May 2004, that the accident had been caused by problems within the air traffic control system and problems with the use of the collision warning system.^{[BFU 1]} On 24 February 2004, the controller who was on duty at the time, the Dane Peter Nielsen, was stabbed to death by Vitaly Kaloyev^[6] who had lost his wife and two children in the accident.^[7][8]

Contents 1 Flights involved 1.1 Notable passengers on Flight 2937 2 Accident 3 Other factors in the crash 3.1 Deviating statements in the official report 4 Failure to learn from prior incident 5 Consequences 5.1 Murder of Peter Nielsen 6 TCAS and Conflicting orders 7 Dramatization 8 References 9 External links 9.1 On conflicting orders

[edit] Flights involved

Flight 2937 was a chartered flight carrying 60 passengers and 9 crew. 45 of the passengers were Bashkortostan schoolchildren being taken to a resort in the Costa Daurada area of Spain^[3] as a prize for their win in republican competitions.^[2][9] They took a train from Ufa to Moscow.^[10] Most of the parents of the children were high-ranking officials in Bashkortostan^[11]. Seven of the children were students at Gymnasium No. 3 in Ufa, which is considered to be one of Ufa's highest-ranked schools.^[12] A local committee for UNESCO organized the holiday trip.^[13] Originally the children were supposed to leave from Sheremetyevo Airport on a Sunday; the children had arrived late in Moscow and they had arrived at the wrong airport.^[10] The children did not leave until Monday (1 July)^[11] from Domodedovo International Airport. A Russian crew operated the aircraft. The captain, Alexander Mihailovich Gross (Александр Михайлович Гросс)^[10], and the first officer and Gross's supervisor, Oleg Pavlovich Grigoriev (Олег Павлович Григорьев)^[10], flew the Tupolev. Grigoriev, the chief pilot of Bashkirian Airlines, used the trip to evaluate Gross's performance. Murat Ahatovich Itkulov (Мурат Ахатович Иткулов)^[10], normally the first officer, did not officially serve on duty because Grigoriev sat in his seat. The crew wanted 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.^[10]

Flight 611 was carrying a load of air freight and had two Bahrain-based^[3][14] crew members aboard, British Captain Paul Phillips and Canadian First Officer Brant Campioni.^[9]

[edit] Notable passengers on Flight 2937

14-year old Kirill Degtyarev created paintings from age 4 to his death and held two public exhibitions before his death. After his death, Ufa hosted one exhibition and Überlingen hosted another exhibition.^[10]

[edit] Accident

The two aircraft were flying at flight level 360 (approximately 36,000 feet (11,000 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 air traffic controller handling the airspace, Peter Nielsen, was working two workstations at the same time and did not realise the danger facing the two aircraft until less than a minute before the accident. At that time he 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.^{[BFU 1]}

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 2,400 feet per minute (12 m/s), not as rapid as the 2,500 to 3,000 ft/min (13 to 15 m/s) 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.^{[BFU 1]}

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.^{[BFU 1]}

The aircraft collided at almost a right angle at an altitude of 34,890 feet (10,630 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. 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.^{[BFU 1]}

[edit] 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.^{[BFU 2]} 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 on a delayed Aero Lloyd Flight 1137 approaching Friedrichshafen Airport.^{[BFU 3]} 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 ordered the Russian plane to descend earlier, the aircraft 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.^{[BFU 4]}

[edit] Deviating statements in the official report

All countries involved could add additional "deviating" statements to the official report. The Kingdom of Bahrain, 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 not commented by the German federal investigators^[15].

The Kingdom of Bahrain, as the home country of the DHL plane, mostly agrees with the findings of the report. They say 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^[15].

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 wrongfully 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^[15].

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^[15].

The change of 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.

[edit] Failure to learn from prior incident

The International Civil Aviation Organization (ICAO) did not take action regarding the near-miss which occurred about a year before the Bashkirian-DHL collision.^[16] During the 2001 Japan Airlines mid-air incident, two Japanese airliners, both Japan Airlines, nearly collided with each other in Japanese skies. Disaster was avoided because one of the pilots made evasive manoeuvres based on a visual judgement, and 677 people were saved. If the collision had occurred, it would have been the deadliest civil aviation accident in terms of passenger lives. The aircraft missed each other by less than 100 metres, and the abrupt manoeuvre necessary to avert disaster left about 100 occupants hurt on one aircraft, some seriously. Japanese authorities called for measures that would prevent similar accidents from happening, but ICAO did not further investigate the incident until after the Germany collision. In addition four near misses in Europe occurred before the Germany 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.^[10]

[edit] Consequences

Nielsen needed medical attention due to traumatic stress caused by the accident.^[17] At Skyguide, his former colleagues maintained a vase with a white rose over Nielsen's former workstation.^[18] Skyguide, after initially having blamed the Russian pilot for the accident, accepted its share of the responsibility and has paid compensation to some of the Russian families.^{[citation needed]}

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.^{[citation needed]}

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.^[19]

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.^[19]

A criminal investigation of Skyguide began as of May 2004^[update]. On 7 August 2006, a Swiss prosecutor filed manslaughter charges against eight employees of Skyguide. The Winterthur prosecutor called for jail terms of 6 to 15 months, alleging "homicide by negligence".^[20] 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.^[21]

[edit] Murder of Peter Nielsen

Grieved by the loss of his family, Vitaly Kaloyev held Peter Nielsen responsible for their deaths. He killed Nielsen at his Kloten home,^[22] near Zürich, on 24 February 2004.^[23] 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.^[24]

[edit] TCAS and Conflicting orders

The accident raised questions on how pilots must react when they receive conflicting orders from the TCAS collision avoidance system and from Air traffic control (ATC). The TCAS system is programmed to assume that both crews will promptly follow the system's instructions. The operations manual clearly states that TCAS should always take predence over any ATC commands: If an instruction to manoeuvre is received simultaneously from an RA (resolution advisory, issued by the TCAS) and from ATC, the advice given by RA should be followed.^{[BFU 1]}

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 transponders in the surrounding area.^{[citation needed]}

However, the Bashkirian pilots were using the Tu-154 Flight Operations Manual, which contains a section that emphasizes the role of the ATC and describes the TCAS system as an additional aid^{[BFU 5]}:

“	For the avoidance of in-flight collisions is the visual control of the situation in the airspace by the crew and the correct execution of all instructions issued by the Air Traffic Controller to be viewed as the most important tool. TCAS is an additional instrument which ensures the timely determination of oncoming traffic, the classification of the risk and, if necessary, planning of an advice for a vertical avoidance manoeuvre.	”
—TU154M Flight Operations Manual

The same flight manual, on a different page, also contains a passage that strictly forbids manoeuvers contrary to the TCAS under any circustances. Nevertheless, the official investigation found that the pilots seemed unaware that the TCAS RA should take precedence.^{[BFU 6]}

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.^{[BFU 7]}

Additionally, an automatic downlink for the TCAS system - which would have alerted the ground controller - had not been deployed worldwide at the time of the accident.^{[BFU 8]}

The investigation report contains a number of recommendations concerning TCAS, calling for upgrades and for better training and clearer instructions to the pilots.^{[BFU 1]}

[edit] Dramatization

This accident was featured in an episode of the Discovery Channel Canada program Mayday.^[25]

"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.^[26]

[edit] References

[edit] External links

• Final Report - German Federal Bureau of Aircraft Accidents Investigation (English)
  • Appendices 1 and 3
  • Appendix 2
• 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

[edit] On conflicting orders

• ACAS II bulletin from Eurocontrol: Follow the RA! (PDF)
• ACAS guiding material: CAP 579 (PDF)
• Script for Case Study – Mid Air Collision over Ueberlingen

v • d • e ← 2001 Aviation accidents and incidents in 2002 2003→ Tampa plane crash (January 5) — Lion Air Flight 386 (January 14) — Garuda Indonesia Flight 421 (January 16) — Shelkovskaya Mi-8 crash (January 27) — TAME Flight 120 (January 28) — Air China Flight 129 (April 15) — 2002 Pirelli Tower plane crash (April 18) — 2002 Jalandhar India MiG-21 crash (May 3) — EAS Airlines Flight 4226 (May 4) — May 7: China Northern Airlines Flight 6136 and EgyptAir Flight 843 — China Airlines Flight 611 (May 25) — Airtanker crash (June 17) — 2002 Überlingen mid-air collision and America West Flight 556 (July 1) — 2002 Bristow Helicopters Sikorsky S-76A crash (July 16) — Airtanker crash (July 18) — Sknyliv airshow disaster (July 27) — Khankala Mi-26 crash (August 16) — Luxair Flight 9642 (November 6) Bold blue indicates incidents resulting at least 50 deaths (current article is always in bold black) Orange indicates the deadliest incident in 2002

v • d • e Lists of aviation accidents and incidents General by year · by death toll · in mid-air Commercial by year · by airline · by location · airliners Military by year (pre-1950 · 1950–1974 · 1975–1999 · 2000–present) · Shootdowns · Sri Lankan Civil War · Coalition aircraft losses in Afghanistan · Iraq War · USAF (B-52, C-130) Other Airships · News aircraft · Spaceflight Deaths by aircraft misadventure · of notable people · Sole survivors Related topics Air safety · Aircraft hijacking · Aviation archaeology · Air crash investigators  · Accident analysis For more exhaustive lists, see the Aircraft Crashes Record Office (ACRO) and Aviation Safety Network websites. Italics indicates the list is a wikicategory.

v • d • e Aviation accidents covered in Mayday/Air Crash Investigation/Air Emergency episodes Season 1 American 1420 · United 811 · Air Transat 236 · Swissair 111 · Aeroperú 603 · Alaska 261 Season 2 British Airways 5390 · ASA 529 · Air France 8969 · Bashkirian 2937 and DHL 611 · American 965 · Avianca 52 Season 3 Aloha 243 · DHL OO-DLL · JAL 123 · FedEx 705 · Iran Air 655 · Philippine 434 · Bristow 56C · EgyptAir 990 · Aeroflot 593 · Ethiopian 961 · KLM Flight 4805 and Pan Am Flight 1736 Season 4 Air France 358 · British Airways 9 · Air Canada 797 · Korean Air 801 · United 585 / USAir 427 / Eastwind 517 · China Airlines 006 · Aeroméxico 498 · USAF 21 · Flash 604 · Helios 522 Season 5 Air Midwest 5481 · American 96 / Turkish 981 · Air Canada 143 · Delta 191 · Southern 242 · South African 295 · Air India 182 · Birgenair 301 · Eastern 401 · GOL 1907 and ExcelAir N600XL Season 6 Pan Am 103 · Saudia 763 and Air Kazakhstan 1907 · China Airlines 611 · Partnair 394 · Operation Babylift · Tuninter 1153 · Adam Air 574 · American Eagle 4184