Bashkirian Airlines Flight 2937

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Bashkirian Airlines Flight 2937
DHL Flight 611

CG rendering of Flight 2937 about to collide with Flight 611.
Summary
Date 1 July 2002
Type Mid-air collision
involving ATC error
Site Flag of Germany Überlingen, Germany
Total fatalities 71
Total survivors 0
First aircraft
Type Tupolev Tu-154M
Operator Bashkirian Airlines
Tail number RA-85816
Flight origin Flag of Russia Domodedovo Int Airport[1][2]
 Moscow, Russia
Destination Flag of Spain Barcelona Int'l Airport
 Barcelona, Spain
Passengers 60
Crew 9
Survivors 0
Second aircraft
Type Boeing 757-200
Operator DHL Aviation
Tail number A9C-DHL
Flight origin Flag of Bahrain Bahrain Int'l Airport[3][4]
Stopover Flag of Italy Orio al Serio Airport
 Bergamo, Italy
Destination Flag of Belgium Brussels Airport, Belgium
Passengers 0
Crew 2
Survivors 0
Site of the crash (Germany)
Site of the crash
Site of the crash
Site of the crash (Germany)
Computer reconstruction of the accident derived from the Flight Data Recorder and collision evidence.
Computer reconstruction of the accident derived from the Flight Data Recorder and collision evidence.
Computer reconstruction (side view).
Computer reconstruction (side view).

Bashkirian Airlines Flight 2937, registration RA-85816, was a Tupolev 154M passenger jet en route from Moscow, Russia, to Barcelona, Spain. DHL Flight 611, registration A9C-DHL, was a Boeing 757-200 cargo jet flying from Bergamo, Italy, to Brussels, Belgium. The two aircraft collided in mid-air on July 1, 2002, at 21:35 (UTC) over the towns of Owingen and Überlingen in Germany, (near Lake Constance), killing all 71 aboard both aircraft. German official investigators determined on May 19, 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.[1] On February 24, 2004, the controller who was on duty at the time, Dane Peter Nielsen, was stabbed to death by Vitaly Kaloyev[5] who had lost his wife and two children in the accident.[6][7]

Contents

[edit] The flights involved

Flight 2937 was a chartered airliner carrying 60 passengers and 9 crew. 45 of the passengers were Bashkortostan schoolchildren being taken to a resort in the Costa Dorada area of Spain[3] as a prize for their win in republican competitions.[2][8] They took a train from Ufa to Moscow.[9] Most of the parents of the children were high-ranking officials in Bashkortostan[10]. Nine children were under the age of 12, and 43 were between the ages of 12 and 18[3]. A local committee for UNESCO organized the holiday trip.[11] 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.[9] The children did not leave until Monday (1 July)[10] from Domodedovo International Airport. A Russian crew operated the aircraft. The captain, Alexander Mihailovich Gross (Александр Михайлович Гросс)[9], and the first officer and Alexander Gross's supervisor, Oleg Pavlovich Grigoriev (Олег Павлович Григорьев)[9], flew the Tupolev. Oleg Grigoriev, the chief pilot of Bashkirian Airlines, used the trip to evaluate Gross's performance. Murat Ahatovich Itkulov (Мурат Ахатович Иткулов)[9], normally the first officer, did not officially serve on duty because Grigoriev sat in his seat. The crew wanted the opinions and guidance of Murat Itkulov, who was slated to be promoted to captain. Sergei Kharlov, a navigator, and a flight engineer joined the three pilots.[9]

Flight 611 was carrying a load of air freight and had two Bahrain-based[12][3] crew members aboard, British Captain Paul Phillips and Canadian First Officer Brant Campioni.[8]

[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.[9]

[edit] The accident

The two aircraft were flying at 36,000 (FL360) feet 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.

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 feet per minute, not as rapid as the 2500-3000 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 other 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 Flight 2937 crew tried to locate the DHL flight visually in the dark, losing reaction time.

The aircraft collided at almost a right angle at 34,890 feet, 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 crippled Boeing, now with 80% of its vertical stabilizer lost, struggled for a further seven kilometres (4.3 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.

[edit] Other factors in the crash

One air traffic controller, Peter Nielsen of ACC Zurich, was controlling the airspace through which the aircraft were transitioning. The only 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 unaware of this or he chose not to use them in order to avoid dangerous boredom.[1]

In addition, a 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; if 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.[1]

The main phone lines at Skyguide was also down as part of the maintenance work, and the backup line was defective. This prevented adjacent air traffic controllers at Karlsruhe from phoning in a warning.

In the minutes before the accident, Nielsen was occupied with an Airbus on a delayed Aero Lloyd Flight 1137 approaching Friedrichshafen Airport.[1] 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. 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. When Nielsen realised that the situation (the multiple factors in two workstations) was overwhelming, it was too late to summon assistance.

[edit] Deviating statements in the official report

All countries involved could add additional "deviating" statements to the official report. The Kingdom of Bahrein, 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[13].

The Kingdom of Bahrein, as a 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. Bahrein'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 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.

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 claim that this was also a cause of the accident. This is in contrast to the official report, which assumes that the Russian pilots must have interpreted the controller's call not as a 'normal' instruction to go to a flight level, but as an emergency call to avoid another plane coming from above. Thus, the BFU report regards the Russian's reaction as normal and not 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 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 proper lessons from the near-miss which occurred about a year before the Bashkirian-DHL collision.[14] 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 manoeuver 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 instead of the TCASs. The ICAO decided to fulfill Japan's request 18 months after the Japan Airlines incident.[9]

[edit] Consequences

Nielsen had retired from his job as controller after the accident, since he had been struck by grief and guilt over the incident. At Skyguide, his former colleagues maintain to this day a vase with a white rose over Nielsen's former workstation. Skyguide, after initially having blamed the Russian pilot for the accident, accepted its part of the responsibility and paid compensation to some of the Russian families.

On May 19, 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 July 27, 2006, the court of Konstanz determined that fault lay exclusively with the German government, since it was against German law to allow Skyguide to offer air traffic control services in German airspace. The government's appeal is currently pending.

A criminal investigation of the Skyguide begun as of May 2004. On August 7, 2006, a Swiss prosecutor filed manslaughter charges against eight employees of Skyguide. The Winterthur prosecutor called for jail terms of six to 15 months, alleging "homicide by negligence".[15] 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.[16]

[edit] Murder of Peter Nielsen

Main article: Vitaly Kaloyev

Grieved by the loss of his family, Vitaly Kaloyev held Peter Nielsen responsible for their deaths and confronted him at Nielson's Kloten home,[17] near Zürich, on February 24, 2004.[18] 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 November 8, 2007 because his mental condition was not sufficiently considered in the initial sentence.

[edit] Conflicting orders

According to the section on TCAS operations in the flight operations manual: If an instruction to manoeuvre is received simultaneously from an RA (resolution advisories, i.e. 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 transponders in the surrounding area.

The pilot, while seemingly following the section of Tu-154 Flight Operations Manual (in Russian), which states according to the official investigation report (page 80): 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., completely disregarded a more strict and clear requirement of the manual, which prohibited him from performing commands opposite RA recommendations („Запрещается выполнять команды противоположные тем, которые выдает система.“, pp. 71 and 106 of the English version of the investigation report).

Before this accident a change proposal (CP 112) for the TCAS II system has been issued. This proposal would have created a "reversal" of the original warning - asking the DHL plane to climb and the Tupolev crew to sink. 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 sink.[1]

[edit] Dramatization

This accident was featured in an episode of the Discovery Channel Canada program Mayday (also known as Air Emergency on the National Geographic Channel in the US or Air Crash Investigation in other parts of the world).

[edit] References

  1. ^ a b c d e f Investigation Report AX001-1-2/02 MAY 2004. Retrieved on 2007-01-17.
  2. ^ a b Gallagher, Paul. Jet pilot's 14 seconds dilemma before fatal crash. scotsman.com. Retrieved on 2007-01-18.
  3. ^ a b c d "Vain attempt to avert deadly crash, CNN
  4. ^ "Mid-air collision of July 1, 2002: sequence of events" (Skyguide).
  5. ^ "Swiss law court decided to free V.Kaloyeva"
  6. ^ Wolfsteller, Pilar. Father 'saw black' as he killed air traffic controller. scotsman.com. Retrieved on 2007-01-18.
  7. ^ "Nothing left to lose: grief-crazed murder suspect haunted by family's air deaths," The Guardian
  8. ^ a b Wild, Matthew. Family devastated by pilot's death. north shore news. Retrieved on 2007-01-18.
  9. ^ a b c d e f g h "Deadly Crossroads," Mayday
  10. ^ a b "Children's holiday party on doomed plane," CNN
  11. ^ "Address by Mr Koïchiro Matsuura," UNESCO
  12. ^ "British pilot 'tried to avert disaster'," BBC
  13. ^ Appendices/Deviating positions for Investigation Report AX001-1-2/02 MAY 2004. Retrieved on 2008-05-05.
  14. ^ report outline. ICAO. Retrieved on 2007-01-22.
  15. ^ Swiss go on trial over air crash - BBC News Online - Retrieved on 15 May 2007
  16. ^ "Four guilty over Swiss air crash," BBC
  17. ^ "Swiss air crash controller killed," CNN
  18. ^ Skyguide - information regarding the air accident. Retrieved on 2007-01-18.

[edit] External links

[edit] Official releases

[edit] Press

[edit] On conflicting orders

[edit] Skyguide

[edit] Camphill School

[edit] Other

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