The 2002 Überlingen midair collision
admiralcloudberg.medium.com
admiralcloudberg.medium.com
Having lived in the are and going to school in Überlingen at the time it is not something I'm ever going to forget.
I did not notice the crash itself (I'm a deep sleeper) but heard about it in the radio at morning. First I thought I must have misheared. Being a vonlunteer firefighter in our village I wondered, why I did not get an alarm. On my way to the train station I stopped at our local fire station but saw only a small transporter was missing, so I figured they may have alarmed only a few people.
There was some sort of "fog of war". Nobody knew anything for sure. There were rumours, that one of the planes crashed into the lake. The crash site being at Hohenbodman did not help because there is a village named Bodman on the other side of the lake.
Waiting for the train and on the train there was nothing else we could talk about. Arriving in Überlingen, we (a classmate and I) went straight down to the lakeside of the city to see if we can catch a glimpse of anything. The atmosphere in the city was surreal.
The route from the city center and train station to our school went over the yard of the city's fire station. And there it hit. Dozens of firefighters, police, red cross, etc. swarmed the place. A search dog unit just arrived. The facial expressions of everybody.
At school there was no lessons of course. Everybody just talked about the crash and the newest rumours. Some classmates arrived by bus and their bus drove straight by the crashsite. They saw corpses under cloth and smoking debris. A few hours later people from the local newspaper arrived to distribute a special issue with the most comprehensive compilation of available information at the time.
(... a few months later ...)
We had local festivities and I helped. It was bigger festivities and we spent days building everything and had to gather stalls, building material and tools from various storage areas, companies, etc. To fetch something I went with someone to a local building company. We went into their warehouse and an overwhelming stench of kerosene hit me. The warehouse was filled with transport container trays full of excavated ground that was contaminated with kerosine (and small debris) from the crash. The guy I went with just mentioned this in a very non-chalant way.
Next day we knew why we all were awake at the same time. Surreal.
But I can disseminate at least two flying maxims you can take away from this tragedy:
1: Do what TCAS is telling you to do.
2: Air Traffic Control does NOT have the final responsibility for your plane, you do.
- The TCAS system had already resolved the safe and correct conflict avoidance maneuvers for both of the transceivers involved (on both aircraft).
- As amazing and professional as our air traffic controllers are (and they are), they to, just like you the pilot are prone to error, and they in fact are not inside your aircraft, nor are they the pilot in command.
I've seen especially in new pilots and people that want to learn to fly this urge to defer to ATC (I even asked a friend who's a huge Flight Simulator enthusiast, of which I was too when young, what he'd do in a purely technical flight situation, and he responded he'd "ask ATC what to do"...).
While yes, Air Traffic Control 'controls' certain air space, they don't control your aircraft or its occupants. FAR 91.3 says it all, I'll let you look it up, it's 2 very brief (thank you FAA/congress) sentences that spell out the end of this discussion. You might get a fine, you might lose your license, etc etc, if you're reasoning for having to deviate from ATC rules aren't sufficient..
But hey in this case would those pilots on those 2 planes in this incident have rather lost their licenses (potentially) or have what happened happen.
Of course this incident is nuanced, as they all are. Flying safely involves mitigating and accepting certain levels of risk. TCAS was a system specifically designed and implemented to resolve collision situations. You test your equipment at regular intervals and pre-flight so that you can be confident they are working properly so that when you get into a situation where TCAS is telling you to do something, you do it.
But the reality is stress, human behavior isms' like maybe say flying in from an eastern european country and wanting to not 'piss off' the Swiss controllers, so deferring to their every direction instead of following your own instruments. << That's a real thing .. when you fly into busy airspace in the US, you quickly realize you just 'don't want to piss anyone off' .. All of these factors influence what should have been a cut and dry collision avoidance dictated by the TCAS system. And this is the cost of human flight.
That guidance to always follow TCAS came in because of this incident.
The FAA said always follow TCAS ("any guidance from TCAS overrides guidance from ATC"), whereas other regulators were either vaguely non-committal to which had overriding priority or assigned priority to ATC.
It also notes that the Russian pilots were not accustomed to TCAS (which was not common in Russia, at the time). Even further, to the extent they were familiar with it, Russian regulations noted that the ATC's guidance superseded all other guidance systems.
Rather, I was pointing out that the international community of aviation regulators had established conflicting norms with regards to the requirement and prioritization of TCAS at the time of the incident.
The conflict in norms was a contributing factor to the incident discussed in the article, and in the aftermath of the incident, those norms were appropriately corrected. The mention of the FAA is relevant because their original guidance (TCAS guidance supersedes ATC guidance) was what the ICAO adopted in response to this incident.
The fact that Russian aviation failed to train (or even require training for that apparently) is absurd, the fact that the EU allowed planes to travel with TCAS but not with pilots that had the most basic understanding of TCAS is a sad example of the results of checkmark based safety.
As even this article acknowledges, TCAS as a system makes no sense of any kind if it can be countermanded by someone other than the pilot. There is no use case for TCAS that makes anything other than "do what it says, a fast as possible" have any value at all. Disobeying TCAS because of ATC is no different than ignoring a stall warning because ATC told you to climb.
Quoting Wikipedia: "The [TCAS] manual described TCAS as "a backup to the ATC system", which could be wrongly interpreted to mean that ATC instructions have higher priority."
In fact, you'd do well to read the entire Wikipedia article to see that this was not the only case where pilots did not have clear guidance on which orders to follow in the case of conflicting ATC and TCAS orders.
Other similar maxim is "In case you are intercepted by a fighter jet, and ATC and the fighter jet issues seemingly conflicting instructions follow what the fighter jet says/signals, and inform about this fact the ATC."
People with missiles trained on you have command priority for all the obvious reasons.
(a) The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft.
(b) In an in-flight emergency requiring immediate action, the pilot in command may deviate from any rule of this part to the extent required to meet that emergency.
(c) Each pilot in command who deviates from a rule under paragraph (b) of this section shall, upon the request of the Administrator, send a written report of that deviation to the Administrator.
In the context of your post, if asked, i wonder if the FAA (or whoever) would say "the pilot has final authority, even if it goes against what the ATC commanded", even with the nuance and additional information that would be required in 91.3c.
for the record, it was 47 cfr 97.405 https://www.ecfr.gov/current/title-47/section-97.405 - and it states clearly:
(a) No provision of these rules prevents the use by an amateur station in distress of any means at its disposal to attract attention, make known its condition and location, and obtain assistance.
(b) No provision of these rules prevents the use by a station, in the exceptional circumstances described in paragraph (a) of this section, of any means of radiocommunications at its disposal to assist a station in distress.
My question was simple - one has a radio what can transmit clearly on a police frequency, that is, if one pushes transmit, police radios and scanners in the area can hear the audio being transmitted. Can one use said radio in an emergency, if they are a licensed part 97 operator?
FCC: "no"
me: "yes, obviously."
2: Air Traffic Control does NOT have the final responsibility for your plane, you do."
I wonder if there is some human bias that preferences human directions/instruction over technologically manufactured ones (TCAS).
Especially when it's a stressful, fast paced situation.
This is one of the reasons that if you're trained in emergency situations they tell you things like "don't yell 'someone call 911' but instead point directly at someone and say 'call 911'".
Not to be pedantic, but there’s def 3 sentences.
Its the first time I read an article about all the details. Thanks for the writeup!
At one point we realised that these where young students like us… And all our firefighters where tasked to help find all those bodies…
https://en.wikipedia.org/wiki/2002_%C3%9Cberlingen_mid-air_c...
Jesus
Also:
"On 8 November 2007, Kaloyev was released from prison on parole after having served two-thirds of his sentence, a total of three and a half years."
"Returning to his home in North Ossetian city of Vladikavkaz, Kaloyev was met with enthusiastic crowds who cheered him as a hero."
Ultimately if you work in a safety-critical field and you don’t speak up when something is very wrong, then you are just as responsible as anyone else.
Plugging away at your job while maintenance people disconnect the phones from ATC is negligent inaction. Without a working phone line the ATC was clearly offline in a very literal sense and he should have recognized that and either passed the responsibilities to another ATC and/or closed the airspace.
They removed one controller. That was... not great, but it seemed okay.
They removed one collision warning system, for a short window. That was... not great, but it seemed okay.
They removed both phone lines. They didn't tell him. That wasn't okay, but he couldn't know that until he needed them.
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This also disregards that someone is always in the chair. Okay, let's say he quits. Then they're short an additional controller, making the situation worse, and someone else is still sitting in the chair when the exact same thing happens. "He voluntarily worked in an unsafe environment" is just a deflection from the responsibility of the people who have the authority and the opportunity not to make the system unsafe. His only agency was to quit his job or not, which wouldn't have any effect on the outcome.
I can sort of see different ways to look at these situations but I usually don't see them that way. While desperately holding together a broken system seems heroic, it assumes that help is on the way. Many times no help is on the way because the system is sort of barely functioning so there is no priority to improve it. If he left maybe the other controllers would all leave as well, ending the farce.
> His only agency was to quit his job or not, which wouldn't have any effect on the outcome.
He probably wouldn't have been murdered and blamed for the the outcome!
The murder of Nielsen is a tragedy, but that doesn't mean he wasn't responsible.
Most of it seems to come down to trying to cut costs and reduce conflict with the staff (the acceptance of the “long breaks” overnight)
None of that lands on the overworked controller trying to do 3 jobs
I'm not spouting my own opinion here, just noting that what the report says is at odds with claims in this thread.
Perhaps you're tripping over "responsible", it helps to read it as "if you, future person, are in this situation, consider how you could avoid a similar accident, given your position in the system".
It does not necessarily mean "this person is incompetent", or "this person is criminally liable". That's outside the scope of such reports.
If it didn't mean that, then someone in the ATC chair in the exact situation tomorrow would need to helplessly watch the same tragedy play out in front of their eyes, would they not? Even if they'd have the benefit of hindsight in having read this report.
After all they'd be a powerless puppet strung along by systemic causes.
Severe Tangent:
It's difficult to change the way you perceive the world, but I invite you to try.
Lately I've been thinking about how we understand and talk about tragedies and atrocities in history. Atrocities are traced back to who is most to blame, but not the conditions that led to the situation, not the political techniques that were used to gain the power, and certainly not how it might apply to ourselves.
When we find someone to blame for evil acts, we can close that mental box. That was the person who did it; I would never do something like that; I would never support someone like that.
But, most of the time, the evil leader did not start their reign with huge atrocities. It may have started with a fight that many of their followers did support.
It's easy to say "I would never support an atrocity", and maybe even say "I would never support someone who talks about any group as less than human".
The problem is, it's always easier to see this in your opponents than in yourself. I'm not making a false equivalence or an excuse; I'm saying it's really difficult and we should not be surprised when it is difficult. When the group mentality gets to a certain point, any reasonable nudge or criticism is taken as an attack.
I don't know of a great solution, but I think about how cult members are de-programmed. They have to remember or find something in the real world that they value. There has to be a bridge, not a demand that they renounce their beliefs.
The person who decided I must blame someone, decided to murder the controller (that the report did not blame) and be celebrated as a hero by a bunch of moronic "manliness" "strong men" in Russia. This BS concept of "manliness" and "being strong" == "being better" needs to be stopped, and it's frustrating to see so much revival and promotion for it on YouTube and the like.
It is sad to see how our civilization collectively decided to throw out several thousands years of tradition and dozen of thousands pages of collective wisdom. The topic GP mentioned has been known for centuries, way before modern psychology. In fact, it is one of the important points of Catholicism (AFAIU) - every single man is a sinner capable of horrible deeds, but that diminishes neither the dignity of every human being nor their ability (with God's grace) of overcoming that.
Why is this treated as a specifically Russian tendency?
The mindset sounds intimately familiar to me as an American. Many people, perhaps even most, operate on that idea. Our politics are heavily dependent on that idea. It also heavily underpins our justice system.
Because everyone in that part of Russia understand and feels that honor-based reaction. The Southern US also has a history and reputation of honor-based communities.
The difference is that in the US, most people do not think this way, and there is a cultural tendency towards accepting and understanding differences with your neighbors, or at least signaling such.
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I think that honor based societies do not do a good job at understanding change. The problem is that the opposite of honor is guilt/shame, and that emotional reaction heavily masks the facts of the situation.
It may be a difficult and foreign concept (It's difficult for me), but reading about guilt-free organizations is very interesting to me. The thing that was hardest for me was understanding that guilt and responsibility are different things.
Would an American (or any person in any country in the EU) receive a medal for such murder? I expect not, and would be horrified otherwise ... But I don't think it's unique for Russia, they just get much more spotlight.
Among many other things, a reminder that software upgrades need to be carefully planned, with an assumption that other stuff might go wrong while the system is offline.
In this case, things that went wrong - and any one of them not going wrong might have averted the disaster:
1. Kids missed the original plane and had to get on this special charter flight instead. 2. Skyguide had just the previous year reduced staff from 3 to 2 controllers at night, and 2'. One of the controllers took an unofficial break. 3. There was an unexpected delayed A320 coming in, distracting the single controller. 4. The Tupolev was equipped with TCAS - if it hadn't been, TCAS on the other plane would not have issued an RA, and they might have stayed level or climbed instead of descending, as instructed by TCAS. (Though without TCAS it would not have been allowed to fly in Europe, probably.) 5. ATC happened to tell the Tupolev to descend, and TCAS happened to tell the 757 to descend. 6. That ATC instruction came exactly at the same time as the TCAS instruction on the 757, so the 757 crew didn't hear the ATC instruction to the Tupolev. 7. The Tupolev crew did not acknowledge that ATC instruction (which the 757 crew might have heard). 8. A bit later ATC repeated the instruction, and exactly at the same time TCAS on the 757 also repeated the instruction, so again they didn't hear the ATC instruction to the Tupolev. 9. Just then, the delayed A320 called ATC again, so the controller was distracted and did not monitor that his instruction to descend resolved the conflict successfully. 10. The copilot in the 757 had to go to the toilet just 18 seconds before all this happened. 11. It was night, making visual separation harder, possibly. 12. The 757 crew was trained to prioritise TCAS > ATC, the Tupolev crew was more or less trained to prioritise ATC > TCAS. 13. The Tupolev crew following ATC over TCAS received an ATC instruction that was in line with their right-of-way rules (left plane climbs, right plane descends), so it must have seemed more plausible. 14. The Tupolev crew had a first officer that suggested following TCAS instead, but he was not sitting in the RHS because there happened to be an extra Instructor Captain on that flight in the RHS who chose to follow ATC. 15. There happened to be a software upgrade at Zuerich ATC that night that disabled the Short-Term Conflict Alert light. 16. That software upgrade also disabled the phone lines, forcing the controller to waste time with the phone when trying to call Friedrichshafen for the delayed A320, and also prevented Karlsruhe ATC from warning Zuerich ATC of the problem. 17. ATC made a small, per se inconsequential, mistake of confusing "at your 2 o'clock" with "at your 10 o'clock". 18. The 757 crew waited 23 seconds to tell ATC that they were in a TCAS RA descent, by which time ATC was busy with the delayed A320. 19. The Tupolev crew was too busy/distracted to hear and understand that 757 TCAS RA descent call. 20. The ATC radar updated only every 12 seconds and did not yet reflect the 757's descent when ATC decided to instruct the Tupolev to descend. 21. The serious incident earlier in Japan with ATC/TCAS mismatch had not yet filtered through to all crews worldwide.
It's just so unlikely.
It's just so unlikely that this particular crash is the one that happens. A crash of this sort was all but inevitable, unless significant changes were made, and significant changes weren't going to be made until a crash of this sort happened. The article details a near-miss 17 months prior that would have killed 677 people. If this had been avoided as well, there would have been another a few months later, and another, and another, until one finally met all the conditions for an actual collision.
Is it unlikely that the roulette wheel will land on 00 this time? Of course. Is it unlikely that it will ever land on 00? No!
A few things that always stand out to me... - the calm demeanor shown by both ATC and pilots. Even in situations that make me cringe sitting at my laptop, everybody involved is steady. I know it's their job, but it still amazes me.
- the complexity of airport operations at a major international is mind-boggling. Hand-offs from ground to tower to departure... and then back again if something goes wrong. And doing that for dozens of planes at a time. Some crewed by pilots with thick accents or static-y radios.
- that air travel is the safest form of transit given the complexity of engineering and human processes involved is truly astounding. I know today's successes are the result of all previous tragedies; it's still something else.
I live under the main international approach to IAD. Watching the heavies fly in makes me smile. Especially the A380. It's a shame the A380 didn't find a long-term market - looking up, it shouldn't be able to fly, but there it is.
My ex-wife was a US air traffic controller, and the training they go through is stunning. They're tested continuously for years, with something like an 80% wash-out rate.
During testing, they get 1-2 tests per week, working a shift just like a controller would, with fake pilots on the radio, and real computer systems. If they let airplanes get even remotely close to each other, they fail. If it happens twice, they're out of the FAA, immediately, permanently. One of the instructors told me, "It's my job to make sure your wife has the worst week of her career, every week, during training - so that when she's actually on the job, every week will seem easy no matter what she's facing."
Even just in training, you could see the stress take its toll on the candidates over the years.
Hmm.. Are there incidents that were caused by Controller's error? (most common seem to be equipment failures, pilot errors, bad weather and bad luck with bird strikes etc.)
There is a nice wikipedia list here: https://en.wikipedia.org/wiki/Category:Aviation_accidents_an...
Of course I don't think it is correct to say that an incident were caused by controller error. It makes it sound like a single controller error was the only thing which went wrong. It is probably more correct to say that controller error contributed to the outcome of some incident.
Like many others (I am sure) I read the comments first and read article later (if I read).
I was responding to the informative comment about the rigorousness of Controller training. As a nervous flier myself, that made me feel a bit better.
- "not an emergency" https://www.youtube.com/shorts/bugknVx5NZ0
- "delta 1943, cancel takeoff clearance" https://www.youtube.com/watch?v=mIiPt1YVkP8&t=581s
disclaimer: I might be talking out my ass
It really seems that crisis response is bimodal. Either you almost completely panic, or you're almost completely focused. Complete focus makes for very clear, focused communication. (Extensive training on procedures, communication, and not panicking certainly helps as well.)
It's actually probably not as amazing as it seems. I was just on a high ropes course, and it's similar to ATC in that if things go pear-shaped, there is just nothing that you can do. So when I saw something going wrong [1], the instinct I had to immediately run and try to help was suppressed, and instead I (and everybody else) was essentially in the same calm-and-collected mood.
[1] Admittedly, this is wrong in the "abnormal operation" sense, not "immediate risk to life" sense.
You drill for emergency situations during training, and you should drill repeatedly afterwards. Any ATP rated pilots do so regularly whether in actual flight or in simulators.
But one flight very early, before I had my pilot's license, flying on a student's permit.. I ran out of fuel during cruise flight.. It was dumb, it was a case of me being a poor just-out-of-college student, and trying to do some very risky calculus with the flight planning and fuel required. There were extenuating factors including the (small) plane's fuel gauges malfunctioning sporadically .. having to 'stick the tank' on the ground (measure the fuel in the plane's wings by using a ruler and chart for how many inches equaled gallons).
.. excuses aside. I ran out of gas at 8000 feet above Columbus Georgia ..
What I remember happening is the engine abruptly lurching, then stopping, sending a massive amount of adrenaline through me.
But almost immediately I started looking for a runway to land at. I knew I had at least 1, maybe 2 airports in range of a glide, and one was relatively in front of me, so I decided on it, and called ATC in Atlanta who were following my flight at that time & declared a 'pan-pan' (step below a mayday .. meaning you have a serious situation on board & require priority attention if available, but you are still in control of the aircraft). They confirmed the vector to the (abandoned, but still in decent condition) airport a few miles in front of me.
Now.. Your original question is probably answered at this point... Basically as long as you can continue to have things to do .. As long as you can envision and work toward a goal (landing the f'n plane safely) .. The stress of the situation tends to just fuel the focus on getting to that goal.
I can't say its going to be the same for every pilot, and maybe it isn't . I did grow up obsessed with flying (after being absolutely horrified by it as a child), and so I had kind of gone over in my mind and in training over and over again this potential type of situation occurring and I wasn't about to let the moment get to big.
This kind of thing does worry me a little bit with our recent explosive need for pilots as commercial aviation expands rapidly. A lot of pilots are going through "0 to ATP" courses to get a good paying job, rather than because they're actually obsessed with flying itself.. Because in those cases, I'm not sure what is going to happen psychologically for those pilots. Again though, this is why you are constantly drilled and trained on these situations, so that you have almost muscle-memory of things to be doing in an emergency situation so that there is no time for you to sit passively and become a victim of circumstance.
Are those "0 to ATP" graduates landing quality jobs? Has pay at the smaller regionals actually moved up into "good paying" ranges (used to be $20-$40k/year starting, and that's usually after $50k+ in tuition/fees to get first set of pilot credentials)?
Last time I checked (10+ years ago), landing a job at a major airline still required years of experience at a regional OR some special combination of degree/networking/military service. And the regionals didn't pay well and had pretty crap working conditions (getting better post-Colgan Air crash, but still not great).
I see United has an in-house "0 to ATP" program now, but it's still more than $70k and a few years to graduate, and then the pilot still spends time at a regional United-affiliate before having the chance to move to United itself.
Really just curious what conditions are like for new pilots today (vs roughly the Colgan Air disaster era). And what the pipeline looks like post-COVID.
PS: Tonight I dreamt of a surreal MD-80 crash.
I like that you explicitly pointed out that flying into a mountain is not the recommended course of action for pilots.
Humor aside, this crash also includes a lot of broken down communication, so in most cases, even if TCAS fails, a crash is not inevitable. A pilot aware of the priority TCAS has will definitely communicate a failure to abide by its orders.
Specifically, the ground proximity warning (as well as the stall warning) takes precedence over TCAS. This is just fine, since the "descend" aircraft in ground proximity will level off while the other climbs. You're not likely to find a condition where neither plane can deviate because the descender gets a ground proximity warning and the ascender gets a stall warning at the same altitude, since those are typically associated with aircraft flying close to their minimum and maximum altitude, respectively. You would need to have two aircraft flying level very close to the ground, at least one of them near its stall speed, which simply is not a flying condition used by commercial airliners.
Under the new management of Skyguide which led to the obvious cut in labor cost like reducing the night shift from 3 to 2 controllers. The private company still tolerated the extended break convention during night shift from before but leaving only one person responsible, now. And guess what? Maybe a software update to make some efficiency steps when we are at it. The single one controller was then informed during the update taking place what was still functioning and not which was very little.
>Part way through Nielsen’s shift, a group of technicians arrived to install the update, and he was informed that his work station’s main computer would have to be shut down, causing his displays to operate in fallback mode — a secondary condition in which several features provided by the main computer became unavailable. In fallback mode, the system which automatically correlated an aircraft’s radar return with its filed flight plan would not work, forcing him to enter the information manually, and the Short-Term Conflict Alert light, which illuminates when the system predicts that two planes will pass too close, would be rendered inoperative. But Nielsen had no idea what features would be lost in fallback mode, nor did he have any obvious way of finding out. And as if that wasn’t enough, a few minutes later the technicians informed him that they would also have to disconnect the control center’s direct telephone landline to neighboring centers
For me also surprisingly shocking that back in Karlsruhe multiple (!) controllers had to literally watch the obvious horror unfold while the one controller responsible was not available because of ... maintenance work.
>Heartbreakingly, controllers in neighboring Karlsruhe saw the collision coming, but they did not have the authority to speak to planes in another sector without permission from the responsible controller. The Karlsruhe controllers tried several times to call Nielsen in the minute before the crash, but the landlines were down and they couldn’t get through. By the time they gave up on this effort, it was too late to prevent the crash even by breaking the rules. The controllers were forced to watch, helpless, as the two planes collided and then disappeared from radar, knowing that dozens of people were dying before their eyes, and that there was nothing they could do to save them.
Edit: According to this article [0] and this verdict [1] the controllers in Karlsruhe had the full authority but were illegally instructed otherwise by DFS (German ATC) management which had an informal agreement with Skyguide (Swiss ATC) over this border region.
In the end the heavily traumatized and retired controller Nielsen was brutally stabbed because the modern diffusion of responsibility of companies only operates on the culture of financial compensation and is blissfully ignorant of a desperate man losing his whole family trying to restore his honor. So, no apology before everything is settled accordingly.
[0]https://www.dw.com/de/deutschland-haftet-f%C3%BCr-fehler-der...
[1]https://research.wolterskluwer-online.de/document/2ceee0e8-5...
Well yeah. I’d still take innocent until proven guilty over any of the blood debt and honour killing cultures. Particularly when the victim sacrificed to restore someone’s “honour” is not responsible. Desperation is no excuse, and of course we should not base our judicial systems on it.
As usual, the real culprits got nothing. As usual, this is unacceptable and, as usual, nothing has been or will be done to change this.
Vitaly Kaloyev, who killed Nielsen, went to jail for it for a few years and, after release, returned to Russia. He then became deputy minister of construction in North Ossetia, Russia.
> The single one controller was then informed during the update taking place what was still functioning and not which was very little.
According to the text you quoted, it's worse:
> But Nielsen had no idea what features would be lost in fallback mode, nor did he have any obvious way of finding out.
Nielsen never knew which systems were out of order. Given the apparent workload he was under, knowing that the collision warning was out of order probably would not have helped, but it seems that he didn't even know for sure that the system was down.
There was too little time. And I imagine it is hard to be that quick and lucid in breaking the rules of ATC.
Edit: I've looked it up and according to this article [0] there was only an informal agreement between Skyguide and the German counterpart DFS regarding this border region. Since ultimately only Germany is solely responsible for their airspace no such an agreement can exist and therefore the federal government (Bund) is partly to blame for the accident.
Indeed the controllers in Karlsruhe had the obligation to intervene asap even without informing the Swiss counterpart but they were instructed otherwise although there had been no legally binding transfer of the sovereign task ("weil es keine rechtlich verbindliche Übertragung der hoheitlichen Aufgabe gegeben habe"); so this was illegal. In both cases a management issue.
[0]https://www.dw.com/de/deutschland-haftet-f%C3%BCr-fehler-der...
> so this was illegal.
> In both cases a management
> issue.
Those controllers were looking at a screen showing that two airplanes were about to crash into one another.
In most other western countries that person would have thought "well, fuck this!" and started yelling at them on the channel itself, implied procedures, stepping on toes, and pecking order be damned.
Given that Edward Snowden isn't a free man, I doubt this.. where is the "media outcry" there?
Plus, a life in the gulag is pretty much a life lost.
With Snowden, it is a lot more complicated - many people don't believe he did the world a service, and is in fact a traitor. (Not to mention, he's living in a Russian apartment which although not my preferred lifestyle, it is still far from being a gulag.)
I'm not sure what to respond. Ok, why do people believe that, label him this - what are their arguments? I think the point here is how authorities act, and what they are allowed to get away with. PRISM, apparently, is something they are allowed to get away way. Where are the "traitors" spying on Americans? Or are those all unquestionably "heros"?
> he's living in a Russian apartment
True, because he managed to escape, and probably is looking over his shoulder a lot in the meanwhile.
On the other hand, if he ended up in US custody, we might know very little until "found dead in his cell", which would no doubt be yet another unaccountable accident.
Technical in the sense of giving priority one over the other; the priority was clear in the US but at the time not strictly set in Europe or Japan (a near miss happened one year before because of conflicting instructions) and in Russia the opposite (highest priority ATC) was true with TCAS being a new thing obligatory for flights to Europe, of the five crew members only one pilot seemed to be aware that the two TCAS are tightly coordinated (CLIMB/DESCEND) for a last resort, but nobody listened to him.
I'm guessing that it does not issue turn instructions because it only gives a Resolution Advisory when a collision is imminent (otherwise they would be giving RAs all the time). At altitude, where the air is thinner, it is much easier for a plane to immediately climb or descend, planes turn very slowly when the air is thin.
https://aviation.stackexchange.com/questions/92495/how-does-...
> But what if the other aircraft is "thinking" the same thing? That's the heart of this question. The answer is, whichever TCAS makes a decision first, and then in case of a tie, the lower Mode S address "wins":
EDIT: FAA PDF on TCAS 7.1 - https://www.faa.gov/documentlibrary/media/advisory_circular/...
This story is a moving example of the self-improvement going on in global air traffic industry; perhaps sometimes slowly, but definitely self-improving. The following book compares the transparency of the air traffic industry with the lack of transparency that currently exists in the medical sector, where errors are denied:
https://www.amazon.com/Black-Box-Thinking-Psychology-Paperba...
1. When TCAS was originally developed, the direction information to the other aircraft was not very accurate, being obtained only via the TCAS antenna. Nowadays GPS information is transmitted via ADS-B and so it's much more accurate, but taking advantage of this would require a major redesign. It may happen eventually, but...
2. Aircraft can change altitude faster than they can change heading. Also, most aircraft can change pitch faster than they can roll, and they are longer and wider than they are high. So effecting enough altitude change to avoid a collision can be done faster than effecting enough heading change to do so.
In this particular accident, it seems like commanding a heading change (to the right for the Tupolev and to the left for the DHL flight) in addition to an altitude change would have avoided the collision.
Yes, intuitively being able to change headings seems like a good thing except that 1) it adds expense and complexity, and thus produces new potential points of failure and 2) it's not necessary. The problem was not that an altitude change was insufficient, the problem was that two sources of command authority (TCAS and ATC) contradicted each other. The solution is simply to add a new rule: if TCAS and ATC disagree, go with TCAS.
I never said we must do X. It's a suggestion which might or might not be worth considering. From the article it appears that the TCAS system was designed with the assumption that pilots would always immediately do what it said. This accident obviously violated that assumption. The question is how best to respond to that as far as the design of TCAS is concerned; the eventual tradeoffs might lead to the answer "do nothing to TCAS" but that doesn't mean it isn't worth considering possible changes.
> it adds expense and complexity
Yes, this is always a tradeoff with safety systems. But the heading change rule would be even simpler than the altitude change rule (which requires negotiation of possible conflicts between the TCAS systems in the two aircraft): the heading rule is simply "turn away from the other aircraft", i.e., if the other aircraft is to your right, turn left, if it's to your left, turn right. That seems like logic that could be implemented, checked, and verified fairly easily, if it were decided to do so.
> it's not necessary
When it comes to safety systems, "necessary" is always a judgment call. Yes, cases in which adding a heading change to TCAS instructions would be helpful are rare (like this crash was). But all aircraft accidents are rare. No rule gets followed exactly as it's given 100% of the time. Taking that into account when deciding on what safety systems to implement is perfectly justified.
> The solution is simply to add a new rule: if TCAS and ATC disagree, go with TCAS.
Or more precisely, to explicitly make that a rule worldwide, instead of just in the US as it was before this accident.
Yes, this is the response the system settled on, but this, too, involves a tradeoff: this rule has to be implemented by humans, and humans are less reliable than automated systems. The international air safety system evidently decided that humans were reliable enough in this case for this rule to be sufficient; but that doesn't mean they didn't make a tradeoff.
Heading and altitude are NOT independent. When an aircraft makes a turn, it banks (it's not like a flat turn you make in your car), and inevitably loses some speed because of extra drag, and some altitude because of loss of lift.
It can be compensated by increasing the engine power, but then you really need to predict that as well.
Yes, I know how planes make turns. It is valid to point out that a TCAS instruction that included a heading change would, at least for the plane whose TCAS instruction was to increase altitude, also have to include an engine power increase, which might not be feasible depending on the altitude (cruise power might already be pretty close to max power). Or else make the turn a very slow one, which would decrease its usefulness in collision avoidance.
Doing both reeks to me of a solution in search of a problem that’s going to end up the target of some later NTSB report when you hit some weird edge case where the dynamics and dimensions of the two planes aren’t fully accounted for.
Yes, but it's also increasing horizontal separation (from a predicted value of zero), which might still be a reasonable tradeoff to consider.
https://www.aopa.org/go-fly/aircraft-and-ownership/ads-b/whe...
Sure, but so what? The lack of universality is not an impediment to implementing a new TCAS system that uses ADS-B data when it's available. (And BTW, the places where ADS-B is not required are generally places where traffic is sparse and so the risk of a collision is pretty low to begin with.)
Given that the clear priority is now to follow a TCAS RA (resolution advisory) over an ATC instruction, I think that the current TCAS approach is good enough to cause aircraft to miss each other and that a GPS-based redesign is unlikely.
1. The Russian airline: it put untrained pilots in charge of a plane. We know they were untrained as they clearly did not understand the most basic concept of TCAS. The article tries to paint this is regulatory confusion - which is patently nonsense, the entire concept of TCAS hinges on it being on par with stall and terrain alerts, where there is a single response, and that response counters any other instruction. The fact that the pilots were aware of the system and failed to learn about it is a failure on their part, the fact that the airline company failed to have the most basic of training on it makes it mostly theirs.
2. The Skyguide company: understaffed a region, and then under equipped it while understaffed, and then failed to have any reasonable back up for anything. Arguably a failure brought on by those people that insist "privatizing a public safety system is efficient".
But then Mr Macho-man had to defend his honor by going and murdering the one remaining victim of the crash, to demonstrate how manly he was. If you feel that murdering an innocent and defenceless person is justified for the "honor" of your family, and to give you value as a "man" I say you've failed the most basic tenets of "honor", and sure as shit don't get to brag about manliness.
Not to condone revenge killings, but Nielsen was obviously part of this accident. It was his choice to work alone that night (rather than waking the other controller) and to allow the technicians to turn off most of his instruments, so the responsibility is partly his. He also issued the fateful descend command - had he literally stayed out of this, the Tupolev pilots would have followed the TCAS guidance and the accident would not have happened.
To put it simply, blaming Nielsen for this accident is like blaming the worker in a car factory that puts the last part on a Ford Pinto.