DHL Flight 611: Wikis

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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/crew/design/training error
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
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
Site of the crash is located in Germany
Site of the crash
Site of the crash (Germany)

Bashkirian Airlines Flight 2937, registration RA-85816, was a Tupolev Tu-154M passenger jet en route from Moscow to Barcelona. 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, Peter Nielsen, the controller who was on duty at the time of the accident, was stabbed to death by Vitaly Kaloyev[6] who had lost his wife and two children in the accident.[7][8]

Contents

Flights involved

Flight 2937 was a chartered flight carrying 60 passengers and 9 crew. 45 of the passengers were Bashkortostan schoolchildren on a school trip to the Costa Daurada area of Spain.[3][2][9] Most of the parents of the children were high-ranking officials in Bashkortostan.[10] A Russian crew operated the aircraft. The captain, Alexander Mihailovich Gross, and first officer Oleg Pavlovich Grigoriev, flew the Tupolev. Grigoriev, the chief pilot of Bashkirian Airlines, used the trip to evaluate Gross's performance. Murat Ahatovich Itkulov, 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.[11]

Flight 611 was carrying a load of air freight and had two Bahrain-based[3][12] crew members aboard, British Captain Paul Phillips and Canadian First Officer Brant Campioni.[9]

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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.[11]

Accident

Computer reconstruction of the accident derived from the Flight Data Recorder and collision evidence.
Computer reconstruction (side view).

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]

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]

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.[13]

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.[13]

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.[13]

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.[13]

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.

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.[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 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.[11]

Consequences

Skyguide memorial to the aviation accident and murder of Peter Nielsen.

Nielsen needed medical attention due to traumatic stress caused by the accident.[15] At Skyguide, his former colleagues maintained a vase with a white rose over Nielsen's former workstation.[16] 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.[17]

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.[17]

A criminal investigation of Skyguide began as of May 2004. 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".[18] 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.[19]

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,[20] near Zürich, on 24 February 2004.[21] 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.[22]

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]

Dramatization

This accident was featured in an episode of the Discovery Channel Canada program Mayday.[23]

"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.[24]

References

  1. ^ "A9C-DHL DHL International Boeing 757-23APF - cn 24635 / ln 258 - Planespotters.net". planespotters.net. http://www.planespotters.net/Production_List/Boeing/757/24635.html. Retrieved 2008-09-06. 
  2. ^ a b Gallagher, Paul. "Jet pilot's 14 seconds dilemma before fatal crash". scotsman.com. http://news.scotsman.com/topics.cfm?tid=455&id=738632002. Retrieved 2007-01-18. 
  3. ^ a b c "Vain attempt to avert deadly crash, CNN.
  4. ^ "Mid-air collision of 1 July 2002: sequence of events" (Skyguide).
  5. ^ "Passenger List". http://www.aktuell.ru/russland/hintergrund_information/passagierliste_flug_2937_der_verunglueckten_tu_154_der_bashkirian_airlines_5.html. Retrieved 2008-11-21. 
  6. ^ "Swiss law court decided to free V.Kaloyeva"
  7. ^ Wolfsteller, Pilar. "Father 'saw black' as he killed air traffic controller". scotsman.com. http://news.scotsman.com/topics.cfm?tid=455&id=2146352005. Retrieved 2007-01-18. 
  8. ^ Harding, Luke; Nick Paton Walsh (28 February 2004). "Nothing left to lose: grief-crazed murder suspect haunted by family's air deaths". The Guardian. http://www.guardian.co.uk/russia/article/0,2763,1158361,00.html. 
  9. ^ a b Wild, Matthew. "Family devastated by pilot's death". north shore news. http://www.nsnews.com/issues02/w070102/071302/news/071302nn2.html. Retrieved 2007-01-18. 
  10. ^ "Children's holiday party on doomed plane," CNN.
  11. ^ a b c "Deadly Crossroads," Mayday
  12. ^ "British pilot 'tried to avert disaster". BBC. 2 July 2002. http://news.bbc.co.uk/1/hi/uk/2081653.stm. 
  13. ^ a b c d "Appendices/Deviating positions for Investigation Report AX001-1-2/02 MAY 2004" (PDF). http://www.bfu-web.de/cln_010/nn_53140/EN/Publications/Investigation_20Report/2002/Report__02__AX001-1-2___C3_9Cberlingen__Appendix__2-10,templateId=raw,property=publicationFile.pdf/Report_02_AX001-1-2_%C3%9Cberlingen_Appendix_2-10.pdf. Retrieved 2008-05-05. 
  14. ^ "report outline". ICAO. http://www.icao.int/ICDB/HTML/English/Representative%20Bodies/Air%20Navigation%20Commission/Working%20Papers%20by%20Year/2002/AN.2002.WP.7760.EN/AN.2002.WP.7760.REP.EN.HTM. Retrieved 2007-01-22. 
  15. ^ "Air crash safety device switched off". BBC NEWS. 2002-07-03. http://news.bbc.co.uk/2/low/europe/2087253.stm. Retrieved 2009-07-14. 
  16. ^ "Information regarding the air accident at Überlingen on 1 July 2002". Skyguide. http://www.skyguide.ch/en/Dossiers/DossierUeberlingen/. Retrieved 2009-07-14. 
  17. ^ a b "Katastrophe von Überlingen - Flugunglück beschäftigt Landgericht". Stuttgarter Zeitung. 2008-04-20. http://www.stuttgarter-zeitung.de/stz/page/detail.php/1688427. Retrieved 2009-06-07. 
  18. ^ "Swiss go on trial over air crash". BBC. 15 May 2007. http://news.bbc.co.uk/1/hi/world/europe/6656487.stm. Retrieved 15 May 2007. 
  19. ^ "Four guilty over Swiss air crash". BBC. 4 September 2007. http://news.bbc.co.uk/1/hi/world/europe/6977136.stm. 
  20. ^ "Swiss air crash controller killed." CNN. Wednesday 25 February 2004. Retrieved on 29 January 2010.
  21. ^ "Skyguide - information regarding the air accident". http://www.skyguide.ch/en/Dossiers/DossierUeberlingen/. Retrieved 2007-01-18. 
  22. ^ Franchetti, Mark (February 10, 2008). "Russia hails Vitaly Kaloyev a hero". The Sunday Times. http://www.timesonline.co.uk/tol/news/world/europe/article3341803.ece. 
  23. ^ Mayday //Deadly Crossroads at the Internet Movie Database
  24. ^ Flug in die Nacht - Das Unglück von Überlingen at the Internet Movie Database

External links

On conflicting orders


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