mid-air collision over ueberlingen, germany, july 1, 2002 · 2014-04-28 · mid-air collision over...
TRANSCRIPT
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Mid-air collision over Ueberlingen, Germany,
July 1, 2002
Christoph GilgenSKYCONTROL/Swiss ATCAGeneva ACC
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Presentation of the mid-air
• Short details• Working arrangements in Zurich• The technical situation• TCAS use and procedures• Safety nets• Legal battle, safety improvement, and
conclusion
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(B757 DHL)DHX 611
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(TU 154 Bashkirian)BTC 3729
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Radar plots
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Tracks
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Diagramm
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Collision diagramm
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Interesting details• Aircraft hit at approximately FL 350• They collided at right angle• TU 154 was heading 274 degrees• B 757 was heading 004 degrees• Both aircraft were TCAS equipped
(Honeywell 2000, version 7.0)• red color marks on the TU 154 (left side
close to the two overwing emergency exits)
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Interesting details
• Parts of the B757’s vertical fin found on the wings and the landing gear
• The B-757 lost only the upper part of its vertical fin
• The wreckage of the B 757 found some 8 km north of the main wreckage of the TU 154
• The first officier of the B 757 was absent (toilet) at the beginning of the collision
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Accident timing (UTC time)
• 21.20.08 initial contact DHX 611 with Zurich radar, FL 260
• 21.22.54 identified, climb FL 320• 21.26.36 climb FL 360• 21.30.11 initial contact BTC 2937, FL 360• 21.30.33 Squawk A 7520• 21.34.49 BTC 2937 descent FL 350,
expedite, I have crossing traffic
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Accident timing (UTC time)
• 21.35.03 (repeat) BTC 2937 descend FL 350, expedite descent
• 21.35.07 readback of BTC 2937• 21.35.13 Traffic information to
BTC 2937 (position wrong)• 21.35.19 TCAS descent reported by DHX
611 (garbeled)• 21.35.32 Collision
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Aircraft system interactions
• 21.30.11 Initial contact BTC 2937, FL 360• 21.30.33 Squawk A 7520• 21.34.42 Both aircraft receive a TCAS TA• 21.34.49 BTC 2937 descent FL 350,
expedite, I have crossing traffic• 21.34.56 Both aircraft receive a TCAS RA:
DHX 611 TCAS descent; TCAS climb for BTC 2937
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Aircraft system interaction
• 21.35.03 (repeat) BTC 2937 descend FL 350, expedite descent
• 21.35.07 readback BTC 2937• 21.35.10 B 757 DHL receives « increase
descent »• 21.35.13 Traffic information BTC 2937
(position wrong)• 21.35.19 TCAS descent by DHX 611
(garbeled)
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Aircraft systems interactions
• 21.35.24 Tupolev receives « increaseclimb »
• 21.35.32 Collision
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What exactly happened on the night of 1st july
BLUE IS TFC INFO / PINK IS TCAS / BLACK RADAR
Diagramm SKYGUIDE
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Meier Tail
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B 757 Wood
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Debris at night
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ATC situation
Zurich ACC
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Zurich Airspace
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Technical situationand working arrangements
Functions and staffing of Zurich’s ATC-system during the night of July
1, 2002
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Zurich radar
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Working arrangements
• Two ATCOs to cover night shift (from 23.00 to 05.30)
• Two controller assistants (CA) to assist (flight data handling, no controller training)
• Usually 1 controller and 1 assistant work at the same time during night
• (long standing arrangement, for years)• Other team is on break on off-duty
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Single man OPS (SMOP)
• Controversial procedure implemented by SKYGUIDE management in late 2001.
• Extension of SMOP procedure to day operations by service order (SO)
• FOCA (the regulator) did not disapprove (despite protests from Unions and associations)
• Many letters exchanged
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Single man OPS (SMOP)
• The SMOP procedure (during day operations) had several conditions
• STCA must be on and functioning• Nowhere it is clearly written that SMOP is
not applicable at night• The procedure was officially forbitten by
the regulator on July 9, 2002
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Friedrichshafen (EDNY)
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Approach and departure services for EDNY
• Airport is situated below delegated zone • Traffic is handled by Zurich ACC
(overflight sector)• At night traffic at this airport is very rare • Different frequency 119.920 MHz and
different radar scope, different settings • at a certain distance
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Degraded Operations
• On July 1, 2002 at Zurich ACC, maintenance work on the main radar system (a new software release must be loaded).
• Radar services with the RDPS in « fallback mode » (stand-by system)
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Radar separation applicable
• The horizontal separation minima had been increased from 5 to 7 nm. According to this, the horizontal distance between aeroplanes flying at the same altitude must be at least 7 nm, which corresponds to a flight time of approxmatively one minute
» Source German BFU, accident investigation board »
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STCA
• The STCA (Short Term Conflict Alert) is switched off
• The Swiss STCA triggers two alerts:• 1) optical alarms• 2) accoustic alarms• The optical alarm was off (not on the fall-
back system)• Accoustic alarm was possibly on
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Telephone system
• The main telephone system was switched off
• The back-up telephone system was available (less performant and flexible)
• Number stored for EDNY-TWR not correct• Karlsruhe Radar could not reach Zurich
(several attempts)
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Factors that have contributed to the mid-air collision
TCAS
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TCAS Implications
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Use of TCAS
• OPERATION OF ACAS EQUIPMENT:«Nothing shall prevent pilots-in-command from exercising their best judgement and full authority in the choice of the best course of action to resolve a conflict »
» ICAO PANS-OPS (DOC 8168) »
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TCAS co-ordination
• « Contrary pilot response »• Manœuvres opposite to the sense of an RA
may result in a reduction in vertical separation with the threat aircraft and therefore must be avoided. This is particularily true in the case of an ACAS-ACAS co-ordinated encounter »
» Annex 10-Aeronautical Telecommunications »
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TCAS considerations
• Once an aircraft departs from its clearance in complicance with a resolution advisory, the controller ceases to be responsible for providing separation between that aircraft and any other aircraft affected as a direct consequence of the manœuvre induced by the Resolution advisory
» Source Doc 4444 (PANS-ATM, 15.6.3.3) »
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The safety nets and how they failed
Source Jane’s Airport ReviewSeptember 2002, vol 14, issue 7
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Safety net 1
• Direct controller surveillance• -single controller (single man OPS)• -two frequencies and two radar scopes
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Safety net 2
• The surveillance system
• The radar was operating in fallback mode requiring that radar separation values were increased from 5 nm to 7 nm
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Safety net 3
• The STCA (short term conflict alert)
• The short term conflict alert was switched off for maintainance
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Safety net 4
• Indirect controller surveillance/telecommunication system
• DFS, the German ATSP has stated that controllers at its Karlsruhe facility noted the emerging conflict two minutes before collision
• The main telephone line was switched off, but the backup (by-pass) line was available
• Karlsruhe tried to alert Zurich via telephone using the priority facility but heard only the ringing or busy tone
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Safety net 5
• The on-board collision avoidance system
• Both aircraft were properly equipped with TCAS• Both airlines had received training packages for
TCAS use• Neither system appears to have failed• The Tu-154, appears, however, to have ignored
the TCAS command to climb
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Legal battle and considerations
• Bashikirian Airlines intended legal actions against SKGUIDE, Honeywell and DHL requesting millions of dollars
• DHL is expected to intend similar legal actions (or has already done so)
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Legal battle and considerations
• The Swiss general prosecutor (in Zurich) has opened an official investigation
• The second controller (on break) is witness only for the time being
• In Germany (Konstanz) a preliminary investigation (against unknown) was opened
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Legal battle and considerations
• In both cases (Zurich and Konstanz) is trying a case for manslaughter by negligence in 71 cases, and endangering of public transport
• Civil court cases: (where the families of the victims might receive compensation)
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Legal battle and compensation
• This battle must be fought in Germany (due to legislation and airspace delegation)
• The German government must proof that they are not responsible
• SKYGUIDE must only pay if they acted deliberately
• The Russian Tupolev was not insured
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Legal battle and considerations
• There are talks on going for out of court settlement (civil case)
• SKYGUIDE has an insurance • For the penal court case in Switzerland, the
« causal factor » was determined (jurisprudence)
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Legal battle and considerations
• All that happened 44 seconds or before, is considered as « contributing factors »
• In this particular case, with TCAS, the chain of events was broken by the system (manoeuvre of DHL following the RA)
• Legal outlook is not very bad for the ATCOs
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TCAS considerations
• Once an aircraft departs from its clearance in complicance with a resolution advisory, the controller ceases to be responsible for providing separation between that aircraft and any other aircraft affected as a direct consequence of the manœuvre induced by the Resolution Advisory
» Source Doc 4444 (PANS-ATM, 15.6.3.3) »» ATMM of Switzerland »
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The controller?
• He has received intensive CISM (especially by Danish ATCOs and specialists) and psychological support afterwards
• He is receiving full legal counseling and legal assistance from the employer and the unions
• He currently works as trainer in the OJT-simulator of SKYGUIDE in Zurich
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Conclusions and Thanks
ThanksAcknowledgement
Excuses
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Contrails