Air Emergency (2003–…): Season 2, Episode 4 - Deadly Crossroads - full transcript
A DHL cargo plane collides with a Russian passenger jet over southern Germany in 2002.
July, 2002
over Germany
The middle of the night
A Russian plane is taking children
on holiday to Spain
But the pilots cannot believe what they see
heading towards them
Climb!
DEADLY CROSSROADS
June, 2002
The city of Ufa, Western Russia
Ufa is populated by both Christians and Muslims
This year, its most outstanding teenagers
have been chosen to go on a two-week vacation
organized by UNESCO,
near Barcelona in Spain
They are among the most clever,
athletic or artistic children of Ufa
Kirill Degtaryeva is 14 year old protege
He has been painting since he is 4 years old
and he already had two public exhibitions
Alina Khannanov is a 12 years old
who had won several gymnastics competitions
The 46 children from Ufa,
accompanied by a few teachers
leave on a train to Moscow
There, they are due to catch their flight
to Barcelona
But in Moscow, things start to go wrong
The Tourist Agency accidently takes
the children to the wrong airport
So they missed their plane
They are terribly disappointed
While the Agency tries to sort out the mess,
the children go site seeing in the Russian Capital
It takes two days to charter another jet
But finally, they are on their way to Barcelona
On July, 1st, 2002
the children from Ufa board their plane
at a Moscow airport
The Kaloyevs are not part of the school group
They are going on a holiday to meet their father,
who is an architect
and is finishing a project near Barcelona.
No fewer than 5 Russians are flying this plane
The captain is Alexander Gross,
who has been a pilot for over 30 years
Alexander had a good theoretical knowledge
He was very smart
Today, the 1st Officer is Oleg Grigoriev
But actually,
Grigoriev is the airline's chief pilot
On this trip
he will be evaluating captain Gross's flying
If you did something wrong,
some captains would criticize you very rudely
Others would be very formerly and polite
But Oleg Grigoriev would express
his disproval with a gesture like that
meaning:
why on earth did you do that?
Captain Gross is in command
Captain Grigoriev is his supervisor
If it comes to the crunch,
who will really be in charge?
Seated in the left rear is Murat Itkulov
normally the 1st Officer
But who is not officially on duty,
because Grigoriev is in his seat
Nevertheless,
since he will soon be promoted to Captain
his opinions are considered
Murat was a very professional pilot,
he loved to fly
Murat was interested in the new stuff in aviation
And always kept up to date
in the most progressive things brought in
Also on the flight deck are
an experienced navigator and a flight engineer.
Just before 11:00 PM,
Bashkirian Airlines Flight 2937 leaves Moscow
The plane is a Tupolev 154
Like most modern aircraft, it carries
collision avoidance equipment called TCAS
Traffic Collision Avoidance System
Descend, descend, descend
TCAS works because all commercial aircraft
carry a transponder
which sends a constant stream of radio-signals,
identifying them and saying where they are
TCAS listens in and calculates where there
are any of the planes is on a collision course
If they are, it will tell the pilot
what action to take to avoid collision
Descend!
If Air Traffic Control should ever let them down,
TCAS will be their last line of defence
Clear of conflict
Hundreds of miles away in Bergamo, Italy,
a Boeing 757 is getting on their way
It is flying for DHL,
the international freight company
and is heading for their European base at Brussels
in Belgium
The Russian Tupolev will cross its path
over Southern Germany
The Boeing has only two people aboard:
Captain Paul Phillips, who is British
and 1st Officer Brant Campioni who is Canadian
and due to fly the next leg of the journey
The DHL takes off at 11:06 PM...
...on what will be its last journey
At 19:50 at the skyguide Area Control CENTER
in Zürich, Switzerland
The busy day-shift has ended
and the night-shift is reporting for work
Peter Nielsen is an experienced controller
He has been doing this job for 8 years
The CENTER regulates traffic in Southern Germany
as well as Northern Switzerland
Tonight, there are only two controllers on duty.
But the traffic in their sector is light
and Nielsen's colleague
decides to take a lengthy break
a common practice at skyguide
Peter Nielsen is now responsible
for all air-traffic on two radar screens
which sits several feet apart
At 23:10 two technicians arrive
They inform Peter that skyguide
management has authorized them
to carry out maintenance
work on the main radar
While they do so,
the screens will work much more slowly
and will give no visual 2 minute warning
if planes are getting too close to each other
The engineers now tell Peter Nielsen
they have to shut down the
telephone system as well
They switch over to the standby phones
No one realizes it yet,
but the seeds of disaster have been sown
The Russian plane, filled with schoolchildren
is now over Central Germany
and flying towards Switzerland
Captain Grigoriev gets final clearance
from the last German Control center
before they cross South
into Switzerland
The German controller hands over
the Russian plane to skyguide
where Peter Nielsen is at the helm.
Meanwhile, the DHL is climbing North over the Alps
and is now entering Swiss Airspace
Zürich, radar, good evening
DHX 611,
I'm climbing flight level 26000 ft, direct Odyssey
Captain Paul Phillips of the DHL
requests clearance to climb to a higher altitude
The thinner air there will
mean less air resistance
and save fuel
Roger climb flight level 32000 ft
Direct TGO
DHX 611 climb flight level 36000 ft
The DHL reaches flight level 360,
or 36000 ft
The same altitude as the Russian plane.
and they are on a collision course
But they are many miles apart...
...so far, no danger
Now, the assistant gives Peter Nielsen
a new flight-strip
An Airbus, Aero Lloyd Flight 1135
is flying to the airport of Friedrichshafen nearby
It is going to increase Peter's workload
dramatically over the next 5 minutes
and have him switching from one screen to another
Peter tries to dial the Airport
Control Tower at Friedrichshafen,
to discuss handing over the
Aero Lloyd flight to them.
But the line is dead
He tries a second time
The phones aren't working
The Aero Lloyd pilot
is trying to make contact with Peter
He has to leave the Russian pilots unattended
Good Evening, BTC
but the Russian pilot is also calling him,
on the other screen
LL 1135, Roger,
I'll call you back
Station calling, please
Ah, Zürich, good evening, BTC, 2937,
our level is 36000 ft
BTC 2937,
00:11:08,123 --> 00:11:10,576
The Aero Lloyd is calling again
Yeah, expect so,
I'll call you back shortly
Now, another plane needs him,
a Thai Airways flight heading North
Thai in 2933, contact now on Munich
132,140, Goodbye
Air Traffic controllers
are used to handle tricky situations,
but tonight,
Peter's equipment isn't working properly
And he is controlling
two screens at the same time
Normally, his radar would warn
of any impending collision
What he doesn't know is that tonight,
it is out of action
Correct, what is your present heading?
Present heading is 265
Roger, right turn heading 280
vector ILS 24
Peter wants to get this Aero Lloyd off his hands
He tries dialling the public number for
the Friedrichshafen control Tower for the 3rd time
Meanwhile, the Russian airliner and the
DHL-plane are still heading towards each other
at a closing speed of over 800 mph
Neither crew is aware
that they are only 2.5 minutes apart
The DHL plane is now approaching the Swiss border
with Germany
The Russian Tupolev is heading
for exactly the same spot...
...and at the same altitude
Finally, someone at another ATC CENTER in Germany
spots the danger
He grabs the phone to warn Nielsen...
...but cannot get through
International air-traffic rules prevent him
from talking to the pilots directly
Look, look at that
Now, for the first time,
the Russian pilots can see the DHL plane
on the screen of their
TCAS anti-collision computer
But Peter Nielsen is still focussed
on getting the Aero Lloyd flight safely down
Aero Lloyd 1135
Yeah, I lost my connection
to Friedrichshafen airport
Could you please call them on your second set
124,35
Tell them
you are coming in ILS 24 with 20 miles now
OKAY, we'll do.
On the DHL cargo plane,
the crew is relaxed.
They don't know they are on a collision course
Their TCAS hasn't sounded a warning yet
The First Officer goes to the wash-room
On the Russian plane,
the pilots are getting concerned
The other plane is getting
closer and closer,
but they are not exactly sure
whether he is on the same altitude
he is going below us
500...
No, 100 meters
TCAS, the collision
avoidance computer,
is warning the Russian pilots that
the other plane is getting too close for comfort
At the same moment, the TCAS in the DHL cockpit
detects the Russian plane
DESCEND, DESCEND
Peter Nielsen finally realizes what is happening
BTC 2937, descend flight level 35000 ft
Expedite,
I have crossing traffic
Descend?
Captain Gross disengages the AUTOPILOT
and starts to descend
CLIMB, CLIMB
TCAS is telling them to climb,
the controller is telling them to descend
It says: CLIMB
He is guiding us down
Peter: BTC 2937,
Descend level 35000ft,
expedite descend
Expedite descend level 35000 ft
Peter Nielsen thinks he has averted a collision
by telling the Russian plane to descend
But what he doesn't know
is that the DHL pilots has received
a TCAS instruction telling THEM to descend
Increase!
They are trying to tell Nielson
that they have a TCAS instruction to descend...
but Peter cannot hear them.
If both planes obey TCAS,
there had been no problem
But the Russians, instead of climbing,
have followed the controller's orders.
Now both planes are diving towards each other
He is going below us
The tail of the DHL
clips the belly of the Tupolev...
...tearing it apart
The pilots soon lose consciousness
The DHL struggles on for another two minutes.
It will crash 4 miles away
Can we go over to Friedrichshafen?
Confirm, bye bye
Peter is unaware of what just happened
BTC 2937
BTC 2937
This is the nightmare, that every controller hopes
will not happen to him:
Two of his aircraft colliding...
killing scores of people
Peter Nielsen leaves the control room
for the last time
but his story is far from over
The wreckage of the two planes is fallen
just outside the small city of Überlingen,
on the German Swiss border
Wreckage is scattered over 130 miles²
It is the worst mid air collision
in German post war history.
Debris comes raining down
around the school for handicapped children
run by Bruno and Stella Wegmüller
The sky was orange-red flaming
and we saw these pieces falling down
and detonations again and again
We realized:
It couldn't have been a normal thunderstorm
It was something
we had never heard and seen before
It was incredible, because,
there are many, many houses here
there was nothing on this place
but around our school
we find bodies, children
We very soon realized
that we couldn't do anything really
We couldn't save anyone,
We couldn't help anyone
The problem was that the bodies and debris
were dispersed over a very very wide area,
approx. 40km²
A corridor, 20 km long and 2 km wide
It was the largest police operation
in the province of Baden Würthemberg,
lasting a week and involving over 6000 people,
searching for the bodies
The people were all very sad
they were all in a state of a shock
and naturally, the rescue-team could feel that
and emphasized with their suffering
The policeman is standing where the DHL crashed
Here, you see no more trees.
The trees have completely burned down
We assumed
that the turbines of the Boeing separated first
Approx. 700 or 800 meter high,
before this plane crashed.
One landed 300 meter that way,
and the other turbine was another 500 meter that way
In this garden lay many of the bodies
of the children of Ufa.
In this part died 28 children
In this field was a child,
more over here, in this field, there was a...
Vitali Kaloyev, the Russian architect
was awaiting his family in Barcelona.
He is one of the first to arrive in Überlingen.
Although the relatives are not encouraged
to participate in the search,
Vitali cannot help himself.
Vitali finds a broken pearl necklace.
He recognizes it as his 4 years old daughter's
Amazingly, amidst all the carnage,
Vitali finds his daughter's body intact.
She did not suffer at all
The mutilated bodies of his wife and son
were not be found until later.
Over 6 days of searching,
the rescue workers gather bodies and body-parts,
scattered all over
the Southern German countryside
By Thursday of that week, two days later,
the relatives started arriving.
They could not all see the bodies we had found
because most of the bodies were badly charred
or mutilated
We did not permit the relatives to view the bodies
in that condition.
In Ufa, in Western Russia,
both Christian and Muslim communities are
devastated by the loss of their children
In the cemetery,
where 53 of the people in the Tupolev were buried
there are two double rows of gravestones,
with the Christian Orthodox on one side,
and the Muslims on the other.
It it eerily reminiscent
of the seating arrangement on the plane.
The monument evokes a flight of paper planes,
frozen in flight.
Vitali Kaloyev, who lost his entire family,
has designed and build a huge monument
in their memory.
Day and night, he lingers at the cemetery,
inconsolable.
At skyguide in Zürich, after the collision,
workers all had come to a standstill
They were shocked,
they were helpless,
There was a lot of sadness, people crying
and being criticized for being too technocratic
after the accident.
I have to accept that
One of the biggest tasks was
to maintain operations
because there were planes
coming in going out after this tragedy
That was a very, very difficult situation
for everybody
For the next 3 weeks
of the Zürich Air Traffic Control center,
capacity is reduced
for lack of available controllers.
Peter Nielsen never again worked
on an Air Traffic workstation.
The hunt begins
If two planes collide in empty skies,
someone must be to blame
At first, some suspect the Russians.
The pilot of the Russian plane
is said to have ignored
repeated instructions from
Air Traffic Controllers
They contacted the Russian pilot
and asked him to change altitude
because he was flying at a level
where he should not have been
The Russian pilot never responded
to those warnings from Air Traffic Control
The Russian pilot, particularly in Soviet times,
also now but to a lesser extend,
were extremely well trained.
I have no concerns about the training of pilots
They have been trained for almost every
operational possibility that could happen
Why did the TCAS device, meant to avoid collisions
in this case maybe help cause one
And why didn't the Russian plane descend
A language problem?
Controller commands are always in English
I knew everybody from that crew
Everybody knew English enough
to speak with the controller.
So, who is to blame?
The media spotlight now falls
on controller Peter Nielsen.
He was the man who guided the two planes
towards each other
They were under his control
He must have caused them to collide
I was in shock that it could have been
with any other name or any other colleague.
I was just very sorry for him
The media coverage about the incident
very often makes you angry
because the statements are taken out of context
You really get the impression
they just want to fill the newspaper
They write whatever they get,
They go after colleagues,
they give them a call at home
They will follow you where ever you are
You don't deserve
to be the boogie man for everybody.
That is something
which is really very difficult to accept
Suddenly we are having to take the blame
because the others are dead
or the others are hiding behind politics, rules...
We started to leave this building
by the underground exit
which leads to another building
Just not to see anybody.
They were asking people on the street in Kloten
People who were not involved at all!
Just to broadcast something in the evening
That makes you angry
You cannot resist it.
What more do we know about this
Swiss control as the center of the investigation?
He was chased by the media
He was accused of being a murderer
He is the man obviously everyone want to talk to
but at the moment the Swiss say
he is in no position to talk
and we heard today that the Swiss authorities
have opened an investigation
to see whether there is enough evidence
for charges of manslaughter
The accusation was manslaughter by negligence
in 71 cases
The speciality is that, in this case,
the investigating judge has been
working on an investigation on his own
independently from what
the Aviation Investigation Board of Germany did
Meanwhile, that investigation is on their way
headed by Germany's air-crash detectives,
the BFU
By the 5th day,
they have read all the black boxes.
This is a typical Voice Recorder
which was built into the Tupolev 154
It shows two reels,
the recording time of this recorder is 30 minutes
It is rather solid,
but the original Voice recorder of the Tupolev
was heavily damaged
So, we had to remove the tape
and we played it on a specialized tape-recorder
This is the hangar
where wreckage of the planes was examined
This is the lower surface of
the right-hand wing of the Tupolev
That remaining went below the Tupolev
and caused these scratches
That top part of the
vertical tail remained
at the accident side on the
main wreckage of the Boeing (DHL)
But could this accident have been avoided?
TCAS normally has a safeguard mechanism,
called a reversal
If an alert is issued
and one aircraft-crew ignores an instruction
TCAS orders a reversal
If the TCAS on aircraft A senses
that aircraft B is still on the collision course
it will tell to go in another direction
But it didn't,
why?
One of the major requirements for that
is that both planes have to be at
least 100 ft apart in altitude
but this requirement was not met at the time
That is why no reversal was given
When the DHL's TCAS saw
that the Tupolev wasn't climbing
it could only tell its pilots
to descend even faster
INCREASE DESCEND
July 2003,
Many parents return to Überlingen in Germany
for the first anniversary.
The Germans build a memorial
on the site of the tragedy
It is made up of a series of giant silver pearls
on a broken necklace
The head of skyguide is among the crowd.
Can you tell us
what are the mistakes you made?
I don't think this is the time to talk about it
I am sure you'll understand
Have you apologized?
OKAY, thank you
Among the parents is Vitaly Kaloyev
He asks the head of skyguide
which controller was responsible for the accident
but receives no answer
The man asked if it possible
to meet the controller
to meet Peter.
And the answer was: It is not possible
The request pass is almost unnoticed;
Vitaly Kaloyev is not satisfied
Meanwhile, as the investigators work,
they discover a fall of confusions around TCAS
When it was introduced 20 years previously,
there had been a fatal omission
No one said what should happen if there was
a conflict between what TCAS was saying
and what the controller was saying
There is no hard and fast rule to guide the pilots
Whilst pilots in the West have always been told
to obey TCAS,
in the rest of the world, it is anyone guess.
we are not accustomed to not trust controllers
In civil aviation, there were lots of situations
when pilots did not follow
the instructions of the controller
and that led to plane crashes or other accidents
The mentality of Russians is still very much
in the lines of the old Soviet ways
They are much more inclined to follow instructions
than to do what they think may be appropriate
They always reckon that the other guy knows better
The potential for a terrible accident was there
and 1.5 year before the Überlingen tragedy,
it nearly happened
Over Japan, two Jumbo jets with 677 people aboard
came so close,
that they filled each others windscreens
The violent avoidance manoeuvre
caused a 100 people to be injured
some of them seriously
This was seconds away from being
the worst plane crash in aviation history
Once again, a pilot had listened to the controller
instead of his TCAS
It should have served as a warning to everyone
Yet, from ICAO,
the International Civil Aviation Organisation,
there was only silence.
ICAO is responsible for drawing up the rules
of commercial aviation
German investigators say
that their vagueness about how to use TCAS
was one of the reasons for the Überlingen disaster
I think this is the first time that I remember
any major accident investigation,
the one run by the BFU
fingering any of the aviation-authorisations
in any serious way,
and this is a serious way,
so I think this is quite unique
If ICAO had carried out detailed investigation
of the incident in Japan
and made recommendations that led to
changes in procedures
this problem would not have happened.
ICAO did not feel it necessary
to get involved in this
They left it entirely up
to the Japanese authorities
Had it been a collision,
maybe they would have got involved
After this near miss, the Japanese government
immediately asked for their guidance
But unfortunately,
ICAO only acted on the request 18 months later...
...after the Überlingen disaster
Perhaps, the ICAO procedures and standards,
but in particular operating procedures
for airborne collision avoidance,
were somewhat ambiguous,
or open to interpretation
The Japanese incident was not the only warning
ICAO received
In the two years
leading up to the Überlingen collision,
four other near misses happened in Europe alone,
because one set of pilots obeyed air control
instead of their TCAS
If I have to summarize the advice
that we gave the world:
If a warning comes from TCAS,
pilots should immediately follow it at all times
with the benefit of hindsight,
You always asks yourself:
Could we have done more?
An accident is a wake up call for everybody.
All of these regrets are of little comfort now
to the grieving parents of Ufa
Everything that was good is in the past
and was connected with my child.
All the hopes, dreams
were connected with him,
with his future
And now, nothing left
At least, I've got nothing left
Our pain doesn't go away
It is getting stronger every year
Some grown up people made a mistake...
...made a fatal mistake
And the kids were gone
This is Kirill's room
Everything in this room was when he was alive...
...nothing has changed.
After he was killed,
there were also two exhibitions
One exhibitions took place here, in Ufa
while the other one was in Germany...
...in Überlingen
Vitaly Kaloyev, the Russian architect
has lost his entire family...
...everything
He himself has gone to pieces
He has become obsessed with finding out
who is responsible for the collision
Kaloyev decides to travel to Zürich
to play out the last tragic chapter
in the Überlingen story
On February, 24th, 2004
a stranger calls at the house of the controller,
Peter Nielsen
It was just the saddest thing you can imagine
I knew his family,
I knew how much he loved his kids and his wife
The presumed perpetrator
is apparently 48 years old
and of Eastern origin.
He is likely the father of one of the families
that was killed at the crash
He likely lost his wife and both their children
They found Vitaly Kaloyev nearby,
in a hotel
Subjected, but not yet charged with the murder
He is presently in a psychiatric clinic,
while they decide whether he is fit to stand trial
We didn't want him to be killed
We didn't want to have more victims
related to that catastrophe
because of our children
The killing of the flight controller
was a very very sad event
And the saddest thing of all
was that he was not actually responsible
for the accident
The system who was
responsible for the accident
was the poor skyguide management and
quality control of their systems
The investigators had worked out exactly
what went wrong that night at skyguide
and how an unfortunate series of events
had made disaster almost inevitable
1st: Peter's colleague goes for a break
leaving him alone to watch 2 radar-screens,
several feet apart
It was a standard practice at the ATC company
that at night, one Air Traffic Controller was
responsible for controlling the entire airspace
Then, following management instructions
the maintenance men started to switch things off
Peter's radar-screen is working more slowly
and will not warn him
if two planes are about to collide
He doesn't know that
During the maintenance work,
the radar system had to be run in fall back mode
In fall back mode,
the controller has no STCA available
STCA is Short Term Collision Alert:
a warning on the radar-screen
that planes are at imminent danger of collision
He did not know
that the STCA system would not be available
Then, by chance, an unexpected aircraft,
the Aero Lloyd tourist plane
arrives at the critical moment
and needs a lot of attention:
it completely distracts Peter
He tries to get outside help
but the main phone system has been accidently
disconnected by the maintenance crew
and the back up phone isn't working
The controller has been robbed
of all the technical support he needs
The phone link with Friedrichshafen was down
At this time there were
various radio transmissions
and the controller had to answer them
on different frequencies
Finally, when both planes are descending,
the DHL pilots cannot tell him what is happening
because the radio frequency is busy
The earliest they could do that
was 23 seconds later
because until then, the frequency was blocked
by the ATC Zürich transmission to the Tupolev crew
May, 2004,
It had taken the German BFU investigators
22 months to publish their final report
They found that the disaster
had two major causes
Firstly Peter Nielsen was too late
in noticing the danger of a collision
Secondly, the Russian crew was wrong
to obey him when he told them to descend,
rather than their own TCAS equipment,
telling them to climb
But other pilots understand their dilemma
The TCAS commands are spoken
in such a dispassionate voice
DESCEND
INCREASE DESCEND
such a matter of fact type of voice
and then there is the voice of the ATC's
urgent command
Descend immediately!
Leave this altitude immediately!
Go to another altitude at once
So, whichever voice sounded more urgent,
was the one the crew obeyed.
Finally, the report severely criticized skyguide
for leaving a lone controller on duty that night
We have learned our lesson
and we don't have single manned operations
or only one controller in front of
a monitor anymore.
This might happen again due to another
badly organized air control service
or a crew making a mistake
You are guilty or you are not guilty,
that is not the meaning of a final report.
The meaning of a final report is
facts: what has happened,
why did it happen
what are the lessons to be learned,
safety requirements
Mistakes were made by us also
and we regret them deeply
we acknowledge our responsibility
as said out in the BFU report
and we ask the families of the victims...
...for forgiveness.
At skyguide in Zürich...
...a rose now sits in a vase
in memory of Peter Nielsen
and the tragedy of Überlingen
Subtitles
Rein Croonen
over Germany
The middle of the night
A Russian plane is taking children
on holiday to Spain
But the pilots cannot believe what they see
heading towards them
Climb!
DEADLY CROSSROADS
June, 2002
The city of Ufa, Western Russia
Ufa is populated by both Christians and Muslims
This year, its most outstanding teenagers
have been chosen to go on a two-week vacation
organized by UNESCO,
near Barcelona in Spain
They are among the most clever,
athletic or artistic children of Ufa
Kirill Degtaryeva is 14 year old protege
He has been painting since he is 4 years old
and he already had two public exhibitions
Alina Khannanov is a 12 years old
who had won several gymnastics competitions
The 46 children from Ufa,
accompanied by a few teachers
leave on a train to Moscow
There, they are due to catch their flight
to Barcelona
But in Moscow, things start to go wrong
The Tourist Agency accidently takes
the children to the wrong airport
So they missed their plane
They are terribly disappointed
While the Agency tries to sort out the mess,
the children go site seeing in the Russian Capital
It takes two days to charter another jet
But finally, they are on their way to Barcelona
On July, 1st, 2002
the children from Ufa board their plane
at a Moscow airport
The Kaloyevs are not part of the school group
They are going on a holiday to meet their father,
who is an architect
and is finishing a project near Barcelona.
No fewer than 5 Russians are flying this plane
The captain is Alexander Gross,
who has been a pilot for over 30 years
Alexander had a good theoretical knowledge
He was very smart
Today, the 1st Officer is Oleg Grigoriev
But actually,
Grigoriev is the airline's chief pilot
On this trip
he will be evaluating captain Gross's flying
If you did something wrong,
some captains would criticize you very rudely
Others would be very formerly and polite
But Oleg Grigoriev would express
his disproval with a gesture like that
meaning:
why on earth did you do that?
Captain Gross is in command
Captain Grigoriev is his supervisor
If it comes to the crunch,
who will really be in charge?
Seated in the left rear is Murat Itkulov
normally the 1st Officer
But who is not officially on duty,
because Grigoriev is in his seat
Nevertheless,
since he will soon be promoted to Captain
his opinions are considered
Murat was a very professional pilot,
he loved to fly
Murat was interested in the new stuff in aviation
And always kept up to date
in the most progressive things brought in
Also on the flight deck are
an experienced navigator and a flight engineer.
Just before 11:00 PM,
Bashkirian Airlines Flight 2937 leaves Moscow
The plane is a Tupolev 154
Like most modern aircraft, it carries
collision avoidance equipment called TCAS
Traffic Collision Avoidance System
Descend, descend, descend
TCAS works because all commercial aircraft
carry a transponder
which sends a constant stream of radio-signals,
identifying them and saying where they are
TCAS listens in and calculates where there
are any of the planes is on a collision course
If they are, it will tell the pilot
what action to take to avoid collision
Descend!
If Air Traffic Control should ever let them down,
TCAS will be their last line of defence
Clear of conflict
Hundreds of miles away in Bergamo, Italy,
a Boeing 757 is getting on their way
It is flying for DHL,
the international freight company
and is heading for their European base at Brussels
in Belgium
The Russian Tupolev will cross its path
over Southern Germany
The Boeing has only two people aboard:
Captain Paul Phillips, who is British
and 1st Officer Brant Campioni who is Canadian
and due to fly the next leg of the journey
The DHL takes off at 11:06 PM...
...on what will be its last journey
At 19:50 at the skyguide Area Control CENTER
in Zürich, Switzerland
The busy day-shift has ended
and the night-shift is reporting for work
Peter Nielsen is an experienced controller
He has been doing this job for 8 years
The CENTER regulates traffic in Southern Germany
as well as Northern Switzerland
Tonight, there are only two controllers on duty.
But the traffic in their sector is light
and Nielsen's colleague
decides to take a lengthy break
a common practice at skyguide
Peter Nielsen is now responsible
for all air-traffic on two radar screens
which sits several feet apart
At 23:10 two technicians arrive
They inform Peter that skyguide
management has authorized them
to carry out maintenance
work on the main radar
While they do so,
the screens will work much more slowly
and will give no visual 2 minute warning
if planes are getting too close to each other
The engineers now tell Peter Nielsen
they have to shut down the
telephone system as well
They switch over to the standby phones
No one realizes it yet,
but the seeds of disaster have been sown
The Russian plane, filled with schoolchildren
is now over Central Germany
and flying towards Switzerland
Captain Grigoriev gets final clearance
from the last German Control center
before they cross South
into Switzerland
The German controller hands over
the Russian plane to skyguide
where Peter Nielsen is at the helm.
Meanwhile, the DHL is climbing North over the Alps
and is now entering Swiss Airspace
Zürich, radar, good evening
DHX 611,
I'm climbing flight level 26000 ft, direct Odyssey
Captain Paul Phillips of the DHL
requests clearance to climb to a higher altitude
The thinner air there will
mean less air resistance
and save fuel
Roger climb flight level 32000 ft
Direct TGO
DHX 611 climb flight level 36000 ft
The DHL reaches flight level 360,
or 36000 ft
The same altitude as the Russian plane.
and they are on a collision course
But they are many miles apart...
...so far, no danger
Now, the assistant gives Peter Nielsen
a new flight-strip
An Airbus, Aero Lloyd Flight 1135
is flying to the airport of Friedrichshafen nearby
It is going to increase Peter's workload
dramatically over the next 5 minutes
and have him switching from one screen to another
Peter tries to dial the Airport
Control Tower at Friedrichshafen,
to discuss handing over the
Aero Lloyd flight to them.
But the line is dead
He tries a second time
The phones aren't working
The Aero Lloyd pilot
is trying to make contact with Peter
He has to leave the Russian pilots unattended
Good Evening, BTC
but the Russian pilot is also calling him,
on the other screen
LL 1135, Roger,
I'll call you back
Station calling, please
Ah, Zürich, good evening, BTC, 2937,
our level is 36000 ft
BTC 2937,
00:11:08,123 --> 00:11:10,576
The Aero Lloyd is calling again
Yeah, expect so,
I'll call you back shortly
Now, another plane needs him,
a Thai Airways flight heading North
Thai in 2933, contact now on Munich
132,140, Goodbye
Air Traffic controllers
are used to handle tricky situations,
but tonight,
Peter's equipment isn't working properly
And he is controlling
two screens at the same time
Normally, his radar would warn
of any impending collision
What he doesn't know is that tonight,
it is out of action
Correct, what is your present heading?
Present heading is 265
Roger, right turn heading 280
vector ILS 24
Peter wants to get this Aero Lloyd off his hands
He tries dialling the public number for
the Friedrichshafen control Tower for the 3rd time
Meanwhile, the Russian airliner and the
DHL-plane are still heading towards each other
at a closing speed of over 800 mph
Neither crew is aware
that they are only 2.5 minutes apart
The DHL plane is now approaching the Swiss border
with Germany
The Russian Tupolev is heading
for exactly the same spot...
...and at the same altitude
Finally, someone at another ATC CENTER in Germany
spots the danger
He grabs the phone to warn Nielsen...
...but cannot get through
International air-traffic rules prevent him
from talking to the pilots directly
Look, look at that
Now, for the first time,
the Russian pilots can see the DHL plane
on the screen of their
TCAS anti-collision computer
But Peter Nielsen is still focussed
on getting the Aero Lloyd flight safely down
Aero Lloyd 1135
Yeah, I lost my connection
to Friedrichshafen airport
Could you please call them on your second set
124,35
Tell them
you are coming in ILS 24 with 20 miles now
OKAY, we'll do.
On the DHL cargo plane,
the crew is relaxed.
They don't know they are on a collision course
Their TCAS hasn't sounded a warning yet
The First Officer goes to the wash-room
On the Russian plane,
the pilots are getting concerned
The other plane is getting
closer and closer,
but they are not exactly sure
whether he is on the same altitude
he is going below us
500...
No, 100 meters
TCAS, the collision
avoidance computer,
is warning the Russian pilots that
the other plane is getting too close for comfort
At the same moment, the TCAS in the DHL cockpit
detects the Russian plane
DESCEND, DESCEND
Peter Nielsen finally realizes what is happening
BTC 2937, descend flight level 35000 ft
Expedite,
I have crossing traffic
Descend?
Captain Gross disengages the AUTOPILOT
and starts to descend
CLIMB, CLIMB
TCAS is telling them to climb,
the controller is telling them to descend
It says: CLIMB
He is guiding us down
Peter: BTC 2937,
Descend level 35000ft,
expedite descend
Expedite descend level 35000 ft
Peter Nielsen thinks he has averted a collision
by telling the Russian plane to descend
But what he doesn't know
is that the DHL pilots has received
a TCAS instruction telling THEM to descend
Increase!
They are trying to tell Nielson
that they have a TCAS instruction to descend...
but Peter cannot hear them.
If both planes obey TCAS,
there had been no problem
But the Russians, instead of climbing,
have followed the controller's orders.
Now both planes are diving towards each other
He is going below us
The tail of the DHL
clips the belly of the Tupolev...
...tearing it apart
The pilots soon lose consciousness
The DHL struggles on for another two minutes.
It will crash 4 miles away
Can we go over to Friedrichshafen?
Confirm, bye bye
Peter is unaware of what just happened
BTC 2937
BTC 2937
This is the nightmare, that every controller hopes
will not happen to him:
Two of his aircraft colliding...
killing scores of people
Peter Nielsen leaves the control room
for the last time
but his story is far from over
The wreckage of the two planes is fallen
just outside the small city of Überlingen,
on the German Swiss border
Wreckage is scattered over 130 miles²
It is the worst mid air collision
in German post war history.
Debris comes raining down
around the school for handicapped children
run by Bruno and Stella Wegmüller
The sky was orange-red flaming
and we saw these pieces falling down
and detonations again and again
We realized:
It couldn't have been a normal thunderstorm
It was something
we had never heard and seen before
It was incredible, because,
there are many, many houses here
there was nothing on this place
but around our school
we find bodies, children
We very soon realized
that we couldn't do anything really
We couldn't save anyone,
We couldn't help anyone
The problem was that the bodies and debris
were dispersed over a very very wide area,
approx. 40km²
A corridor, 20 km long and 2 km wide
It was the largest police operation
in the province of Baden Würthemberg,
lasting a week and involving over 6000 people,
searching for the bodies
The people were all very sad
they were all in a state of a shock
and naturally, the rescue-team could feel that
and emphasized with their suffering
The policeman is standing where the DHL crashed
Here, you see no more trees.
The trees have completely burned down
We assumed
that the turbines of the Boeing separated first
Approx. 700 or 800 meter high,
before this plane crashed.
One landed 300 meter that way,
and the other turbine was another 500 meter that way
In this garden lay many of the bodies
of the children of Ufa.
In this part died 28 children
In this field was a child,
more over here, in this field, there was a...
Vitali Kaloyev, the Russian architect
was awaiting his family in Barcelona.
He is one of the first to arrive in Überlingen.
Although the relatives are not encouraged
to participate in the search,
Vitali cannot help himself.
Vitali finds a broken pearl necklace.
He recognizes it as his 4 years old daughter's
Amazingly, amidst all the carnage,
Vitali finds his daughter's body intact.
She did not suffer at all
The mutilated bodies of his wife and son
were not be found until later.
Over 6 days of searching,
the rescue workers gather bodies and body-parts,
scattered all over
the Southern German countryside
By Thursday of that week, two days later,
the relatives started arriving.
They could not all see the bodies we had found
because most of the bodies were badly charred
or mutilated
We did not permit the relatives to view the bodies
in that condition.
In Ufa, in Western Russia,
both Christian and Muslim communities are
devastated by the loss of their children
In the cemetery,
where 53 of the people in the Tupolev were buried
there are two double rows of gravestones,
with the Christian Orthodox on one side,
and the Muslims on the other.
It it eerily reminiscent
of the seating arrangement on the plane.
The monument evokes a flight of paper planes,
frozen in flight.
Vitali Kaloyev, who lost his entire family,
has designed and build a huge monument
in their memory.
Day and night, he lingers at the cemetery,
inconsolable.
At skyguide in Zürich, after the collision,
workers all had come to a standstill
They were shocked,
they were helpless,
There was a lot of sadness, people crying
and being criticized for being too technocratic
after the accident.
I have to accept that
One of the biggest tasks was
to maintain operations
because there were planes
coming in going out after this tragedy
That was a very, very difficult situation
for everybody
For the next 3 weeks
of the Zürich Air Traffic Control center,
capacity is reduced
for lack of available controllers.
Peter Nielsen never again worked
on an Air Traffic workstation.
The hunt begins
If two planes collide in empty skies,
someone must be to blame
At first, some suspect the Russians.
The pilot of the Russian plane
is said to have ignored
repeated instructions from
Air Traffic Controllers
They contacted the Russian pilot
and asked him to change altitude
because he was flying at a level
where he should not have been
The Russian pilot never responded
to those warnings from Air Traffic Control
The Russian pilot, particularly in Soviet times,
also now but to a lesser extend,
were extremely well trained.
I have no concerns about the training of pilots
They have been trained for almost every
operational possibility that could happen
Why did the TCAS device, meant to avoid collisions
in this case maybe help cause one
And why didn't the Russian plane descend
A language problem?
Controller commands are always in English
I knew everybody from that crew
Everybody knew English enough
to speak with the controller.
So, who is to blame?
The media spotlight now falls
on controller Peter Nielsen.
He was the man who guided the two planes
towards each other
They were under his control
He must have caused them to collide
I was in shock that it could have been
with any other name or any other colleague.
I was just very sorry for him
The media coverage about the incident
very often makes you angry
because the statements are taken out of context
You really get the impression
they just want to fill the newspaper
They write whatever they get,
They go after colleagues,
they give them a call at home
They will follow you where ever you are
You don't deserve
to be the boogie man for everybody.
That is something
which is really very difficult to accept
Suddenly we are having to take the blame
because the others are dead
or the others are hiding behind politics, rules...
We started to leave this building
by the underground exit
which leads to another building
Just not to see anybody.
They were asking people on the street in Kloten
People who were not involved at all!
Just to broadcast something in the evening
That makes you angry
You cannot resist it.
What more do we know about this
Swiss control as the center of the investigation?
He was chased by the media
He was accused of being a murderer
He is the man obviously everyone want to talk to
but at the moment the Swiss say
he is in no position to talk
and we heard today that the Swiss authorities
have opened an investigation
to see whether there is enough evidence
for charges of manslaughter
The accusation was manslaughter by negligence
in 71 cases
The speciality is that, in this case,
the investigating judge has been
working on an investigation on his own
independently from what
the Aviation Investigation Board of Germany did
Meanwhile, that investigation is on their way
headed by Germany's air-crash detectives,
the BFU
By the 5th day,
they have read all the black boxes.
This is a typical Voice Recorder
which was built into the Tupolev 154
It shows two reels,
the recording time of this recorder is 30 minutes
It is rather solid,
but the original Voice recorder of the Tupolev
was heavily damaged
So, we had to remove the tape
and we played it on a specialized tape-recorder
This is the hangar
where wreckage of the planes was examined
This is the lower surface of
the right-hand wing of the Tupolev
That remaining went below the Tupolev
and caused these scratches
That top part of the
vertical tail remained
at the accident side on the
main wreckage of the Boeing (DHL)
But could this accident have been avoided?
TCAS normally has a safeguard mechanism,
called a reversal
If an alert is issued
and one aircraft-crew ignores an instruction
TCAS orders a reversal
If the TCAS on aircraft A senses
that aircraft B is still on the collision course
it will tell to go in another direction
But it didn't,
why?
One of the major requirements for that
is that both planes have to be at
least 100 ft apart in altitude
but this requirement was not met at the time
That is why no reversal was given
When the DHL's TCAS saw
that the Tupolev wasn't climbing
it could only tell its pilots
to descend even faster
INCREASE DESCEND
July 2003,
Many parents return to Überlingen in Germany
for the first anniversary.
The Germans build a memorial
on the site of the tragedy
It is made up of a series of giant silver pearls
on a broken necklace
The head of skyguide is among the crowd.
Can you tell us
what are the mistakes you made?
I don't think this is the time to talk about it
I am sure you'll understand
Have you apologized?
OKAY, thank you
Among the parents is Vitaly Kaloyev
He asks the head of skyguide
which controller was responsible for the accident
but receives no answer
The man asked if it possible
to meet the controller
to meet Peter.
And the answer was: It is not possible
The request pass is almost unnoticed;
Vitaly Kaloyev is not satisfied
Meanwhile, as the investigators work,
they discover a fall of confusions around TCAS
When it was introduced 20 years previously,
there had been a fatal omission
No one said what should happen if there was
a conflict between what TCAS was saying
and what the controller was saying
There is no hard and fast rule to guide the pilots
Whilst pilots in the West have always been told
to obey TCAS,
in the rest of the world, it is anyone guess.
we are not accustomed to not trust controllers
In civil aviation, there were lots of situations
when pilots did not follow
the instructions of the controller
and that led to plane crashes or other accidents
The mentality of Russians is still very much
in the lines of the old Soviet ways
They are much more inclined to follow instructions
than to do what they think may be appropriate
They always reckon that the other guy knows better
The potential for a terrible accident was there
and 1.5 year before the Überlingen tragedy,
it nearly happened
Over Japan, two Jumbo jets with 677 people aboard
came so close,
that they filled each others windscreens
The violent avoidance manoeuvre
caused a 100 people to be injured
some of them seriously
This was seconds away from being
the worst plane crash in aviation history
Once again, a pilot had listened to the controller
instead of his TCAS
It should have served as a warning to everyone
Yet, from ICAO,
the International Civil Aviation Organisation,
there was only silence.
ICAO is responsible for drawing up the rules
of commercial aviation
German investigators say
that their vagueness about how to use TCAS
was one of the reasons for the Überlingen disaster
I think this is the first time that I remember
any major accident investigation,
the one run by the BFU
fingering any of the aviation-authorisations
in any serious way,
and this is a serious way,
so I think this is quite unique
If ICAO had carried out detailed investigation
of the incident in Japan
and made recommendations that led to
changes in procedures
this problem would not have happened.
ICAO did not feel it necessary
to get involved in this
They left it entirely up
to the Japanese authorities
Had it been a collision,
maybe they would have got involved
After this near miss, the Japanese government
immediately asked for their guidance
But unfortunately,
ICAO only acted on the request 18 months later...
...after the Überlingen disaster
Perhaps, the ICAO procedures and standards,
but in particular operating procedures
for airborne collision avoidance,
were somewhat ambiguous,
or open to interpretation
The Japanese incident was not the only warning
ICAO received
In the two years
leading up to the Überlingen collision,
four other near misses happened in Europe alone,
because one set of pilots obeyed air control
instead of their TCAS
If I have to summarize the advice
that we gave the world:
If a warning comes from TCAS,
pilots should immediately follow it at all times
with the benefit of hindsight,
You always asks yourself:
Could we have done more?
An accident is a wake up call for everybody.
All of these regrets are of little comfort now
to the grieving parents of Ufa
Everything that was good is in the past
and was connected with my child.
All the hopes, dreams
were connected with him,
with his future
And now, nothing left
At least, I've got nothing left
Our pain doesn't go away
It is getting stronger every year
Some grown up people made a mistake...
...made a fatal mistake
And the kids were gone
This is Kirill's room
Everything in this room was when he was alive...
...nothing has changed.
After he was killed,
there were also two exhibitions
One exhibitions took place here, in Ufa
while the other one was in Germany...
...in Überlingen
Vitaly Kaloyev, the Russian architect
has lost his entire family...
...everything
He himself has gone to pieces
He has become obsessed with finding out
who is responsible for the collision
Kaloyev decides to travel to Zürich
to play out the last tragic chapter
in the Überlingen story
On February, 24th, 2004
a stranger calls at the house of the controller,
Peter Nielsen
It was just the saddest thing you can imagine
I knew his family,
I knew how much he loved his kids and his wife
The presumed perpetrator
is apparently 48 years old
and of Eastern origin.
He is likely the father of one of the families
that was killed at the crash
He likely lost his wife and both their children
They found Vitaly Kaloyev nearby,
in a hotel
Subjected, but not yet charged with the murder
He is presently in a psychiatric clinic,
while they decide whether he is fit to stand trial
We didn't want him to be killed
We didn't want to have more victims
related to that catastrophe
because of our children
The killing of the flight controller
was a very very sad event
And the saddest thing of all
was that he was not actually responsible
for the accident
The system who was
responsible for the accident
was the poor skyguide management and
quality control of their systems
The investigators had worked out exactly
what went wrong that night at skyguide
and how an unfortunate series of events
had made disaster almost inevitable
1st: Peter's colleague goes for a break
leaving him alone to watch 2 radar-screens,
several feet apart
It was a standard practice at the ATC company
that at night, one Air Traffic Controller was
responsible for controlling the entire airspace
Then, following management instructions
the maintenance men started to switch things off
Peter's radar-screen is working more slowly
and will not warn him
if two planes are about to collide
He doesn't know that
During the maintenance work,
the radar system had to be run in fall back mode
In fall back mode,
the controller has no STCA available
STCA is Short Term Collision Alert:
a warning on the radar-screen
that planes are at imminent danger of collision
He did not know
that the STCA system would not be available
Then, by chance, an unexpected aircraft,
the Aero Lloyd tourist plane
arrives at the critical moment
and needs a lot of attention:
it completely distracts Peter
He tries to get outside help
but the main phone system has been accidently
disconnected by the maintenance crew
and the back up phone isn't working
The controller has been robbed
of all the technical support he needs
The phone link with Friedrichshafen was down
At this time there were
various radio transmissions
and the controller had to answer them
on different frequencies
Finally, when both planes are descending,
the DHL pilots cannot tell him what is happening
because the radio frequency is busy
The earliest they could do that
was 23 seconds later
because until then, the frequency was blocked
by the ATC Zürich transmission to the Tupolev crew
May, 2004,
It had taken the German BFU investigators
22 months to publish their final report
They found that the disaster
had two major causes
Firstly Peter Nielsen was too late
in noticing the danger of a collision
Secondly, the Russian crew was wrong
to obey him when he told them to descend,
rather than their own TCAS equipment,
telling them to climb
But other pilots understand their dilemma
The TCAS commands are spoken
in such a dispassionate voice
DESCEND
INCREASE DESCEND
such a matter of fact type of voice
and then there is the voice of the ATC's
urgent command
Descend immediately!
Leave this altitude immediately!
Go to another altitude at once
So, whichever voice sounded more urgent,
was the one the crew obeyed.
Finally, the report severely criticized skyguide
for leaving a lone controller on duty that night
We have learned our lesson
and we don't have single manned operations
or only one controller in front of
a monitor anymore.
This might happen again due to another
badly organized air control service
or a crew making a mistake
You are guilty or you are not guilty,
that is not the meaning of a final report.
The meaning of a final report is
facts: what has happened,
why did it happen
what are the lessons to be learned,
safety requirements
Mistakes were made by us also
and we regret them deeply
we acknowledge our responsibility
as said out in the BFU report
and we ask the families of the victims...
...for forgiveness.
At skyguide in Zürich...
...a rose now sits in a vase
in memory of Peter Nielsen
and the tragedy of Überlingen
Subtitles
Rein Croonen