4 Swiss ATC managers found guilty in 2002 crash

[atwork]

http://www.cbc.ca/world/story/2007/09/0 ... crash.html

[invertedattitude]

Second of all, fix your title, the article I read, and others stated the 4 that were charged were managers not Air Traffic controllers.

Big Difference!

Three of those convicted Tuesday, all middle managers, received one-year suspended prison sentences. The fourth, a project manager, was ordered to pay a $11,200 fine for his role in the collision, on July 1, 2002, of a Bashkirian Airlines plane and a DHL cargo jet near the south German town of Ueberlingen, killing the two cargo pilots and everyone on the passenger plane.

Fix the title, ASAP please

[atwork]

The ICAO rules for following TCAS were changed as a result of this accident, as far as I understand the Russians were trained at that time to always obey ATC.
As for the title of the thread, that is the title of the news article not something I made up.
The plain and simple fact is one of the controllers went for a nap when he shouldn't have the guy on duty got busy and didn't want to disturb his buddies sleep. The techs were working on stuff and like normal things were not always coordinated properly and the managers took the heat for it all even though they were not even there. I wonder if the other controller on duty that was sleeping in the break room was implicated at all. The holes all lined up and a horrible accident happened let just hope it never happens again.

[invertedattitude]

Are you an Air Traffic Controller?

I'd still like you to fix the title, just because the CBC doesn't know how to do proper reasearch doesn't mean you have to copy them.

The title is incorrect. In fact the Swiss controller was exonorated shortly after his murder.

the managers took the heat for it all even though they were not even there

That's because there wasn't proper procedures set in place ahead of time, which the managers should have done long before this incident.

[atwork]

Happy now?????? Still doesn't change the facts on what happened.

[invertedattitude]

Happy now?????? Still doesn't change the facts on what happened.

You're right. The Air Traffic Controllers were found not guilty completely the opposite of the original thread title.

I don't want to start a pissing match, but facts are facts.

[kevenv]

atwork:
We have studied the events and facts of this accident during recurrent training 2 years ago. The controllers on duty, sleeping or otherwise were not found guilty of anything. They were exonerated at the accident investigation and in a court of law. Thats 2 separate bodies that found them innocent. What are you basing your statements on? Skyguide, their employer, took all of the blame during the accident investigation, and as we see now, their managers were found guilty in a civil trial. FYI, there are always managers of one sort or another on duty. As well, TCAS procedures were not changed as a result of this. It was always the expected procedure that aircraft would respond to an RA and ignore ATC instructions. The fact that the Russian pilots ignored the RA was a contributing factor in the accident.

[Doc]

Sleeping? Comforting thought. Kind of reminds me of the LEX accident, which could have been prevented by the tower controller looking out the window to confirm the aircraft he had cleared for take off, was, indeed taking off from the runway as cleared. As I've mentioned in other threads, the tower controller was not at fault....or is he? In my book, he gets .1% of the blame...but that's all that was required.
As always, the controllers rally around their kind, even though, in this case, their kind happen to be an ocean away, they still take it personally.
Funny, as pilots, we eat our own when they screw up. I guess, it's way too easy to pass the blame on to middle management? Or, blame the pilots. In this case, the Russians, who, reacted as they were trained (rightly or not) to react.
Al these accidents are so easy to prevent. It's time to wake up, and smell the coffee.
Man, I'll probably get killed for this post.

[Czar]

Once again, the media gets it wrong:



That characterization is 100% false. The controller did not "mistakenly" tell the Russian plane to descend. He gave them an instruction that was designed to avoid a collision. The Russian pilots acted contrary to internationally established procedures that dictate that in the event of a TCAS RA, the pilots are to follow the RA and not the controller's instructions.

Had the Russians followed the TCAS RA as they were required to do, this would have been nothing more than a story retold in the hangar.

Cpl_atc,

Would you mind elaborating on your comment. How did the controller "gave them an instruction that was designed to avoid the collision"?

From what I understand, the controller did give a wrong instruction. Now, according to the rules, the Russian pilots should have followed the TCAS instructions. But that does NOT exonerate the controllers wrong instruction.
At least, this added to the confusion and to the chain of contributing factors of the accident.

[Jerricho]

From what I understand, the controller did give a wrong instruction. Now, according to the rules, the Russian pilots should have followed the TCAS instructions. But that does NOT exonerate the controllers wrong instruction

Rubbish.

The controller did not "issue a wrong instruction". He issued an descent instruction to resolve the confliction. The Tupolov TCAS issued a climb RA, which coupled with the descent RA the TCAS in the 757. The Russian crew did not follow the RA. Those are facts. The circumstances both aircraft were head on, same altitude is a culmination of some very unfortunate holes lining up...........holes which I hope a ruling such as in this case will never be allowed to present again. The controller was "rubbernecking" 2 radar screen, providing a Single Man Operation (SMOP as Skyguide refer to it). When the procedure was implemented in 2001, the Swiss Controller's Union opposed it, but it was still implemented. It was decreed under SMOP that Short Term Conflict Alert (STCA) is to be on and fully functional. It was not.

atwork, I think you should probably be told that ICAO "rules" aren't necessarily implemented by signatory states. I would have to do some hunting around, but are you aware that some operators have it written into their operations that if an RA is received and the pilot can visually acquire the traffic, they don't have to follow the RA. Are you also aware that in the Bashkirian Operations manual, words to the effect of "consider both ATC instructions and TCAS advisories"

Doc, I find it amusing in this thread you mention the LEX incident and attribute "blame", yet in another thread you're admonishing a controller who pedantically corrects a clearance "to the Blah-Blah airport". Come on mate, you can't have it both ways.

[Czar]

From what I understand, the controller did give a wrong instruction. Now, according to the rules, the Russian pilots should have followed the TCAS instructions. But that does NOT exonerate the controllers wrong instruction

Rubbish.

The controller did not "issue a wrong instruction". He issued an descent instruction to resolve the confliction. The Tupolov TCAS issued a climb RA, which coupled with the descent RA the TCAS in the 757. The Russian crew did not follow the RA. Those are facts.

Okay, I'll bite.
First off, this was a tragic accident that effected a lot of people and I truly sympathize.
However, don't try to mix other events leading to the circumstances with my main question (therefore, everything after your facts is 'rubbish'). I know the circumstances and I am not denying them. There were many contributing faults; undeniably, the Russian pilots share part of the fault by not following the TCAS. But to lay blame squarely on the 'russkies' will not hold.

So, please, would you care to explain to me why the controller provided contradicting instructions to resolve this conflict? I know he had very little time to react since, like you said, the events prior played a role.

A key question is, maybe, was there a lack of situational control? what factors lead to the loss of situational control? Did the controller fully recognize the urgency and his limited awareness? Why give instructions that may be erroneous?

[Pygmie]

...
So, please, would you care to explain to me why the controller provided contradicting instructions to resolve this conflict? I know he had very little time to react since, like you said, the events prior played a role.

A key question is, maybe, was there a lack of situational control? what factors lead to the loss of situational control? Did the controller fully recognize the urgency and his limited awareness? Why give instructions that may be erroneous?

The controller had no way of knowing his instructions were contradicting. When the controller realized the problem, what he saw was two aircraft, on intercepting tracks, at the exact same altitude. At this point he told the Russian aircraft to descend, and had NO WAY of knowing that they were being told by their TCAS to climb.

TCAS works entirely independant of any ground-based systems, and as such controllers have no access to it or any indication that a TCAS resolution is being provided to either aircraft. Unless the pilot of either aircraft tells the controller a TCAS climb/descent is in progress, the controller has no way of knowing, and as such has an OBLIGATION to issue instructions to minimize the risk of an accident and regain his separation.

If a controller is told by a pilot that a TCAS climb/descent has been initiated, then yes, the controller must not issue any instructions to those aircraft until the pilots report the manouver is complete. In the situation that happened in this case, the DHL pilots made a call indicating a TCAS descent was in progress, but unfortunately that radio call was blocked or lost in the confusion.

To address your other point, the situation control/awareness was non-existant because the procedures in place at the time has one controller watching and controlling traffic in two different peices of airspace, at two different control positions, on two different screens. Think about that for a moment. . . . He was having to control aircraft on two different screens, which are a few meters apart. Far enough that it is NOT POSSIBLE to see the information on both screens without either sliding a few meters over on your chair, or getting up and moving over. Even worse, one of the positions was a terminal control position and the other was an en-route position.

In the time leading up to this incident the controller was trying to get an aircraft down and co-ordinate the arrival with the tower at the terminal position, which normally wouldn't take but a few seconds. Unfortunately, the phone lines to the tower had been taken offline by the techs who were working on the systems at the time, along with the conflict alert system, and some of the radar processing fuctions.

That's one of the big issues here, the controller was having to deal with two positions, both of which had major parts taken offline for repairs that he didn't know about, but had been approved by management. That's a huge part of why the situational control was lacking, as you put it.

[Czar]

Thanks Pygmie,
That was an informative response. I think I was just caught up on the wording. I still think the controller made a mistake (hence the accident) caused by surrounding circumstances which were at fault.

I honestly hope that this incident brought about some safety changes that will prevent a re-occurence of this kind in the future.

[Jerricho]

Damn good response there Pygmie. You should be a terminal controller

Czar, I think you've misunderstood me. At no stage have I ever said the sole reason for this incident were the actions of the Russian crew. Have a little read of my post again..........."The circumstances both aircraft were head on, same altitude is a culmination of some very unfortunate holes lining up.".

I've been thinking about what Doc has mentioned about Air Trafficers closing ranks to protect their own. Perhaps it's some what of a cultural thing where, when the finger pointing starts and people start looking for someone to blame, it certainly goes against my ethos of "Why the hell did this happen, and how can we stop it.". You can list all the contributing factors you like and proportion percentages of culpability.........priority should be directed into identifying WHY and making damn sure the holes don't line up again.

[kevenv]

Damn good response there Pygmie. You should be a terminal controller

Terminal Controller?????/ The fact that Pygmie's response was so well reasoned and articulated suggests to me that he is an en route controller! Why take a step backwards!

[invertedattitude]

This accident, and the Gol/Legacy accident should remind pilots and controllers, TCAS isn't going to fix Mid-airs in IFR controller airspace.

Skyguide, was and is a leader in ANS, it can and will happen to the best of them. Like was said stop the holes from lining up, everyone can do their part for that.