Ueberlingen collision final report
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Ueberlingen collision final report
The German Federal Bureau of Aircraft Accident Investigations (BFU) will be publishing its report on its investigation into the Überlingen air accident of July 1, 2002 on May 19. 2004 .
There are already speculations that it could change the lifestyle of some managers and even Politicians in Swiss land .
There are already speculations that it could change the lifestyle of some managers and even Politicians in Swiss land .
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Now this is a rumor only, originating from someone who saw the report and couldn't keep his mouth shut:
Apparently the CWR from the tupolev contains a debate between the Cap. and the FO. FO wants to follow the TCAS, but CAP overrules him and orders him to follow the ATCO's instructions.
Apparently the CWR from the tupolev contains a debate between the Cap. and the FO. FO wants to follow the TCAS, but CAP overrules him and orders him to follow the ATCO's instructions.
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There is another thread about this on Rumour & News
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B:P: :
What is sad in all this is that most of us ( controllers ) knew when TCAS was forced on us from the USA that it had problems :
one of them was the confusion between an Human based ATC system and an automated system mixing each other. The first question we all asked then was precisely this : what if my clearance is in contradiction with the RA ?
The answer then was that once a pilot reports an RA , ATC ceases to be responsible. What happens when a pilot does not report and RA but follows it ? This was not supposed to happen we were told.
In this case the 757 pilot waited 22 seconds before reporting and the TU pilot(s) never reported the RA.
Here we are ...
For your info :
I have just posted the following on Rumours : I extract what I think is relevant for ATC :
The ( quite good ) report goes in great details to explain certain things but pass very fast on others.
Some of them I would like to have seen mentionned :
The name RA for "Resolution Advisory " was choosen by the FAA to limit the liability of the US manufacturer of the Software ( The Mitre Corporation ) Only in the US was it known implicitely that although for legal reason we call it an advisory, it is in fact a command .
Unfortunately when you translate the manuals and the procedures in other languages, Advisories remain advisories.
TCAS was made by the US for the US... (on one of its first report Eurocontrol mentionned that TCAS II logic behaved badly in European types of en-route airspace...)
To follow an RA you need to be 2 in the cockpit : one that look outside to identify the intruder, the other that look at the display and follow the needle to keep it in the green.
Attempting to do both at the same time results in large deviations...
The 757 pilot was alone for a great part of the RA..( I do not believe this played a role in this case , but it show us that Murphy' s law is always valid...)
The unsheduled late inbound to to Friedrichshafen was, from an ATC point of view the most important link of the chain of event that led to this collision.
The paramount importance of this fact is missing
This forced the controller to look into two different scopes a few meters appart, and monitor alone two different active fequencies whit degraded telephone system and faulty back ups. This led to the late detection of the conflict and the late decent clearance to the TU.( which was the action most controllers would have taken since the TU was pllanned and coordinated with the adjacent centre at 350 and the DHL had just reached his cruising altitude ) .
.
Various Management levels put the controller into that position that night. This later also cost him his life.
I hope that never again would any controller find himself in that position...
What is sad in all this is that most of us ( controllers ) knew when TCAS was forced on us from the USA that it had problems :
one of them was the confusion between an Human based ATC system and an automated system mixing each other. The first question we all asked then was precisely this : what if my clearance is in contradiction with the RA ?
The answer then was that once a pilot reports an RA , ATC ceases to be responsible. What happens when a pilot does not report and RA but follows it ? This was not supposed to happen we were told.
In this case the 757 pilot waited 22 seconds before reporting and the TU pilot(s) never reported the RA.
Here we are ...
For your info :
I have just posted the following on Rumours : I extract what I think is relevant for ATC :
The ( quite good ) report goes in great details to explain certain things but pass very fast on others.
Some of them I would like to have seen mentionned :
The name RA for "Resolution Advisory " was choosen by the FAA to limit the liability of the US manufacturer of the Software ( The Mitre Corporation ) Only in the US was it known implicitely that although for legal reason we call it an advisory, it is in fact a command .
Unfortunately when you translate the manuals and the procedures in other languages, Advisories remain advisories.
TCAS was made by the US for the US... (on one of its first report Eurocontrol mentionned that TCAS II logic behaved badly in European types of en-route airspace...)
To follow an RA you need to be 2 in the cockpit : one that look outside to identify the intruder, the other that look at the display and follow the needle to keep it in the green.
Attempting to do both at the same time results in large deviations...
The 757 pilot was alone for a great part of the RA..( I do not believe this played a role in this case , but it show us that Murphy' s law is always valid...)
The unsheduled late inbound to to Friedrichshafen was, from an ATC point of view the most important link of the chain of event that led to this collision.
The paramount importance of this fact is missing
This forced the controller to look into two different scopes a few meters appart, and monitor alone two different active fequencies whit degraded telephone system and faulty back ups. This led to the late detection of the conflict and the late decent clearance to the TU.( which was the action most controllers would have taken since the TU was pllanned and coordinated with the adjacent centre at 350 and the DHL had just reached his cruising altitude ) .
.
Various Management levels put the controller into that position that night. This later also cost him his life.
I hope that never again would any controller find himself in that position...
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To follow an RA you need to be 2 in the cockpit : one that look outside to identify the intruder, the other that look at the display and follow the needle to keep it in the green
Have just re-read the report following ATC Watchers post, and just spotted the huge flaw in our training. Although BOAC is quite right in saying you only need one person to follow an RA, our training always relates to have both crew members in their seats. This means that PF reacts to the RA, and the PNF reports TCAS manoeuvre immediately. In this case the report took 23 seconds because the copilot was out of his seat. 23 seconds is an absolute age in an event such as this. Even a report 10 seconds after the RA may have made a difference. I am in no way criticising the crew (most of us would have done the same), but the increasingly sterile training environment we find ourselves in, that wants to train "by numbers".
