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Mid-Air Collision over Southern Germany (merged)

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Old 3rd Jul 2002, 22:59
  #261 (permalink)  
 
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Skyguide's media handling

Swiss ATC remains the focus of criticism following the mid-air disaster in Southern Germany. On Wednesday, Skyguide had yet again to correct its own earlier statements. A recent report by the Swiss BFU (Air Accident Investigation Bureau) has also pointed to deficiencies in Skyguide’s radar systems.

According to Skyguide’s latest statement, there is no doubt that their conflict warning system at Zurich Kloten was out of service on the night of the mid-air collision. Anton Maag, the manager of the Air Control Centre, confirmed this on late Tuesday night on Swiss TV. Software modifications were being carried out at the time which necessitated that the system be turned off. But Skyguide spokesman Patrick Herr insists that it is a purely hypothetical question whether this system – if it had been switched on – could have prevented the disaster.

Skyguide has served up confusing information concerning the movements of the second controller on duty that night, and who had been on a break at the time of the mid-air collision. Maag had said on Swiss radio that by taking this break, the second controller had breached internal rules. A few hours later, this statement was rejected by Philipp Seiler, Skyguide’s operations expert. He said that the cited internal rules requiring two controllers to be on duty at all times only applied to day time operations; at night, such breaks may be taken by arrangement between the two duty controllers even if the conflict warning system is inactive.

Skyguide rejected accusations that it was providing information piecemeal and insists it is only releasing continuous updates as new insights become available. “It is absolutely not our intention to apportion blame or to try and absolve ourselves of our responsibilities” said Herr.

Separately, arecent report by the Swiss Air Accident Investigation Bureau (BFU) has raised further questions about Skyguide’s reliability with regard to its radar systems. The report, released on 26 June, points to deficiencies – and in one particular case the BFU experts categorize the problem as “serious” – in comparison with standards at Eurocontrol; the paper contains a number of specific recommendations to raise safety standards. Skyguide’s Philipp Seiler refused to comment on the individual points raised by the report, citing these were technically very complex issues, but he stated that Skyguide would investigate all problems mentioned.



The above based on AP
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Old 3rd Jul 2002, 23:01
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Those that are condemming the speculation need to remember we are not just concerned about THIS incident, but about possible future incidents as well, many of us have seen areas where the system is not perfect (eg since sept11 having to do all coms through the cabin call system) and some of these are being raised as much to avoid this in the future as to suggest a possible cause for the Germany crash.
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Old 3rd Jul 2002, 23:12
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I have followed vanman's link to the chart (as posted by Skyguide) regarding the a/c tracks before the collision. As depicted, the DHL a/c was heading on an "eastbound" course. So, am I missing something here? According to RVSM, it should have been cruising at an odd FL at first place, should'n it? Not trying to blame anybody...just trying to understand the situation (neither a pilot, nor an ATCO) .

Regards and my sincere condolencies
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Old 3rd Jul 2002, 23:18
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mid air collision

What puzzles me is the "coordination" of Eurocontrol.How come this two flights ,in a converging route,were not separated long before they entered swiss airspace ? I´m not sure the lone swiss controller is the only culprit,although it seems he still had enough time to correct a dangerous "handover".But the question remains:
Are the different sectors of air traffic control talking to each other?
Can we trust this system or should we go back to "blind" transmissions to protect ourselves and our pax ?
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Old 3rd Jul 2002, 23:23
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Swiss Air Accident Investigation Bureau's report on Skyguide

Investigating near misses in 1998 and 2000, Switzerland's Air Accident Investigation Bureau (BFU) has released a report with a number of findings that in light of this week's mid-air collision are worth considering,

The paper, titled “Final Report on Skyguide Radar Systems” was released on 26 June 2002. Its main finding is the underlying inaccuracy of the radar system used by Skyguide. Radar data acquired in Zurich and Geneva respectively contains significant discrepancies to the extent that serious questions have to be raised about its integrity.

The data did also not conform to Eurocontrol standards which require all radar data to be time-stamped with UTC.

The problem areas uncovered by the report were considered particularly serious in their impact on interaction with ATC systems in neighbouring countries and on military ATC (Switzerland’s Skyguide is unique in Europe as it handles both civilian and military ATC). Even just a few seconds of discrepancy in timing during handovers would be sufficient to falsify the position of a/c by 500 meters or more.

The findings of BFU’s investigation of the near misses of 14 January 2000 and 24 August 2000 also highlight that the flight paths of aircraft may either not show up on a controller’s screen or that aircraft previously shown on a screen can vanish. The BFU report thus recommends augmenting the ATC secondary radar system with primary radar system capable of providing total and around-the-clock coverage of the entire air space. The Swiss government commissioned a study into this on 26 June 2002 (i.e. on the day the report was released).

Finally, a third problem area was identified in that the legal recordings did not concur with the flight paths and data shown on controllers’ screens. This means that the reliability of Skyguide’s recorded data used for accident investigation purposes is inherently compromised. The report urges to upgrade Skyguide’s legal recording capability to Eurocontrol standards, so that any event may be reconstructed at controller level. In particular, data reconstruction must be made available for the display of aircraft position, screen display settings and all control panel settings.

Last edited by Alpha Leader; 3rd Jul 2002 at 23:27.
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Old 4th Jul 2002, 01:15
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Boulderman

'Climb' and 'Increase Climb' RAs are inhibited based on altitude / config parameters. These inhibitions are gross only, the crew must protect the flight envelope. E.G. lets say you've got some ice on the airframe. TCAS can't account for that, so you might get an unachievable climb.

Crews should be trained to do the best they can. E.G. manoeuvre in the correct sense as much as possible. Even doing nothing (say engine fails as you go to pull up) is safer than thinking 'can't climb! I'll have to dive under him....'.

Incidentally, at low rad alts, 'descend' and 'increase descent' RAs get ihibited as well.


Sponix,

Granted the media are saying b757 descended after the t154, but thats not consistent with the RA alerting time at that altitude versus the report of the t154 leaving at 25 seconds.

The RA alerting time is at that level, if memory serves, 35 seconds, which incuding 5 seconds reaction time put the b757 out of its level just before the t154...



Findo,

No, the message is 'Never manoeuvre opposite to an RA', which is quite different to 'Never choose not to follow an RA'.


Whippersnapper

TCAS does not take precedence to GPWS.
GPWS warnings have higher priority than TCAS. TCAS Aurals are inhibited by GPWS activation.

Rationale - Most potential collision scenarios would be a horizontal near miss even without TCAS. Better to risk that than to hit terrain.


Nigel On Draft

The London Terminal Control trainers have been teaching this for several years (they were kind enough to help us out with ATC procedures for our TCAS course, so that the crew would know what was going on at the other end of the radio).

The intermittent contacts on your traffic display are caused by your TCAS going in and out of 'Interference limiting mode'. It is quite normal - only traffic in full time tracking is shown, which any threat will be. Remember, the traffic display is not really designed to give you SA, but only to get your eyes on the target in the event of a TA. Anything else is a bonus, and must be viewed with caution. If you want more info about Interference limiting mode, drop me an email.


Everyone.

On the topic of the Mk 1 eyeball, can I please draw your attention to this post I have made on Tech Log. I don't claim it is a factor in this terrible accident, but I hope people may find it of interest / use.

http://www.pprune.org/forums/showthr...threadid=58559

CPB

Last edited by Capt Pit Bull; 4th Jul 2002 at 01:58.
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Old 4th Jul 2002, 01:54
  #267 (permalink)  
 
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Skyguide now say second controller did not take unauthorized break

Conflicting and evasive statements by various Skyguide executives are fuelling suspicions about the events that tragically ended in a mid-air collision over Southern Germany on Monday night.

Whilst Skyguide’s Air Control Centre manager Anton Maag had said earlier on Wednesday that the second controller on duty at the time of the disaster had taken an unauthorized break from work, this statement was retracted later in the day by Skyguide’s Operations Manager, Philipp Seiler. He contended that the break taken by the second controller did not contravene internal regulations, thus contradicting head-on his own superior’s statement made only hours earlier during a radio interview. Maag had said that the second controller should not have left his post as the in-house conflict warning system was down at the time.

According to Seiler, Maag’s initial statement was based on the wrong assumption that the internal regulations he was referring to were valid for both day and night duty, whereas at night, according to Seiler, breaks may be taken when mutually agreed between the two controllers on duty. Whilst being adamant that his version was the correct one, he refused to provide hard copies of the internal guidelines, citing this was against company policy.


Above compiled from Swiss agency reports
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Old 4th Jul 2002, 02:21
  #268 (permalink)  
 
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midair / crz lvls

VFR

An earlier post had the 757 on UN851, which is non-standard ICAO RVSM levels Eastbnd i.e. EVENs, which wud put him at a similar profile as the westbound TU154 on UL856 which is standard ICAO westbnd levels i.e. EVENs !

Last edited by 14FIVE785; 4th Jul 2002 at 02:41.
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Old 4th Jul 2002, 03:20
  #269 (permalink)  
 
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Skyguide a definite casualty

Given the amount of back-crawling Skyguide's executives have had to perform, the company's image is taking a battering at a time that could not have come worse.

Last FY: CHF16million loss on CHF275m revenue; this FY: loss of CHF15million forecast.

This could well blow out, as the current impass over a Swiss-German air agreement (which includes ATC sectors) is going to be harder to solve and no German politician can be expected to let Skyguide continue to control air space over German territory.

Skyguide has also committed to spending CHF85million to move its ACC from Zurich-Kloten to nearby Dübendorf Air Base.
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Old 4th Jul 2002, 07:45
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so much bad information

I wish everyone on this forum would stop speculating and giving bad information.
for example...
UN851 does not use even levels?? All northbound routes are EVEN and southbound routes are ODD get it right guys!!
You guys talk about a dangerous handover and a need to change some sort of procedure blah blah...
well how do you know this??? are you familiar with the procedures at Zurich ACC??
Talk to someone that flies in and out of Munich and they will tell you that there is a change from ODD to EVEN/EVEN to ODD flight levels on the route
I take it most of these posts are from pilots who do not have a fundamental understanding of ATC. Why don't we all as professionals sit and wait for all the facts.
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Old 4th Jul 2002, 08:26
  #271 (permalink)  
 
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n response...

Old jet jockey quotes...

"If the system is working as designed the controller should not be faced with a traffic confliction. This should have been resolved during co-ordination prior to handover so no time should be needed. If however the co-ordination was faulty one might expect a wide awake controller to identify the conflict on initial contact."

WOW, when was the last time you worked enroute control? We are handed conflicts at least half a dozen an hour. There are 6 ACC's handing over traffic to us where I work..conflicts are inevitable...
If we had to co-ordinated level changes before handover to avoid conflicts a flight would climb and descend 1000 ft at least a dozen times during his flight...
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Old 4th Jul 2002, 08:43
  #272 (permalink)  
 
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Euro ATC.

I understand where you are coming from, and it is understandable that you are concerned that speculation is based on non-factual (pre-investigation) information.

The reality of the matter is as follows.

If you look at the Pprune, the name says it all, RUMOUR NETWORK. People here are speculating, they are discussing possibilities based on experiences, rumours, press releases etc….

Whilst there are some unnecessary comments, and some way out theories, generally the moderators tend to keep things in check.

What we as professional members of the aviation community can do is to shed light on the situation, either from a technical or a procedural perspective, always remembering that even we may not fully understand the specific details or human factors that may or may not affect this specific case.

If you find the concept of speculation unbearable, then you should CHOOSE not to take it seriously, or even CHOOSE not visit the web site.

With regard to this specific accident, there are some concerns that seem to catch my eye (I am an ATC)

Skyguide has made numerous press releases over the past few days that either contradict previous statements, or based on their content, appear to be pretty incriminating in one way or another.

Based on some of the information that is available, there seems to be some glaring questions with respect to the controllers' lack of action immediately after the BTC came onto the frequency. That is to say during the four minutes between initial contact (hand-off) and the first decent instruction (50s prior to impact).

There may have been no requirement based on SOP’s to coordinate an alternate level inbound for the BTC, and that I accept, what I find difficult to understand is why it took so long to initiate a decent instruction to the BTC (or any other means to establish standard separation).
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Old 4th Jul 2002, 08:50
  #273 (permalink)  
 
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Question What are airspace details please..

Can anyone provide some information for me please...

1. What is the name of the (North-South) AWY that the DHL was on?

2. What is the name of the (East-West) AWY that the BTC was on?

3. What is the name of the intersection at which these aircraft collided?

4. What are the names of the respective sector entry positions that these aircraft entered the swiss sector on?

5. What are the respective distances between the sector entry positions and the intersection where they collided?

Thank you in advance
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Old 4th Jul 2002, 09:17
  #274 (permalink)  
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I flew through this airspace less than an hour before the crash, blissfully unaware that the Swiss ATC was operating at anything less than full capability.

For you Controllers heres a question:

Would it be feasible to indicate on radar identification that your system is operating at less than 100% (eg conflict warning system not operating)?

This could be done by changing the phrase "radar identified" to some other term which would make pilots aware of what is happenning. Anytime the system was operating with less than full backup we as pilots would know to listen out more attentively and perhaps delay tasks which require one pilot to leave the ATC frequency.

How often does this conflict warning system get turned off?
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Old 4th Jul 2002, 09:17
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The following link provides a very alarming development in UK airspace.


http://www.pprune.org/forums/showthr...threadid=58576
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Old 4th Jul 2002, 10:09
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BL,

I appreciate your concern; however there are a few things to consider;

There are many places in the world that do not have STCA or MTCD. There are also different types of conflict detection tools in use at places that are equipped. The differences between these are based in the manufactures formulas and mathematical algorithms used to to determine weather or not a conflict exist. Some are simple and others are complex. It may not be practical to have various specific types of identification based on equipment serviceability status.

You have however raised am interesting point. It may be worth having various sectors graded according to their respective conflict detection abilities and serviceability levels of that equipment (including levels of redundancy). Such grading could be agreed on and established by the appropriate authorities (ICAO, JAA, FAA, CAA etc) and published in the respective AIP’s, with downgrades due to maintenance promulgated in NOTAM format.

Regarding to the switching off of Conflict Detection Equipment.

I am not very clued up in this regard and will await a response from a more qualified source, along with you.

PS: Ice Pack, It's "Hear Hear"
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Old 4th Jul 2002, 11:07
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National Boundaries

Whilst doing a bit of research in an attempt to answer some of Standard Departure's questions above (sorry - no luck as yet) I came across this quote on the Skyguide www site. For the record it's buried in http://www.skyguide.ch/flash/anim1.htm. But it reads:-


quote:
--------------------------------------------------------------------------------
"Switzerland being a small territory, the controllers are given very little time to react. Due to high density, climbing and descending traffic air navigation services in Switzerland are complex and difficult to handle."
--------------------------------------------------------------------------------



This to me sounds like a clear admission of the problems associated with the lack of a pan European ATC structure. Clearly such a restructuring would allow sector boundaries to be constructed so as to maximise aircraft throughput and safety, rather than to (broadly) align with national boundaries.

I am aware that this latest accident occurred over German territory in Swiss controlled airspace, but clearly, by there own admission, it is still of insufficient size to allow effective ATC to take place.

Please also spare a thought for the occupants of the Crossair Bae RJ which recently crashed on hills East of ZRH whilst performing a non-precision approach to RWY 28 as they were procluded from flying the serviceable ILS onto RWY 14 at that time of the evening as it generates noise on the ground below in what is German territory.

If we wish to push more and more aircraft into the same infrastructure safely, then national boundaries have got to go...
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Old 4th Jul 2002, 11:25
  #278 (permalink)  
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Anyone who’d care to take a look at my posting history will see that I’m an unabashed ‘single issue’ poster, and that my as yet totally unsuccessful crusade touches closely on this tragic event.

There have been some gems among the dross of what must be one of the longest threads I’ve ever seen on Pprune.
Fox3snapshot:
Additionally my fear is that amongst Aircrew and ATC alike, too much emphasis and reliance is being placed on the TCAS system…
I liken TCAS to a safety catch on a loaded weapon – and how many people have blown themselves (or a colleague) away after pointing a weapon at themselves or their colleague saying those famous last words, “Don’t worry, it’s not loaded” or “Don’t worry, the safety’s on”? I’m very glad we have TCAS, but I can’t for the life of me understand the way so many of my colleagues seem to think they can totally dispense with other pre-emptive measures to avoid collision because “TCAS will save them”.
willadvise:
Without preempting official investigations and if the information provided in Alpha Leader's post is correct, I would suggest that 50-90s prior to conflict time is far too late to initiate a level change.
Standard_Departure:
Surely it is not normal to leave a separation instruction so late that a non-compliance immediately causes a bad situation to turn into a desperate disaster..
Don’tPanic_Don’tPanic:
I also feel very uncomfortable about the ATCO waiting approx. 1 min. prior to "loss of separation" before instructing an aircraft to change level. Compounded by the fact the pilot did not immediately respond/comply. It's a sad reality that pilots do not always do what we tell them to do immediately.
vertigo:
I have been involved in an incident when TCAS instructed a climb to resolve one conflict, only for a TCAS descent instruction immediately after the climb was commenced as there was further traffic descending 1000' on top. The pilot was left with little option but to take a 500' level and try his best to steer between them.
That’s exactly what TCAS is designed to do when confronted by multiple ‘above and below’ conflicting traffic.
vertigo (again):
I offer no speculation on this tragic accident, merely stating TCAS is not perfect and all of us should endeavour to understand its limitations.
Wise words, but as I’ve stated on this site a very long time ago, the major limitation of TCAS is that it relies on both pilots doing exactly the right thing, sometimes immediately – and in some cases, (not, I stress, in this case), that immediate, correct action might be demanded of a very junior, inexperienced second officer occupying the Pilot Flying seat as cruise pilot.

The other shortcoming, as mentioned in another post, was highlighted in the BA/KAL very near miss over China some years ago – which involved two 747’s full of passengers. Trusting in TCAS, you’re trusting that some unknown technician from some unknown other company hasn’t mangled the canon plug in the other aircraft’s TCAS system so that it is providing inaccurate altitude information – as happened in that case.
vertigo (yet again):
I'm sure there will be lots of lessons for all of us from this tragedy.
Amen to that – and let’s hope someone in authority has the foresight – and guts – to slam the stable door before the proverbial horse has bolted on what to me is an obvious glaring potential for disaster. The extreme accuracy of GPS/IRS makes the possibility of something like this occurring again less than remote. It is no slur on the professionalism of Air Traffic Controllers for us, the line pilots, to insist that a system be put in place that does not demand instant, absolutely correct reactions from a Duty Controller should one solitary mistake be made by him one of the many pilots he deals with or the controller in a neighbouring sector. Offsetting would provide that extra buffer in many, if not most enroute conflicts – although I accept, not in this case. But do we have to wait until such a head-to-head mid-air occurs to prove it might help prevent one occurring?
Captain PPruNe:
How many times, especially at night have any of us missed an initial call?
Guilty as charged – as recently as last night, on a flight duty that was all of ten minutes under the maximum allowed.
shakespeare:
know we have flogged this one to death before, but this possibly would not have happened had BOTH a/c been cruising at STANDARD cruising levels.
Both aircraft were at the correct standard flight level – FL360 is a correct cruising level for a westerly track under RVSM.

I live in hope that there’s one journalist out there who might look beyond the ‘blame game’ so many in the media seem to be playing after this tragic incident. Maybe he or she could do some research – (much information is available on this site) - and demand a few answers from ICAO and ATC over the well-documented and (by far too few, it would seem) acknowledged problem that ultra accurate GPS/IRS navigation systems have brought up in ensuring that opposing traffic occupies exactly the same piece of sky in azimuth. Start with
http://www.pprune.org/go.php?go=/pub/tech/MidAir.html
and
http://www.pprune.org/go.php?go=/pub/tech/MidAir2.html
and then just check out my many posts on this subject on this site.
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Old 4th Jul 2002, 11:56
  #279 (permalink)  
 
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There will be a press conferece held at the BFU at 13:00 UTC with the german minister of transportation and the director of the BFU speaking.

First RUMOURS indicate that a first glance at the 154 CVR is performed showing that the first radio contact was about 90 s before the crash (as skyguard initially stated), BUT this contact was the 154 asking ATC how they should avoid the traffic ahead ....

confirmation in about 1 hour (maybe)
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Old 4th Jul 2002, 12:05
  #280 (permalink)  
 
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Angry whatever the outcome....

....of the investigations, one thing should be emphasised (as it permeates from the euro_atcontrollers email group):

it will be very unfortunate (looking for a stronger word here) if a 1976 Zagreb (during Tito's heyday) type of trial is to be repeated in Switzerland.

ATCO's all over Europe are standing by their Swiss colleagues!
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