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The 2002 Überlingen midair collision

259 points by vinnyglennon 3y ago

pwesner 3y ago
Did not expect this story on hackernews. I witnessed the crash. It was such a surreal moment… Its the first time I read an article about all the details. Thanks for the writeup!
- throwawaylinux 3y ago
  Sorry to hear that. Must be be a heavy thing to carry.
- distortionfield 3y ago
  You witnessed the crash? Care to elaborate on that? Sounds very interesting!
  - pwesner 3y ago
    I was in a boarding school close by (just 400m close to location 7 from the map showing the impacts). I did not see the crash in the sky (some did see an explosion). I heard a noise like a thunder but it did not stop. It was burning parts falling from the sky. The noise was from the flames. My first guess was that it will hit us so I rushed and woke up anybody I could grab. Back to my window I noticed that we are save - not by much. After falling to the ground it exploded with a gigantic fireball. We had our own firefighter devision at the school. They where the first on site. The week afterwards was very stressful. Constant helicopter and fighter jet noises. Press calling us, etc… At one point we realised that these where young students like us… And all our firefighters where tasked to help find all those bodies…
laydn 3y ago
Anyone know why the TCAS only instructs the two approaching aircraft to change altitude only, but not heading?
- ceejayoz 3y ago
  https://aviation.stackexchange.com/questions/36451/why-does-tcas-not-issue-turning-commands-as-resolution-advisory https://aviation.stackexchange.com/questions/36451/why-does-...
- MerelyMortal 3y ago
  I met someone who says he helped develop TCAS, and that it decides which one to climb or descend based on the registration number. I'm guessing that it does not issue turn instructions because it only gives a Resolution Advisory when a collision is imminent (otherwise they would be giving RAs all the time). At altitude, where the air is thinner, it is much easier for a plane to immediately climb or descend, planes turn very slowly when the air is thin.
  - ceejayoz 3y ago
    That's only partially true, in the case of a tie. https://aviation.stackexchange.com/questions/92495/how-does-the-tcas-decide-which-aircraft-to-climb-and-which-to-descend https://aviation.stackexchange.com/questions/92495/how-does-... > But what if the other aircraft is "thinking" the same thing? That's the heart of this question. The answer is, whichever TCAS makes a decision first, and then in case of a tie, the lower Mode S address "wins":
    - jll29 3y ago
      Thanks for answering my question, namely how does the collision resolution in TCAS work? (Different from, say, TCP, which uses randomness) EDIT: FAA PDF on TCAS 7.1 - https://www.faa.gov/documentlibrary/media/advisory_circular/tcas%20ii%20v7.1%20intro%20booklet.pdf https://www.faa.gov/documentlibrary/media/advisory_circular/... This story is a moving example of the self-improvement going on in global air traffic industry; perhaps sometimes slowly, but definitely self-improving. The following book compares the transparency of the air traffic industry with the lack of transparency that currently exists in the medical sector, where errors are denied: https://www.amazon.com/Black-Box-Thinking-Psychology-Paperback/dp/0111254744 https://www.amazon.com/Black-Box-Thinking-Psychology-Paperba...
stall84 3y ago
Posts like this painfully push me to finish setting up my blog where I'm going to mostly opine on and outline aviation incidents like this.. But I can disseminate at least two flying maxims you can take away from this tragedy: 1: Do what TCAS is telling you to do. 2: Air Traffic Control does NOT have the final responsibility for your plane, you do. - The TCAS system had already resolved the safe and correct conflict avoidance maneuvers for both of the transceivers involved (on both aircraft). - As amazing and professional as our air traffic controllers are (and they are), they to, just like you the pilot are prone to error, and they in fact are not inside your aircraft, nor are they the pilot in command. I've seen especially in new pilots and people that want to learn to fly this urge to defer to ATC (I even asked a friend who's a huge Flight Simulator enthusiast, of which I was too when young, what he'd do in a purely technical flight situation, and he responded he'd "ask ATC what to do"...). While yes, Air Traffic Control 'controls' certain air space, they don't control your aircraft or its occupants. FAR 91.3 says it all, I'll let you look it up, it's 2 very brief (thank you FAA/congress) sentences that spell out the end of this discussion. You might get a fine, you might lose your license, etc etc, if you're reasoning for having to deviate from ATC rules aren't sufficient.. But hey in this case would those pilots on those 2 planes in this incident have rather lost their licenses (potentially) or have what happened happen. Of course this incident is nuanced, as they all are. Flying safely involves mitigating and accepting certain levels of risk. TCAS was a system specifically designed and implemented to resolve collision situations. You test your equipment at regular intervals and pre-flight so that you can be confident they are working properly so that when you get into a situation where TCAS is telling you to do something, you do it. But the reality is stress, human behavior isms' like maybe say flying in from an eastern european country and wanting to not 'piss off' the Swiss controllers, so deferring to their every direction instead of following your own instruments. << That's a real thing .. when you fly into busy airspace in the US, you quickly realize you just 'don't want to piss anyone off' .. All of these factors influence what should have been a cut and dry collision avoidance dictated by the TCAS system. And this is the cost of human flight.
- bfeynman 3y ago
  I find this type of writing compelling, so if you write a blog I think you would get people to read it. One thing I've seen after the fact is the schism between media and evidence which adds an extra dimension here with the air traffic controller's story. The post mortem investigation usually takes a long time, and by then the media has completely moved on. Reminds me of the Boeing MCAS incidents, which interestingly I had a few airline industry friends, and internally according to them almost incidents were due inadequate training of pilots, but no one would say that since there is a nationalistic aspect to it.
rossdavidh 3y ago
Admiralcloudberg is, you know, never really a pick-me-up story kind of place, but this one is particularly grim. Among many other things, a reminder that software upgrades need to be carefully planned, with an assumption that other stuff might go wrong while the system is offline.
- FabHK 3y ago
  What is somewhat encouraging while reading the (grim) narratives of aviation accidents is this: how much has to go wrong for things to go seriously wrong (compare James Reason's Swiss Cheese model of accidents), and how most similar cases end well. In this case, things that went wrong - and any one of them not going wrong might have averted the disaster: 1. Kids missed the original plane and had to get on this special charter flight instead. 2. Skyguide had just the previous year reduced staff from 3 to 2 controllers at night, and 2'. One of the controllers took an unofficial break. 3. There was an unexpected delayed A320 coming in, distracting the single controller. 4. The Tupolev was equipped with TCAS - if it hadn't been, TCAS on the other plane would not have issued an RA, and they might have stayed level or climbed instead of descending, as instructed by TCAS. (Though without TCAS it would not have been allowed to fly in Europe, probably.) 5. ATC happened to tell the Tupolev to descend, and TCAS happened to tell the 757 to descend. 6. That ATC instruction came exactly at the same time as the TCAS instruction on the 757, so the 757 crew didn't hear the ATC instruction to the Tupolev. 7. The Tupolev crew did not acknowledge that ATC instruction (which the 757 crew might have heard). 8. A bit later ATC repeated the instruction, and exactly at the same time TCAS on the 757 also repeated the instruction, so again they didn't hear the ATC instruction to the Tupolev. 9. Just then, the delayed A320 called ATC again, so the controller was distracted and did not monitor that his instruction to descend resolved the conflict successfully. 10. The copilot in the 757 had to go to the toilet just 18 seconds before all this happened. 11. It was night, making visual separation harder, possibly. 12. The 757 crew was trained to prioritise TCAS > ATC, the Tupolev crew was more or less trained to prioritise ATC > TCAS. 13. The Tupolev crew following ATC over TCAS received an ATC instruction that was in line with their right-of-way rules (left plane climbs, right plane descends), so it must have seemed more plausible. 14. The Tupolev crew had a first officer that suggested following TCAS instead, but he was not sitting in the RHS because there happened to be an extra Instructor Captain on that flight in the RHS who chose to follow ATC. 15. There happened to be a software upgrade at Zuerich ATC that night that disabled the Short-Term Conflict Alert light. 16. That software upgrade also disabled the phone lines, forcing the controller to waste time with the phone when trying to call Friedrichshafen for the delayed A320, and also prevented Karlsruhe ATC from warning Zuerich ATC of the problem. 17. ATC made a small, per se inconsequential, mistake of confusing "at your 2 o'clock" with "at your 10 o'clock". 18. The 757 crew waited 23 seconds to tell ATC that they were in a TCAS RA descent, by which time ATC was busy with the delayed A320. 19. The Tupolev crew was too busy/distracted to hear and understand that 757 TCAS RA descent call. 20. The ATC radar updated only every 12 seconds and did not yet reflect the 757's descent when ATC decided to instruct the Tupolev to descend. 21. The serious incident earlier in Japan with ATC/TCAS mismatch had not yet filtered through to all crews worldwide. It's just so unlikely.
ogig 3y ago
Ok, last week or so it was posted another long read blog post from Admiralcloudberg. Somebody commented that the rest of her posts were very nice. So true, I went into rabbit hole mode, been reading the rest avidly, just a few to go. Be warned! PS: Tonight I dreamt of a surreal MD-80 crash.
- TravisLS 3y ago
  I came here to say the same thing. I've read about 20 of them in the past few days and they're absolutely captivating. The TWA 800 post got me started and is a must-read: https://admiralcloudberg.medium.com/memories-of-flame-the-crash-of-twa-flight-800-fecfd651a157 https://admiralcloudberg.medium.com/memories-of-flame-the-cr...
- EdwardDiego 3y ago
  AdmiralCloudberg is well worth supporting on Patreon IMO.
dav_Oz 3y ago
While TCAS priority was the technical point of failure, I feel that the transition phase from public to private of the Swiss air traffic control services in 2001 seems to be the greatest disruption of this finely coordinated ATC. Under the new management of Skyguide which led to the obvious cut in labor cost like reducing the night shift from 3 to 2 controllers. The private company still tolerated the extended break convention during night shift from before but leaving only one person responsible, now. And guess what? Maybe a software update to make some efficiency steps when we are at it. The single one controller was then informed during the update taking place what was still functioning and not which was very little. >Part way through Nielsen’s shift, a group of technicians arrived to install the update, and he was informed that his work station’s main computer would have to be shut down, causing his displays to operate in fallback mode — a secondary condition in which several features provided by the main computer became unavailable. In fallback mode, the system which automatically correlated an aircraft’s radar return with its filed flight plan would not work, forcing him to enter the information manually, and the Short-Term Conflict Alert light, which illuminates when the system predicts that two planes will pass too close, would be rendered inoperative. But Nielsen had no idea what features would be lost in fallback mode, nor did he have any obvious way of finding out. And as if that wasn’t enough, a few minutes later the technicians informed him that they would also have to disconnect the control center’s direct telephone landline to neighboring centers For me also surprisingly shocking that back in Karlsruhe multiple (!) controllers had to literally watch the obvious horror unfold while the one controller responsible was not available because of ... maintenance work. >Heartbreakingly, controllers in neighboring Karlsruhe saw the collision coming, but they did not have the authority to speak to planes in another sector without permission from the responsible controller. The Karlsruhe controllers tried several times to call Nielsen in the minute before the crash, but the landlines were down and they couldn’t get through. By the time they gave up on this effort, it was too late to prevent the crash even by breaking the rules. The controllers were forced to watch, helpless, as the two planes collided and then disappeared from radar, knowing that dozens of people were dying before their eyes, and that there was nothing they could do to save them. Edit: According to this article [0] and this verdict [1] the controllers in Karlsruhe had the full authority but were illegally instructed otherwise by DFS (German ATC) management which had an informal agreement with Skyguide (Swiss ATC) over this border region. In the end the heavily traumatized and retired controller Nielsen was brutally stabbed because the modern diffusion of responsibility of companies only operates on the culture of financial compensation and is blissfully ignorant of a desperate man losing his whole family trying to restore his honor. So, no apology before everything is settled accordingly. [0]https://www.dw.com/de/deutschland-haftet-f%C3%BCr-fehler-der-schweizer-flugsicherung/a-2111635 https://www.dw.com/de/deutschland-haftet-f%C3%BCr-fehler-der... [1]https://research.wolterskluwer-online.de/document/2ceee0e8-5b5d-44f6-bc3b-a1d335cad3a0 https://research.wolterskluwer-online.de/document/2ceee0e8-5...
alistairSH 3y ago
ATC communication is fascinating to me. I go down the Youtube rabbit hole a few times a month. A few things that always stand out to me... - the calm demeanor shown by both ATC and pilots. Even in situations that make me cringe sitting at my laptop, everybody involved is steady. I know it's their job, but it still amazes me. - the complexity of airport operations at a major international is mind-boggling. Hand-offs from ground to tower to departure... and then back again if something goes wrong. And doing that for dozens of planes at a time. Some crewed by pilots with thick accents or static-y radios. - that air travel is the safest form of transit given the complexity of engineering and human processes involved is truly astounding. I know today's successes are the result of all previous tragedies; it's still something else. I live under the main international approach to IAD. Watching the heavies fly in makes me smile. Especially the A380. It's a shame the A380 didn't find a long-term market - looking up, it shouldn't be able to fly, but there it is.
- jcranmer 3y ago
  > the calm demeanor shown by both ATC and pilots. Even in situations that make me cringe sitting at my laptop, everybody involved is steady. I know it's their job, but it still amazes me. It's actually probably not as amazing as it seems. I was just on a high ropes course, and it's similar to ATC in that if things go pear-shaped, there is just nothing that you can do. So when I saw something going wrong [1], the instinct I had to immediately run and try to help was suppressed, and instead I (and everybody else) was essentially in the same calm-and-collected mood. [1] Admittedly, this is wrong in the "abnormal operation" sense, not "immediate risk to life" sense.
  - reddit_clone 3y ago
    What is amazing to me is how do Pilots stay calm when their own lives are under imminent threat?
    - stall84 3y ago
      I've had just one definite emergency experience and it's only 1 data point to draw on, and it's definitely not going to be the same for everyone flying.. You drill for emergency situations during training, and you should drill repeatedly afterwards. Any ATP rated pilots do so regularly whether in actual flight or in simulators. But one flight very early, before I had my pilot's license, flying on a student's permit.. I ran out of fuel during cruise flight.. It was dumb, it was a case of me being a poor just-out-of-college student, and trying to do some very risky calculus with the flight planning and fuel required. There were extenuating factors including the (small) plane's fuel gauges malfunctioning sporadically .. having to 'stick the tank' on the ground (measure the fuel in the plane's wings by using a ruler and chart for how many inches equaled gallons). .. excuses aside. I ran out of gas at 8000 feet above Columbus Georgia .. What I remember happening is the engine abruptly lurching, then stopping, sending a massive amount of adrenaline through me. But almost immediately I started looking for a runway to land at. I knew I had at least 1, maybe 2 airports in range of a glide, and one was relatively in front of me, so I decided on it, and called ATC in Atlanta who were following my flight at that time & declared a 'pan-pan' (step below a mayday .. meaning you have a serious situation on board & require priority attention if available, but you are still in control of the aircraft). They confirmed the vector to the (abandoned, but still in decent condition) airport a few miles in front of me. Now.. Your original question is probably answered at this point... Basically as long as you can continue to have things to do .. As long as you can envision and work toward a goal (landing the f'n plane safely) .. The stress of the situation tends to just fuel the focus on getting to that goal. I can't say its going to be the same for every pilot, and maybe it isn't . I did grow up obsessed with flying (after being absolutely horrified by it as a child), and so I had kind of gone over in my mind and in training over and over again this potential type of situation occurring and I wasn't about to let the moment get to big. This kind of thing does worry me a little bit with our recent explosive need for pilots as commercial aviation expands rapidly. A lot of pilots are going through "0 to ATP" courses to get a good paying job, rather than because they're actually obsessed with flying itself.. Because in those cases, I'm not sure what is going to happen psychologically for those pilots. Again though, this is why you are constantly drilled and trained on these situations, so that you have almost muscle-memory of things to be doing in an emergency situation so that there is no time for you to sit passively and become a victim of circumstance.
PetitPrince 3y ago
As the article highlights with the Japan near-miss, "Regulations are written in blood". What a tragic story for everyone involved.
- jandrese 3y ago
  That anecdote about the Japanese 747 near miss that required a dive so hard it sent a drink cart through the ceiling and injured nearly a quarter of the crew and passengers is also shocking. That's the reason you keep your seatbelt on even when the captain turns off the sign.
gok 3y ago
If you'd like to feel extra uncomfortable next time you get on an airplane, read a bit more about limitations of TCAS that still exist today. For example, it doesn't actually model aircraft performance, so TCAS occasionally issues resolution advisories that are not physically possible. It also does not integrate with terrain awareness, so sometimes to avoid a collision with an aircraft it may suggest flying into a mountain (pilots are instructed to ignore TCAS RAs in this situation).
- ilyt 3y ago
  In this case it appears it would've worked just fine
- pc86 3y ago
  This is a real issue, especially for GA aircraft in hard IMC at low altitudes, but airliners almost never receive RAs because they're almost never close enough to, especially enroute.
- Retric 3y ago
  Fixing either of those comes at significant risk because you are making the TCAS system significantly more complicated and it needs to work across multiple manufacturers and equipment build decades apart.
- FabHK 3y ago
  Have these limitations ever been a problem in practice? As long as one plane climbs and the other doesn't, the conflict should be resolved, no?
- Sebb767 3y ago
  > pilots are instructed to ignore TCAS RAs in this situation I like that you explicitly pointed out that flying into a mountain is not the recommended course of action for pilots. Humor aside, this crash also includes a lot of broken down communication, so in most cases, even if TCAS fails, a crash is not inevitable. A pilot aware of the priority TCAS has will definitely communicate a failure to abide by its orders.
omnibrain 3y ago
The plane crash storyline in Breaking Bad seems to be in part inspired by this event. Having lived in the are and going to school in Überlingen at the time it is not something I'm ever going to forget. I did not notice the crash itself (I'm a deep sleeper) but heard about it in the radio at morning. First I thought I must have misheared. Being a vonlunteer firefighter in our village I wondered, why I did not get an alarm. On my way to the train station I stopped at our local fire station but saw only a small transporter was missing, so I figured they may have alarmed only a few people. There was some sort of "fog of war". Nobody knew anything for sure. There were rumours, that one of the planes crashed into the lake. The crash site being at Hohenbodman did not help because there is a village named Bodman on the other side of the lake. Waiting for the train and on the train there was nothing else we could talk about. Arriving in Überlingen, we (a classmate and I) went straight down to the lakeside of the city to see if we can catch a glimpse of anything. The atmosphere in the city was surreal. The route from the city center and train station to our school went over the yard of the city's fire station. And there it hit. Dozens of firefighters, police, red cross, etc. swarmed the place. A search dog unit just arrived. The facial expressions of everybody. At school there was no lessons of course. Everybody just talked about the crash and the newest rumours. Some classmates arrived by bus and their bus drove straight by the crashsite. They saw corpses under cloth and smoking debris. A few hours later people from the local newspaper arrived to distribute a special issue with the most comprehensive compilation of available information at the time. (... a few months later ...) We had local festivities and I helped. It was bigger festivities and we spent days building everything and had to gather stalls, building material and tools from various storage areas, companies, etc. To fetch something I went with someone to a local building company. We went into their warehouse and an overwhelming stench of kerosene hit me. The warehouse was filled with transport container trays full of excavated ground that was contaminated with kerosine (and small debris) from the crash. The guy I went with just mentioned this in a very non-chalant way.
- leipert 3y ago
  I was on vacation at Lake Constance that night. We didn’t hear anything consciously, but _everyone_ (four people) was awake at the time of the crash (unlikely, right?) and heading to the toilet/grabbing a water. Next day we knew why we all were awake at the same time. Surreal.
cobaltoxide 3y ago
"In 2004, Peter Nielsen, the air traffic controller on duty at the time of the collision, was murdered in an apparent act of revenge by Vitaly Kaloyev, a Russian citizen whose wife and two children had been killed in the accident." https://en.wikipedia.org/wiki/2002_%C3%9Cberlingen_mid-air_collision https://en.wikipedia.org/wiki/2002_%C3%9Cberlingen_mid-air_c... Jesus Also: "On 8 November 2007, Kaloyev was released from prison on parole after having served two-thirds of his sentence, a total of three and a half years." "Returning to his home in North Ossetian city of Vladikavkaz, Kaloyev was met with enthusiastic crowds who cheered him as a hero."
- MattRix 3y ago
  The article covers this at some length.
- olliej 3y ago
  Yup, murdered the only person involved in the collision that didn't actually cause it. Celebrated as a hero because "honor" is achieved by murdering an unarmed man who didn't kill your family, rather than the people in charge of the airline and ATC company that did. After all honor is defined by many as "murdering someone, regardless of what they did".
  - avar 3y ago
    The first line in the "causes" section of the official accident investigation blames ATC. The murder of Nielsen is a tragedy, but that doesn't mean he wasn't responsible.
    - tass 3y ago
      ATC being the company, its procedures, operating with limited staff, etc. Not the controller.
      - avar 3y ago
        You're simply misreading it, ATC refers to the specific person(s) responsible at the time. Perhaps you're tripping over "responsible", it helps to read it as "if you, future person, are in this situation, consider how you could avoid a similar accident, given your position in the system". It does not necessarily mean "this person is incompetent", or "this person is criminally liable". That's outside the scope of such reports. If it didn't mean that, then someone in the ATC chair in the exact situation tomorrow would need to helplessly watch the same tragedy play out in front of their eyes, would they not? Even if they'd have the benefit of hindsight in having read this report. After all they'd be a powerless puppet strung along by systemic causes.
csours 3y ago
> The way this particular segment of Russian society reacted to the crash and the murder was an ugly reflection of a national tendency to blame whoever happens to be present at the moment of a tragedy, while those responsible for creating the unsafe condition go unnamed and unpunished. Severe Tangent: It's difficult to change the way you perceive the world, but I invite you to try. Lately I've been thinking about how we understand and talk about tragedies and atrocities in history. Atrocities are traced back to who is most to blame, but not the conditions that led to the situation, not the political techniques that were used to gain the power, and certainly not how it might apply to ourselves. When we find someone to blame for evil acts, we can close that mental box. That was the person who did it; I would never do something like that; I would never support someone like that. But, most of the time, the evil leader did not start their reign with huge atrocities. It may have started with a fight that many of their followers did support. It's easy to say "I would never support an atrocity", and maybe even say "I would never support someone who talks about any group as less than human". The problem is, it's always easier to see this in your opponents than in yourself. I'm not making a false equivalence or an excuse; I'm saying it's really difficult and we should not be surprised when it is difficult. When the group mentality gets to a certain point, any reasonable nudge or criticism is taken as an attack. I don't know of a great solution, but I think about how cult members are de-programmed. They have to remember or find something in the real world that they value. There has to be a bridge, not a demand that they renounce their beliefs.
- olliej 3y ago
  Literally the whole point of NTSB and similar investigations is to find the cause of accidents, and this article is almost entirely sourced from those reports. The person who decided I must blame someone, decided to murder the controller (that the report did not blame) and be celebrated as a hero by a bunch of moronic "manliness" "strong men" in Russia. This BS concept of "manliness" and "being strong" == "being better" needs to be stopped, and it's frustrating to see so much revival and promotion for it on YouTube and the like.
  - mbork_pl 3y ago
    On the contrary, the concept of "manliness" and "being strong" (which does not necessarily mean "better", btw) needs to be promoted more - but also understood correctly, as the ability to conquer your own weaknesses, like the one GP is talking about. It is sad to see how our civilization collectively decided to throw out several thousands years of tradition and dozen of thousands pages of collective wisdom. The topic GP mentioned has been known for centuries, way before modern psychology. In fact, it is one of the important points of Catholicism (AFAIU) - every single man is a sinner capable of horrible deeds, but that diminishes neither the dignity of every human being nor their ability (with God's grace) of overcoming that.
sklargh 3y ago
I’m consistently amazed by how many aviation accidents are caused by errant human interaction with properly functioning or unused but safety-critical automated systems. This is a theme of almost every major airliner loss in the 2000s.
olliej 3y ago
Oh this is the one where privatization of ATC killed a bunch of people, and then one asshole decided that it was ok to murder the one person involved who was explicitly not responsible. The responsible parties - as outlined in the report: 1. The Russian airline: it put untrained pilots in charge of a plane. We know they were untrained as they clearly did not understand the most basic concept of TCAS. The article tries to paint this is regulatory confusion - which is patently nonsense, the entire concept of TCAS hinges on it being on par with stall and terrain alerts, where there is a single response, and that response counters any other instruction. The fact that the pilots were aware of the system and failed to learn about it is a failure on their part, the fact that the airline company failed to have the most basic of training on it makes it mostly theirs. 2. The Skyguide company: understaffed a region, and then under equipped it while understaffed, and then failed to have any reasonable back up for anything. Arguably a failure brought on by those people that insist "privatizing a public safety system is efficient". But then Mr Macho-man had to defend his honor by going and murdering the one remaining victim of the crash, to demonstrate how manly he was. If you feel that murdering an innocent and defenceless person is justified for the "honor" of your family, and to give you value as a "man" I say you've failed the most basic tenets of "honor", and sure as shit don't get to brag about manliness.
- Fissionary 3y ago
  > the one person involved who was explicitly not responsible Not to condone revenge killings, but Nielsen was obviously part of this accident. It was his choice to work alone that night (rather than waking the other controller) and to allow the technicians to turn off most of his instruments, so the responsibility is partly his. He also issued the fateful descend command - had he literally stayed out of this, the Tupolev pilots would have followed the TCAS guidance and the accident would not have happened.
  - olliej 3y ago
    He did not cause the accident, all the reports on the accident say his actions were the result of Skyguide, the company, as it tried to make public safety profitable. To put it simply, blaming Nielsen for this accident is like blaming the worker in a car factory that puts the last part on a Ford Pinto.

259 points by vinnyglennon 3y ago

Did not expect this story on hackernews. I witnessed the crash. It was such a surreal moment… Its the first time I read an article about all the details. Thanks for the writeup!

throwawaylinux 3y ago
Sorry to hear that. Must be be a heavy thing to carry.
distortionfield 3y ago
You witnessed the crash? Care to elaborate on that? Sounds very interesting!
- pwesner 3y ago
  I was in a boarding school close by (just 400m close to location 7 from the map showing the impacts). I did not see the crash in the sky (some did see an explosion). I heard a noise like a thunder but it did not stop. It was burning parts falling from the sky. The noise was from the flames. My first guess was that it will hit us so I rushed and woke up anybody I could grab. Back to my window I noticed that we are save - not by much. After falling to the ground it exploded with a gigantic fireball. We had our own firefighter devision at the school. They where the first on site. The week afterwards was very stressful. Constant helicopter and fighter jet noises. Press calling us, etc… At one point we realised that these where young students like us… And all our firefighters where tasked to help find all those bodies…

laydn 3y ago

Anyone know why the TCAS only instructs the two approaching aircraft to change altitude only, but not heading?

ceejayoz 3y ago
https://aviation.stackexchange.com/questions/36451/why-does-tcas-not-issue-turning-commands-as-resolution-advisory https://aviation.stackexchange.com/questions/36451/why-does-...
MerelyMortal 3y ago
I met someone who says he helped develop TCAS, and that it decides which one to climb or descend based on the registration number. I'm guessing that it does not issue turn instructions because it only gives a Resolution Advisory when a collision is imminent (otherwise they would be giving RAs all the time). At altitude, where the air is thinner, it is much easier for a plane to immediately climb or descend, planes turn very slowly when the air is thin.
- ceejayoz 3y ago
  That's only partially true, in the case of a tie. https://aviation.stackexchange.com/questions/92495/how-does-the-tcas-decide-which-aircraft-to-climb-and-which-to-descend https://aviation.stackexchange.com/questions/92495/how-does-... > But what if the other aircraft is "thinking" the same thing? That's the heart of this question. The answer is, whichever TCAS makes a decision first, and then in case of a tie, the lower Mode S address "wins":
  - jll29 3y ago
    Thanks for answering my question, namely how does the collision resolution in TCAS work? (Different from, say, TCP, which uses randomness) EDIT: FAA PDF on TCAS 7.1 - https://www.faa.gov/documentlibrary/media/advisory_circular/tcas%20ii%20v7.1%20intro%20booklet.pdf https://www.faa.gov/documentlibrary/media/advisory_circular/... This story is a moving example of the self-improvement going on in global air traffic industry; perhaps sometimes slowly, but definitely self-improving. The following book compares the transparency of the air traffic industry with the lack of transparency that currently exists in the medical sector, where errors are denied: https://www.amazon.com/Black-Box-Thinking-Psychology-Paperback/dp/0111254744 https://www.amazon.com/Black-Box-Thinking-Psychology-Paperba...

stall84 3y ago

Posts like this painfully push me to finish setting up my blog where I'm going to mostly opine on and outline aviation incidents like this.. But I can disseminate at least two flying maxims you can take away from this tragedy: 1: Do what TCAS is telling you to do. 2: Air Traffic Control does NOT have the final responsibility for your plane, you do. - The TCAS system had already resolved the safe and correct conflict avoidance maneuvers for both of the transceivers involved (on both aircraft). - As amazing and professional as our air traffic controllers are (and they are), they to, just like you the pilot are prone to error, and they in fact are not inside your aircraft, nor are they the pilot in command. I've seen especially in new pilots and people that want to learn to fly this urge to defer to ATC (I even asked a friend who's a huge Flight Simulator enthusiast, of which I was too when young, what he'd do in a purely technical flight situation, and he responded he'd "ask ATC what to do"...). While yes, Air Traffic Control 'controls' certain air space, they don't control your aircraft or its occupants. FAR 91.3 says it all, I'll let you look it up, it's 2 very brief (thank you FAA/congress) sentences that spell out the end of this discussion. You might get a fine, you might lose your license, etc etc, if you're reasoning for having to deviate from ATC rules aren't sufficient.. But hey in this case would those pilots on those 2 planes in this incident have rather lost their licenses (potentially) or have what happened happen. Of course this incident is nuanced, as they all are. Flying safely involves mitigating and accepting certain levels of risk. TCAS was a system specifically designed and implemented to resolve collision situations. You test your equipment at regular intervals and pre-flight so that you can be confident they are working properly so that when you get into a situation where TCAS is telling you to do something, you do it. But the reality is stress, human behavior isms' like maybe say flying in from an eastern european country and wanting to not 'piss off' the Swiss controllers, so deferring to their every direction instead of following your own instruments. << That's a real thing .. when you fly into busy airspace in the US, you quickly realize you just 'don't want to piss anyone off' .. All of these factors influence what should have been a cut and dry collision avoidance dictated by the TCAS system. And this is the cost of human flight.

bfeynman 3y ago
I find this type of writing compelling, so if you write a blog I think you would get people to read it. One thing I've seen after the fact is the schism between media and evidence which adds an extra dimension here with the air traffic controller's story. The post mortem investigation usually takes a long time, and by then the media has completely moved on. Reminds me of the Boeing MCAS incidents, which interestingly I had a few airline industry friends, and internally according to them almost incidents were due inadequate training of pilots, but no one would say that since there is a nationalistic aspect to it.

rossdavidh 3y ago

Admiralcloudberg is, you know, never really a pick-me-up story kind of place, but this one is particularly grim. Among many other things, a reminder that software upgrades need to be carefully planned, with an assumption that other stuff might go wrong while the system is offline.

FabHK 3y ago
What is somewhat encouraging while reading the (grim) narratives of aviation accidents is this: how much has to go wrong for things to go seriously wrong (compare James Reason's Swiss Cheese model of accidents), and how most similar cases end well. In this case, things that went wrong - and any one of them not going wrong might have averted the disaster: 1. Kids missed the original plane and had to get on this special charter flight instead. 2. Skyguide had just the previous year reduced staff from 3 to 2 controllers at night, and 2'. One of the controllers took an unofficial break. 3. There was an unexpected delayed A320 coming in, distracting the single controller. 4. The Tupolev was equipped with TCAS - if it hadn't been, TCAS on the other plane would not have issued an RA, and they might have stayed level or climbed instead of descending, as instructed by TCAS. (Though without TCAS it would not have been allowed to fly in Europe, probably.) 5. ATC happened to tell the Tupolev to descend, and TCAS happened to tell the 757 to descend. 6. That ATC instruction came exactly at the same time as the TCAS instruction on the 757, so the 757 crew didn't hear the ATC instruction to the Tupolev. 7. The Tupolev crew did not acknowledge that ATC instruction (which the 757 crew might have heard). 8. A bit later ATC repeated the instruction, and exactly at the same time TCAS on the 757 also repeated the instruction, so again they didn't hear the ATC instruction to the Tupolev. 9. Just then, the delayed A320 called ATC again, so the controller was distracted and did not monitor that his instruction to descend resolved the conflict successfully. 10. The copilot in the 757 had to go to the toilet just 18 seconds before all this happened. 11. It was night, making visual separation harder, possibly. 12. The 757 crew was trained to prioritise TCAS > ATC, the Tupolev crew was more or less trained to prioritise ATC > TCAS. 13. The Tupolev crew following ATC over TCAS received an ATC instruction that was in line with their right-of-way rules (left plane climbs, right plane descends), so it must have seemed more plausible. 14. The Tupolev crew had a first officer that suggested following TCAS instead, but he was not sitting in the RHS because there happened to be an extra Instructor Captain on that flight in the RHS who chose to follow ATC. 15. There happened to be a software upgrade at Zuerich ATC that night that disabled the Short-Term Conflict Alert light. 16. That software upgrade also disabled the phone lines, forcing the controller to waste time with the phone when trying to call Friedrichshafen for the delayed A320, and also prevented Karlsruhe ATC from warning Zuerich ATC of the problem. 17. ATC made a small, per se inconsequential, mistake of confusing "at your 2 o'clock" with "at your 10 o'clock". 18. The 757 crew waited 23 seconds to tell ATC that they were in a TCAS RA descent, by which time ATC was busy with the delayed A320. 19. The Tupolev crew was too busy/distracted to hear and understand that 757 TCAS RA descent call. 20. The ATC radar updated only every 12 seconds and did not yet reflect the 757's descent when ATC decided to instruct the Tupolev to descend. 21. The serious incident earlier in Japan with ATC/TCAS mismatch had not yet filtered through to all crews worldwide. It's just so unlikely.

ogig 3y ago

Ok, last week or so it was posted another long read blog post from Admiralcloudberg. Somebody commented that the rest of her posts were very nice. So true, I went into rabbit hole mode, been reading the rest avidly, just a few to go. Be warned! PS: Tonight I dreamt of a surreal MD-80 crash.

TravisLS 3y ago
I came here to say the same thing. I've read about 20 of them in the past few days and they're absolutely captivating. The TWA 800 post got me started and is a must-read: https://admiralcloudberg.medium.com/memories-of-flame-the-crash-of-twa-flight-800-fecfd651a157 https://admiralcloudberg.medium.com/memories-of-flame-the-cr...
EdwardDiego 3y ago
AdmiralCloudberg is well worth supporting on Patreon IMO.

dav_Oz 3y ago

While TCAS priority was the technical point of failure, I feel that the transition phase from public to private of the Swiss air traffic control services in 2001 seems to be the greatest disruption of this finely coordinated ATC. Under the new management of Skyguide which led to the obvious cut in labor cost like reducing the night shift from 3 to 2 controllers. The private company still tolerated the extended break convention during night shift from before but leaving only one person responsible, now. And guess what? Maybe a software update to make some efficiency steps when we are at it. The single one controller was then informed during the update taking place what was still functioning and not which was very little. >Part way through Nielsen’s shift, a group of technicians arrived to install the update, and he was informed that his work station’s main computer would have to be shut down, causing his displays to operate in fallback mode — a secondary condition in which several features provided by the main computer became unavailable. In fallback mode, the system which automatically correlated an aircraft’s radar return with its filed flight plan would not work, forcing him to enter the information manually, and the Short-Term Conflict Alert light, which illuminates when the system predicts that two planes will pass too close, would be rendered inoperative. But Nielsen had no idea what features would be lost in fallback mode, nor did he have any obvious way of finding out. And as if that wasn’t enough, a few minutes later the technicians informed him that they would also have to disconnect the control center’s direct telephone landline to neighboring centers For me also surprisingly shocking that back in Karlsruhe multiple (!) controllers had to literally watch the obvious horror unfold while the one controller responsible was not available because of ... maintenance work. >Heartbreakingly, controllers in neighboring Karlsruhe saw the collision coming, but they did not have the authority to speak to planes in another sector without permission from the responsible controller. The Karlsruhe controllers tried several times to call Nielsen in the minute before the crash, but the landlines were down and they couldn’t get through. By the time they gave up on this effort, it was too late to prevent the crash even by breaking the rules. The controllers were forced to watch, helpless, as the two planes collided and then disappeared from radar, knowing that dozens of people were dying before their eyes, and that there was nothing they could do to save them. Edit: According to this article [0] and this verdict [1] the controllers in Karlsruhe had the full authority but were illegally instructed otherwise by DFS (German ATC) management which had an informal agreement with Skyguide (Swiss ATC) over this border region. In the end the heavily traumatized and retired controller Nielsen was brutally stabbed because the modern diffusion of responsibility of companies only operates on the culture of financial compensation and is blissfully ignorant of a desperate man losing his whole family trying to restore his honor. So, no apology before everything is settled accordingly. [0]https://www.dw.com/de/deutschland-haftet-f%C3%BCr-fehler-der-schweizer-flugsicherung/a-2111635 https://www.dw.com/de/deutschland-haftet-f%C3%BCr-fehler-der... [1]https://research.wolterskluwer-online.de/document/2ceee0e8-5b5d-44f6-bc3b-a1d335cad3a0 https://research.wolterskluwer-online.de/document/2ceee0e8-5...

alistairSH 3y ago

ATC communication is fascinating to me. I go down the Youtube rabbit hole a few times a month. A few things that always stand out to me... - the calm demeanor shown by both ATC and pilots. Even in situations that make me cringe sitting at my laptop, everybody involved is steady. I know it's their job, but it still amazes me. - the complexity of airport operations at a major international is mind-boggling. Hand-offs from ground to tower to departure... and then back again if something goes wrong. And doing that for dozens of planes at a time. Some crewed by pilots with thick accents or static-y radios. - that air travel is the safest form of transit given the complexity of engineering and human processes involved is truly astounding. I know today's successes are the result of all previous tragedies; it's still something else. I live under the main international approach to IAD. Watching the heavies fly in makes me smile. Especially the A380. It's a shame the A380 didn't find a long-term market - looking up, it shouldn't be able to fly, but there it is.

jcranmer 3y ago
> the calm demeanor shown by both ATC and pilots. Even in situations that make me cringe sitting at my laptop, everybody involved is steady. I know it's their job, but it still amazes me. It's actually probably not as amazing as it seems. I was just on a high ropes course, and it's similar to ATC in that if things go pear-shaped, there is just nothing that you can do. So when I saw something going wrong [1], the instinct I had to immediately run and try to help was suppressed, and instead I (and everybody else) was essentially in the same calm-and-collected mood. [1] Admittedly, this is wrong in the "abnormal operation" sense, not "immediate risk to life" sense.
- reddit_clone 3y ago
  What is amazing to me is how do Pilots stay calm when their own lives are under imminent threat?
  - stall84 3y ago
    I've had just one definite emergency experience and it's only 1 data point to draw on, and it's definitely not going to be the same for everyone flying.. You drill for emergency situations during training, and you should drill repeatedly afterwards. Any ATP rated pilots do so regularly whether in actual flight or in simulators. But one flight very early, before I had my pilot's license, flying on a student's permit.. I ran out of fuel during cruise flight.. It was dumb, it was a case of me being a poor just-out-of-college student, and trying to do some very risky calculus with the flight planning and fuel required. There were extenuating factors including the (small) plane's fuel gauges malfunctioning sporadically .. having to 'stick the tank' on the ground (measure the fuel in the plane's wings by using a ruler and chart for how many inches equaled gallons). .. excuses aside. I ran out of gas at 8000 feet above Columbus Georgia .. What I remember happening is the engine abruptly lurching, then stopping, sending a massive amount of adrenaline through me. But almost immediately I started looking for a runway to land at. I knew I had at least 1, maybe 2 airports in range of a glide, and one was relatively in front of me, so I decided on it, and called ATC in Atlanta who were following my flight at that time & declared a 'pan-pan' (step below a mayday .. meaning you have a serious situation on board & require priority attention if available, but you are still in control of the aircraft). They confirmed the vector to the (abandoned, but still in decent condition) airport a few miles in front of me. Now.. Your original question is probably answered at this point... Basically as long as you can continue to have things to do .. As long as you can envision and work toward a goal (landing the f'n plane safely) .. The stress of the situation tends to just fuel the focus on getting to that goal. I can't say its going to be the same for every pilot, and maybe it isn't . I did grow up obsessed with flying (after being absolutely horrified by it as a child), and so I had kind of gone over in my mind and in training over and over again this potential type of situation occurring and I wasn't about to let the moment get to big. This kind of thing does worry me a little bit with our recent explosive need for pilots as commercial aviation expands rapidly. A lot of pilots are going through "0 to ATP" courses to get a good paying job, rather than because they're actually obsessed with flying itself.. Because in those cases, I'm not sure what is going to happen psychologically for those pilots. Again though, this is why you are constantly drilled and trained on these situations, so that you have almost muscle-memory of things to be doing in an emergency situation so that there is no time for you to sit passively and become a victim of circumstance.

PetitPrince 3y ago

As the article highlights with the Japan near-miss, "Regulations are written in blood". What a tragic story for everyone involved.

jandrese 3y ago
That anecdote about the Japanese 747 near miss that required a dive so hard it sent a drink cart through the ceiling and injured nearly a quarter of the crew and passengers is also shocking. That's the reason you keep your seatbelt on even when the captain turns off the sign.

gok 3y ago

If you'd like to feel extra uncomfortable next time you get on an airplane, read a bit more about limitations of TCAS that still exist today. For example, it doesn't actually model aircraft performance, so TCAS occasionally issues resolution advisories that are not physically possible. It also does not integrate with terrain awareness, so sometimes to avoid a collision with an aircraft it may suggest flying into a mountain (pilots are instructed to ignore TCAS RAs in this situation).

ilyt 3y ago
In this case it appears it would've worked just fine
pc86 3y ago
This is a real issue, especially for GA aircraft in hard IMC at low altitudes, but airliners almost never receive RAs because they're almost never close enough to, especially enroute.
Retric 3y ago
Fixing either of those comes at significant risk because you are making the TCAS system significantly more complicated and it needs to work across multiple manufacturers and equipment build decades apart.
FabHK 3y ago
Have these limitations ever been a problem in practice? As long as one plane climbs and the other doesn't, the conflict should be resolved, no?
Sebb767 3y ago
> pilots are instructed to ignore TCAS RAs in this situation I like that you explicitly pointed out that flying into a mountain is not the recommended course of action for pilots. Humor aside, this crash also includes a lot of broken down communication, so in most cases, even if TCAS fails, a crash is not inevitable. A pilot aware of the priority TCAS has will definitely communicate a failure to abide by its orders.

omnibrain 3y ago

The plane crash storyline in Breaking Bad seems to be in part inspired by this event. Having lived in the are and going to school in Überlingen at the time it is not something I'm ever going to forget. I did not notice the crash itself (I'm a deep sleeper) but heard about it in the radio at morning. First I thought I must have misheared. Being a vonlunteer firefighter in our village I wondered, why I did not get an alarm. On my way to the train station I stopped at our local fire station but saw only a small transporter was missing, so I figured they may have alarmed only a few people. There was some sort of "fog of war". Nobody knew anything for sure. There were rumours, that one of the planes crashed into the lake. The crash site being at Hohenbodman did not help because there is a village named Bodman on the other side of the lake. Waiting for the train and on the train there was nothing else we could talk about. Arriving in Überlingen, we (a classmate and I) went straight down to the lakeside of the city to see if we can catch a glimpse of anything. The atmosphere in the city was surreal. The route from the city center and train station to our school went over the yard of the city's fire station. And there it hit. Dozens of firefighters, police, red cross, etc. swarmed the place. A search dog unit just arrived. The facial expressions of everybody. At school there was no lessons of course. Everybody just talked about the crash and the newest rumours. Some classmates arrived by bus and their bus drove straight by the crashsite. They saw corpses under cloth and smoking debris. A few hours later people from the local newspaper arrived to distribute a special issue with the most comprehensive compilation of available information at the time. (... a few months later ...) We had local festivities and I helped. It was bigger festivities and we spent days building everything and had to gather stalls, building material and tools from various storage areas, companies, etc. To fetch something I went with someone to a local building company. We went into their warehouse and an overwhelming stench of kerosene hit me. The warehouse was filled with transport container trays full of excavated ground that was contaminated with kerosine (and small debris) from the crash. The guy I went with just mentioned this in a very non-chalant way.

leipert 3y ago
I was on vacation at Lake Constance that night. We didn’t hear anything consciously, but _everyone_ (four people) was awake at the time of the crash (unlikely, right?) and heading to the toilet/grabbing a water. Next day we knew why we all were awake at the same time. Surreal.

cobaltoxide 3y ago

"In 2004, Peter Nielsen, the air traffic controller on duty at the time of the collision, was murdered in an apparent act of revenge by Vitaly Kaloyev, a Russian citizen whose wife and two children had been killed in the accident." https://en.wikipedia.org/wiki/2002_%C3%9Cberlingen_mid-air_collision https://en.wikipedia.org/wiki/2002_%C3%9Cberlingen_mid-air_c... Jesus Also: "On 8 November 2007, Kaloyev was released from prison on parole after having served two-thirds of his sentence, a total of three and a half years." "Returning to his home in North Ossetian city of Vladikavkaz, Kaloyev was met with enthusiastic crowds who cheered him as a hero."

MattRix 3y ago
The article covers this at some length.
olliej 3y ago
Yup, murdered the only person involved in the collision that didn't actually cause it. Celebrated as a hero because "honor" is achieved by murdering an unarmed man who didn't kill your family, rather than the people in charge of the airline and ATC company that did. After all honor is defined by many as "murdering someone, regardless of what they did".
- avar 3y ago
  The first line in the "causes" section of the official accident investigation blames ATC. The murder of Nielsen is a tragedy, but that doesn't mean he wasn't responsible.
  - tass 3y ago
    ATC being the company, its procedures, operating with limited staff, etc. Not the controller.
    - avar 3y ago
      You're simply misreading it, ATC refers to the specific person(s) responsible at the time. Perhaps you're tripping over "responsible", it helps to read it as "if you, future person, are in this situation, consider how you could avoid a similar accident, given your position in the system". It does not necessarily mean "this person is incompetent", or "this person is criminally liable". That's outside the scope of such reports. If it didn't mean that, then someone in the ATC chair in the exact situation tomorrow would need to helplessly watch the same tragedy play out in front of their eyes, would they not? Even if they'd have the benefit of hindsight in having read this report. After all they'd be a powerless puppet strung along by systemic causes.

csours 3y ago

> The way this particular segment of Russian society reacted to the crash and the murder was an ugly reflection of a national tendency to blame whoever happens to be present at the moment of a tragedy, while those responsible for creating the unsafe condition go unnamed and unpunished. Severe Tangent: It's difficult to change the way you perceive the world, but I invite you to try. Lately I've been thinking about how we understand and talk about tragedies and atrocities in history. Atrocities are traced back to who is most to blame, but not the conditions that led to the situation, not the political techniques that were used to gain the power, and certainly not how it might apply to ourselves. When we find someone to blame for evil acts, we can close that mental box. That was the person who did it; I would never do something like that; I would never support someone like that. But, most of the time, the evil leader did not start their reign with huge atrocities. It may have started with a fight that many of their followers did support. It's easy to say "I would never support an atrocity", and maybe even say "I would never support someone who talks about any group as less than human". The problem is, it's always easier to see this in your opponents than in yourself. I'm not making a false equivalence or an excuse; I'm saying it's really difficult and we should not be surprised when it is difficult. When the group mentality gets to a certain point, any reasonable nudge or criticism is taken as an attack. I don't know of a great solution, but I think about how cult members are de-programmed. They have to remember or find something in the real world that they value. There has to be a bridge, not a demand that they renounce their beliefs.

olliej 3y ago
Literally the whole point of NTSB and similar investigations is to find the cause of accidents, and this article is almost entirely sourced from those reports. The person who decided I must blame someone, decided to murder the controller (that the report did not blame) and be celebrated as a hero by a bunch of moronic "manliness" "strong men" in Russia. This BS concept of "manliness" and "being strong" == "being better" needs to be stopped, and it's frustrating to see so much revival and promotion for it on YouTube and the like.
- mbork_pl 3y ago
  On the contrary, the concept of "manliness" and "being strong" (which does not necessarily mean "better", btw) needs to be promoted more - but also understood correctly, as the ability to conquer your own weaknesses, like the one GP is talking about. It is sad to see how our civilization collectively decided to throw out several thousands years of tradition and dozen of thousands pages of collective wisdom. The topic GP mentioned has been known for centuries, way before modern psychology. In fact, it is one of the important points of Catholicism (AFAIU) - every single man is a sinner capable of horrible deeds, but that diminishes neither the dignity of every human being nor their ability (with God's grace) of overcoming that.

sklargh 3y ago

I’m consistently amazed by how many aviation accidents are caused by errant human interaction with properly functioning or unused but safety-critical automated systems. This is a theme of almost every major airliner loss in the 2000s.

olliej 3y ago

Oh this is the one where privatization of ATC killed a bunch of people, and then one asshole decided that it was ok to murder the one person involved who was explicitly not responsible. The responsible parties - as outlined in the report: 1. The Russian airline: it put untrained pilots in charge of a plane. We know they were untrained as they clearly did not understand the most basic concept of TCAS. The article tries to paint this is regulatory confusion - which is patently nonsense, the entire concept of TCAS hinges on it being on par with stall and terrain alerts, where there is a single response, and that response counters any other instruction. The fact that the pilots were aware of the system and failed to learn about it is a failure on their part, the fact that the airline company failed to have the most basic of training on it makes it mostly theirs. 2. The Skyguide company: understaffed a region, and then under equipped it while understaffed, and then failed to have any reasonable back up for anything. Arguably a failure brought on by those people that insist "privatizing a public safety system is efficient". But then Mr Macho-man had to defend his honor by going and murdering the one remaining victim of the crash, to demonstrate how manly he was. If you feel that murdering an innocent and defenceless person is justified for the "honor" of your family, and to give you value as a "man" I say you've failed the most basic tenets of "honor", and sure as shit don't get to brag about manliness.

Fissionary 3y ago
> the one person involved who was explicitly not responsible Not to condone revenge killings, but Nielsen was obviously part of this accident. It was his choice to work alone that night (rather than waking the other controller) and to allow the technicians to turn off most of his instruments, so the responsibility is partly his. He also issued the fateful descend command - had he literally stayed out of this, the Tupolev pilots would have followed the TCAS guidance and the accident would not have happened.
- olliej 3y ago
  He did not cause the accident, all the reports on the accident say his actions were the result of Skyguide, the company, as it tried to make public safety profitable. To put it simply, blaming Nielsen for this accident is like blaming the worker in a car factory that puts the last part on a Ford Pinto.