Blame for The Lake Constance Aircraft Crash
In year 2002, a Tupolev aircraft carrying 70 children from Russia on a trip to Spain collided with DHL's Boing. Initially Russian pilots were blamed by Europe for not obeying orders from air traffic controller, but in the end it was discovered that they did and the blame was largely shifted to the air traffic controller himself.
I just watched a documentary regarding this tragic event on the Discovery channel. It was night and that meant that there were two air traffic controllers on a shift. However, a standard practice in Skyguide (the Swiss air traffic controller company) was to let one of the air traffic controllers go to rest if the sky was not crowded. That's what happened on that night. Also system maintenance was scheduled and the main radar was turned off. Instead, a backup radar was used, which had much lower resolution, and most critically, did not have a system for notification of upcoming collisions. Moreover, the backup controller had to use two backup radar screens, with distance of three meters between them, instead of one.
That's not it. The same night, telephone system maintenance was also scheduled and telephones were switched to backup system. Guess what, the backup system was not working and did not accept either incoming or outgoing calls; of course the air traffic controller was not aware about that.
At a certain point of time, an Airbus plane comes into the airspace which needs to be guided to landing in the airport, which is a labour-intensive procedure. The air traffic controller, whom we shall call Peter, tries to pass guidance of the airplane to the airport's control tower, but cannot call the airport due to the failed telephone system. He has to guide the plane himself.
A bit later, we have Boeing and Tupolev in the airspace, flying on the same altitude towards each other. Controllers from another post try to reach Peter by phone to notify that planes are heading towards collision; but the telephone call is not going through. Peter, being busy with the Airbus on another radar, doesn't notice the problem until 43 seconds before the collision. After he notices it, he commands the Tupolev to go down by 1000 feet, a command which Tupolev's crew follows.
At the same time, an automatic collision prevention system gets activated on both of the planes. It tells Tupolev to go up, and Boeing to go down. Boing follows the command of the collision prevention system. The Tupolev crew decides to follow the commands from the ground. Both airplanes descent.
A minute later, Peter notices that the aircraft have disappeared from the radar.
Is he really to blame for this horrible chain of events? Was he just part of a system which was meant to break sooner or later? Personally I would blame policies and procedures which allowed lives of people to depend on one overstressed person.
...
In February 2004, Peter is stabbed to death by a man whose wife, son and daughter were on-board the plane.
I just watched a documentary regarding this tragic event on the Discovery channel. It was night and that meant that there were two air traffic controllers on a shift. However, a standard practice in Skyguide (the Swiss air traffic controller company) was to let one of the air traffic controllers go to rest if the sky was not crowded. That's what happened on that night. Also system maintenance was scheduled and the main radar was turned off. Instead, a backup radar was used, which had much lower resolution, and most critically, did not have a system for notification of upcoming collisions. Moreover, the backup controller had to use two backup radar screens, with distance of three meters between them, instead of one.
That's not it. The same night, telephone system maintenance was also scheduled and telephones were switched to backup system. Guess what, the backup system was not working and did not accept either incoming or outgoing calls; of course the air traffic controller was not aware about that.
At a certain point of time, an Airbus plane comes into the airspace which needs to be guided to landing in the airport, which is a labour-intensive procedure. The air traffic controller, whom we shall call Peter, tries to pass guidance of the airplane to the airport's control tower, but cannot call the airport due to the failed telephone system. He has to guide the plane himself.
A bit later, we have Boeing and Tupolev in the airspace, flying on the same altitude towards each other. Controllers from another post try to reach Peter by phone to notify that planes are heading towards collision; but the telephone call is not going through. Peter, being busy with the Airbus on another radar, doesn't notice the problem until 43 seconds before the collision. After he notices it, he commands the Tupolev to go down by 1000 feet, a command which Tupolev's crew follows.
At the same time, an automatic collision prevention system gets activated on both of the planes. It tells Tupolev to go up, and Boeing to go down. Boing follows the command of the collision prevention system. The Tupolev crew decides to follow the commands from the ground. Both airplanes descent.
A minute later, Peter notices that the aircraft have disappeared from the radar.
Is he really to blame for this horrible chain of events? Was he just part of a system which was meant to break sooner or later? Personally I would blame policies and procedures which allowed lives of people to depend on one overstressed person.
...
In February 2004, Peter is stabbed to death by a man whose wife, son and daughter were on-board the plane.
Now that's a sad story... :(
Posted by Leonid — 29 Dec 2004, 05:48
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Posted by wss — 17 Jun 2015, 05:53