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.
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.
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.
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.
According to the article, there were actually conflicting guidelines.
The FAA said always follow TCAS ("any guidance from TCAS overrides guidance from ATC"), whereas other regulators were either vaguely non-committal to which had overriding priority or assigned priority to ATC.
It also notes that the Russian pilots were not accustomed to TCAS (which was not common in Russia, at the time). Even further, to the extent they were familiar with it, Russian regulations noted that the ATC's guidance superseded all other guidance systems.
What the FAA had to say on the matter isn't relevant, and doesn't contribute to there being "conflicting guidelines". The FAA doesn't regulate European airspace.
Sorry, I didn't mean to suggest that the pilots were operating under conflicting regulatory guidances.
Rather, I was pointing out that the international community of aviation regulators had established conflicting norms with regards to the requirement and prioritization of TCAS at the time of the incident.
The conflict in norms was a contributing factor to the incident discussed in the article, and in the aftermath of the incident, those norms were appropriately corrected. The mention of the FAA is relevant because their original guidance (TCAS guidance supersedes ATC guidance) was what the ICAO adopted in response to this incident.
The guidance and sole purpose of TCAS is "do what it says", in that respect it is no different from a stall warning.
The fact that Russian aviation failed to train (or even require training for that apparently) is absurd, the fact that the EU allowed planes to travel with TCAS but not with pilots that had the most basic understanding of TCAS is a sad example of the results of checkmark based safety.
As even this article acknowledges, TCAS as a system makes no sense of any kind if it can be countermanded by someone other than the pilot. There is no use case for TCAS that makes anything other than "do what it says, a fast as possible" have any value at all. Disobeying TCAS because of ATC is no different than ignoring a stall warning because ATC told you to climb.
When it was introduced - and it was new at the time - not everything was as neat and clear as you state.
Quoting Wikipedia: "The [TCAS] manual described TCAS as "a backup to the ATC system", which could be wrongly interpreted to mean that ATC instructions have higher priority."
In fact, you'd do well to read the entire Wikipedia article to see that this was not the only case where pilots did not have clear guidance on which orders to follow in the case of conflicting ATC and TCAS orders.
Other similar maxim is "In case you are intercepted by a fighter jet, and ATC and the fighter jet issues seemingly conflicting instructions follow what the fighter jet says/signals, and inform about this fact the ATC."
People with missiles trained on you have command priority for all the obvious reasons.
(a) The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft.
(b) In an in-flight emergency requiring immediate action, the pilot in command may deviate from any rule of this part to the extent required to meet that emergency.
(c) Each pilot in command who deviates from a rule under paragraph (b) of this section shall, upon the request of the Administrator, send a written report of that deviation to the Administrator.
as an aside i once called the FCC to get a definitive answer about a part 97 rule, and they put me on hold, and gave me the answer i was suspecting they would, which i am nearly positive is the wrong answer.
In the context of your post, if asked, i wonder if the FAA (or whoever) would say "the pilot has final authority, even if it goes against what the ATC commanded", even with the nuance and additional information that would be required in 91.3c.
(a) No provision of these rules prevents the use by an amateur station in distress of any means at its disposal to attract attention, make known its condition and location, and obtain assistance.
(b) No provision of these rules prevents the use by a station, in the exceptional circumstances described in paragraph (a) of this section, of any means of radiocommunications at its disposal to assist a station in distress.
My question was simple - one has a radio what can transmit clearly on a police frequency, that is, if one pushes transmit, police radios and scanners in the area can hear the audio being transmitted. Can one use said radio in an emergency, if they are a licensed part 97 operator?
2 is very hard to keep in mind, because in a stressful situation we seem to naturally want someone "to tell us what to do".
This is one of the reasons that if you're trained in emergency situations they tell you things like "don't yell 'someone call 911' but instead point directly at someone and say 'call 911'".
Yes this definitely is a thing. Like I mentioned, there is a real desire 'to be liked' by ATC from the pilot. It happens to me, it happens to many pilots.. They give you an instruction and you want to show how quickly and efficiently you can execute it.
The hardest part is when your own flying intuition tells you to not do what they're requesting, or even worse when it merely makes you question the instruction.. leaving you in a decision paralysis.
It's ultimately a culture war of neuro-types, controllfreaks and those who yearn for irresponsibility in some underling caste vs idealistic humanists dreaming of everyone being there own company,master and commander. These characters and their constructs collided that night with two planes. How to plan and prepare for this? No, idea.
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…
"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."
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".
Not to justify the murder or anything, but I don’t think that Nielsen can be said to have zero responsibility. He voluntarily worked in such an unsafe environment.
Ultimately if you work in a safety-critical field and you don’t speak up when something is very wrong, then you are just as responsible as anyone else.
Plugging away at your job while maintenance people disconnect the phones from ATC is negligent inaction. Without a working phone line the ATC was clearly offline in a very literal sense and he should have recognized that and either passed the responsibilities to another ATC and/or closed the airspace.
They boiled the frog on him. They had redundancy - two controllers, two phone lines, two collision warning systems.
They removed one controller. That was... not great, but it seemed okay.
They removed one collision warning system, for a short window. That was... not great, but it seemed okay.
They removed both phone lines. They didn't tell him. That wasn't okay, but he couldn't know that until he needed them.
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This also disregards that someone is always in the chair. Okay, let's say he quits. Then they're short an additional controller, making the situation worse, and someone else is still sitting in the chair when the exact same thing happens. "He voluntarily worked in an unsafe environment" is just a deflection from the responsibility of the people who have the authority and the opportunity not to make the system unsafe. His only agency was to quit his job or not, which wouldn't have any effect on the outcome.
> This also disregards that someone is always in the chair. Okay, let's say he quits. Then they're short an additional controller, making the situation worse, and someone else is still sitting in the chair when the exact same thing happens. "He voluntarily worked in an unsafe environment" is just a deflection from the responsibility of the people who have the authority and the opportunity not to make the system unsafe.
I can sort of see different ways to look at these situations but I usually don't see them that way. While desperately holding together a broken system seems heroic, it assumes that help is on the way. Many times no help is on the way because the system is sort of barely functioning so there is no priority to improve it. If he left maybe the other controllers would all leave as well, ending the farce.
> His only agency was to quit his job or not, which wouldn't have any effect on the outcome.
He probably wouldn't have been murdered and blamed for the the outcome!
I agree with you, but it sounds like the maintenance causing systems offline happened relatively quickly with no prior communication. In which case Nielsen was stuck trying to manage the two urgent situations that had arisen at the same time.
The reduction from 3 to 2 operators, the acceptance of long breaks when there were two operators so there was only 1 in the room for a prolonged period of time, the pressure to cut costs, the lack of understanding of what systems were down during the upgrade, the surprising loss of hard lines without a tested alternative, the lack of a supervisor concentrating on the upgrades at the time, the lack of appropriate assessment of the risks.
Most of it seems to come down to trying to cut costs and reduce conflict with the staff (the acceptance of the “long breaks” overnight)
None of that lands on the overworked controller trying to do 3 jobs
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.
> 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.
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.
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.
I also found that quote very odd, for similar reasons. My immediate question was:
Why is this treated as a specifically Russian tendency?
The mindset sounds intimately familiar to me as an American. Many people, perhaps even most, operate on that idea. Our politics are heavily dependent on that idea. It also heavily underpins our justice system.
> Why is this treated as a specifically Russian tendency?
Because everyone in that part of Russia understand and feels that honor-based reaction. The Southern US also has a history and reputation of honor-based communities.
The difference is that in the US, most people do not think this way, and there is a cultural tendency towards accepting and understanding differences with your neighbors, or at least signaling such.
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I think that honor based societies do not do a good job at understanding change. The problem is that the opposite of honor is guilt/shame, and that emotional reaction heavily masks the facts of the situation.
It may be a difficult and foreign concept (It's difficult for me), but reading about guilt-free organizations is very interesting to me. The thing that was hardest for me was understanding that guilt and responsibility are different things.
> Why is this treated as a specifically Russian tendency?
Would an American (or any person in any country in the EU) receive a medal for such murder? I expect not, and would be horrified otherwise ... But I don't think it's unique for Russia, they just get much more spotlight.
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.
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.
You forgot the karlruhe controllers who saw it all, and tried to call but the phone lines were down. They obeyed protocol and didn’t contact the planes that weren’t in their sector,even though they could have.
It's a tough call. If they had contacted them, they also could have talked over instructions from the other sector's controller, for all they knew, which is presumably the reason for the protocol? Tough decision.
I wonder whether, had they chosen to contact the aircraft outside their sector, the Skyguide controller would have heard them. With VHF radio being line of sight, the aircraft would probably have heard them, but Skyguide would be based at a ground station that was perhaps occluded by nearby mountains or other buildings. Where I live, I can't pick up a VHF ground station which is nearly in my line of sight only fifty kilometres away.
It's just so unlikely that this particular crash is the one that happens. A crash of this sort was all but inevitable, unless significant changes were made, and significant changes weren't going to be made until a crash of this sort happened. The article details a near-miss 17 months prior that would have killed 677 people. If this had been avoided as well, there would have been another a few months later, and another, and another, until one finally met all the conditions for an actual collision.
Is it unlikely that the roulette wheel will land on 00 this time? Of course. Is it unlikely that it will ever land on 00? No!
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.
My ex-wife was a US air traffic controller, and the training they go through is stunning. They're tested continuously for years, with something like an 80% wash-out rate.
During testing, they get 1-2 tests per week, working a shift just like a controller would, with fake pilots on the radio, and real computer systems. If they let airplanes get even remotely close to each other, they fail. If it happens twice, they're out of the FAA, immediately, permanently. One of the instructors told me, "It's my job to make sure your wife has the worst week of her career, every week, during training - so that when she's actually on the job, every week will seem easy no matter what she's facing."
Even just in training, you could see the stress take its toll on the candidates over the years.
Good to know. I am glad it is such a strenuous training/testing. It has to be, given the price of failure.
Hmm.. Are there incidents that were caused by Controller's error? (most common seem to be equipment failures, pilot errors, bad weather and bad luck with bird strikes etc.)
Of course I don't think it is correct to say that an incident were caused by controller error. It makes it sound like a single controller error was the only thing which went wrong. It is probably more correct to say that controller error contributed to the outcome of some incident.
As they say, every regulation is written in blood. An exaggeration for sure, but not by much. Many regs can point to a specific, not always fatal crash or series of incidents as the reason it exists.
> 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.
> 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.
disclaimer: I might be talking out my ass
It really seems that crisis response is bimodal. Either you almost completely panic, or you're almost completely focused. Complete focus makes for very clear, focused communication. (Extensive training on procedures, communication, and not panicking certainly helps as well.)
idk there's plenty of black box recordings of pilots panicking when a crash is imminent. ATC controllers on the other hand have training and physically don't have much to lose.
> 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.
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.
A lot of pilots are going through "0 to ATP" courses to get a good paying job...
Are those "0 to ATP" graduates landing quality jobs? Has pay at the smaller regionals actually moved up into "good paying" ranges (used to be $20-$40k/year starting, and that's usually after $50k+ in tuition/fees to get first set of pilot credentials)?
Last time I checked (10+ years ago), landing a job at a major airline still required years of experience at a regional OR some special combination of degree/networking/military service. And the regionals didn't pay well and had pretty crap working conditions (getting better post-Colgan Air crash, but still not great).
I see United has an in-house "0 to ATP" program now, but it's still more than $70k and a few years to graduate, and then the pilot still spends time at a regional United-affiliate before having the chance to move to United itself.
Really just curious what conditions are like for new pilots today (vs roughly the Colgan Air disaster era). And what the pipeline looks like post-COVID.
Many major European airlines have such programmes, including KLM and Virgin Atlantic. This would not be possible in the USA, considering the American requirement to amass 1500 flying hours without passengers before being granted an ATPL. I don't know what the salary is like, but there aren't as many scholarships available as there used to be. Virgin Atlantic charge £100k for their complete ATPL program, for instance, although they do guarantee employment at the end of the course.
What would panicing gain them? Honestly if anything it's more amazing that people still go into panic at all - it seems almost like a kind of learned helplessness thing.
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!
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.
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).
> 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.
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.
> (pilots are instructed to ignore TCAS RAs in this situation)
Specifically, the ground proximity warning (as well as the stall warning) takes precedence over TCAS. This is just fine, since the "descend" aircraft in ground proximity will level off while the other climbs. You're not likely to find a condition where neither plane can deviate because the descender gets a ground proximity warning and the ascender gets a stall warning at the same altitude, since those are typically associated with aircraft flying close to their minimum and maximum altitude, respectively. You would need to have two aircraft flying level very close to the ground, at least one of them near its stall speed, which simply is not a flying condition used by commercial airliners.
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.
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.
> 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.
Well yeah. I’d still take innocent until proven guilty over any of the blood debt and honour killing cultures. Particularly when the victim sacrificed to restore someone’s “honour” is not responsible. Desperation is no excuse, and of course we should not base our judicial systems on it.
As usual, the real culprits got nothing. As usual, this is unacceptable and, as usual, nothing has been or will be done to change this.
Vitaly Kaloyev, who killed Nielsen, went to jail for it for a few years and, after release, returned to Russia. He then became deputy minister of construction in North Ossetia, Russia.
> The single one controller was then informed during the update taking place what was still functioning and not which was very little.
According to the text you quoted, it's worse:
> But Nielsen had no idea what features would be lost in fallback mode, nor did he have any obvious way of finding out.
Nielsen never knew which systems were out of order. Given the apparent workload he was under, knowing that the collision warning was out of order probably would not have helped, but it seems that he didn't even know for sure that the system was down.
Is there not a point where ignoring what you’re allowed to do and doing what’s best if it prevents massive human catastrophe is the correct option regardless of personal consequences? Nobody is going to jail for saving hundreds of lives. The media outcry would likely prevent any job loss…or was it that their systems wouldn’t allow them?
>By the time they gave up on this effort, it was too late to prevent the crash even by breaking the rules.
There was too little time. And I imagine it is hard to be that quick and lucid in breaking the rules of ATC.
Edit: I've looked it up and according to this article [0] there was only an informal agreement between Skyguide and the German counterpart DFS regarding this border region. Since ultimately only Germany is solely responsible for their airspace no such an agreement can exist and therefore the federal government (Bund) is partly to blame for the accident.
Indeed the controllers in Karlsruhe had the obligation to intervene asap even without informing the Swiss counterpart but they were instructed otherwise although there had been no legally binding transfer of the sovereign task ("weil es keine rechtlich verbindliche Übertragung der hoheitlichen Aufgabe gegeben habe"); so this was illegal. In both cases a management issue.
> so this was illegal.
> In both cases a management
> issue.
I think attempting to call the other ATC 11 (!) times in the span of a couple of minutes before the crash goes way beyond a management issue, it's also a cultural issue.
Those controllers were looking at a screen showing that two airplanes were about to crash into one another.
In most other western countries that person would have thought "well, fuck this!" and started yelling at them on the channel itself, implied procedures, stepping on toes, and pecking order be damned.
I wasn't aware of any direct connection between Snowden's leaks and lives saved. I have seen vague-ish claims from intel communities that he cost lives, but not the other way around. Anything concrete about how he saved lives?
It isn't necessary. "How someone who breaks the rules for the sake of greater good" is the relevant metric, whether it pertains to life, health or liberty.
Plus, a life in the gulag is pretty much a life lost.
Sorry, I thought in your previous comment you were drawing a connection with Snowden due to the "lives saved" quotation you included.
With Snowden, it is a lot more complicated - many people don't believe he did the world a service, and is in fact a traitor. (Not to mention, he's living in a Russian apartment which although not my preferred lifestyle, it is still far from being a gulag.)
> many people don't believe he did the world a service, and is in fact a traitor.
I'm not sure what to respond. Ok, why do people believe that, label him this - what are their arguments? I think the point here is how authorities act, and what they are allowed to get away with. PRISM, apparently, is something they are allowed to get away way. Where are the "traitors" spying on Americans? Or are those all unquestionably "heros"?
> he's living in a Russian apartment
True, because he managed to escape, and probably is looking over his shoulder a lot in the meanwhile.
On the other hand, if he ended up in US custody, we might know very little until "found dead in his cell", which would no doubt be yet another unaccountable accident.
He is a free man, he is a citizen of Russia living in Russia. We can speculate on whether he would have been successfully prosecuted and would still be in prison today had he not left the US, but he is definitely not in jail.
Why was TCAS priority the point of failure? As I understood it, the TCAS said the correct thing to both aircraft, but the ATC overrode it in one, resulting in the accident.
>Official guidance from the International Civil Aviation Organization, or ICAO, which signatory nations use to create their own regulations, did not say what to do if TCAS and ATC issued conflicting avoidance instructions. Similarly, European regulations failed to cover this scenario.
Technical in the sense of giving priority one over the other; the priority was clear in the US but at the time not strictly set in Europe or Japan (a near miss happened one year before because of conflicting instructions) and in Russia the opposite (highest priority ATC) was true with TCAS being a new thing obligatory for flights to Europe, of the five crew members only one pilot seemed to be aware that the two TCAS are tightly coordinated (CLIMB/DESCEND) for a last resort, but nobody listened to him.
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.
> 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":
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:
Good answers in sibling comments, but for those who don't want to grovel through a lot of stackexchange answers here is the TLDR: There are two reasons:
1. When TCAS was originally developed, the direction information to the other aircraft was not very accurate, being obtained only via the TCAS antenna. Nowadays GPS information is transmitted via ADS-B and so it's much more accurate, but taking advantage of this would require a major redesign. It may happen eventually, but...
2. Aircraft can change altitude faster than they can change heading. Also, most aircraft can change pitch faster than they can roll, and they are longer and wider than they are high. So effecting enough altitude change to avoid a collision can be done faster than effecting enough heading change to do so.
I don't think the GP was asking about changing heading instead of altitude; I think they were asking about changing heading in addition to altitude. Sure, the altitude change is going to achieve better separation faster, but a heading change in addition to the altitude change will act as a backup in case for some reason something goes wrong with the altitude change.
In this particular accident, it seems like commanding a heading change (to the right for the Tupolev and to the left for the DHL flight) in addition to an altitude change would have avoided the collision.
This is fallacious reasoning. "X would have prevented Y, and Y was a bad outcome, therefore we must do X." You can plug in many things for X which reveal this to be an unsound argument.
Yes, intuitively being able to change headings seems like a good thing except that 1) it adds expense and complexity, and thus produces new potential points of failure and 2) it's not necessary. The problem was not that an altitude change was insufficient, the problem was that two sources of command authority (TCAS and ATC) contradicted each other. The solution is simply to add a new rule: if TCAS and ATC disagree, go with TCAS.
> This is fallacious reasoning. "X would have prevented Y, and Y was a bad outcome, therefore we must do X."
I never said we must do X. It's a suggestion which might or might not be worth considering. From the article it appears that the TCAS system was designed with the assumption that pilots would always immediately do what it said. This accident obviously violated that assumption. The question is how best to respond to that as far as the design of TCAS is concerned; the eventual tradeoffs might lead to the answer "do nothing to TCAS" but that doesn't mean it isn't worth considering possible changes.
> it adds expense and complexity
Yes, this is always a tradeoff with safety systems. But the heading change rule would be even simpler than the altitude change rule (which requires negotiation of possible conflicts between the TCAS systems in the two aircraft): the heading rule is simply "turn away from the other aircraft", i.e., if the other aircraft is to your right, turn left, if it's to your left, turn right. That seems like logic that could be implemented, checked, and verified fairly easily, if it were decided to do so.
> it's not necessary
When it comes to safety systems, "necessary" is always a judgment call. Yes, cases in which adding a heading change to TCAS instructions would be helpful are rare (like this crash was). But all aircraft accidents are rare. No rule gets followed exactly as it's given 100% of the time. Taking that into account when deciding on what safety systems to implement is perfectly justified.
> The solution is simply to add a new rule: if TCAS and ATC disagree, go with TCAS.
Or more precisely, to explicitly make that a rule worldwide, instead of just in the US as it was before this accident.
Yes, this is the response the system settled on, but this, too, involves a tradeoff: this rule has to be implemented by humans, and humans are less reliable than automated systems. The international air safety system evidently decided that humans were reliable enough in this case for this rule to be sufficient; but that doesn't mean they didn't make a tradeoff.
> I think they were asking about changing heading in addition to altitude
Heading and altitude are NOT independent. When an aircraft makes a turn, it banks (it's not like a flat turn you make in your car), and inevitably loses some speed because of extra drag, and some altitude because of loss of lift.
It can be compensated by increasing the engine power, but then you really need to predict that as well.
Yes, I know how planes make turns. It is valid to point out that a TCAS instruction that included a heading change would, at least for the plane whose TCAS instruction was to increase altitude, also have to include an engine power increase, which might not be feasible depending on the altitude (cruise power might already be pretty close to max power). Or else make the turn a very slow one, which would decrease its usefulness in collision avoidance.
Also that bank means you have a wing tilted up and a wing tilted down, increasing the vertical height of the plane at a time you’re trying to increase vertical separation.
Doing both reeks to me of a solution in search of a problem that’s going to end up the target of some later NTSB report when you hit some weird edge case where the dynamics and dimensions of the two planes aren’t fully accounted for.
> bank means you have a wing tilted up and a wing tilted down, increasing the vertical height of the plane at a time you’re trying to increase vertical separation
Yes, but it's also increasing horizontal separation (from a predicted value of zero), which might still be a reasonable tradeoff to consider.
ADS-B is not guaranteed to be available from all aircraft in most of the airspace below 10K feet MSL. (Basically, if a transponder used to be optional before, ADS-B out is also optional.) Mode-C (altitude encoded transponder replies) are also not required, but the equipage rate is very high at this point, which is less the case for ADS-B among GA aircraft.
> ADS-B is not guaranteed to be available from all aircraft in most of the airspace below 10K feet MSL.
Sure, but so what? The lack of universality is not an impediment to implementing a new TCAS system that uses ADS-B data when it's available. (And BTW, the places where ADS-B is not required are generally places where traffic is sparse and so the risk of a collision is pretty low to begin with.)
If the expense and lead time for the redesign now that more reliable and precise position (and first derivative thereof) are available from GPS via ADS-B are to be considered, it's fair to ask "well, what are the downsides as compared to using altitude for separation as today?" and one of them is "a higher percentage of aircraft are transmitting mode-C than will be transmitting ADS-B out".
Given that the clear priority is now to follow a TCAS RA (resolution advisory) over an ATC instruction, I think that the current TCAS approach is good enough to cause aircraft to miss each other and that a GPS-based redesign is unlikely.
I have to imagine that if there was a #3 on that list it would be that introducing a random heading change adds follow-on complexity that could be dangerous itself. Now the planes are not just at different altitudes, but pointed who-knows-where.
You could imagine if, in addition to obeying the altitude change, every plane began to turn rapidly to the right, it could only help the situation? As long as we all agree to turn right in case of a collision warning?
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.
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.
> 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.
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.
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.