On 1 July 2002, BAL Bashkirian Airlines Flight 2937 collides with DHL International Aviation ME Flight 611 in German airspace near Überlingen, killing all 71 people on board the two aircraft.
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00:00A horrific collision in the skies above southern Germany is witnessed by people on the ground.
00:23Seventy-one people are dead.
00:25We as accident investigators did not have an idea of what exactly happened.
00:34It doesn't make sense.
00:37The radar data only deepens the mystery.
00:40Neither one is trying to get out of the way.
00:42Just got to use the facilities.
00:44Descent? Really? We're going to descend?
00:47Expedite descend.
00:49To solve the mystery, investigators will need to disentangle a web of critical radio transmissions.
00:56The controller is guiding us down.
00:58A lot of things had to fall into place just the wrong way for this to occur.
01:02And really woke a lot of people up.
01:04Medendate!
01:06Medendate!
01:08POP!
01:11POP!
01:13every one-one-one-other-one-one-one-one-one-one-one!
01:16How did they help?
01:18it's 11 p.m. in switzerland and airports across the region are closing down for the night
01:34you're off see you in a few hours in the sky guide control center in Zurich tie into 933 proceed to
01:48Algoi copy proceed to Algoi I enter 933 air traffic controller Peter Nielsen is working
01:57the night shift very in 305 descend flight level 220 he's been on the clock for just over three
02:06hours and has six more to go Tom Lawson is a former sky guide controller who worked with Peter Nielsen
02:16the night shift in Zurich at the time had quite a lot of traffic but around 1130 12 o'clock it
02:26reduced to five to seven aircrafts an hour and it was possible to do it alone top Swiss 935 proceed
02:34direct to torpa top Swiss 935 thank you Nielsen manages the safe transit of all aircraft in his
02:44airspace for further instructions contact Padua 120.72 bye-bye air traffic control is one of the
02:54most stressful jobs in the world and a lot of it does hinge on decisions made by one person
03:00ah Swiss radar good evening tillman 611 Nielsen hears from another plane in his airspace
03:08just leveling at flight level 260 Dillman 611 is the call sign for a Boeing cargo jet owned by the courier DHL
03:21it departed from Bergamo Italy and is flying through Swiss then German airspace on its way to Brussels
03:30Belgium Dillman 611 squawk 7524 7524 611 climb flight level 320 Nielsen clears the flight to climb to a
03:49higher altitude and requesting 360 thanks if it's available pilots ask for the most efficient flight
04:01level that they can fly at and in this case 36,000 feet is much more fuel efficient Dillman 611 climb
04:10flight level 360 climb flight level 360 Dillman 611 Nielsen clears flight 611 to 36,000 feet and tracks the
04:27change you use flight strips to plan the traffic ahead with the strips and flight screen we have a good
04:38picture of what is going to happen but at 1130 Nielsen's night shift takes a turn
04:47two transmissions come in together one at the workstation beside him there's an airbus on approach to
05:06the Friedrichshafen and another plane flying at a higher altitude in the upper sector
05:13aeroloid 1135 descending flight level 80 Nielsen briefly responds to the airbus now on approach
05:23aeroloid 1135 roger call you back
05:28he needs to identify the aircraft now entering the upper sector
05:35station calling say again please
05:38the aircraft is a Bashkirian Airlines Tupolev 154
05:48the Russian plane is slightly ahead of schedule crossing from Moscow to Barcelona
05:57but I will tango Charlie 2937 level 60 year old Oleg Grigoriev is Bashkirian Airlines chief pilot
06:13tonight he's evaluating the 52 year old captain Alexander Gross who has more than 10 years flying experience
06:22but has flown to Barcelona only once before smooth enough for you so far
06:32a bit bumpy back here
06:35first officer Murat it cool off 41 is the captain's second pair of eyes
06:40the flight is carrying a group of students and some of their parents on a school trip to Spain
06:55as Nielsen gives the Tupolev crew their transponder code
07:05I will tango Charlie 2937 squawk 7520
07:12the airbus crew on approach tries to confirm their landing instructions
07:17yes I expect so call you back shortly
07:31aeroloid 1135 send flight level seven zero
07:35flight level seven zero
07:37aeroloid 1135
07:40as the airbus gets closer to Friedrichshafen
07:44Nielsen calls the tower controller to hand off the aircraft
07:50but he can't get through
07:52find me the number for Friedrichshafen tower
07:54he tries again
08:04the desired connection is not possible
08:07please check the number
08:09I'm working out here
08:09aeroloid 1135
08:13aeroloid 1135 go ahead sir
08:17I lost my phone connection with Friedrichshafen
08:19can you please call them on 124.35 and tell them you're coming ILS 24 with 20 miles now
08:26okay
08:27will do
08:28thank you
08:32with the approaching airbus handed off
08:34Nielsen returns to his other aircraft
08:37the Tupolev passenger jet that's westbound to Barcelona
08:42and the Boeing cargo jet northbound to Luxembourg
08:49Nielsen notices that both planes are moving towards each other at 36,000 feet
08:58controllers will react
09:00they will do something to separate aircrafts
09:05Nielsen realizes that Tupolev is soon scheduled to descend to 35,000 feet
09:10Bravo Tango Charlie 2937 descend flight level 350
09:15expedite I have crossing traffic
09:19descending an aircraft is an automatic response for air traffic controllers
09:24because descending is a lot easier than climbing
09:28it's the easiest way to solve a conflict
09:32Bravo Tango Charlie 2937 descend level 350 expedite descent
09:37expedite descend level 350 bravo Tango Charlie 2937
09:46yes we have traffic in your position now at 360
09:52from the aeroloid 1135
09:54yes go ahead
09:56we've made contact with Friedrichshafen airport
09:59but then as the aeroloid flight signs off
10:10affirm bye bye
10:18the Boeing has disappeared from the controller's screen
10:21and the Tupolev's radar signal is lost
10:35Bravo Tango Charlie 2937
10:38air traffic controller peter nielsen has lost contact with two planes flying over southern germany
10:44he called the aircrafts and got no response
11:09he must have understood that it was a collision
11:14the plane
11:29near the town of uberlingen
11:31people watch as fireballs fall out of the sky
11:34huge sections of both planes have crashed to the ground
11:51there is no shortage of witnesses
11:53it is
12:12the first responders are on site within minutes
12:16And by dawn, crash investigators from Germany's Federal Bureau of Aircraft Accident Investigation, the BFU, are there too.
12:29At the accident site, you just document what the wreckage tells you.
12:39The wreckage of the Tupolev is spread over four distinct areas.
12:46There would be maybe 100 meters between some parts, so it clearly indicates that there must have been an in-flight breakup of the Tupolev.
13:00Most of the bowing is found in a forest outside the village of Teisersdorf, but one section is missing.
13:07The only part of the bowing that was missing was the vertical tail, and this later has been found together with parts from the Tupolev, indicating that the collision took place between the two aircraft.
13:2371 people are dead.
13:3345 of them are Russian students from the city of Ufa.
13:37Investigators soon recover much of the wreckage, including the black boxes from both planes.
14:00Hey, over here.
14:07But before they get readouts from the black boxes, investigators start to reconstruct the collision.
14:16So this piece is interesting.
14:18We, as accident investigators, did not have an idea about the details of what exactly happened.
14:30This red paint could have come from the Boeing.
14:33Mm-hmm.
14:35And then over here.
14:36The main issue is to understand which aircraft part collide with the other one, and which came from the impact to the ground.
14:50Okay, so I've marked all the areas where the red paint from the Boeing transferred onto the Tupolev.
14:58And we even found part of the Boeing's rudder embedded in the Tupolev right here.
15:06The only way this could have happened is if the Tupolev flew straight into the Boeing like this.
15:20The question is, how can it happen that two planes are at the same place at the same time?
15:44Okay, so we've compiled all of the radar data from air traffic control.
15:52Okay.
15:53Let's see what happened.
15:58Both planes are cruising at 36,000 feet.
16:03They both start descending.
16:06At exactly the same time.
16:07Neither one is trying to get out of the way.
16:1990 degrees at the same altitude is about as simple as it comes.
16:23A turn, a descent of one, a climb of one.
16:26So, how did we get to this point?
16:31It doesn't make sense.
16:32Why would both planes descend?
16:40We all were of the opinion that the air traffic control system in Europe would be very, very safe.
16:48So, it was really hard to understand that an accident like this could occur.
16:53So, let's explore this.
16:57Look at the weather data.
17:00The basic way for pilots to avoid collisions is called see and avoid.
17:07The pilots look out the window, see the other aircrafts, and don't collide.
17:12It was a clear night.
17:17No moon at the time of the collision.
17:20The sky was pitch black.
17:24Even with anti-collision lights, judging altitude and distance, would have been impossible.
17:29For jets operating at high altitudes, moving at seven miles a minute, finding some little dot even in a clear sky, is nearly impossible.
17:44So, we can eliminate that.
17:48What about ATC separation?
17:51Can we interview the controller yet?
17:53We're making arrangements to speak with him about the accident.
17:56And where are we at with the TCAS recovery?
17:59I'll check.
18:05The TCAS, or Traffic Collision Avoidance System, uses transponders on the aircraft to transmit a plane's location to others.
18:14If two aircraft appear to be on a collision course, an alarm sounds warning pilots to change course.
18:22TCAS is intended for, when we need a last-ditch effort, to just keep them from hitting.
18:29Yeah, thank you.
18:34We've got the tubal of TCAS, but no lock on the Boeing.
18:40It's too damaged.
18:40The major question for us, did the TCAS computer work as per design?
18:53The TCAS computer of the Boeing was destroyed completely.
18:58And that was a problem.
19:01If TCAS is at fault, it could threaten the safety of air travel throughout the world.
19:12Investigators looking into the Uberlinger mid-air collision examine the TCAS data from the Tupolev plane to determine if it was working properly.
19:21Wait a sec.
19:26The Tupolev's TCAS recorded data for both planes.
19:38There's an identical set of files for both flights.
19:42That was a big moment in the course of the investigation, and we were very happy about that.
19:52Investigators compare the TCAS altitude data with the radar data from both planes.
20:01The altitudes match perfectly.
20:04What instruction did TCAS give each plane?
20:07Start with the Boeing.
20:08Did TCAS provide each aircraft with the proper instructions to avoid each other?
20:19Told them to descend.
20:22Which the Boeing did.
20:26Now the Tupolev.
20:32Investigators discover that TCAS correctly advised the Tupolev pilots to climb.
20:38But they descended.
20:41Just like the Boeing.
20:43So why didn't they follow the TCAS instruction?
20:53TCAS did what TCAS should have done.
20:57If pilots would follow the TCAS instruction, TCAS would have prevented the accident.
21:03Investigators turned to the Tupolev's cockpit voice recording, or CVR, to determine why the Russian crew disobeyed the TCAS instruction.
21:14They first became aware of the Boeing two and a half minutes before the collision.
21:31They're still more than 25 miles apart.
21:39It's ample time to avoid the Boeing.
21:41So, why didn't they?
21:43Okay.
21:47We have the same altitude.
21:52It's coming towards us.
21:54For the next minute and a half, the crew discusses the Boeing's position.
22:09Here, visually.
22:10This is showing us zero.
22:15Zero on the TCAS means there is no difference in altitude between them and the approaching Boeing.
22:25They seem unsure if the Boeing is actually a threat.
22:29Agreed.
22:30But TCAS should warn them if the Boeing is getting too close.
22:34Traffic.
22:38Traffic.
22:38There it is.
22:40Traffic.
22:40Traffic.
22:41Traffic.
22:43Traffic.
22:44Traffic.
22:4550 seconds before impact, the TCAS issues the first oral warning when the oncoming plane is less than 10 miles away and closing fast.
22:54Traffic.
22:56Traffic.
22:58Moments later, the crew receives an instruction from air traffic control.
23:02Bravo Tango Charlie 2936.
23:05Send flight level 350.
23:08Expedite.
23:08I have crossing traffic.
23:10Descent.
23:13Followed by a different instruction from TCAS.
23:16One.
23:18One.
23:19One.
23:21One.
23:21One.
23:24The crew got conflicting instructions.
23:27TCAS told the crew to climb.
23:35One.
23:35One.
23:35One.
23:36The controller told them to descend.
23:38One.
23:39One.
23:39One.
23:39One.
23:39One.
23:39One.
23:39One.
23:40One.
23:40One.
23:40One.
23:40One.
23:41One.
23:41One.
23:41The controller is guiding us down.
23:43One.
23:43Descent?
23:44One.
23:44One.
23:45One.
23:45One.
23:45One.
23:46One.
23:46One.
23:46One.
23:47One.
23:47One.
23:48The captain follows the chief pilot's command and puts the plane into a steep descent.
23:53Bravo Tango Charlie 2937.
23:55Descend level 350.
23:58Expedite descent.
24:00Descend.
24:01Level 350.
24:03Bravo Tango Charlie 2937.
24:05Yes.
24:06We have traffic in your position now at 360.
24:14Moments from disaster, TCAS issues a final command.
24:18Increase one.
24:19Increase one.
24:20Increase one.
24:21Increase one.
24:22But it comes too late.
24:24Well, there we have it.
24:45The chief pilot followed the controller's instruction to descend instead of the TCAS' instruction
24:53to climb.
25:03Each one of these guys got TCAS training.
25:08They should have known that TCAS is the final authority.
25:13So why did the chief pilot listen to the controller instead of TCAS?
25:18No.
25:28Investigators of the Uberlingon disaster examined the TCAS training of the Russian crew
25:34to determine why they followed the ATC instruction instead of TCAS.
25:39Hey, I think I found something. TCAS-2000 is intended as a backup to visual collision avoidance, application of right-of-way rules, and ATC separation services.
25:53A backup?
26:00Look at this.
26:01For the avoidance of in-flight collisions, instructions issued by ATC is the most important tool. TCAS is an additional instrument.
26:15So, if it comes down to TCAS versus ATC, the Russian pilots go with the ATC's instructions?
26:23It seems that way.
26:24We asked Russian flight crews, and pilots told us, yes, it's a backup for ATC.
26:34And so, they explained that the flight crew of the Tupolev did what they should have done.
26:41But the Boeing crew followed the TCAS instruction.
26:47Descend. Descend.
26:50I wonder if they informed the controller they were descending.
26:57The final approach weeks for ILS runway 24.
27:00Did the controller know the Boeing was also descending?
27:04Call you back shortly.
27:07Let's have a listen to the cockpit voice recording.
27:11For the flight crews, there's a clear operating procedure.
27:15As soon as possible, they have to report it to ATC.
27:21That was the reason why we had to listen to the Boeing cockpit voice recorder.
27:25Ah, Swiss radar. Good evening.
27:27Tillman 611.
27:30Tillman 611.
27:31Climb flight level 360.
27:34Climb flight level 360.
27:37Tillman 611.
27:38The flight is uneventful, right up until a minute before the collision.
27:45First officer, Brandt Campione, sees an opportunity to take a quick break.
27:51Just got to use the facilities.
27:55Handing over?
27:57Okay, taking over.
27:58Well...
27:58Captain Paul Phillips takes control of the flight.
28:04Anything can get you?
28:09No, I'm good.
28:13Traffic.
28:14Traffic.
28:16Traffic.
28:17That's the TCAS' first conflict alert.
28:20Descend.
28:22Descend.
28:24Descend.
28:25Descend.
28:26Descend.
28:34Descend.
28:36Descend.
28:36Elk.
28:37Elk.
28:37Traffic.
28:38Right there.
28:39Yep.
28:4150 seconds before the collision, TCAS warns the Boeing crew of the Tupolevs' approach.
28:47Increase descent.
28:48Increase descent.
28:50Increase?
28:50Increase descent.
28:52Increase descent.
28:55DELMA 600.
29:01TECAS descent.
29:02Descend.
29:04No doubt about it. They informed the ATC that they were descending.
29:13Let's hear the rest.
29:19Increase descent. Increase descent.
29:23Descent!
29:25Increase descent.
29:27Descent hard!
29:34Descent hard!
29:41Descent hard!
29:54Okay, so the Boeing crew did nothing wrong.
29:58They followed TCAS and informed the controller.
30:02But the controller instructs the Tupolev to descend twice.
30:09Warns them about the crossing traffic.
30:14And then immediately, the Boeing reports it's descending.
30:19He's still got two planes on a collision course.
30:22He's already been talking to the Tupolev crew, so why didn't he just tell them to change course and climb?
30:32If the controller knew the Boeing was descending, why did he let the Tupolev also descend?
30:39The major part of the investigation was to identify what the controller did and how he did perform his job.
30:49Did Peter Nielsen's actions play a role in the Uberlingen mid-air collision?
30:56Bravo Tango Charlie 2937, expedite descent.
31:04Investigators listened to Peter Nielsen's radio transmissions to determine how two planes on his watch could have collided over Uberlingen Germany.
31:12Let's start 30 seconds before the collision, when the Boeing pilots informed the controller of their descent.
31:21Descenting flight level 7-0, aeroloid 1-1-3-5.
31:27That sounds like the controller was talking to a third aircraft.
31:34Just as the Boeing aircraft advised the controller of their TCAS descent.
31:39Dillon 600, TCAS descent.
31:410-0, aeroloid 1-1-3-5.
31:42Yes, go ahead.
31:44The controller received a simultaneous message from another aircraft.
31:48We've made contact with Frederick Schiffen Airport.
31:51So the call from the Boeing crew came in at exactly the same time as the controller was dealing with the aeroloid flight.
32:02When the Boeing pilots mentioned TCAS descent, he probably didn't even hear it,
32:07or it just was something that he didn't process as an issue, thinking that everything over on that airspace was already taken care of.
32:14But juggling three planes isn't unusual. There's got to be more to this.
32:23Investigators listen to earlier parts of the ATC recording.
32:29Zurich, good evening. Bravo, Tanko Charles, 2937.
32:35Hello, aeroloid 1-1-3-5.
32:36They hear the Tupolev and Aeroloid flights competing for Nielsen's attention.
32:46Aeroloid 1-1-3-5, Roger.
32:49Good evening.
32:51Bravo, Tanko Charlie, 2937.
32:52Call you back.
32:56Station calling, say again, please.
32:58Zurich, good evening.
33:00Bravo, Tanko Charlie, 2937.
33:03Level 360.
33:04Aeroloid 1-1-3-5.
33:10Aeroloid 1-1-3-5, descend flight level 7-0.
33:13During the last five minutes before the collision, the workload increased very much.
33:21Investigators hear Nielsen having difficulty contacting the airport where the aeroloid flight was due to land.
33:29The desired connection is not possible.
33:33Find me the number for Friedrichshafen Tower.
33:37How many times does he try calling Friedrichshafen?
33:42Seven.
33:44He spent a lot of time on something that should have taken seconds.
33:47The desired connection is not possible. Please check the number.
33:56This isn't working either.
33:57So, how did he end up in this situation in the first place?
34:09Normally, an inbound call is just a few seconds.
34:11But dealing with the communication system took a lot of time that then allowed the two collision aircraft to get ever closer at this very high rate of speed.
34:26Thanks for coming in.
34:31Investigators interview Peter Nielsen to assess his workload on the night of the accident.
34:37So, at the time of the accident, you seem to be working two different workstations. Why?
34:47There are two controllers on the night shift, but one controller always takes a rest as traffic decreases for the night.
34:52You're off. See you in a few hours.
35:04They come back in the morning when traffic picks up.
35:08And is that standard procedure?
35:13It's not written down anywhere in company policies, but management lets us do it.
35:21Okay.
35:24So, 13 seconds before the collision, the Boeing radioed that they were doing a TCAS descent.
35:31Did you hear that transmission?
35:34No, I didn't.
35:35I guess I was dealing with the AeroLoid flight approaching Friedrichshafen.
35:41Couldn't get through to the airport.
35:43The phone was down for some reason.
35:47Is there anything else you can think of that might help us?
35:51Yeah.
35:54Normally, the computer system issues an alert well before two planes get too close together.
36:00But I never got that alert.
36:05The air traffic control radar system has what's called conflict alert system.
36:19It's looking at the airplanes and based on their current speed and altitude and heading is projecting out to see if airplanes are coming into conflict with each other.
36:29The controller was under very high pressure during the last minutes.
36:33The controller was under very high pressure during the last minutes.
36:37Expedite descend, level 350.
36:40It was, at the end for him, a really difficult situation.
36:45Was Peter Nielsen fully equipped to prevent the collision that cost the lives of 71 people?
36:56Investigators interview officials from Sky Guide to find out why Peter Nielsen never received a warning of the impending collision above Uberlingen, Germany.
37:08Why were the control systems conflict alert and telephones both down?
37:19What's this?
37:21A work order for a computer upgrade.
37:29A new software was to be implemented on the main screen, which meant that the controller had to work on the backup system.
37:38The software in the telephone system also had to be updated.
37:42So, is this why there was no phone or visual conflict alert?
37:50Yes.
37:52But it doesn't say that anywhere.
37:58Was Nielsen warned about this before his shift?
38:02Not that I'm aware.
38:03One other thing.
38:06Why does management allow one of the controllers working nights to be on break most of the shift?
38:16It started when there were three controllers at night.
38:19But there are only two now.
38:24We didn't change the practice.
38:34That was the way they did it.
38:38One controller on screen and the other was on break.
38:42And this was accepted by the management.
38:45Bravo Tango Charlie 2937.
38:48Descend flight level 350.
38:50Climb.
38:52It says climb.
38:54The controller is guiding us down.
38:56Descend? Really?
38:58We're going to descend?
39:00Investigators now understand.
39:01Bravo Tango Charlie 2937.
39:05Descend level 350.
39:06Expedite descent.
39:08Expedite descent.
39:10Level 350.
39:12Bravo Tango Charlie 2937.
39:14Why two flights...
39:16Descend?
39:18Descend hard!
39:20Ended in disaster.
39:21Ended in disaster.
39:22Ended in disaster.
39:23Ended in disaster.
39:36Ending.
39:37while completing their final report BFU hello what the story of the uberling
39:56and midair collision takes another tragic turn on February the 24th 2004 almost two years after
40:10the uberling and disaster Peter Nielsen is murdered in his front garden his wife and three children
40:17are witnesses to the crime we couldn't believe it we couldn't believe it because it was for
40:26us like a TV story and it was not a real life but yes it was real life did they catch the killer
40:40yeah apparently his family was on the troupe live
40:47a Russian man Vitaly Kaloyev is arrested for Peter Nielsen's murder
41:00Kaloyev's wife and two children were killed in the uberling and collision he tells police he went to
41:11Nielsen's house seeking an apology but Nielsen isn't found at fault for the collision in the BFU's final
41:26report instead it concludes he was unable to safely carry out the tasks required of him the BFU points
41:45to the fact that Nielsen was working alone as a cause for the accident
41:50but the report also highlights deficiencies in aviation regulations that allowed for the Russian
42:09pilots confusion over the use of TCAS it says climb on the controller is guiding us down descend we're going
42:18to descend the BFU's most prominent recommendation is simple pilots have to follow the TCAS instruction
42:31not to follow the ATC instruction because TICAS is a safety net eventually four sky guide middle managers who
42:43weren't even working the night of the uberling and disaster are convicted of negligent homicide
42:48this accident it was really a watershed event a lot of things had to fall into place just the wrong ways for this to occur
43:00I mean it changed a lot of things
43:03a lot of the way people looked at ATC collision avoidance and it really woke a lot of people up
43:11in 2005 Vitaly Kaloyev is convicted of the premeditated homicide of Peter Nielsen
43:22two years later he's released from prison
43:28today nine steel pearls representing a torn necklace mark the locations where victims bodies were found
43:48and a memorial inside sky guide marks both the date of the collision and that of Peter Nielsen's murder
43:58you