Bashkirian Airlines Flight 2937
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Bashkirian Airlines Flight 2937 was a Russian aircraft which collided with a DHL-owned cargo plane, on July 1, 2002 at 21:35 (UTC), near the German town of Überlingen, near Lake Constance.
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The flights involved
The Bashkirian Airlines plane was a Tupolev 154, travelling from Moscow to Barcelona carrying 57 passengers and 12 crew. Fifty-two of the passengers were Russian children, whose school had won them a trip to Spain.
The DHL plane was a Boeing 757, travelling from Bergamo, Italy, to Brussels with two crewmembers aboard.
The accident itself
The two planes were flying at 36,000 feet, on a collision course. The air space, even though it lies in Germany, was controlled from Zürich by the private Swiss airspace control company Skyguide.
The air-traffic controller was working two work stations at the same time and was late to realise the danger facing the two planes. However, less than a minute before the crash he did contact the Russian plane, instructing the pilot to descend by 1,000 feet to avoid collision with crossing traffic (i.e., the DHL Boeing). Seconds after the Russian crew initiated the descent, their TCAS collision avoidance system instructed them to climb, while at about the same time the TCAS on the DHL flight instructed that pilot to descend. Had both planes followed those instructions, the collision may not have occurred. The DHL pilot followed the TCAS instructions and initiated a descent, but the Russian pilot did not, continuing to obey the airspace control instructions, as per standard operating procedures as set out in Russian aviation law.
Unaware of the TCAS-issued alerts, the air-traffic controller at Zürich repeated his instruction to the Russian plane to descend, giving the crew incorrect information as to the position of the other plane. Precious seconds were lost as the Tupolev crew tried to locate the DHL flight visually in the dark, all the time following the ground control orders instead of those given by the collision avoidance system. Thus, both planes descended.
The results were fatal. The planes collided at a right angle, and all 71 people were killed.
Other factors in the crash
Only a single air-traffic controller, Peter Nielsen of ACC Zürich, was controlling the airspace the planes were in. His colleague had taken an unauthorized break, and he was apparently overburdened. Nielsen was handling two workstations at once, he did not spot the danger until about a minute before impact. Part of the reason for that was that he was distracted by another collision risk which he spotted on his absent colleague's station, and which demanded his attention for a few minutes that would have been crucial to prevent the Bashkirian disaster. Had he ordered the Russian plane to descend earlier, the collision avoidance systems would never have issued any instructions.
In addition, a ground based collision warning system, which would have alerted the controller to imminent collisions early, had been switched off for maintenance. Phone lines at Skyguide were down, also as part of maintenance work, which prevented adjacent air-traffic controllers at Karlsruhe from phoning in a warning. Nielsen, when he realized that the situation (the multiple factors in two workstations) was overwhelming, tried to call for assistance, but was unable to get through due to the communications malfunction in Skyguide. Finally, the Bashkirian crew was delayed in getting vital instructions from Nielsen, as their transmission calling for instructions on how to avoid the DHL plane was blocked by the Skyguide transmission to the cargo plane. In essence, while Nielsen was speaking to the DHL flight, the early calls for assistance from the Russian crew could not be received by the controller. This caused a 23-second delay in Nielsen's response to the commercial flight, which could also have made a difference in avoiding the collision.
Related events
Many believe that this accident could have been avoided if the proper lessons had been taken from a similar incident which did not result in a midair collision by very little. About one year before the Bashkirian-DHL collision, two Japanese airliners, one of them from Japan Air, nearly missed each other in Japanese skies. The two planes were in a collision course, and the pilots of both planes were getting conflicting instructions from their TCAS units and the flight controller. Disaster was avoided because, by sheer luck, both pilots, each unaware of the other's decisions, followed the TCAS instructions, ignoring the controller's orders. Even so, they missed each other by less than 100 meters, and the brusque maneuvers that were necessary to avert disaster left about a hundred passengers hurt, a few of them suffered severe injuries. Japanese authorities called for measures that would prevent similar accidents from happening, but their request went unanswered.
Peter Nielsen was stabbed to death in front of his home in Zürich on February 24, 2004. A Russian man, Vitaly Kaloyev, was arrested within a few days. Kaloyev had lost his wife and both of his children, who were aboard Bashkirian Airlines 2937. He is reported to have suffered a nervous breakdown following the loss of his entire family, especially since he was one of the first relatives to arrive at the crash site. Kaloyev participated in the search for the bodies and, tragically enough, located his own daughter's body, which was surprisingly intact (unlike his wife's and son's, which were found only days later, mutilated). Kaloyev spent the first year after the accident lingering in the graves of his family, and on the memorial service for the first anniversary of the tragedy, in 2003, he inquired the head of Skyguide about the possibility of meeting the controller who had been responsible for the disaster. He was ignored. After travelling to Zürich and stabbing Nielsen, Kaloyev was found in his hotel room, apparently in shock. He claimed having no memory of what he had done, and was taken to a mental hospital, where he was to be evaluated in order to determine if he is fit to stand trial. He remains incarcerated in Switzerland.
The entire situation is made more tragic by the fact that Nielsen was not the sole responsible for the collision. As it is explained above, a series of coincidences played a key role for the accident to happen, but Kaloyev was unaware of the circumstances leading to the accident. Experts have argued that, given what happened, Nielsen could not even be blamed for the disaster. He could have prevented it, had he been fortunate enough to notice the risk of collision sooner, but since he did not, many factors made it nearly impossible for Nielsen, or anyone who had been there, to prevent the accident. In fact, Nielsen had retired from his job as controller, since he had been struck by grief and guilt over the incident. At Skyguide, his former colleagues maintain, to this day, a vase with a white rose over Nielsen's workstation.
On May 19, 2004, the German federal aviation accident investigative office BFU made the results of their inquiry into the crash public. Skyguide, after initially having blamed the Russian pilot for the accident, accepted responsibility and has paid compensation to some of the Russian families. A criminal investigation of the Skyguide actions is ongoing as of May 2004.
External links
- Investigation Report of the German BFU (http://www.bfu-web.de/berichte/02_ax001efr.pdf) (PDF), and also:
- Appendices 1 and 3 (http://www.bfu-web.de/berichte/02_ax001ea1.pdf)
- Appendices 2 and 4-10 (http://www.bfu-web.de/berichte/02_ax001ea2.pdf)
- Intermediary report by the German BFU (http://www.skyguide.ch/scripts/ueberlingen_docs/happen/e/BFUStatus_Aug02_E.pdf) (PDF)
- Guardian piece on the murder (http://www.guardian.co.uk/russia/article/0,2763,1158361,00.html)
- Skyguide accepts blame for the crash (http://www.russiajournal.com/news/cnews-article.shtml?nd=43853)
- Photos of the crash site (http://www.airdisaster.com/photos/bts2937/photo.shtml)
- Peter Nielsen stabbed to death: http://www.theage.com.au/articles/2004/02/28/1077677014178.html
- A woman accompanying the air traffic controller?: http://english.pravda.ru/world/2002/07/13/32439.html