- hace 10 horas
El 1 de julio de 2002, la tripulación del vuelo 2397 de Bashkirian Airlines desobedeció el sistema de alerta de tráfico y evasión de colisión (TCAS) e impactó con el vuelo 611 de DHL, en el espacio aéreo alemán, cerca de Überlingen, matando a las 71 personas a bordo de ambas aeronaves. Los pilotos del vuelo 611 siguieron las advertencias del TCAS que les indicó descender. Sin embargo, los pilotos del vuelo 2397 obedecieron al controlador de tráfico aéreo en vez del TCAS y descendieron. Había un solo controlador a cargo de dos pantallas, ya que su compañero estaba tomando un descanso.
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TVTranscripción
00:03A horrible collision in the skies above southern Germany
00:09Is witnessed by people on the ground
00:2371 people are dead
00:28We as excellent investigators did not have an idea of what exactly happened
00:35It 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
00:45Descend? Really? We're going to descend?
00:48Expedite, 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
01:27It's 11pm in Switzerland
01:30And airports across the region are closing down for the night
01:40You're off
01:42See you in a few hours
01:43In the Sky Guide Control Center in Zurich
01:47Tie, enter 933, proceed to Algoy
01:49Copy, proceed to Algoy
01:51Tie, enter 933
01:53Air traffic controller Peter Nielsen is working the night shift
01:58Varian 305, descend flight level 220
02:03He's been on the clock for just over three hours
02:06And has six more to go
02:12Tom Lawson is a former Sky Guide controller
02:15Who worked with Peter Nielsen
02:19The night shift in Zurich at the time had quite a lot of traffic
02:23But around 11.30, 12 o'clock
02:26Reduced to five to seven aircrafts an hour
02:29And it was possible to do it alone
02:31Top Swiss 935, proceed direct to Torpa
02:35Direct to Torpa, Top Swiss 935, thank you
02:40Nielsen manages the safe transit of all aircraft in his airspace
02:44For further instructions, contact Padua 120.72
02:49Bye-bye
02:52Air traffic control is one of the most stressful jobs in the world
02:55And a lot of it does hinge on decisions made by one person
03:01Ah, Swiss radar, good evening
03:03Tillman 611
03:05Nielsen hears from another plane in his airspace
03:09Just levelling at flight level 260
03:14Dillman 611 is the call sign for a Boeing cargo jet
03:19Owned by the courier DHL
03:23It departed from Bergamo, Italy
03:25And is flying through Swiss, then German airspace
03:28On its way to Brussels, Belgium
03:32Dillman 611, squawk 7524
03:367524
03:37611
03:41Dillman 611
03:42Climb flight level 320
03:47Nielsen clears the flight to climb to a higher altitude
03:50Roger, climb flight level 320
03:53And requesting 360, thanks, if it's available
03:58Pilots ask for the most efficient flight level that they can fly at
04:03And in this case 36,000 feet is much more fuel efficient
04:07Dillman 611, climb flight level 360
04:12Climb flight level 360
04:14Dillman 611
04:21Nielsen clears flight 611 to 36,000 feet
04:26And tracks the change
04:30You use flight strips to plan the traffic ahead
04:34With the strips and flight screen
04:37We have a good picture of what is going to happen
04:43But at 1130, Nielsen's night shift takes a turn
04:48Zürich, good evening
04:50Bravo Tango Charlie, 2937
04:562 transmissions come in together
04:59One at the workstation beside him
05:04There's an airbus on approach to Friedrichshafen
05:08And another plane flying at a higher altitude
05:12In the upper sector
05:15Aeroloid 1135
05:17Descending flight level 80
05:19Nielsen briefly responds to the airbus now on approach
05:23Aeroloid 1135, Roger
05:26Call you back
05:31He needs to identify the aircraft now entering the upper sector
05:37Station calling, say again please
05:39Ah, Zürich, good evening
05:43The aircraft is a Bashkirian Airlines Tupolev 154
05:51The Russian plane is slightly ahead of schedule
05:54Crossing from Moscow to Barcelona
05:58Bravo Tango Charlie, 2937
06:01Level 360
06:0940-year-old Oleg Grigoryev is Bashkirian Airlines chief pilot
06:14Tonight he's evaluating the 52-year-old captain Alexander Gross
06:19Who has more than 10 years flying experience
06:22But has flown to Barcelona only once before
06:25Smooth enough for you
06:27So far
06:32It's a bit bumpy back here
06:35First officer Murat Itkulov, 41
06:38Is the captain's second pair of eyes
06:40Then you better tighten your belt, eh?
06:49The flight is carrying a group of students
06:51And some of their parents
06:53On a school trip to Spain
07:00As Nielsen gives the Tupolev crew their transponder code
07:04Bravo Tango Charlie, 2937
07:06Squawk, uh, 7520
07:09Is inbound, the final approach
07:12The Airbus crew on approach
07:14Tries to confirm their landing instructions
07:17Yes, I expect so
07:18Call you back shortly
07:39As the Airbus gets closer to Friedrichshafen
07:43Nielsen calls the tower controller
07:46To hand off the aircraft
07:47The desired connection is not possible
07:49But he can't get through
07:52Find me the number for Friedrichshafen tower
08:03He tries again
08:04The desired connection is not possible
08:07Please check the number
08:12Air Lloyd, 1135
08:14Air Lloyd, 1135
08:16Go ahead, sir
08:17I lost my phone connection with Friedrichshafen
08:20Can you please call them on 124.35
08:22And tell them you're coming ILS 24 with 20 miles now?
08:26Okay, will do
08:27Thank you
08:31With the approaching Airbus handed off
08:34Nielsen returns to his other aircraft
08:37The Tupolev passenger jet
08:39That's westbound to Barcelona
08:41And the Boeing cargo jet
08:44Northbound to Luxembourg
08:50Nielsen notices that both planes
08:53Are moving towards each other
08:54At 36,000 feet
08:58Controllers will react
08:59They will do something
09:01To separate aircraft
09:05Nielsen realizes
09:06The Tupolev is soon scheduled
09:08To descend to 35,000 feet
09:10Bravo Tango Charlie 2937
09:12Descend flight level 350
09:15Expedite
09:16I have crossing traffic
09:19Descending an aircraft
09:21Is an automatic response
09:23For air traffic controllers
09:24Because descending
09:25Is a lot easier than climbing
09:27It's the easiest way
09:30To solve a conflict
09:32Bravo Tango Charlie 2937
09:34Descend level 350
09:36Expedite descent
09:37Expedite descent
09:39Level 350
09:40Bravo Tango Charlie 2937
09:45Yes, we have traffic
09:47In your position now at 360
09:53Yes, go ahead
10:00But then
10:02As the Aero-Lloyd flight
10:04Signs off
10:10Affirm, bye-bye
10:11Bye-bye
10:17The Boeing has disappeared
10:19From the controller's screen
10:22And the Tupolev's radar signal
10:24Is lost
10:34Bravo Tango Charlie 2937
10:37Air traffic controller
10:39Peter Nielsen
10:40Has lost contact
10:41With two planes
10:43Flying over southern Germany
10:46Bravo Tango Charlie 2937
10:52He called the aircraft
10:53And got no response
11:09He must have understood
11:10That it was a collision
11:29Near the town of Uberlingen
11:31People watch as fireballs
11:33Fall out of the sky
11:43Huge sections of both planes
11:45Have crashed to the ground
11:50There is no shortage of witnesses
12:13First responders are on site within minutes
12:16And by dawn
12:19Crash investigators
12:20From Germany's Federal Bureau
12:22Of Aircraft Accident Investigation
12:24The BFU
12:25Are there too
12:29At the accident site
12:31You just document
12:32What the wreckage
12:35Tells you
12:39The wreckage
12:40Of the Tupolev
12:41Is spread over four distinct areas
12:48There would be
12:49Maybe a hundred meters
12:51Between some parts
12:52So it clearly indicates
12:54That there must have been
12:55An in-flight breakup
12:56Of the Tupolev
13:00Most of the Boeing
13:01Is found in a forest
13:02Outside the village
13:04Of Teisersdorf
13:05But one section
13:06Is missing
13:09The only part of the Boeing
13:11That was missing
13:12Was the vertical tail
13:13And this later
13:15Has been found
13:16Together with parts
13:17From the Tupolev
13:18Indicating that
13:20The collision took place
13:21Between the two aircraft
13:2871 people are dead
13:3345 of them
13:35Are Russian students
13:36From the city
13:36Of Ufa
13:55Investigators soon recover
13:56Much of the wreckage
13:57Including the black boxes
13:59From both planes
14:04Hey
14:05Over here
14:07But before they get
14:08Readouts from the black boxes
14:10Investigators start to
14:12Reconstruct the collision
14:16So this piece is interesting
14:20We as excellent investigators
14:22Did not have an idea
14:25About the details
14:26Of what exactly happened
14:29This red paint
14:31Could have come from the Boeing
14:34And then over here
14:37And then over here
14:37The main issue is
14:39To understand
14:40Which aircraft part
14:42Collide with the other one
14:44And which came
14:45From the impact
14:46To the ground
14:50Okay so
14:51I've marked all the areas
14:53Where the red paint
14:54From the Boeing
14:55Transferred onto the Tupolev
14:57And we even found
14:59Part of the Boeing's rudder
15:01Embedded in the Tupolev
15:03Right here
15:05The only way
15:08This could have happened
15:11Is
15:12If the Tupolev
15:14Flew straight
15:15Into the Boeing
15:16Like
15:19This
15:31The question is
15:33How can it happen
15:34That two planes
15:35Are at the same place
15:37At the same time
15:43Thank you
15:47Okay
15:47So
15:48We've compiled
15:49All of the radar data
15:50From air traffic control
15:52Okay
15:53Let's see what happened
15:58Both planes are cruising
15:59At 36,000 feet
16:03They both start descending
16:06At exactly the same time
16:11Neither one is trying
16:12To get out of the way
16:1990 degrees
16:20At the same altitude
16:21It's about as simple
16:22As it comes
16:22A turn
16:23A descent of one
16:24A climb of one
16:26So how did we get
16:27To this point
16:29It doesn't make sense
16:32Why would
16:32Both planes
16:33Descend
16:38We all were of the opinion
16:40That the air traffic
16:42Control system
16:43In Europe
16:43Would be very
16:44Very safe
16:47So it was really
16:48Hard to understand
16:49That an accident
16:50Like this
16:51Could occur
16:53Let's explore this
16:55Get the weather data
16:58The basic way
17:00For pilots to avoid collisions
17:02Is called
17:03See and avoid
17:04The pilots look out the window
17:06See the other aircrafts
17:07And
17:09Don't collide
17:11It was a clear night
17:14No moon at the time
17:15Of the collision
17:17The sky was pitch black
17:21Even with anti-collision lights
17:22Judging altitude
17:23And distance
17:24Would have been impossible
17:29For jets operating
17:30At high altitudes
17:31Moving at
17:32Seven miles a minute
17:34Finding some little dot
17:36Even in a clear sky
17:37Is
17:38Nearly impossible
17:39So
17:40We can eliminate that
17:43What about
17:44ATC separation
17:45Can we
17:46Interview
17:46Making arrangements
17:47To speak with him
17:48About the accident
17:49Where are we at
17:50With the TCAS
17:51I'll check
17:57The TCAS
17:59Or traffic collision
18:00Avoidance system
18:01Uses transponders
18:03On the aircraft
18:04To transmit a plane's
18:05Location to others
18:06If two aircraft
18:08Appeared on a collision course
18:10Traffic
18:10Traffic
18:11An alarm sounds
18:13Warning pilots
18:14To change course
18:15TCAS
18:17Is intended for
18:18When we need
18:18A last ditch effort
18:19To just
18:20Keep them from hitting
18:21Yeah
18:22Thank you
18:26We got the two below
18:27TCAS
18:28But no lock
18:29On the Boeing
18:29It's too damaged
18:35The major question was
18:37Did the TCAS computer
18:39Work as per design
18:42The TCAS computer
18:44Of the Boeing
18:45Was destroyed completely
18:47And that was the problem
18:50If TCAS is at fault
18:53It could threaten
18:54The safety of air travel
18:56Throughout the world
19:02Investigators looking into
19:03The Uberlingon midair collision
19:05Examine the TCAS data
19:07From the Tupolev plane
19:08To determine if it was
19:10Working properly
19:15Wait a sec
19:21The Tupolev TCAS recorded data
19:23For both planes
19:28There's an identical set of files
19:30For both flights
19:33That was a big moment
19:34In the course
19:35Of the investigation
19:36And we were very happy
19:37About that
19:42Investigators compare
19:43The TCAS altitude data
19:45With the radar data
19:47From both planes
19:50The altitudes match perfectly
19:52What instruction
19:54Did TCAS give each plane?
19:57Start with the Boeing
20:00Did TCAS provide each aircraft
20:03With the proper instructions
20:04To avoid each other?
20:09Told them to descend
20:12Which the Boeing did
20:16Now the Tupolev
20:22Investigators discover
20:24That TCAS correctly advised
20:26The Tupolev pilots to climb
20:28But they descended
20:31Just like the Boeing
20:33So why didn't they follow
20:36The TCAS instruction?
20:43TCAS did what TCAS should have done
20:47If pilots would follow
20:50The TCAS instruction
20:51TCAS would have prevented
20:52The accident
20:55Investigators turned
20:56To the Tupolev's cockpit
20:58Voice recording
20:59Or CVR
21:00To determine why
21:01The Russian crew
21:02Disobeyed the TCAS instruction
21:08Look here
21:09On the VSI
21:11There's a plane
21:13Approaching on our left
21:17They first became aware
21:19Of the Boeing
21:20Two and a half minutes
21:21Before the collision
21:26They're still more than
21:2825 miles apart
21:29It's ample time
21:31To avoid the Boeing
21:31So why didn't they?
21:38We have the same altitude
21:43It's coming towards us
21:46No
21:47He has a parallel heading
21:54For the next minute and a half
21:56The crew discusses
21:58The Boeing's position
21:59Here
22:00Visually
22:03This is showing us zero
22:06Zero on the TCAS
22:08Means there is no difference
22:09In altitude
22:10Between them
22:11And the approaching Boeing
22:16They seem
22:18Unsure if the Boeing
22:19Is actually a threat
22:21Agreed
22:21But TCAS
22:23Should warn them
22:24If the Boeing
22:25Is getting too close
22:28Traffic
22:30Traffic
22:30There it is
22:30Traffic
22:31Traffic
22:33Traffic
22:33Traffic
22:34Traffic
22:35Traffic
22:3550 seconds before impact
22:38The TCAS issues
22:39The first oral warning
22:41When the oncoming plane
22:42Is less than 10 miles away
22:44And closing fast
22:46Traffic
22:46Traffic
22:50Moments later
22:51The crew receives an instruction
22:53From air traffic control
22:54Bravo Tango Charlie
22:552937
22:56Ascent flight level
22:58350
22:59Expedite
23:00I have crossing traffic
23:01Descent
23:04Ascent flight level
23:06350
23:07Expedite
23:08I have crossing traffic
23:09Descent
23:18Ascent flight level
23:19350
23:20Expedite
23:22I have crossing traffic
23:23Descent
23:25Instruction from TCAS
23:27One
23:28One
23:30One
23:35The crew got
23:36Conflicting instructions
23:43TCAS told the crew
23:45To climb
23:46Descend
23:47Level
23:47350
23:48Expedite
23:50Descent
23:50Descend
23:52Level
23:53350
23:53Bravo Tango
23:55Charlie
23:552937
23:56Yes
23:58We have traffic
23:59In your position
24:00Now at 360
24:06Moments from disaster
24:07TCAS issues
24:08A final command
24:10Increase
24:11Flight
24:12Increase
24:13Flight
24:14But it comes
24:15Too late
24:35Well
24:35There we have it
24:38The chief pilot
24:40Followed the controller's
24:41Instruction to descend
24:42Instead of the TCAS's
24:44Instruction to climb
24:55Each one of these guys
24:57Got TCAS training
25:00They should have known
25:01The TCAS is the final authority
25:05So
25:05Why did the chief pilot
25:07Listen to the controller
25:09Instead of TCAS
25:21Investigators of the Uberlingon disaster
25:23Examined the TCAS training
25:25Of the Russian crew
25:26To determine why they followed
25:28The ATC instruction
25:30Instead of TCAS
25:32Hey
25:33I think I found something
25:36TCAS 2000
25:38Is intended as a backup
25:40To visual collision avoidance
25:42Application of right-of-way rules
25:43And ATC separation services
25:45A backup
25:51Look at this
25:55For the avoidance
25:57For the avoidance of in-flight collisions
25:58Instructions issued by ATC
26:00Is the most important tool
26:02TCAS is an additional instrument
26:07So
26:08If it comes down to TCAS
26:10Versus ATC
26:11The Russian pilots
26:13Go with the ATC's instructions
26:15It seems that way
26:20We asked Russian flight crews
26:22And pilots told us
26:24Yes, it's a backup
26:25For ATC
26:26And so
26:27They explained that
26:28The flight crew of the Tupolev
26:30Did what they should have done
26:34But
26:35The Boeing crew
26:37Followed the TCAS instruction
26:39Descend
26:42Descend
26:44I wonder
26:45If they informed
26:47The controller
26:48They were descending
26:49The final approach
26:51VIX for ILS runway
26:53Did the controller know
26:55The Boeing was also descending
26:57Call you back shortly
27:00Let's have a listen
27:02To the cockpit voice recording
27:05For the flight crews
27:06There's a clear operating procedure
27:09As soon as possible
27:11They have to report it to ATC
27:14That was the reason
27:15Why we had to listen
27:16To the Boeing cockpit voice recorder
27:18Ah, Swiss radar
27:19Good evening
27:20Dillman 611
27:23Dillman 611
27:25Climb flight level 360
27:28Climb flight level 360
27:30Dillman 611
27:31Dillman 611
27:33The flight is uneventful
27:35Right up until a minute
27:36Before the collision
27:38First officer
27:39Brandt Campione
27:40Sees an opportunity
27:42To take a quick break
27:45Just got to use the facilities
27:48Handing over
27:50Okay, taking over
27:55Captain Paul Phillips
27:57Takes control
27:58Of the flight
28:00Anything can get you?
28:02No, I'm good
28:06Traffic
28:07Traffic
28:09Traffic
28:10That's the TCAS'
28:12First conflict alert
28:14Descend
28:15Descend
28:19Descend
28:31Traffic
28:32Right there
28:33Yep
28:3450 seconds
28:36Before the collision
28:37TCAS warns
28:38The Boeing crew
28:39Of the Tupolev's approach
28:40Increase descent
28:42Increase descent
28:44Increase?
28:45Increase descent
28:46Increase descent
29:14Increase descent
29:16Increase descent
29:18Increase descent
29:18Descend
29:20Descend
29:21Descend
29:23Descend
29:24Board
29:24Increase descent
29:25Descend
29:25Descend
29:25Descend
29:42Descend
29:43Horde
29:44Okay, so the Boeing crew did nothing wrong.
29:48They followed TCAS and informed the controller.
29:52But the controller instructs the Tupolev to descend twice, warns them about the crossing traffic.
30:03And then immediately the Boeing reports it's descending.
30:09He's still got two planes on a collision course.
30:12He's already been talking to the Tupolev crew, so why didn't he just tell them to change course and climb?
30:22If the controller knew the Boeing was descending, why did he let the Tupolev also descend?
30:31The major part of the investigation was to identify what the controller did and how he did perform his job.
30:40Did Peter Nielsen's actions play a role in the Uberlingen mid-air collision?
30:46Bravo Tango Charlie 2937, expedite descent.
30:55Investigators listened to Peter Nielsen's radio transmissions to determine how two planes on his watch could have collided over Uberlingen,
31:03Germany.
31:04Let's start 30 seconds before the collision, when the Boeing pilots informed the controller of their descent.
31:14Descenting flight level 7-0, aero-loid 1-1-3-5.
31:19This sounds like the controller was talking to a third aircraft.
31:24Just as the Boeing aircraft advised the controller of their TCAS descent...
31:29Filming 600, TCAS descent.
31:31Aero-loid 1-1-3-5.
31:33Yes, go ahead.
31:34The controller received a simultaneous message from another aircraft.
31:39We've made contact with Frederick Schaefn Airport.
31:46So the call from the Boeing-Aero-loid flight, the controller was dealing with the Aero-loid flight.
31:54When the Boeing pilots mentioned TCAS descent, he probably didn't even hear it, or it just was something that he
32:01didn't process as an issue, thinking that everything over on that airspace was already taken care of.
32:07But juggling three planes isn't unusual.
32:11There's got to be more to this.
32:16Investigators listen to earlier parts of the ATC recording.
32:21Zurich, good evening.
32:23Bravo, Tanko Charlie, 2937.
32:26Aero-loid 1-1-3-5.
32:31They hear the Tupolev and Aero-loid flights competing for Nielsen's attention.
32:38Aero-loid 1-1-3-5, roger.
32:40Good evening.
32:41Bravo, Tanko Charlie, 2937.
32:43Call you back.
32:47Station calling, say again, please.
32:50Zurich, good evening.
32:51Bravo, Tanko Charlie, 2937.
32:54Level 360.
32:56Aero-loid.
32:571-1-3-5.
33:01Aero-loid 1-1-3-5, descend flight level 7-0.
33:05During the last five minutes before the collision, the workload increased very much.
33:13Investigators hear Nielsen having difficulty contacting the airport where the Aero-loid flight was due to land.
33:21The desired connection is not possible.
33:24Find me the number for Friedrichshafen Tower.
33:28How many times does he try calling Friedrichshafen?
33:34Seven.
33:35He spent a lot of time on something that should have taken seconds.
33:44The desired connection is not possible.
33:47Please check the number.
33:48This isn't working either.
33:53So, how did he end up in this situation in the first place?
34:00Normally, an inbound call is just a few seconds.
34:05But dealing with the communication system took a lot of time that then allowed the two collision aircraft to get
34:11ever closer at this very high rate of speed.
34:19Thanks for coming in.
34:24Investigators interview Peter Nielsen to assess his workload on the night of the accident.
34:32So, at the time of the accident, you seem to be working two different workstations.
34:38Why?
34:39There are two controllers on the night shift, but one controller always takes a rest as traffic decreases for the
34:45night.
34:53You're off?
34:55See you in a few hours.
34:59They come back in the morning when traffic picks up.
35:03And is that standard procedure?
35:06It's not written down anywhere in company policies, but management lets us do it.
35:14Okay.
35:17So, 13 seconds before the collision, the Boeing radio that they were doing a TCAS descent.
35:25Did you hear that transmission?
35:27No, I didn't.
35:29I guess I was dealing with the AeroLoid flight, approaching Friedrichshafen.
35:34Couldn't get through to the airport.
35:36The phone was down for some reason.
35:40Is there anything else you can think of that might help us?
35:44Yeah.
35:47Normally, the computer system issues an alert well before two planes get too close together.
35:54But I never got that alert.
36:08The air traffic control radar system has what's called conflict alert system.
36:13It's looking at the airplanes and based on their current speed and altitude and heading is projecting out to see
36:21if airplanes are coming into conflict with each other.
36:30It was, at the end for him, a really difficult situation.
36:37Was Peter Nielsen fully equipped to prevent the collision that cost the lives of 71 people?
36:48Investigators interview officials from Sky Guide to find out why Peter Nielsen never received a warning of the impending collision
36:56above Uberlingen, Germany.
36:59Why were the control systems conflict alert and telephones both down?
37:10What's this?
37:11A work order for a computer upgrade.
37:18A new software was to be implemented on the main screen, which meant that the controller had to work on
37:25the backup system.
37:28The software in the telephone system also had to be updated.
37:32So, is this why there was no phone or visual conflict alert?
37:39Yes.
37:41But it doesn't say that anywhere.
37:47Was Nielsen warned about this before his shift?
37:51Not that I'm aware.
37:56One other thing.
37:59Why does management allow one of the controllers working nights to be on break most of the shift?
38:05It started when there were three controllers at night.
38:10But there are only two now.
38:13We didn't change the practice.
38:21Thank you.
38:25That was the way they did it.
38:28One controller on screen and the other was on break.
38:32And this was accepted by the management.
38:36Bravo Tango Charlie 2937.
38:38Descend flight level 350.
38:41Climb.
38:42It says climb.
38:43Climb.
38:44The controller is guiding us down.
38:46Climb.
38:46Descend?
38:47Really?
38:48We're going to descend?
38:51Investigators now understand.
38:53Bravo Tango Charlie 2937.
38:55Descend level 350.
38:57Expedite descent.
38:59Expedite descent level 350.
39:02Bravo Tango Charlie 2937.
39:05Why two flights...
39:07Increased descent.
39:08Descend.
39:09Descend forward.
39:12Ended in disaster.
39:14Increased.
39:14¡No!
39:16¡No!
39:30While completing their final report.
39:34BFU, hello.
39:40What?
39:45The story of the Uberlingen mid-air collision takes another tragic turn.
39:56On February the 24th, 2004, almost two years after the Uberlingen disaster,
40:04Peter Nielsen is murdered in his front garden.
40:08His wife and three children are witnesses to the crime.
40:13We couldn't believe it.
40:15We couldn't believe it because it was for us like a TV story,
40:20and it was not a real life,
40:23but yes, it was real life.
40:30Did they catch the killer?
40:35Yeah.
40:37Apparently his family was on the Trupaliv.
40:47A Russian man, Vitaly Kaloyev, is arrested for Peter Nielsen's murder.
40:56Kaloyev's wife and two children were killed in the Uberlingen collision.
41:01He tells police he went to Nielsen's house seeking an apology.
41:14But Nielsen isn't found at fault for the collision in the BFU's final report.
41:27Instead, it concludes he was unable to safely carry out the tasks required of him.
41:37The BFU points to the fact that Nielsen was working alone as a cause for the accident.
41:48Bravo Tango Charlie 2937.
41:50Descend flight level 350.
41:53Expedite.
41:54I have crossing traffic.
41:55Descend.
41:56But the report also highlights deficiencies in aviation regulations
42:01that allowed for the Russian pilots' confusion over the use of TCAS.
42:06It says climb.
42:08The controller is guiding us down.
42:10Descend.
42:11We're going to descend.
42:13Climb.
42:14Climb.
42:16Climb.
42:17The BFU's most prominent recommendation is simple.
42:22Pilots have to follow the TCAS instruction,
42:26not to follow the ATC instruction,
42:29because TCAS is a safety net.
42:34Eventually, four Sky Guide middle managers,
42:37who weren't even working the night of the Uberlingen disaster,
42:41are convicted of negligent homicide.
42:46This accident, it was really a watershed event.
42:50A lot of things had to fall into place just the wrong ways for this to occur.
42:57And it changed a lot of things.
43:01A lot of the way people looked at ATC, collision avoidance,
43:05and it really woke a lot of people up.
43:11In 2005, Vitaly Kaloyev is convicted of the premeditated homicide of Peter Nielsen.
43:20Two years later, he's released from prison.
43:36Today, nine steel pearls, representing a torn necklace,
43:41mark the locations where victims' bodies were found.
43:46And a memorial inside Sky Guide marks both the date of the collision
43:51and that of Peter Nielsen's murder.
43:54is connected to the