Mayday (2013) s02e04 Episode Script
Deadly Crossroads
July 2002, over Germany, the middle of the night.
Where is it!? A Russian plane is taking children on holiday to Spain, but the pilots can't believe what they see heading towards them.
- Here on the left! - BEEPING AUTOMATED VOICE: Increase climb.
- Climb it says! - Climb! Climb! June 2002, the city of Ufa in western Russia.
Ufa is populated by both Christians and Muslims.
This year, its most outstanding teenagers have been chosen to go on a two-week vacation organised by UNESCO, near Barcelona in Spain.
They are among the most clever, athletic or artistic children of Ufa.
Kirill Degtaryeva is a 14-year-old prodigy.
He's been painting since he was four years old and has already had two public exhibitions.
Alina Khannanova is a 12-year-old who's won several gymnastics competitions.
The 46 children from Ufa, accompanied by a few teachers, leave on a train to Moscow.
There, they're due to catch their flight to Barcelona.
But in Moscow, things start to go wrong.
The tourist agency accidentally takes the children to the wrong airport, so they miss their plane.
They're terribly disappointed.
While the agency tries to sort out the mess, the children go sightseeing in the Russian capital.
It takes two days to charter another jet, but finally, they're on their way to Barcelona.
GENTLE PIANO MUSIC On July 1, 2002, the children from Ufa board their plane at a Moscow airport.
The Kaloyevs are not part of the school group.
They're going on a holiday to meet their father, who is an architect and is finishing a project near Barcelona.
No fewer than five Russians are flying this plane.
The captain is Alexander Gross, who has been a pilot for over 30 years.
(speaks Russian) INTERPRETER: Alexander had a good theoretical knowledge.
He was very smart.
Today, the first officer is Oleg Grigoriev, but actually, Grigoriev is the airline's chief pilot.
On this trip, he'll be evaluating Captain Gross's flying.
(speaks Russian) INTERPRETER: If you did something wrong, some captains would criticise you very rudely.
Others would be very formal and polite.
But only Grigoriev would express his disapproval in a gesture, like that, meaning, "Why on earth did you do that?" Captain Gross is in command, but Captain Grigoriev is his supervisor.
If it comes to the crunch, who will really be in charge? Seated in the left rear is Murat Itkulov, normally the first officer but who is not officially on duty because Grigoriev is in his seat.
Nevertheless, since he'll soon be promoted to captain, his opinions are considered.
(speaks Russian) INTERPRETER: Murat was a very professional pilot.
He loved to fly.
Murat was interested in the new stuff in aviation .
.
and always kept up to date on the most progressive things brought in.
Also on the flight deck are an experienced navigator and a flight engineer.
Just before 11:00 that evening, Bashkirian Airlines flight 2937 leaves Moscow.
The plane is a Tupolev 154.
ENGINES ROAR Like most modern aircraft, it carries collision-avoidance equipment called TCAS, or Traffic Collision Avoidance System.
TCAS: Descend.
Descend.
Descend.
TCAS works because all commercial aircraft carry a transponder which sends a constant stream of radio signals identifying them and saying where they are.
TCAS listens in and calculates whether any of the planes is on a collision course.
If they are, it will tell the pilot what action to take to avoid collision.
TCAS: Descend.
Descend.
If Air Traffic Control should ever let them down, TCAS will be their last line of defence.
TCAS: Clear of conflict.
Hundreds of miles away in Bergamo, Italy, a Boeing 757 is getting under way.
It is flying for DHL, the international freight company and is heading for their European base at Brussels in Belgium.
The Russian Tupolev will cross its path over southern Germany.
The Boeing has only two people aboard, Captain Paul Philips, who is British, and first officer Brant Campioni, who is Canadian, and due to fly the next leg of the journey.
The DHL takes off at 11:06 on what will be its last journey.
7:50 at the Skyguide Area Control Centre in Zurich, Switzerland.
The busy day shift has ended and the night shift is reporting for work.
Peter Nielsen is an experienced controller.
He's been doing this job for eight years.
The centre regulates air traffic in southern Germany as well as northern Switzerland.
Tonight, there are only two controllers on duty.
But the traffic in their sector is light and Nielsen's colleague decides to take a lengthy break, a common practice at Skyguide.
Peter Nielsen is now responsible for all air traffic on two radar screens which sit several feet apart.
At 11:10, two technicians arrive.
They inform Peter that Skyguide management has authorised them to carry out maintenance work on the main radar.
While they do so, the screens will work much more slowly and will give no visual two-minute warning if planes are getting too close to each other.
Thai Inter 933.
(speaks German) Bavarian 350, descend flight level 270.
The engineers now tell Peter Nielsen they have to shut down the telephone system as well.
They switch over to the stand-by phones.
No-one realises it yet, but the seeds of disaster have been sown.
The Russian plane, filled with schoolchildren, is now over central Germany and flying towards Switzerland.
Captain Grigoriev gets final clearance from the last German control centre before they cross south into Switzerland.
128.
05 - bravo, tango, charlie.
2937, goodbye.
The German controller hands over the Russian plane to Skyguide where Peter Nielsen is at the helm.
Meanwhile, the DHL plane is climbing north over the Alps and is now entering Swiss air space.
Zurich, radar, good evening.
Dilmoon 611, I'm climbing flight level 260 direct.
Captain Paul Philips of the DHL requests clearance to climb to a higher altitude.
The thinner air there will mean less air resistance and save fuel.
Roger, climb flight level 320.
Direct tango, golf, oscar and requesting 360, thanks, if it's available.
Dilmoon 611, climb flight level 360.
The DHL reaches flight level 360, or 36,000 feet - the same altitude as the Russian plane and they're on a collision course, but they're many miles apart.
So far, no danger.
Now the assistant gives Peter Nielsen a new flight strip.
An airbus, Aero Lloyd flight 1135 is flying to the airport of Friedrichshafen, nearby.
It's going to increase Peter's work load dramatically over the next five minutes, and have him switching from one screen to another.
Peter tries to dial the airport control tower at Friedrichshafen to discuss handing over the Aero Lloyd flight to them, but the line is dead.
He tries a second time.
AUTOMATED MESSAGE PLAYS The phones aren't working.
MAN SPEAKS GERMAN ON RADIO The Aero Lloyd pilot is trying to make contact with Peter.
He has to leave the Russian pilots unattended.
Zurich, good evening.
Bravo, tango, charlie.
But the Russian pilot is also calling him on the other screen.
Aero Lloyd 1135, roger.
Call you back.
Station calling.
Say again, please.
Ah, Zurich, good evening.
Bravo, tango, charlie, 2937.
Level 360.
Bravo, tango, charlie, 2937.
Squawk 7520.
(man speaks indistinctly) The Aero Lloyd is calling again.
Is inbound the final? Yeah, expect so.
Call you back shortly.
Now another plane needs him.
A Thai Airways flight heading north.
Thai Inter 933, contact now on Munich 132.
140.
Goodbye.
Air traffic controllers are used to handling tricky situations.
But tonight, Peter's equipment isn't working properly and he's controlling two screens at the same time.
Normally, his radar would warn of any impending collision.
What he doesn't know is that tonight, it's out of action.
Correct.
What is your present heading? Present heading is 265.
Roger.
Right turn, heading 280, vector ILS24.
Flight heading 2804, vector ILS24, Aero Lloyd.
Peter wants to get this Aero Lloyd flight off his hands.
He tries dialling the public number for the Friedrichshafen control tower for the third time.
AUTOMATED MESSAGE PLAYS Meanwhile, the Russian airliner and the DHL plane are still heading towards each other at a closing speed of over 800 miles per hour.
Neither crew is aware that they're only two-and-a-half minutes apart.
The DHL plane is now approaching the Swiss border with Germany.
The Russian Tupolev is heading for exactly the same spot and at the same altitude.
Finally, someone at another air traffic control centre in Germany spots the danger.
AUTOMATED VOICE: Conflict.
Conflict.
He grabs the phone to warn Nielsen, but can't get through.
International air traffic rules prevent him from talking to the pilots directly.
BEEP Look, look at that.
Now, for the first time, the Russian pilots can see the DHL plane on the screen of their TCAS anti-collision computer.
But Peter Nielsen is still focused on getting the Aero Lloyd flight safely down.
Aero Lloyd 1135.
Aero Lloyd 1135, go ahead, sir.
Yeah, I lost my connection to Friedrichshafen airport.
Could you please call them on your second set, 124.
35.
Tell them you are coming in ILS 24 with 20 miles, now.
Okay, will do.
Thank you.
Okay.
Taking over.
On the DHL cargo plane, the crew is relaxed.
They don't know they're on a collision course.
Their TCAS hasn't sounded a warning yet.
Stuff I can get you? The first officer goes to the washroom.
On the Russian plane, the pilots are getting concerned.
The other plane is getting closer and closer, but they're not exactly sure whether he's on the same altitude as them.
He's going below us.
- Why below? - 500 - no, 100 metres.
TCAS: Traffic, traffic.
- Fucking traffic! - Why? Traffic, traffic! TCAS, the collision-avoidance computer is warning the Russian pilots that the other plane is getting too close for comfort.
BEEP At the same moment, the TCAS in the DHL cockpit detects the Russian plane.
TCAS: Descend.
Descend.
Peter Nielsen finally realises what's happening.
Bravo, tango, charlie, 2937, descend flight level 350.
Expedite.
I have crossing traffic.
Descend.
Captain Gross disengages the autopilot and starts to descend.
TCAS: Climb.
Climb.
TCAS is telling them to climb, the controller is telling them to descend.
It says climb! He is guiding us down.
Descend? Bravo, tango, charlie, 2937.
Descend level 350, expedite descent! Expedite descent level 350.
Bravo, tango, charlie, 2937.
Peter Nielsen thinks he's averted a collision by telling the Russian plane to descend.
But what he doesn't know is that the DHL pilots have received a TCAS instruction telling THEM to descend.
Increase! Dilmoon 600, TCAS descent! They're trying to tell Nielsen that they have a TCAS instruction to descend, but Peter can't hear them.
If both planes obeyed TCAS there would be no problem, but the Russians, instead of climbing, have followed the controller's orders.
Now both planes are diving towards each other.
He is going below us.
Fuck, where is it? Here on the left! TCAS: Increase climb.
Increase climb.
- Climb, it says! - Climb! Argh! Descend! Fuck, descend hard! - Climb! - Argh! (both yell and scream) EXPLOSION The tail of the DHL clips the belly of Tupolev tearing it apart.
The pilots soon lose consciousness.
(pilots scream) The DHL struggles on for another two minutes.
It will crash four miles away.
Can we go over to Friedrichshafen? Affirm.
Bye-bye.
Bye-bye.
Peter is unaware of what just happened.
Bravo, tango, charlie, 2937.
(anxiously) Bravo, tango, charlie, 2937.
Bravo, tan-go, charlie This is the nightmare that every controller hopes will not happen to him.
Two of his aircraft colliding, killing scores of people.
(cries) Oh! Peter Nielsen leaves the control room for the last time, but his story is far from over.
HELICOPTER WHIRRS SIREN WAILS The wreckage of the two planes has fallen just outside the small city of Uberlingen on the German-Swiss border.
Wreckage is scattered over 130 square miles.
It's the worst mid-air collision in German post-war history.
Debris comes raining down around a school for handicapped children run by Bruno and Stella Wegmuller.
STELLA: The sky was orange, red, flaming and we saw these pieces falling down and detonations again and again, and we realised it couldn't have been a normal thunderstorm.
It was something we had never heard and seen before.
BRUNO: It was incredible because there are many, many houses here and there was nothing on this place but around our school we find the bodies of children.
We very soon also realised that we couldn't do anything, really.
We couldn't save anyone, we couldn't help anyone.
INTERPRETER: The problem was that the bodies and debris were dispersed over a very, very wide area - approximately 40 square kilometres, a corridor 20 kilometres long and two kilometres wide.
It was the largest police operation in the province of Baden-Wurttemberg, lasting a week and involving over 6,000 people searching for the bodies.
The people were all very sad.
They were all in a state of extreme shock, and naturally, the rescue team could feel that and empathised with their suffering.
The policeman is standing where the DHL crashed.
Here you see no more trees.
The trees have completely burned down.
We assumed that the turbines of the Boeing separated first, approximately 700 to 800 metres high before this plane crashed.
One landed 300 metres that way and the other turbine was another 500 metres that way.
In this garden lay many of the bodies of the children of Ufa.
In this part, died 28 children.
In this fieldthere was a child, more over here in this field there was ahere GENTLE MUSIC Vitaly Kaloyev, the Russian architect, was awaiting his family in Barcelona.
He's one of the first to arrive in Uberlingen.
Although the relatives are not encouraged to participate in the search, Vitaly cannot help himself.
Vitaly finds a broken pearl necklace.
He recognises it as his four-year-old daughter's.
Amazingly, amidst all the carnage, Vitaly finds his daughter's body, intact.
She did not suffer at all.
The mutilated bodies of his wife and son won't be found until later.
Over six days of searching, the rescue workers gather bodies and body parts scattered all over the southern German countryside.
INTERPRETER: By Thursday of that week, two days later, the relatives started arriving.
They could not all see the bodies we had found because most of the bodies were badly charred or mutilated.
We didn't permit the relatives to view the bodies in that condition.
(women sob) GENTLE MUSIC In Ufa in western Russia, both Christian and Muslim communities are devastated by the loss of their children.
In the cemetery where 53 of the people in the Tupolev are buried, there are two double rows of grave stones, with the Christian Orthodox on one side and the Muslims on the other.
It's eerily reminiscent of the seating arrangement on the plane.
The monument evokes a flight of paper planes frozen in flight.
Vitaly Kaloyev, who lost his entire family, has designed and built a huge monument in their memory.
Day and night he lingers at the cemetery, inconsolable.
At Skyguide in Zurich, after the collision, work has all but come to a standstill.
They were shocked, they were helpless, there was a lot of sadness, people crying.
We were criticised for being too technocratic after the accident.
I have to accept that.
One of the biggest tasks was to maintain operations because there were planes coming in, going out after this tragedy and it was a very, very difficult situation for everybody.
For the next three weeks at the Zurich Air Traffic Control Centre capacity is reduced for lack of available controllers.
Peter Nielsen never again worked on an air traffic work station.
Peter Nielsen never again worked on an air traffic work station.
The hunt begins for a scapegoat.
The hunt begins for a scapegoat.
If two planes collide in empty skies, someone must be to blame, but first, some suspect the Russians.
REPORTER: The pilot of the Russian plane is said to have ignored repeated instructions from air traffic controllers.
Repeatedly, they contacted the Russian pilot and asked him to change altitude because he was flying at a level where he should not have been.
Now, the Russian pilot never responded to those warnings from air traffic control.
The Russian pilots, particularly in Soviet times and also now, but to a lesser extent, were extremely well-trained.
I have no concerns about the training of pilots.
They have been trained for almost every operational possibility that could happen.
Why did the TCAS device, meant to avoid collisions, in this case maybe help cause one? Why didn't the Russian plane descend when first ordered? A language problem? Controller commands are always in English.
I knew everybody from that group.
Everybody knew English enough to speak with the controller.
So, who is to blame? The media spotlight now falls on controller Peter Nielsen.
He was the man who had guided the two planes towards each other.
They were under his control.
He must have caused them to collide.
I was as shocked as I could have been with any other name or any other colleague.
I was just very sorry for him.
The media coverage about the incident very often makes you angry because these statements are taken out of context.
You really get the impression they just want to fill the newspaper, they write whatever they get.
They go after colleagues, they give them a call at home, they follow you wherever you are.
You don't deserve to be the boogie man for everybody and that's something which really is still very difficult to accept that suddenly we are somehow having to take the blame because the others are dead or the others are hiding behind politics, rules and things like this.
We started to leave this building by the underground exit which leads through another building, just not to see anybody.
They were asking people on the street in Kloten, people who were not involved at all, just to broadcast something in the evening and that makes you angry and you cannotresist it.
What more do we know about this Swiss controller at the centre of the investigation? PATRICK HERR: He was chased by the media, he was accused of being a murderer.
He is the man, obviously, everyone wants to talk to, but, at the moment, the Swiss say he's in no position to talk.
The Swiss authorities have opened an investigation to see whether there's enough evidence for charges of manslaughter.
The accusation was manslaughter by negligence in 71 cases and the speciality is that, in this case, the investigating judge has been working on an investigation on his own independently from what the aviation investigation board in Germany did.
Meanwhile, that investigation is under way, headed by Germany's air crash detectives, the BFU.
By the fifth day, they've read all the black boxes.
So, this is a typical voice recorder which was built into the Tupolev 154.
It shows two reels.
The recording time of this recorder is 30 minutes.
It is rather solid, but the original voice recorder of the Tupolev was heavily damaged.
So, we had to remove the tape and replay it on such a specialised tape recorder.
This is the hangar where wreckage of the planes was examined.
This one here is the lower surface of the right wing of the Tupolev and that remaining stuff here went below the Tupolev and caused these scratches.
That top part of the vertical tail remained at the accident site on the main wreckage of the Boeing.
But could this accident have been avoided? TCAS normally has a safeguard mechanism called a 'reversal'.
If an alert is issued and one aircraft crew ignores an instruction, TCAS orders a reversal.
If the TCAS on aircraft A senses that aircraft B is still on a collision course, it will tell it to go in another direction, but it didn't.
Why? (speaks German) INTERPRETER: One of the major requirements for that is that both planes have to be at least 100 feet apart in altitude.
But this requirement was not met at the time.
That's why no reversal was given.
When the DHL's TCAS saw that the Tupolev wasn't climbing, it could only tell its pilots to descend even faster.
TCAS: Increase descent.
July 2003, many parents returned to Uberlingen in Germany for the first anniversary.
The Germans built a memorial on the site of the tragedy.
It's made up of a series of giant silver pearls, on a broken necklace.
The head of Skyguide is among the crowd.
REPORTER: Can you tell us what are the mistakes you made? INTERPRETER: I don't think this is the time to talk about it.
I'm sure you'll understand.
- Have you apologised? - Okay.
Thank you.
Among the parents is Vitaly Kaloyev.
He asks the head of Skyguide which controller was responsible for the accident, but receives no answer.
Yes, in fact, the man asked if it is possible to meet the controller, to meet Peter, and the answer was, "It is not possible.
" The request passes almost unnoticed but Vitaly Kaloyev is not satisfied.
TCAS: Descend, crossing.
Meanwhile, as the investigators work, they discover a fog of confusion surrounding TCAS.
When it was introduced 20 years previously, there had been a fatal omission.
Descend flight level 350, expedite.
No-one said what should happen if there was a conflict between what TCAS was saying and what the controller was saying.
It says climb.
There's no hard-and-fast rule to guide the pilots.
He is guiding us down.
TCAS: Increase descent.
Whilst pilots in the west have always been taught to obey TCAS TCAS descent! .
.
in the rest of the world, it's anyone's guess.
INTERPRETER: We're not accustomed to not trusting controllers.
INTERPRETER: In civil aviation, there were lots of situations when pilots didn't follow instructions of the controller, and that led to plane crashes or other accidents.
The mentality of Russians is still very much in the lines of the old Soviet ways, and they are much more inclined to follow instructions than to do what they think may be appropriate.
They always reckon that the other guy knows better.
The potential for a terrible accident was there, and in a year and a half before the Uberlingen tragedy, it nearly happened.
Over Japan, two jumbo jets with 677 people aboard came so close that they filled each other's windscreens.
The violent avoidance manoeuvre caused 100 people to be injured, some of them seriously.
This was seconds away from being the worst plane crash in aviation history.
Once again, a pilot had listened to the controller instead of his TCAS.
It should have served as a warning to everyone.
Yet from ICAO, the International Civil Aviation Organisation, there was only silence.
ICAO is responsible for drawing up the rules of commercial aviation.
German investigators say that their vagueness about how to use TCAS was one of the reasons for the Uberlingen disaster.
I think this is the first time that I remember any major accident investigation, the one done by the BFU, fingering any of the aviation authorities in any serious way and this is a serious way.
So I think this is quite unique.
(speaks Russian) If ICAO had carried out a detailed investigation of the incident in Japan and made recommendations that led to changes in procedures, this probably would not have happened.
IACO did not feel it necessary to get involved in this and they left it entirely up to the Japanese authorities.
Had it been a collision, maybe they would have got involved.
After this near miss, the Japanese government immediately asked for their guidance.
But, unfortunately, IACO only acted on the request 18 months later, after the Uberlingen disaster.
Perhaps the ICAO procedures and standards, but, in particular, operating procedures for airborne collision avoidance, were somewhat ambiguous or open to interpretation.
The Japanese incident was not the only warning IACO received.
In the two years leading up to the Uberlingen collision, four other near misses happened in Europe alone because one set of pilots obeyed air traffic control instead of their TCAS.
If I have to summarise the advice that we gave the world, if a warning comes from ACAS, pilots should immediately follow it at all times.
With the benefit of hindsight you always ask yourself, "Could we have done more?" An accident is a wake-up call for everybody.
All of these regrets are of little comfort now to the grieving parents of Ufa.
INTERPRETER: Everything that was good is in the past and was connected with my child, all the hopes, dreams were connected with him, with his future.
And now, nothing left.
At least, I've got nothing left.
INTERPRETER: Our pain doesn't go away, it's getting stronger every year.
Some grown-up people made a mistake, made a fatal mistake.
And the kids were gone.
This is Kirill's room.
Everything in this room is like it was when he was alive.
Nothing's changed.
After he was killed, there were also two exhibitions.
One exhibition took place here in Ufa while the other one was in Germany, in Uberlingen.
Vitaly Kaloyev, the Russian architect, has lost his entire family, everything.
He himself has gone to pieces.
He's become obsessed with finding out who is responsible for the collision.
Kaloyev decides to travel to Zurich to play out the last tragic chapter in the Uberlingen story.
THUNDER ROLLS On February 24, 2004, a stranger calls at the house of the controller, Peter Nielsen.
Ya? Get out of my face.
Arggh! It was just the saddest thing you can imagine.
I knew his family, I knew how much he loved his kids and his wife andand, uh The presumed perpetrator is apparently 48 years old and of eastern origin.
He is likely the father of one of the families that was killed at the crash.
He likely lost his wife and both their children.
They found Vitaly Kaloyev nearby in a hotel.
Suspected, but not yet charged with the murder, he is presently in a psychiatric clinic while they decide whether he's fit to stand trial.
We didn't want him to be killed.
We didn't want to have more victims related to that catastrophe because of our children.
The killing of the flight controller was a very, very sad event.
The saddest thing of all was that he was not actually responsible for the accident.
The system responsible for the accident was the poor Skyguide management and quality control of their system.
The investigators had worked out exactly what went wrong that night at Skyguide and how an unfortunate series of events had made disaster almost inevitable.
First, Peter's colleague goes for a break, leaving him alone to watch two radar screens several feet apart.
It was a standard practice at the ATC company that, at night, one air traffic controller was responsible for controlling the entire air space of ATC Zurich.
Then, following management instructions, the maintenance men start to switch things off.
Peter's radar screen is working more slowly and will not warn him if two planes are about to collide.
He doesn't know that.
During the maintenance work, the radar system had to be run in fall-back mode.
In fall-back mode, the controller has no STCA available.
STCA is Short-Term Collision Alert, a warning on the radar screen that planes are in imminent danger of collision.
He did not know that the STCA system would not be available.
Then, by chance, an unexpected aircraft, the Aero Lloyd tourist plane, arrives at the critical moment and needs a lot of attention.
It completely distracts Peter.
He tries to get outside help, but the main phone system has been accidentally disconnected by the maintenance crew and the back-up phone isn't working.
The controller has been robbed of all the technical support he needs.
The phone link with Friedrichshafen was down.
At this time, there were various radio transmissions and the controller had to answer them on the different frequencies.
Finally, when both planes are descending, the DHL pilots cannot tell him what's happening, because the radio frequency is busy.
TCAS Descent! The earliest they could do that was 23 seconds later, because, until then, the frequency was blocked by the ATC Zurich transmission to the Tupolev crew.
May 2004.
It had taken the German BFU investigators 22 months to publish their final report.
They found that the disaster had two major causes.
Firstly, Peter Nielsen was too late in noticing the danger of a collision.
Secondly, the Russian crew was wrong to obey him when he told them to descend, rather than their own TCAS equipment telling them to climb.
But other pilots understand their dilemma.
INTERPRETER: The TCAS commands are spoken in such a dispassionate voice, "Descend, increase descent," such a matter-of-fact type of voice, and then there is the voice of the air traffic controller's urgent command, "Descend immediately! Leave this altitude immediately! "Go to another altitude at once!" So, whichever voice sounded more urgent was the one the crew obeyed.
Finally, the report severely criticised Skyguide for leaving a lone controller on duty that night.
We have learned our lesson.
We don't have single-manned operations or only one controller in front of a monitor anymore.
This might happen again, another badly organised air control service or a crew might make a mistake.
You're guilty or not guilty.
That's not the meaning of a final report.
The meaning of a final report is facts.
What has happened? Why did it happen? What are the lessons to be learned? Safety requirements.
INTERPRETER: Mistakes were made by us also, and we regret them deeply.
We acknowledge our responsibility as set out in the BFU report .
.
and we ask the families of the victims for forgiveness.
At Skyguide in Zurich, a rose now sits in a vase in memory of Peter Nielsen and the tragedy of Uberlingen.
Where is it!? A Russian plane is taking children on holiday to Spain, but the pilots can't believe what they see heading towards them.
- Here on the left! - BEEPING AUTOMATED VOICE: Increase climb.
- Climb it says! - Climb! Climb! June 2002, the city of Ufa in western Russia.
Ufa is populated by both Christians and Muslims.
This year, its most outstanding teenagers have been chosen to go on a two-week vacation organised by UNESCO, near Barcelona in Spain.
They are among the most clever, athletic or artistic children of Ufa.
Kirill Degtaryeva is a 14-year-old prodigy.
He's been painting since he was four years old and has already had two public exhibitions.
Alina Khannanova is a 12-year-old who's won several gymnastics competitions.
The 46 children from Ufa, accompanied by a few teachers, leave on a train to Moscow.
There, they're due to catch their flight to Barcelona.
But in Moscow, things start to go wrong.
The tourist agency accidentally takes the children to the wrong airport, so they miss their plane.
They're terribly disappointed.
While the agency tries to sort out the mess, the children go sightseeing in the Russian capital.
It takes two days to charter another jet, but finally, they're on their way to Barcelona.
GENTLE PIANO MUSIC On July 1, 2002, the children from Ufa board their plane at a Moscow airport.
The Kaloyevs are not part of the school group.
They're going on a holiday to meet their father, who is an architect and is finishing a project near Barcelona.
No fewer than five Russians are flying this plane.
The captain is Alexander Gross, who has been a pilot for over 30 years.
(speaks Russian) INTERPRETER: Alexander had a good theoretical knowledge.
He was very smart.
Today, the first officer is Oleg Grigoriev, but actually, Grigoriev is the airline's chief pilot.
On this trip, he'll be evaluating Captain Gross's flying.
(speaks Russian) INTERPRETER: If you did something wrong, some captains would criticise you very rudely.
Others would be very formal and polite.
But only Grigoriev would express his disapproval in a gesture, like that, meaning, "Why on earth did you do that?" Captain Gross is in command, but Captain Grigoriev is his supervisor.
If it comes to the crunch, who will really be in charge? Seated in the left rear is Murat Itkulov, normally the first officer but who is not officially on duty because Grigoriev is in his seat.
Nevertheless, since he'll soon be promoted to captain, his opinions are considered.
(speaks Russian) INTERPRETER: Murat was a very professional pilot.
He loved to fly.
Murat was interested in the new stuff in aviation .
.
and always kept up to date on the most progressive things brought in.
Also on the flight deck are an experienced navigator and a flight engineer.
Just before 11:00 that evening, Bashkirian Airlines flight 2937 leaves Moscow.
The plane is a Tupolev 154.
ENGINES ROAR Like most modern aircraft, it carries collision-avoidance equipment called TCAS, or Traffic Collision Avoidance System.
TCAS: Descend.
Descend.
Descend.
TCAS works because all commercial aircraft carry a transponder which sends a constant stream of radio signals identifying them and saying where they are.
TCAS listens in and calculates whether any of the planes is on a collision course.
If they are, it will tell the pilot what action to take to avoid collision.
TCAS: Descend.
Descend.
If Air Traffic Control should ever let them down, TCAS will be their last line of defence.
TCAS: Clear of conflict.
Hundreds of miles away in Bergamo, Italy, a Boeing 757 is getting under way.
It is flying for DHL, the international freight company and is heading for their European base at Brussels in Belgium.
The Russian Tupolev will cross its path over southern Germany.
The Boeing has only two people aboard, Captain Paul Philips, who is British, and first officer Brant Campioni, who is Canadian, and due to fly the next leg of the journey.
The DHL takes off at 11:06 on what will be its last journey.
7:50 at the Skyguide Area Control Centre in Zurich, Switzerland.
The busy day shift has ended and the night shift is reporting for work.
Peter Nielsen is an experienced controller.
He's been doing this job for eight years.
The centre regulates air traffic in southern Germany as well as northern Switzerland.
Tonight, there are only two controllers on duty.
But the traffic in their sector is light and Nielsen's colleague decides to take a lengthy break, a common practice at Skyguide.
Peter Nielsen is now responsible for all air traffic on two radar screens which sit several feet apart.
At 11:10, two technicians arrive.
They inform Peter that Skyguide management has authorised them to carry out maintenance work on the main radar.
While they do so, the screens will work much more slowly and will give no visual two-minute warning if planes are getting too close to each other.
Thai Inter 933.
(speaks German) Bavarian 350, descend flight level 270.
The engineers now tell Peter Nielsen they have to shut down the telephone system as well.
They switch over to the stand-by phones.
No-one realises it yet, but the seeds of disaster have been sown.
The Russian plane, filled with schoolchildren, is now over central Germany and flying towards Switzerland.
Captain Grigoriev gets final clearance from the last German control centre before they cross south into Switzerland.
128.
05 - bravo, tango, charlie.
2937, goodbye.
The German controller hands over the Russian plane to Skyguide where Peter Nielsen is at the helm.
Meanwhile, the DHL plane is climbing north over the Alps and is now entering Swiss air space.
Zurich, radar, good evening.
Dilmoon 611, I'm climbing flight level 260 direct.
Captain Paul Philips of the DHL requests clearance to climb to a higher altitude.
The thinner air there will mean less air resistance and save fuel.
Roger, climb flight level 320.
Direct tango, golf, oscar and requesting 360, thanks, if it's available.
Dilmoon 611, climb flight level 360.
The DHL reaches flight level 360, or 36,000 feet - the same altitude as the Russian plane and they're on a collision course, but they're many miles apart.
So far, no danger.
Now the assistant gives Peter Nielsen a new flight strip.
An airbus, Aero Lloyd flight 1135 is flying to the airport of Friedrichshafen, nearby.
It's going to increase Peter's work load dramatically over the next five minutes, and have him switching from one screen to another.
Peter tries to dial the airport control tower at Friedrichshafen to discuss handing over the Aero Lloyd flight to them, but the line is dead.
He tries a second time.
AUTOMATED MESSAGE PLAYS The phones aren't working.
MAN SPEAKS GERMAN ON RADIO The Aero Lloyd pilot is trying to make contact with Peter.
He has to leave the Russian pilots unattended.
Zurich, good evening.
Bravo, tango, charlie.
But the Russian pilot is also calling him on the other screen.
Aero Lloyd 1135, roger.
Call you back.
Station calling.
Say again, please.
Ah, Zurich, good evening.
Bravo, tango, charlie, 2937.
Level 360.
Bravo, tango, charlie, 2937.
Squawk 7520.
(man speaks indistinctly) The Aero Lloyd is calling again.
Is inbound the final? Yeah, expect so.
Call you back shortly.
Now another plane needs him.
A Thai Airways flight heading north.
Thai Inter 933, contact now on Munich 132.
140.
Goodbye.
Air traffic controllers are used to handling tricky situations.
But tonight, Peter's equipment isn't working properly and he's controlling two screens at the same time.
Normally, his radar would warn of any impending collision.
What he doesn't know is that tonight, it's out of action.
Correct.
What is your present heading? Present heading is 265.
Roger.
Right turn, heading 280, vector ILS24.
Flight heading 2804, vector ILS24, Aero Lloyd.
Peter wants to get this Aero Lloyd flight off his hands.
He tries dialling the public number for the Friedrichshafen control tower for the third time.
AUTOMATED MESSAGE PLAYS Meanwhile, the Russian airliner and the DHL plane are still heading towards each other at a closing speed of over 800 miles per hour.
Neither crew is aware that they're only two-and-a-half minutes apart.
The DHL plane is now approaching the Swiss border with Germany.
The Russian Tupolev is heading for exactly the same spot and at the same altitude.
Finally, someone at another air traffic control centre in Germany spots the danger.
AUTOMATED VOICE: Conflict.
Conflict.
He grabs the phone to warn Nielsen, but can't get through.
International air traffic rules prevent him from talking to the pilots directly.
BEEP Look, look at that.
Now, for the first time, the Russian pilots can see the DHL plane on the screen of their TCAS anti-collision computer.
But Peter Nielsen is still focused on getting the Aero Lloyd flight safely down.
Aero Lloyd 1135.
Aero Lloyd 1135, go ahead, sir.
Yeah, I lost my connection to Friedrichshafen airport.
Could you please call them on your second set, 124.
35.
Tell them you are coming in ILS 24 with 20 miles, now.
Okay, will do.
Thank you.
Okay.
Taking over.
On the DHL cargo plane, the crew is relaxed.
They don't know they're on a collision course.
Their TCAS hasn't sounded a warning yet.
Stuff I can get you? The first officer goes to the washroom.
On the Russian plane, the pilots are getting concerned.
The other plane is getting closer and closer, but they're not exactly sure whether he's on the same altitude as them.
He's going below us.
- Why below? - 500 - no, 100 metres.
TCAS: Traffic, traffic.
- Fucking traffic! - Why? Traffic, traffic! TCAS, the collision-avoidance computer is warning the Russian pilots that the other plane is getting too close for comfort.
BEEP At the same moment, the TCAS in the DHL cockpit detects the Russian plane.
TCAS: Descend.
Descend.
Peter Nielsen finally realises what's happening.
Bravo, tango, charlie, 2937, descend flight level 350.
Expedite.
I have crossing traffic.
Descend.
Captain Gross disengages the autopilot and starts to descend.
TCAS: Climb.
Climb.
TCAS is telling them to climb, the controller is telling them to descend.
It says climb! He is guiding us down.
Descend? Bravo, tango, charlie, 2937.
Descend level 350, expedite descent! Expedite descent level 350.
Bravo, tango, charlie, 2937.
Peter Nielsen thinks he's averted a collision by telling the Russian plane to descend.
But what he doesn't know is that the DHL pilots have received a TCAS instruction telling THEM to descend.
Increase! Dilmoon 600, TCAS descent! They're trying to tell Nielsen that they have a TCAS instruction to descend, but Peter can't hear them.
If both planes obeyed TCAS there would be no problem, but the Russians, instead of climbing, have followed the controller's orders.
Now both planes are diving towards each other.
He is going below us.
Fuck, where is it? Here on the left! TCAS: Increase climb.
Increase climb.
- Climb, it says! - Climb! Argh! Descend! Fuck, descend hard! - Climb! - Argh! (both yell and scream) EXPLOSION The tail of the DHL clips the belly of Tupolev tearing it apart.
The pilots soon lose consciousness.
(pilots scream) The DHL struggles on for another two minutes.
It will crash four miles away.
Can we go over to Friedrichshafen? Affirm.
Bye-bye.
Bye-bye.
Peter is unaware of what just happened.
Bravo, tango, charlie, 2937.
(anxiously) Bravo, tango, charlie, 2937.
Bravo, tan-go, charlie This is the nightmare that every controller hopes will not happen to him.
Two of his aircraft colliding, killing scores of people.
(cries) Oh! Peter Nielsen leaves the control room for the last time, but his story is far from over.
HELICOPTER WHIRRS SIREN WAILS The wreckage of the two planes has fallen just outside the small city of Uberlingen on the German-Swiss border.
Wreckage is scattered over 130 square miles.
It's the worst mid-air collision in German post-war history.
Debris comes raining down around a school for handicapped children run by Bruno and Stella Wegmuller.
STELLA: The sky was orange, red, flaming and we saw these pieces falling down and detonations again and again, and we realised it couldn't have been a normal thunderstorm.
It was something we had never heard and seen before.
BRUNO: It was incredible because there are many, many houses here and there was nothing on this place but around our school we find the bodies of children.
We very soon also realised that we couldn't do anything, really.
We couldn't save anyone, we couldn't help anyone.
INTERPRETER: The problem was that the bodies and debris were dispersed over a very, very wide area - approximately 40 square kilometres, a corridor 20 kilometres long and two kilometres wide.
It was the largest police operation in the province of Baden-Wurttemberg, lasting a week and involving over 6,000 people searching for the bodies.
The people were all very sad.
They were all in a state of extreme shock, and naturally, the rescue team could feel that and empathised with their suffering.
The policeman is standing where the DHL crashed.
Here you see no more trees.
The trees have completely burned down.
We assumed that the turbines of the Boeing separated first, approximately 700 to 800 metres high before this plane crashed.
One landed 300 metres that way and the other turbine was another 500 metres that way.
In this garden lay many of the bodies of the children of Ufa.
In this part, died 28 children.
In this fieldthere was a child, more over here in this field there was ahere GENTLE MUSIC Vitaly Kaloyev, the Russian architect, was awaiting his family in Barcelona.
He's one of the first to arrive in Uberlingen.
Although the relatives are not encouraged to participate in the search, Vitaly cannot help himself.
Vitaly finds a broken pearl necklace.
He recognises it as his four-year-old daughter's.
Amazingly, amidst all the carnage, Vitaly finds his daughter's body, intact.
She did not suffer at all.
The mutilated bodies of his wife and son won't be found until later.
Over six days of searching, the rescue workers gather bodies and body parts scattered all over the southern German countryside.
INTERPRETER: By Thursday of that week, two days later, the relatives started arriving.
They could not all see the bodies we had found because most of the bodies were badly charred or mutilated.
We didn't permit the relatives to view the bodies in that condition.
(women sob) GENTLE MUSIC In Ufa in western Russia, both Christian and Muslim communities are devastated by the loss of their children.
In the cemetery where 53 of the people in the Tupolev are buried, there are two double rows of grave stones, with the Christian Orthodox on one side and the Muslims on the other.
It's eerily reminiscent of the seating arrangement on the plane.
The monument evokes a flight of paper planes frozen in flight.
Vitaly Kaloyev, who lost his entire family, has designed and built a huge monument in their memory.
Day and night he lingers at the cemetery, inconsolable.
At Skyguide in Zurich, after the collision, work has all but come to a standstill.
They were shocked, they were helpless, there was a lot of sadness, people crying.
We were criticised for being too technocratic after the accident.
I have to accept that.
One of the biggest tasks was to maintain operations because there were planes coming in, going out after this tragedy and it was a very, very difficult situation for everybody.
For the next three weeks at the Zurich Air Traffic Control Centre capacity is reduced for lack of available controllers.
Peter Nielsen never again worked on an air traffic work station.
Peter Nielsen never again worked on an air traffic work station.
The hunt begins for a scapegoat.
The hunt begins for a scapegoat.
If two planes collide in empty skies, someone must be to blame, but first, some suspect the Russians.
REPORTER: The pilot of the Russian plane is said to have ignored repeated instructions from air traffic controllers.
Repeatedly, they contacted the Russian pilot and asked him to change altitude because he was flying at a level where he should not have been.
Now, the Russian pilot never responded to those warnings from air traffic control.
The Russian pilots, particularly in Soviet times and also now, but to a lesser extent, were extremely well-trained.
I have no concerns about the training of pilots.
They have been trained for almost every operational possibility that could happen.
Why did the TCAS device, meant to avoid collisions, in this case maybe help cause one? Why didn't the Russian plane descend when first ordered? A language problem? Controller commands are always in English.
I knew everybody from that group.
Everybody knew English enough to speak with the controller.
So, who is to blame? The media spotlight now falls on controller Peter Nielsen.
He was the man who had guided the two planes towards each other.
They were under his control.
He must have caused them to collide.
I was as shocked as I could have been with any other name or any other colleague.
I was just very sorry for him.
The media coverage about the incident very often makes you angry because these statements are taken out of context.
You really get the impression they just want to fill the newspaper, they write whatever they get.
They go after colleagues, they give them a call at home, they follow you wherever you are.
You don't deserve to be the boogie man for everybody and that's something which really is still very difficult to accept that suddenly we are somehow having to take the blame because the others are dead or the others are hiding behind politics, rules and things like this.
We started to leave this building by the underground exit which leads through another building, just not to see anybody.
They were asking people on the street in Kloten, people who were not involved at all, just to broadcast something in the evening and that makes you angry and you cannotresist it.
What more do we know about this Swiss controller at the centre of the investigation? PATRICK HERR: He was chased by the media, he was accused of being a murderer.
He is the man, obviously, everyone wants to talk to, but, at the moment, the Swiss say he's in no position to talk.
The Swiss authorities have opened an investigation to see whether there's enough evidence for charges of manslaughter.
The accusation was manslaughter by negligence in 71 cases and the speciality is that, in this case, the investigating judge has been working on an investigation on his own independently from what the aviation investigation board in Germany did.
Meanwhile, that investigation is under way, headed by Germany's air crash detectives, the BFU.
By the fifth day, they've read all the black boxes.
So, this is a typical voice recorder which was built into the Tupolev 154.
It shows two reels.
The recording time of this recorder is 30 minutes.
It is rather solid, but the original voice recorder of the Tupolev was heavily damaged.
So, we had to remove the tape and replay it on such a specialised tape recorder.
This is the hangar where wreckage of the planes was examined.
This one here is the lower surface of the right wing of the Tupolev and that remaining stuff here went below the Tupolev and caused these scratches.
That top part of the vertical tail remained at the accident site on the main wreckage of the Boeing.
But could this accident have been avoided? TCAS normally has a safeguard mechanism called a 'reversal'.
If an alert is issued and one aircraft crew ignores an instruction, TCAS orders a reversal.
If the TCAS on aircraft A senses that aircraft B is still on a collision course, it will tell it to go in another direction, but it didn't.
Why? (speaks German) INTERPRETER: One of the major requirements for that is that both planes have to be at least 100 feet apart in altitude.
But this requirement was not met at the time.
That's why no reversal was given.
When the DHL's TCAS saw that the Tupolev wasn't climbing, it could only tell its pilots to descend even faster.
TCAS: Increase descent.
July 2003, many parents returned to Uberlingen in Germany for the first anniversary.
The Germans built a memorial on the site of the tragedy.
It's made up of a series of giant silver pearls, on a broken necklace.
The head of Skyguide is among the crowd.
REPORTER: Can you tell us what are the mistakes you made? INTERPRETER: I don't think this is the time to talk about it.
I'm sure you'll understand.
- Have you apologised? - Okay.
Thank you.
Among the parents is Vitaly Kaloyev.
He asks the head of Skyguide which controller was responsible for the accident, but receives no answer.
Yes, in fact, the man asked if it is possible to meet the controller, to meet Peter, and the answer was, "It is not possible.
" The request passes almost unnoticed but Vitaly Kaloyev is not satisfied.
TCAS: Descend, crossing.
Meanwhile, as the investigators work, they discover a fog of confusion surrounding TCAS.
When it was introduced 20 years previously, there had been a fatal omission.
Descend flight level 350, expedite.
No-one said what should happen if there was a conflict between what TCAS was saying and what the controller was saying.
It says climb.
There's no hard-and-fast rule to guide the pilots.
He is guiding us down.
TCAS: Increase descent.
Whilst pilots in the west have always been taught to obey TCAS TCAS descent! .
.
in the rest of the world, it's anyone's guess.
INTERPRETER: We're not accustomed to not trusting controllers.
INTERPRETER: In civil aviation, there were lots of situations when pilots didn't follow instructions of the controller, and that led to plane crashes or other accidents.
The mentality of Russians is still very much in the lines of the old Soviet ways, and they are much more inclined to follow instructions than to do what they think may be appropriate.
They always reckon that the other guy knows better.
The potential for a terrible accident was there, and in a year and a half before the Uberlingen tragedy, it nearly happened.
Over Japan, two jumbo jets with 677 people aboard came so close that they filled each other's windscreens.
The violent avoidance manoeuvre caused 100 people to be injured, some of them seriously.
This was seconds away from being the worst plane crash in aviation history.
Once again, a pilot had listened to the controller instead of his TCAS.
It should have served as a warning to everyone.
Yet from ICAO, the International Civil Aviation Organisation, there was only silence.
ICAO is responsible for drawing up the rules of commercial aviation.
German investigators say that their vagueness about how to use TCAS was one of the reasons for the Uberlingen disaster.
I think this is the first time that I remember any major accident investigation, the one done by the BFU, fingering any of the aviation authorities in any serious way and this is a serious way.
So I think this is quite unique.
(speaks Russian) If ICAO had carried out a detailed investigation of the incident in Japan and made recommendations that led to changes in procedures, this probably would not have happened.
IACO did not feel it necessary to get involved in this and they left it entirely up to the Japanese authorities.
Had it been a collision, maybe they would have got involved.
After this near miss, the Japanese government immediately asked for their guidance.
But, unfortunately, IACO only acted on the request 18 months later, after the Uberlingen disaster.
Perhaps the ICAO procedures and standards, but, in particular, operating procedures for airborne collision avoidance, were somewhat ambiguous or open to interpretation.
The Japanese incident was not the only warning IACO received.
In the two years leading up to the Uberlingen collision, four other near misses happened in Europe alone because one set of pilots obeyed air traffic control instead of their TCAS.
If I have to summarise the advice that we gave the world, if a warning comes from ACAS, pilots should immediately follow it at all times.
With the benefit of hindsight you always ask yourself, "Could we have done more?" An accident is a wake-up call for everybody.
All of these regrets are of little comfort now to the grieving parents of Ufa.
INTERPRETER: Everything that was good is in the past and was connected with my child, all the hopes, dreams were connected with him, with his future.
And now, nothing left.
At least, I've got nothing left.
INTERPRETER: Our pain doesn't go away, it's getting stronger every year.
Some grown-up people made a mistake, made a fatal mistake.
And the kids were gone.
This is Kirill's room.
Everything in this room is like it was when he was alive.
Nothing's changed.
After he was killed, there were also two exhibitions.
One exhibition took place here in Ufa while the other one was in Germany, in Uberlingen.
Vitaly Kaloyev, the Russian architect, has lost his entire family, everything.
He himself has gone to pieces.
He's become obsessed with finding out who is responsible for the collision.
Kaloyev decides to travel to Zurich to play out the last tragic chapter in the Uberlingen story.
THUNDER ROLLS On February 24, 2004, a stranger calls at the house of the controller, Peter Nielsen.
Ya? Get out of my face.
Arggh! It was just the saddest thing you can imagine.
I knew his family, I knew how much he loved his kids and his wife andand, uh The presumed perpetrator is apparently 48 years old and of eastern origin.
He is likely the father of one of the families that was killed at the crash.
He likely lost his wife and both their children.
They found Vitaly Kaloyev nearby in a hotel.
Suspected, but not yet charged with the murder, he is presently in a psychiatric clinic while they decide whether he's fit to stand trial.
We didn't want him to be killed.
We didn't want to have more victims related to that catastrophe because of our children.
The killing of the flight controller was a very, very sad event.
The saddest thing of all was that he was not actually responsible for the accident.
The system responsible for the accident was the poor Skyguide management and quality control of their system.
The investigators had worked out exactly what went wrong that night at Skyguide and how an unfortunate series of events had made disaster almost inevitable.
First, Peter's colleague goes for a break, leaving him alone to watch two radar screens several feet apart.
It was a standard practice at the ATC company that, at night, one air traffic controller was responsible for controlling the entire air space of ATC Zurich.
Then, following management instructions, the maintenance men start to switch things off.
Peter's radar screen is working more slowly and will not warn him if two planes are about to collide.
He doesn't know that.
During the maintenance work, the radar system had to be run in fall-back mode.
In fall-back mode, the controller has no STCA available.
STCA is Short-Term Collision Alert, a warning on the radar screen that planes are in imminent danger of collision.
He did not know that the STCA system would not be available.
Then, by chance, an unexpected aircraft, the Aero Lloyd tourist plane, arrives at the critical moment and needs a lot of attention.
It completely distracts Peter.
He tries to get outside help, but the main phone system has been accidentally disconnected by the maintenance crew and the back-up phone isn't working.
The controller has been robbed of all the technical support he needs.
The phone link with Friedrichshafen was down.
At this time, there were various radio transmissions and the controller had to answer them on the different frequencies.
Finally, when both planes are descending, the DHL pilots cannot tell him what's happening, because the radio frequency is busy.
TCAS Descent! The earliest they could do that was 23 seconds later, because, until then, the frequency was blocked by the ATC Zurich transmission to the Tupolev crew.
May 2004.
It had taken the German BFU investigators 22 months to publish their final report.
They found that the disaster had two major causes.
Firstly, Peter Nielsen was too late in noticing the danger of a collision.
Secondly, the Russian crew was wrong to obey him when he told them to descend, rather than their own TCAS equipment telling them to climb.
But other pilots understand their dilemma.
INTERPRETER: The TCAS commands are spoken in such a dispassionate voice, "Descend, increase descent," such a matter-of-fact type of voice, and then there is the voice of the air traffic controller's urgent command, "Descend immediately! Leave this altitude immediately! "Go to another altitude at once!" So, whichever voice sounded more urgent was the one the crew obeyed.
Finally, the report severely criticised Skyguide for leaving a lone controller on duty that night.
We have learned our lesson.
We don't have single-manned operations or only one controller in front of a monitor anymore.
This might happen again, another badly organised air control service or a crew might make a mistake.
You're guilty or not guilty.
That's not the meaning of a final report.
The meaning of a final report is facts.
What has happened? Why did it happen? What are the lessons to be learned? Safety requirements.
INTERPRETER: Mistakes were made by us also, and we regret them deeply.
We acknowledge our responsibility as set out in the BFU report .
.
and we ask the families of the victims for forgiveness.
At Skyguide in Zurich, a rose now sits in a vase in memory of Peter Nielsen and the tragedy of Uberlingen.