Original subtitles

FLIGHT ATTENDANT: Ladies and gentlemen,

we are starting our approach.

PILOT: We lost both engines.

PILOT: Mayday.

Mayday.

FLIGHT ATTENDANT: Brace for impact!

MAN: He's gonna crash!

NARRATOR: July 2002, over Germany,

the middle of the night--

What is it?

NARRATOR: A Russian plane is taking children on holiday

to Spain.

But the pilots can't believe what

they see heading toward them.

Get an eye on it!

Increase climb.

Climb, he said!

Climb!

Ah!

Climb!

NARRATOR: It's among the most poignant air

disasters of recent times.

How could two planes collide over one of the most closely

regulated areas in the world?

Bravo Tango Charlie.

NARRATOR: Faulty technology or human error?

Oh!

NARRATOR: 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, organized by UNESCO, near Barcelona in Spain.

They are among the most clever, athletic,

or artistic children of Ufa.

Kiril Degtaryev is a 14-year-old prodigy.

He's been painting since he was four years old,

and has already had two public exhibitions.

He's halfway through his new work.

INTERPRETER: He was very good at painting.

He felt colors.

He received good reviews.

He just graduated from grade nine.

He needed some rest, and it was a good opportunity

for a summer holiday.

NARRATOR: Elena Khannanova is a 12-year-old

who has won several gymnastics competitions.

INTERPRETER: We were very glad for her

because indeed very smart and very talented

children were flying there--

all extraordinary children in terms of their personalities.

She studied very well and she got only excellent marks.

NARRATOR: 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.

On July 1, 2002, the children from Ufa

aboard 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's an architect and is finishing

a project near Barcelona.

No fewer than five Russians are flying this plane.

The captain is Alexander Gross, who's

been a pilot for over 30 years.

INTERPRETER: Alexander had a good theoretical knowledge.

He was very smart.

NARRATOR: Today the first officer is Oleg Grigoriev.

But, actually, Grivoriev is the airline's chief pilot.

On this trip, he'll be evaluating

Captain Gross's flying.

INTERPRETER: If you did something wrong,

some captains would criticize you very rudely.

Others would be very formal and polite.

But Oleg Grigoriev would express his disapproval

in a gesture, like that, meaning why on Earth did you do that.

NARRATOR: Captain Gross is in command,

but Captain Grigoriev is his superior.

In case of emergency, 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.

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.

NARRATOR: 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.

Like most modern aircraft, it carries

collision avoidance equipment called TCAS or traffic

collision avoidance system.

AUTOMATED VOICE: Descend.

Descend.

Descend.

NARRATOR: 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.

AUTOMATED VOICE: Descend.

Descend.

NARRATOR: If air traffic control should ever let them down,

TCAS will be their last line of defense.

AUTOMATED VOICE: Clear of conflict.

NARRATOR: Hundreds of miles away, in Bergamo, Italy,

a Boeing 757 is getting under way.

It's 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 Phillips, who's British,

and First Officer Brant Campioni,

who's Canadian and due to fly the next leg of the journey.

The DHL takes off at 6 minutes past 11:00 on what

will be its last journey.

10 to 8:00 at the Skyguide Area Control

Center 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 center 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 10 past 11:00, two technicians arrive.

They inform Peter that Skyguide Management

has authorized 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 2-minute warning if planes are getting

too close to each other.

Tie into 933.

Bavarian 350, descend flight level 270.

NARRATOR: The engineers now tell Peter

Nielsen they have to shut down the telephone system, as well.

They switch over to the standby phones.

No one realizes it yet, but the seeds of disaster

have been sown.

NARRATOR: The Russian plane filled

with schoolchildren is now over Central Germany

and flying toward Switzerland.

Captain Grivoriev gets final clearance

from the last German control center

before they cross South into Switzerland.

128.05, Bravo Tango Charlie 2937.

Goodbye.

NARRATOR: 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 airspace.

Zurich radar, good evening.

Dilmun 611.

I'm climbing flight level 260 direct ABC.

NARRATOR: Captain Paul Phillips of the DHL requests clearance

to climb to a higher altitude.

The thinner air there will mean less air resistance,

and will save fuel.

Roger.

Climb flight level 320.

Direct Tango Golf Oscar and requesting

360, thanks, if it's available.

Dilmun 611, climb flight level 360.

NARRATOR: 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 workload 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.

The phones aren't working.

AERO LLOYD PILOT (ON RADIO):

NARRATOR: The Aero Lloyd pilot is trying

to make contact with Peter.

He has to leave the Russian pilots unattended.

ACTOR AS OLEG PAVLOVICH (ON RADIO): Good evening.

Bravo Tango Charlie.

NARRATOR: But the Russian pilot is also calling him

on the other screen.

Aero Lloyd 1135, Roger.

Call you back.

Station calling.

Say again, please.

Zurich, good evening.

Bravo Tango Charlie 2937, level 360.

Bravo Tango Charlie 2937, squad 7520.

AERO LLOYD PILOT (ON RADIO):

NARRATOR: The Aero Lloyd is calling again.

Yeah.

Expect so.

Call you back shortly.

NARRATOR: Now another plane needs him,

a Thai Airways flight heading north.

Thai, enter 933.

Contact now on Munich 132.140.

Goodbye.

NARRATOR: 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?

AERO LLOYD PILOT (ON RADIO): Present heading is 265.

Roger.

Right turn, heading 280, vector ILS 24.

AERO LLOYD PILOT (ON RADIO): Right.

Heading 280 for two expect us 24, Aero Lloyd.

NARRATOR: Peter wants to get this Aero

Lloyd flight off his hands.

He tries dialing the public number

for the Friedrichshafen control tower for the third time.

AUTOMATED VOICE (ON PHONE):

NARRATOR: Meanwhile, the Russian airliner and the DHL plane

are still heading towards each other

at a closing speed of over 800 miles an hour.

Neither crew is aware that they are

only 2 and 1/2 minutes apart.

The DHL plane is now approaching the Swiss border with Germany.

The Russian Tupolev is heading for exactly the same spot

at the same altitude.

Finally, someone at another air traffic control center

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.

Look.

Look at that.

NARRATOR: Now, for the first time,

the Russian pilots can see the 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 PILOT (ON RADIO): 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're coming in ILS 24 with 20 miles now.

AERO LLOYD PILOT (ON RADIO): OK.

Will do.

Thank you.

OK.

Taking over.

NARRATOR: 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?

No.

NARRATOR: 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 at

the same altitude as they are.

He's going below us.

Why below?

500-- no, 100 meters.

AUTOMATED VOICE: Traffic.

Traffic.

- Now traffic. - Why?

Traffic.

Traffic.

NARRATOR: TCAS, the collision avoidance computer,

is warning the Russian pilots that the other plane is

getting too close for comfort.

At the same moment, the TCAS in the DHL cockpit

detects the Russian plane.

AUTOMATED VOICE: Descend.

Descend.

NARRATOR: Peter Nielsen finally realizes what's happening.

Bravo Tango Charlie 2937, descend flight level 350.

Expedite.

I have crossing traffic.

Descend.

NARRATOR: Captain Gross disengages the autopilot

and starts to descend.

AUTOMATED VOICE: Climb.

Climb.

NARRATOR: 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.

NARRATOR: 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!

Dilmun 600, TCAS descent.

NARRATOR: They're trying to tell Nielsen

that they have a TCAS instruction to descend,

but Peter can't hear them.

If both planes obey TCAS, there'd be no problem.

But the Russians, instead of climbing,

have followed the controller's orders.

Now both planes are diving toward each other.

He is going below us!

What is it?

Here on the left!

AUTOMATED VOICE: Increase climb.

Increase climb.

Climb, he says!

Climb.

Descend.

Descend hard!

Climb!

Ah!

NARRATOR: The tail of the DHL clips the belly of the Tupolev,

tearing it apart.

The pilots soon lose consciousness.

The DHL struggles on for another two minutes.

It will crash four miles away.

AERO LLOYD PILOT (ON RADIO): Can we go over to 33,000?

Affirming.

Bye-bye.

AERO LLOYD PILOT (ON RADIO): Bye-bye.

NARRATOR: Peter is unaware of what just happened

Bravo Tango Charlie 2937.

Bravo Tango Charlie 2937.

Bravo Tango Charlie--

NARRATOR: This is the nightmare that every controller

hopes will not happen to him.

Two of his aircraft collided, killing scores of people.

Oh!

NARRATOR: Peter Nielsen leaves the control

room for the last time, but his story is far from over.

NARRATOR: 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 midair collision in German postwar history.

Debris comes raining down around a school

for handicapped children run by Bruno and Stella Vegmula.

STELLA VEGMULA: The sky was orange-red, flaming.

And we saw these pieces falling down,

and detonations again and again.

And we realized it couldn't have been a normal thunderstorm.

It was something we had never heard and seen before.

BRUNO VEGMULA: It was incredible because it--

there are many, many houses here and there

was nothing on this place.

But around our school we find the bodies, children.

STELLA VEGMULA: We very soon also realized that we

couldn't do anything, really.

We couldn't save anyone.

We couldn't help anyone.

INTERPRETER: Yhe problem was that the bodies

and debris were dispersed over a very, very wide area--

approximately 40 square kilometers--

a corridor 20 kilometers long and 2 kilometers wide.

NARRATOR: It was the largest police operation

in the province of Baden-Wurttemberg,

lasting a week and involving over 6,000 people.

INTERPRETER: The people were all very sad.

They were you're in a state of extreme shock.

And, naturally, the rescue team could feel that

and empathized with their suffering.

NARRATOR: The policeman is standing

where the DHL plane crashed.

INTERPRETER: Here you see no more trees.

The trees have completely burned down.

We assume that the turbines of the Boeing

separated first, approximately 700 to 800 meters high,

before this plane crashed.

One landed 300 meters that way, and the other turbine was

another 500 meters that way.

NARRATOR: In this garden lay many of the bodies

of the children of Ufa.

In this part died 28 children.

In this field there was a child.

More over here in this field, there was a--

here.

INTERPRETER: When they showed a close up of an airplane,

I saw an emblem of our Bashkir Airlines

on the rear of the aircraft.

I was in the kitchen.

Everybody was still asleep.

I nearly fainted.

I leaned to the table.

I didn't know what to do.

NARRATOR: The Khannanov family lost their only daughter.

Irina Degtaryeva lost her only child.

IRINA DEGTARYEVA:

INTERPRETER: We hoped for some kind of a miracle,

that he missed the plane.

In a word, we didn't want to believe in this news.

It was like thunder in a clear sky,

and God forbid anyone gets news like this.

NARRATOR: Vitaly Kaloyev, a Russian architect,

was awaiting his family in Barcelona.

He is one of the first to arrive in Uberlingen.

Although the relatives are not encouraged

to participate in this search, Vitaly cannot help himself.

Vitaly finds a broken pearl necklace.

He recognizes it as his four-year-old daughter's.

My angel.

NARRATOR: Amazingly, amidst all the carnage,

Vitaly finds his daughter's body intact.

She did not suffer at all.

NARRATOR: The mutilated bodies of his wife and son

won't be found until later.

Over six days of searching, the rescue workers

gathered 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'd found because most of the bodies were badly charred

or mutilated.

We didn't permit the relatives to view

the bodies in that condition.

NARRATOR: In Ufa, in Western Russia,

both the Christian and Muslim communities are devastated

by the loss of their children.

In a cemetery, where 53 of the people in the Tupolev

are buried, there are two double rows of gravestones,

with the Christian Orthodox on one side

and the Muslims on the other.

This is Kiril's grave, the young talented artist.

And this is Elena's, the 12-year-old gymnast.

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 all but comes to a standstill.

PATRICK HERR: People were in a state of shock.

They were shocked.

They were helpless.

There was a lot of sadness, people crying.

One of the biggest tasks was to maintain operations,

because there were planes coming in,

going out after this tragedy.

And that was a very, very difficult

situation for everybody.

NARRATOR: For three weeks after the collision,

capacity is reduced for lack of available controllers.

Peter Nielsen never again worked on an air traffic workstation.

If you go through something like that,

you're not able to come back.

It's too deep in, and it's too, too big.

NARRATOR: The hunt begins for a scapegoat.

Blame for the collision initially

falls on the Russians.

REPORTER (VOICEOVER): 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.

As 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've 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?

And why didn't the Russian plane descend when first ordered?

A language problem?

Controller commands are always in English.

I knew everybody from that crew,

and everybody knew English enough

to speak with controller.

NARRATOR: So who is to blame?

The media spotlight now falls on controller Peter Nielsen.

He was the man who had guided the two

planes toward 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 that they just

want to fill the newspaper.

They write whatever they get.

And what more do we know about this Swiss controller

at the center of the investigation?

He was chased by the media.

He was accused of being a murderer.

He's the man, obviously, everyone wants to talk to.

But at the moment, the Swiss say he's in no position to talk.

And we heard today the Swiss authorities have opened

an investigation to see whether there's enough evidence

for charges of manslaughter.

NARRATOR: Meanwhile, a forensic investigation

is also underway, headed by Germany's air crash detectives,

the BFU.

This is the hangar where wreckage of the planes

was examined.

This one here is the lowest surface of the right wing

of the Tupolev.

And that remaining stump 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.

NARRATOR: 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 sense is that Aircraft B is still

on a collision course, it will tell

it to go in another direction.

But it didn't.

Why?

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.

NARRATOR: When the DHL's TCAS saw that the Tupolev wasn't

climbing, it could only tell its pilots to descend even faster.

AUTOMATED VOICE: Increase descent.

NARRATOR: If the reversal had been possible,

the children of Ufa might have lived.

July 2003, many parents return 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 in the crowd.

INTERPRETER: 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.

INTERPRETER: Have you apologized?

INTERPRETER: OK, thank you.

NARRATOR: Among the parents is Vitaly Kaloyev.

He asks the head of Skyguide which controller was

responsible for the accident.

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.

NARRATOR: The request passes almost unnoticed.

But Vitaly Kaloyev is not satisfied.

AUTOMATED VOICE: Descend.

NARRATOR: Meanwhile, as the investigators work,

they discover a fog of confusion surrounding TCAS.

When it was introduced 20 years before,

there had been a fatal omission.

Descend, flight level 350.

Expedite.

NARRATOR: 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.

NARRATOR: There is no hard and fast rule to guide the pilots.

He is guiding us down.

AUTOMATED VOICE: Increase descent.

NARRATOR: Pilots in the West are taught to obey TCAS.

Dilmun 600, TCAS descent.

NARRATOR: In the rest of the world, it was 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.

NARRATOR: The potential for a terrible accident was there.

And a year and a half before the collision

over Uberlingen, 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 maneuver caused 100 people

to be injured, some of them seriously.

This was seconds away from being the worst plane crash

in aviation history, because a pilot

had listened to the controller instead of his TCAS.

AUTOMATED VOICE: Descend.

NARRATOR: It should have served as a warning to everyone.

Yet, from ICAO, the International Civil Aviation

Organization, there was only silence.

ICAO is responsible for drawing up the rules

of commercial aviation.

INTERPRETER: 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.

NARRATOR: The Japanese government

immediately asked for ICAO's guidance after their near-miss.

But, unfortunately, ICAO only acted on the request

18 months later, after the collision over Uberlingen.

German investigators say that ICAO's vagueness on TCAS

was one reason for 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.

NARRATOR: The Japanese incident was not

the only warning ICAO received.

In the two years before the Uberlingen collision,

four other near-misses occurred over Europe alone

because one set of pilots obeyed air traffic

control instead of their TCAS.

If I have to summarize the advice that we gave the world--

if a warning comes from TCAS, pilots should immediately

follow it at all times.

With the benefit of hindsight, you always ask yourself could

we have done more.

And an accident is a wake up call for everybody.

NARRATOR: All of these regrets are 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.

So the right way to put it is my life didn't change.

It stopped.

INTERPRETER: Our pain doesn't go away, you know, it's

getting stronger every year.

It's getting hard to live.

At first we had a hope that she'd

come back, that time would pass and things

would fall into right places.

And now the hope is gone.

NARRATOR: The architect Vitaly Kaloyev

has lost his entire family and is obsessed with revenge.

He decides to travel to Zurich to play

out the last tragic chapter in the Uberlingen story.

NARRATOR: On February 24, 2004, a stranger

calls at the house of the controller Peter Nielsen.

Yeah?

Get out of my face.

Just go away.

Ah!

It was just the saddest thing you can imagine.

I knew his family.

I know-- I knew how much he loved his kids and his wife.

And-- and--

INTERPRETER: 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.

NARRATOR: They find Vitaly Kaloyev

nearby in a hotel, suspected but not

yet charged with the murder.

He is sent to a psychiatric clinic

while they decide if he's fit to stand trial.

INTERPRETER: Did he have the capacity to discern?

Was it an impulse or did he have the capacity to commit a crime?

INTERPRETER: Certain traces and police evidence

were found which seemed to indicate

that he could be the murderer.

INTERPRETER: We are working on this theory

after the accused himself conceded

that he could be the murderer.

INTERPRETER: We didn't want him to be killed.

We didn't want to have more victims

related to that catastrophe because of our children.

NARRATOR: Convicted of murder in 2005,

Vitaly Kaloyev served two years in a Swiss prison.

The killing of the flight controller

was a very, very sad event.

And 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.

NARRATOR: The investigators worked out exactly what went

wrong that night at Skyguide, and how

an unfortunate series of events made

disaster almost inevitable.

First Peter's colleague goes for a break,

leaving him alone to watch two radar

screens several feet apart.

INTERPRETER: It was a standard practice at the ATC company

that, at night, one air traffic controller

was responsible for controlling the entire airspace of ATC

Zurich.

NARRATOR: 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.

INTERPRETER: During the maintenance work

the radar system had to be run in fallback mode.

In fallback mode, the controller has no STCA available.

NARRATOR: STCA is short-term collision alert, a warning

on the radar screen that planes are in imminent danger

of collision.

INTERPRETER: He did not know that the STCA

system would not be available.

NARRATOR: Then, by chance, an unexpected aircraft--

the Aero Lloyd tourist plane--

arrives at a 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 backup phone isn't working.

The controller has been robbed of all

the technical support he needs.

INTERPRETER: 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.

NARRATOR: Finally, when both planes are descending,

the DHL pilots cannot tell him what

is happening because the radio frequency is busy.

600 TCAS descent!

INTERPRETER: 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.

NARRATOR: May 2004-- it had taken

the German BFU investigators 22 months

to publish their final report.

The Boeing--

NARRATOR: They found that the disaster had two major causes.

First, Peter Nielsen was too late in noticing

the danger of a collision.

Second, the Russian crew was wrong to obey him when he told

them to descend rather than their own TCAS equipment

telling them to climb.

Finally, the report severely criticized

Skyguide for leaving a lone controller on duty that night.

We have learned our lesson, and we don't have single-manned

operations or only one controller

in front of a monitor anymore.

INTERPRETER: Why didn't they provide

safety during that flight when my child was on board?

They must take the responsibility

for not providing security for that flight.

INTERPRETER: Mistakes were made by us also,

and we regret them deeply.

We acknowledge our responsibility

as set out in the BFI report, and we ask the families

of the victims for forgiveness.

NARRATOR: At Skyguide in Zurich, a

rose now sits in a vase in memory of Peter Nielsen

and the tragedy of Uberlingen.