In your own words, what is the summary of the case?

On July 1st, 2002 in the Zurich Area Control Center, Air Traffic Controller, Peter Neilson is the only
responsible on duty to Zurich Area Airspace while his colleague takes a break. The radar would be under
repair by maintenance engineers at the time, forcing the phone to go into backup mode. Bashkirian
Airlines Flight 2937, a flight from Moscow, was delayed and was about to land in Barcelona when it
collided with DHL Flight 611. Peter Nielsen tries to contact the crew AEF1135 but is unable to do so due
to technical difficulties with the backup connection. As a result of his conduct, he was unaware of the
impending collision of the two flights he was working on at the same time. According to the Sky Guide
Policy, at any given time, there must be at least two air traffic controllers. Peter Nielsen only contacted
the Russian crew 43 seconds before the collision due to technical problems and a lack of personnel. The
black box in the commercial plane proved that both planes were warned via Traffic Collision Avoidance
System(TCAS) before the collision. DHL Flight 611 followed TCAS's instructions to lower its altitude. Since
Russian crews are instructed to prioritize ATC instructions over TCAS, as specified in the operations
manual at the time, the Russian crew did not obey the TCAS instructions (Ascend). Due to stress and
pressure, Peter Nielsen ordered the Russian crew to descend. He also confirmed that the colliding
aircraft would collide on the right side rather than the left, leaving the crew little time to prevent the
collision. As a result, the two planes collided as they descended at the same time. Due to a collision with
the vertical stabilizer of a Boeing 757-23APF Cargo Aircraft, the Tupolev Tu-154M Commercial Aircraft
was ripped into four parts. On the Tupolev, all 69 passengers and crew members died, as did the two
passengers and crew members on the Boeing. And on February 4th, 2004, Peter Nielsen was killed by
Vitaly Kaloyev, a member of one of the victims' families who wanted to blame the incident on the air
traffic controller.

Who are the organizations involved in the case? *

The German Federal Bureau of Aircraft Accident Investigation lead the investigation to the plane crash of
the Bashkirian Airline Aircraft and the DHL plane in Überlingen, near Berlin, southern German. Where
the pieces of evidence were collected and used as to study the accident of the mid-air crash of the two
aircrafts. And which was recorded by the Zurich Area Control Center who was given the responsibility of
the Air Traffic System and also has the signal and record of the aircrafts crossing to their center. The
Skyguide an air navigation service provider took over the responsibility of the accident and was charged
for the casualties of the disastrous event.

When did it happen, and what are the type of aircrafts involved in the accident? *

At the night of July 21, 2002, the mid-air collision of Bashkirian Airlines Flight 2937, a Tupolev-Tu-
154M passenger jet that carries 69 passengers, and the DHL Flight 611, a Boeing 757-23APF, with two
aircraft crews.

Identify the latent conditions present before the accident. In the workplace? In the organization? Explain
why you think so. *

The first one is that Bashkirian Airlines Flight 2937 was delayed and about to land in Barcelona that was
unexpected to the radar signal of Zurich Area Control Center. Then, the complacent restriction of having
less than the minimum required of two Air Traffic Controller in the Zurich Area Control Center when
Peter Neilson colleague take a break. And the poor maintenance of the communication in the Air Traffic
Control that missteps the connection between the Air Traffic Control and the aircrafts that crossing their
system that has also have a stressed and pressured controller.

List down the errors and violations made by the human factor. Explain why you think so. *

The unconcerned minimum required Air Traffic Controller, which is two, when leaving his colleague all
alone with a mindset of 'the less busy the air traffic at night, the less technicalities they would get' that
resulted to wrong decisioning of backing up the xerox radar, since it's in maintenance, that blocks the
connection of the pilots and the ATC controller.

The stress and pressure of the only controller of giving directions of instead 'to the right hand side', he
gave the wrong signal to the Russian that the approaching airplane is actually going to the left.

The fidelity of the Russian pilot of trusting the person in-charge to the Air Traffic Control, instead of
deciding to use the alarming Traffic Collision Avoidance System (TCAS) that the both aircrafts have.

What are the defenses available during the operation? Were they operational? How were they
breached? If not breached, then include the defenses present. *

The Traffic Collision Avoidance System (TCAS) that the both DHL Flight 611 and Bashkirian Airlines Flight
2937 have. They were operational at the same time as it give them the alarming capacity they have.
Since the DHL Flight lost it's communication to the Swiss ATC, and the Russian Pilots trust the in-charge
person in the Swiss ATC that barriers them to use the ability of the TCAS.

Which among the Dirty Dozen have you noticed in the case? Identify and explain where along the case
was it present and what should have been done to prevent it. *

Number 1 is the Lack of Communication, the controller and the pilot lost their communication while in
serious operation. They should have always a high maintenance on the radar system especially to the
communication.

Next is the Complacency of the crews in the Swiss ATC for leaving a person in-charge which must have at
least 2 controllers per ATC in action. They should have followed the protocol no matter what happen.

Distraction is also visible in the case for having poor maintenance to the Swiss ATC systems that is
needed to be on fully function in every piece of time. They need to check it regularly and should not
leave broken as soon as possible they can fix the systems.

Lack of teamwork, due to working alone and lack of communication, an accident happened. They
shouldn't leave their teammate working alone.
Pressure, Lack of Assertiveness, and Stress in one reasonable cause that Peter Neilsen lost his ability to
think peacefully as he gave commands to the radio of the pilots. He should have create a peaceful mind
while performing his tasks and also he shouldn't be left alone in the first place.

The Lack of awareness of the Russian pilots of the alarming TCAS that there's another aircraft in their
radar that was approaching to them. They don't have their own decision making that went through
should also be done to protect the trust in the operator or the ATC.

What are the recommendations to prevent the accident from happening again? Do you think it is
enough why? *

Just like in the end where the Skyguide upgraded their systems with high maintenance and also having
enough workers even at the less busy flight hours. Improving the communication and radar system to
the incoming flights in the future that may allow their scope or area of responsibility in the air traffic.

Who will be responsible for these recommendations? *

To all the aviation industry all over the world, they should have enough capacity of operation of their
systems of their airlines, their Air Traffic Control Center, and airports to have a safe flight on the land
and on the air as they prevent accident and malfunction to system especially to the Air Traffic.

What is your conclusion for the case? *

Overall, having enough operation and building up innovation to the system is the number one key to
have a descent flight to have at least prevent the prevailing effect that should not be happening in all
time. A single mistake of an aviation worker can have a huge effect to the whole industry. Proper
knowledge with proper thinking is the best characteristic that they should acquire. To prevent accident
like the Uberlingen mid-air collision of the DHL 611 and Bashkrian Airline Flight 2937, learn from the
mistake from the past and never stop following the etiquettes and safeties to prevent another accident
in the present up to the future. Everything matters in the aviation industry especially when it comes to
the safety of the passenger on a single aircraft.