Faculty of Electrical Engineering PROFESSIONAL ENGINEERING PRACTICES (SEE 4012)

LONG REPORT UEBERLINGEN AIRCRAFT COLLISION

No 1 2 3 4 5 6 7

Name MOHD ATHIR BIN KAMARUDDIN MOHD FADZLI BIN ABDUL RAHMAN ABDUL MALEK BIN ALI UMAIRA BINTI OMAR MOHD HAIRUL FADLI BIN MOHD HASHIM

Matrix ID SX090689EEJ04 SX090693EEJ04 SX091583EEJ04 SX070506EEJ04 SX080631EEJ04

Lecturer: Dr. Salinda Binti Buyamin Date:

TABLE OF CONTENTS

NO. 1.0 2.0 3.0 4.0 5.0 6.0 7.0 ABSTRACT OBJECTIVES INTRODUCTION

TITLE

PAGE

GENERAL OVERVIEW DISCUSSION CONCLUSION REFERENCES

1.0

ABSTRACT
This report deals with the collision of two aircraft in Uberlingen caused by several factors related to the practice of engineering ethics. In this report, we describe how the incident took place and what the causes and suggest ways to the solution and the precautions to be taken.

2.0

OBJECTIVE
The main objective of this report is to define and analyze the causes of accidents and to suggest ways to the solution and precautions based on SEE 4012 subjects (Engineering Professional Practice).

3.0

INTRODUCTION

A mid-air collision is an aviation accident in which two or more aircraft come into contact during flight. Owing to the relatively high velocities involved and any subsequent impact on the ground or sea, very severe damage or the total destruction of at least one of the aircraft involved usually results. The chance of surviving a major mid-air collision is virtually zero in the absence of ejector seats and parachutes, as indicated below, although occasionally this rule may be violated. The potential for a mid-air collision is increased by miscommunication, error in navigation, and deviations from flight plans. Albeit a rare occurrence due to the vastness of open space available, collisions often happen near or at airports, due to the large volume of aircraft and closer spacing compared to general flight. In 2002 mid-air collision at Uberlingen occur between the Bashkirian Airlines flight 2937 that passenger aircraft TU-154M Tupalev the way from Moscow to Barcelona to carry 57 passengers, mostly students and 12 flight crew and 611 of DHL Boeing cargo plane 75723APF the way from Bergamo, Italy to Brussels, Belgium, conducted by two pilot have collided in the air on July 1, 2002, 21:35 UTC around the city Owigen and Uberligen in southern Germany near Lake Constance in which killed all 71 people in both planes. Surveys Bureau of National Aircraft Accident Germany (BFU) concludes on May 19, 2004, in which the accident was caused by problems related to traffic control system in which air traffic controllers were assigned to expedite and ensure the flow of air traffic a safe and orderly in air traffic control systems worldwide. Air traffic controller positions requiring highly specialized skills for the controller set rules which set the minimum distance that must be maintained between aircraft in the area of jurisdiction, and move all aircraft safely and efficiently through the air space assigned to him. In addition, problems of use violation warning system is also one main cause, which the Traffic Violation Prevention System otherwise known as the Warning System and Traffic Anti-Violation (TCAS) is a plane traffic deterrent system, designed to reduce collisions between aircraft in the air. It monitors the airspace around the aircraft for other aircraft equipped with transponders, not dependent on air traffic controllers and warned the pilot about the presence of other aircraft with a transponder that has the potential of the air collision (MAC). It is a violation of Air Prevention System prescribed by the International Civil Aviation to be included on all aircraft with maximum takeoff mass (MTOM) exceeding 5700 kg (12.586 lbs) or which carry more than 19 passengers. The official definition EXCISE ACT-ATM (Nov 2007): ACAS / TCAS is an aircraft system based on radar transponder signal into two (SSR), which operate without depending on the equipment on the ground to advise the pilots of the potential for conflict with the aircraft, which is supplied with SSR transponder. In the cockpit of modern aircraft, the TCAS display integrated in hand navigation display (ND), in the old aircraft cockpit and with a mechanical indicator, TCAS display replaces the Vertical Speed Indicator that shows the up and down the aircraft.

4.0

GENERAL OVERVIEW
Flight 2937 that led Bashkortostan School students brought to the resort on the Costa Daurada in Spain are as their prize in the competition republic. Many of the children's parents are senior government officials in Bashkortostan. Seven of the children are students at the Gymnasium No. 3 in Ufa, which is known as one of the high-class school in Ufa. At first, the child should be in flight from Sheremetyevo Airport on Sunday, but the child is late arriving in Moscow and arrived at the wrong airport. The child did not leave Moscow until Monday (July 1) from Domodedovo International Airport. The aircraft captain, Alexander Mihailovich Gross, and the first officer who is also the supervisor Gross, Oleg Pavlovich Grigoriev, flying Tupolev. Grigoriev, chief pilot of the Bashkirian Airlines, use this exploration to assess the ability of Gross. Murat Ahatovich Itkulov, should be the first officer, but does not work because Grigoriev sitting in his seat. Crew wanted Itkulov opinion and guidance, which should help the captain. Sergei Kharlov, a navigator and flight engineer also joined the crew of three. 611 flights carrying cargo goods, with two crew Bahrain. Captain Paul Phillips, a British citizen and Officer Brant Campioni of a Canadian. Two aircraft flying at flight level 36.000 feet (11,000 m) above Mean Sea level is at risk of infringement. In German, the airspace controlled from Zrich, Switzerland by Swiss Air Traffic Control Skyguide Company. Air traffic controllers on duty, Peter Nielsen, his worked in two jobs at the same time and not aware of the hazards that will befall the two aircraft to less than a minute before the breach. At the time he contacted Flight 2937, ordered the pilot to go up to ten thousand feet to avoid collisions with crossing traffic that Flight 611. A few seconds after the Russian crew do to drop, Traffic Violation Prevention System (TCAS) for them, instructed them to climb, while at the same time TCAS on Flight 611 DHL direct the pilots of the airplane to to down. DHL 611 pilots immediately follow TCAS instructions and do drop, but they did not immediately inform the controller that they have a reckoning with Flight 2937. Russian pilots in Tupelov ignore TCAS instruction to climb and start to decline, as directed by the controller and both planes simultaneously down. Not being aware of the warnings raised by TCAS, Nielsen repeated his instruction to Flight 2937 to descend, giving false information to the crew of the aircraft position Tupelov about DHL. Maintenance work has affected the primary radar system, which means that the controller had to use a slower system. On the night of the accident the main telephone system was also out for maintenance and the back-up system had a software failure, which no one in the company had noticed, not even during tests run three month before the accident. As a result, when the controller tried to contact the FHA tower to inform them that the second aircraft was requesting a different approach, he could not get through. So therefore, the two aircraft had

collided at right angles at an altitude of 34.890 feet (10.630 m), with horizontal stabilizer Flight 2937 Boeing split the fuselage near the wing Tupelov. The Tupelov has exploded and broke into several pieces, flying in the local area. The front of the plane fell vertically and tail where the engine up and then fall. Boeing plane that lost 80% of the its horizontal stabilizer structure, fell as far as seven kilometers (four miles) before crashing into the forest near the village Taisersdorf at down an angle of 70 degrees. Each engine is broken as far as several hundred meters from the remnants of the main and tail plane separated from the fuselage fell into a tree. All 69 people in the Tupelov and two people in the Boeing were killed.

5.0

DISCUSSION 5.1 Personal Ethic , Business Ethic, Engineering Ethic (Hairul) 5.1.1 Personal Ethic
On 24 February 2004, Peter Nielsen, the air traffic controller on duty at the time of the accident, was stabbed to death by Vitaly Kaloyev. He needs to control 2 frequencies and monitor 2 separates screen at the same time. Nielsen repeated his instruction to Flight 2937 to descend, giving the Tupolev crew incorrect information as to the position of the DHL plane. Flight 611's pilots on the Boeing jet initially followed the TCAS instructions and initiated a descent, but could not immediately inform the controller due to the fact that he was dealing with Flight 2937. The Russian pilot on the Tupolev disregarded the TCAS instruction to climb and instead began to descend, as instructed by the controller, thus both planes were now descending. Nielsen had a stand-by controller and system manager on call. He was unaware of this. When Nielsen realized that the situation had subtly increased beyond his span of control, it was too late to summon assistance.

5.1.2 Business Ethic

The other controller on duty was resting in another room for the night. This was against the regulations, but had been a common practice for years and was known and tolerated by management. At the control tower, handling two workstations at once, Nielsen struggled with the malfunctioning phone system that he was trying to use to call the Friedrichshafen airport to announce the approaching Aero Lloyd. On 19 May 2004, the official investigators found that managerial incompetence and systems failures were the main cause for the accident.

5.1.3 Engineering Ethic

It is between 2 pilots behavior. Russians pilot advised to obey orders from the ground control for the first place. Europe and American standard procedure set TCAS over the ground control orders to be priority. Maintenance work was being carried out on the main radar system, which meant that the controllers were forced to use a slower system to communicate. The only air traffic controller handling the airspace, Peter Nielsen, was working two workstations at the same time and he did not realize the problem in time and thus failed to keep the aircraft at a safe distance from each other. The main phone lines at Skyguide were down due to maintenance work, and the backup line was defective. The faulty phone lines also prevented adjacent air traffic controllers at Karlsruhe from phoning in a warning the groundbased optical collision warning system, which would have alerted the controller to imminent collisions early, had been switched off for maintenance and Nielsen was unaware of this.

5.2

Ethical Theory, application and Problem Solving (Athir)

At the time of this accident, only one air traffic controller assigned to control air traffic, where it is one of the causes of the accident, which is less supervision or assistance in the critical security situation. Single Man Operating Procedure (SMOP) is controversial procedure in which it was implemented in 2001, but has received numerous protests from air traffic controllers union, but the leaching does not pay any attention. At night, the maintenance work is being done on the main radar system, which causes their radar service at fallback mode. As a result, the minimum separation between aircraft has increased from 5 miles to 7 miles (equivalent to about one minute). As for the main phone system at the time, is in the works under maintenance and backup system software failure, where no person in the company is given notice, even though the test was conducted three months before the accident. As a result, when air traffic controllers tried to contact the FHA tower to inform them that a second aircraft had requested a different approach, he could not contact him. Referring to the above, why the management of only one on duty at a time, why there was no backup system that has the same capacity with the main system to be used when the main system is maintained and why the notice is not given, when the maintenance performed. This clearly shows the properties that are not ethical because ethical is an individuals behaviour or individual's character how to cope with something that is right or wrong or something bad or good in one's actions. Individuals who are ethical would give good things where it will be responsible in everything they do and prioritize the health and safety of others or user.

As a supposed ethical, they must provide two or more radar systems that have the same capacity, when one serves as the main system and other radar systems will be the backup system. In addition, management should put two or more air traffic controllers on duty at a time to enable him to detect or control certain conditions more quickly and effectively. The management should also inform or give notice to all staff on the maintenance or upgrading the system to enable staff made ready to take other actions. Although it will involve higher costs but as individuals who are ethical, quality, health and consumer safety to be prioritized.

5.3

Moral Theory and (Humaiera)

Moral Theory Definition Is A moral theory defines terms in uniform ways and links ideas and problems together in consistent ways. There are several of the basic moral Theories and among the theories. For this study case will discuss three of them such as: i. ii. iii. iv. Utilitarian theories. Duty theories. Rights theories. Virtue theories.

A theory of the good is a claim about what it means for a human life to be going well or about what sorts of events and developments in their lives human beings have strongest reason to desire or approve. For example, theories of the good say (variously) that a human life goes well insofar the person living that life exercises a certain sort of deliberate control over its major directions and aims; or insofar as the life contributes to the well-being of others; Moral or ethical theory may consider the application of rules or the consequences of actions. In term of Utilitarianism Theories, based on the investigation report one of factor of this incident which is due to corporate culture undertaken by the pilots of both aircraft. Utilitarianism Theory means produces the most good for the most people. In this situation, both of pilots responded to the right action and being in a good moral situation. From data analysis suggests that whereas the B757 pilot followed the TCAS advisory to descend, the T-154 pilot opted out of following this advisory to climb and followed controller instructions to descend. This raises the issue of why the pilots of two separate aircraft would respond to the system in such a different way. When presented with conflicting information between ATC and TCAS, European pilots are advised to follow TCAS whereas Russian pilots are trained to take both into account before rendering a decision. In most instances, the latter group will follow ATC. This may help explain why the B757 pilot who was British and the T154 pilot acted in the manner observed. Furthermore trust can be seen as a potential explanation why the

pilot crew of the Tupolev followed the instructions of the controller. Trust basically expresses the expectation of a trusting party to receive something positive from another party. These parties do not necessarily have to be human. Trust would not be necessary without the potential danger of the passengers deaths. From the reports of actual incidents, the two pilots were taking the action to save the situation despite the slight misunderstanding when a decision is made. Both pilots have been in accordance with the regulations and SOPs should be done when situations like that happen. In this situation, the pilots are right and they were in good morality. It can also be associated with Right Theories because they act like the theories which Rights theories state that an action is acceptable if it respects the human rights of everyone involved. In other situation, there is only one air controller on duty at night only event and the need to control two of the radar system are running. This was against the regulations, but had been a common practice for years and was known and tolerated by management. The presence of only one controller working the radar screen represents one of the underlying causes of the accident, namely lack of supervision or assistance in safety-critical situation. There are two important issues to note here. Firstly, arrival traffic at that airport at night was extremely rare. Secondly, the controller chose to have the radar information for traffic approaching the airport displayed on a separate monitor. In this situation the air controllers could not be blamed entirely, as he was trying to help control radar for its partners but the policy did not specifically state that the SMOP should not be used at night; a period during which staffing levels are extremely low, making it harder to catch errors. No matter what the policy is also provided by the relevant authorities should it hold the appropriate moral theory because it involves other people. The air controller could be regarded as unethical the right when taking the decision to control radar alone knowing many possibilities that could occur if the die cannot control the radar very well and that is what has happened. He shall be presumed to comply with the moral theory in Duty Theories and Right Theories. Duty Theories means actions are good when they respect the rights of individuals while Rights theories state that an action is acceptable if it respects the human rights of everyone involved. Our culture is certainly more accepting of this approach than it used to be. There is still the problem of how to decide what to do when the rights of two or more people come into conflict.

5.4 5.5

Criteria for save design (Adi) Conflict of interest (Malek)

Without supposing to prejudge the result of the accident investigation, the bare facts appear to be as follows: Zurich area control centre (ACC) was working a fall-back mode due to maintenance, so that the short term-conflict alert (STCA) system was not available to warn controllers of developing collision threats. To compensate,

controllers had increased aircraft separation minima from 5nm to 7nm, a distance that corresponds to approximately one minute of flying time. At a critical moment the phone lines from Zurich ACC to the adjacent Karlsruhe ACC facility were busy or unavailable. As the disaster path developed, a single controller was monitoring two radar sectors, while a second controller was taking a break. Apparently at about this time another aircraft was being handed over for approach to the nearby Friedrichshafen airport. An assistant controller was available at the work position, but she had no ATC tasks, being responsible for position reporting and flight plans. The ATC crew composition was standard for the relatively quiet night shift at Zurich ACC.About two minutes prior to the collision the STCA system at Karlsruhe warned of a threat of collision and the controller tried several times unsuccessfully to get through on the direct telephone line to Zurich ACC.

5.6

Professional VS Non-Professional (Humaierah)

Professional ethics has become more important over the years. As we become more specialized in our occupation, the issues become that much more complex. Professional ethics helps a professional choose what to do when faced with a problem at work that raises a moral issue. One can certainly study what professionals do when faced with such problems, and confine the enquiry to the description. There are some situations where professional ethics in the work is found to not meet the requirements as a professional in their duties. First there is only one controller works at a given time, while the other controller is on break, an accepted and long standing arrangement. The presence of only one controller working the radar screen represents one of the underlying causes of the accident, namely lack of supervision or assistance in safety-critical situation. This is against the rules that must be followed by both the air controllers. Besides that, on that night there maintenance work was being done on the main radar system. After the maintenance the result show separation minimums between aircraft were increased from 5 miles to 7 miles which corresponding to approximately one minute. Furthermore fallback radar mode also meant that the STCA was not available. This also is identifying a contributing factor to the accident. This is a non-professional action by those concerned as they should be aware of the consequences that may be encountered when the moments that happen like this breach. Other situation is main telephone system was also out for maintenance. On the night of the accident the main telephone system was out for maintenance and the back-up system had a software failure. In this situation no one in the company had noticed, not even during tests run three month before the accident. Action does not make them relevant information is one of the incident. Irresponsibility and not Professional

provides a substantial impact in world aviation history. As the professionals in their career they should consider the effects when taking the decision to make any action. Many codes of ethics require that the professional be objective in their work. Thus, not only does the concept of the reasonable peer apply in the objectivity of ethical thinking, it also applies in the giving of professional advice.

5.7

Types of accident
I. Procedural an Accident (Fadzli) Peter Nielson gave contradictory instructions to the TCAS instruction to both the pilot. II. Engineering Accident (Athir) Perform maintenance on the main radar system despite knowing backup radar system has a poor operating and perform maintenance on the phone system despite knowing the backup systems have a software problem and not giving any notice to the staff about the matter. SOP conflict between two airlines companies where the European pilots are trained to follow TCAS instruction because TCAS instructions is more important than ATC instructions. Meanwhile, the Russian pilots are trained to take account of both to make a decision and instruction from ATC is more important than TCAS because the TCAS is only a backup device. III. Systemic Accident (Fadzli) The integration of ACAS/TCAS II into the system aviation was insufficient and did not correspond in all points with the system philosophy. The regulations concerning ACAS/TCAS published by ICAO and as a result the regulations of national aviation authorities, operational and procedural instructions of the TCAS manufacturer and the operators were not standardised, incomplete and partially contradictory. Management and quality assurance of the air navigation service company did not ensure that during the night all open workstations were continuously staffed by controllers. Management and quality assurance of the air navigation service company tolerated for years that during times of low traffic flow at night only one controller worked and the other one retired to rest.

5.8

Factor effecting risk (Adi)

5.9

Osha/Health Officer and committee (Malek)

Following the accident, the Federal Department of Environment, Transport, Energy and Communication (DETEC) launched a thorough and independent review of the safety systems in Swiss air transport. Federal Councillor Moritz Leuenberger has regularly informed the Federal Council of the relevant findings and has initiated the measures required. As part of the "Safety First (SAFIR)" action plan, safety management is being reorganized at all levels. At the FOCA, the safety and policy sectors are being separated; the numbers of staff in the safety sector will be increased. The Federal Council has submitted a request to parliament to that effect. The procedure prior to publication of investigation reports by the Swiss Air Accident Investigation Bureau has been tightened thereby enabling safety recommendations to be implemented more swiftly. As part of an overall package of measures, amendments to the relevant provisions of the Civil Aviation Act and its ordinances will be required. It is now no longer the task of the FOCA to decide on the implementation of these recommendations, but rather the Department. The implementation of the new safety policy is one of the prime tasks of the new Director of the Federal Office for Civil Aviation, Raymond Cron, who took over the running of the FOCA at the beginning of May. Sky guide AG has several tasks to fulfill as part of the "SAFIR" action plan, with the aim of significantly raising the level of air transport safety within months. The company must establish and improve a safety-oriented corporate culture, increase its training capacities increase staffing levels expand its risk management and introduce a licensing procedure for its staff and a certification process for its technical facilities.

6.0

CONCLUSION (Hairul)
Technical solutions Before this accident a change proposal (CP 112) for the TCAS II system had been issued. This proposal would have created a "reversal" of the original warning asking the DHL plane to climb and the Tupolev crew to descend. According to an analysis by Eurocontrol this would have avoided the collision if the DHL crew had followed the new instructions and the

Tupolev had continued to descend. Additionally, an automatic downlink for the TCAS which would have alerted the air traffic controller had not been deployed worldwide at the time of the accident. Recommendations after the accident The investigation report contains a number of recommendations concerning TCAS, calling for upgrades and for better training and clearer instructions to the 245ipilots. Notable passengers on Flight 2937 Fourteen-year old Kirill Degtyarev created paintings from age 4 to his death and had held two public exhibitions. After his death, Ufa hosted one exhibition and berlingen hosted another exhibition.[12] The family of future deputy North Ossetian housing minister Vitaly Kaloyev all died. Kaloyev would later go on to murder Nielsen.

7.0

REFERENCES
1. Final Report: Review of the BFU berlingen Accident Report (Version 1: 17/12/2004). 2. Nunes, A. & Laursen, T. (2004) Identifying the factors that led to the Ueberlingen mid-air collision: implications for overall system safety. 3. Jing, H.-S., Lu, C.J., Peng, S.-J., (2001) "Culture, Authoritarianism and Commercial Aircraft Accidents", Human Factors and Aerospace Safety. 4. Brooker, P. (2005) "Reducing Mid-Air Collision Risk in Controlled Airspace: Lessons from Hazardous Incidents", Safety Science. 5. Helmreich, R. L. (1997) "Managing Human Error in Aviation", Scientific American. 6. Nordwall, B. D. (2002) "Tcas More 'Foolproof' Than Generally Recognized", Aviation Week & Space Technology. 7. http://www.iasa.com.au/folders/Safety_Issues/others/TCASisgood.html 8. http://www.waymarking.com/waymarks/WM1ZN8_berlingen_Mid_air_Collision_berlingen_ Germany 9. http://www.avweb.com/news/sayagain/191072-1.html