B752/T154, Skyguide, Uberlingen Germany, 2002 (Legal Process - Air Traffic Controller, ATC Supervisor, Air Traffic Engineers)

Article Information
Category:	Human Error in Aviation and Legal Process
Content source:	SKYbrary
Content control:	SKYbrary

The Event

Date: 01 July 2002

Location: Overhead Lake Constance, near Uberlingen, southern Germany

Summary: After loss of prescribed separation between crossing traffic at cruise altitude at night, a conflict between a Tupolev Tu 154 and a Boeing 757, both following valid ATC clearances, led to a co-ordinated TCAS RA occurring at about the same time as the controller issued an avoidance instruction to one of the aircraft, which then followed this rather than the RA with the effect that a collision occurred and all 71 occupants of both aircraft were killed.

The Non Judicial Investigations

Carried out by:

• Skyguide as ANSP
• BFU Germany under Annex 13 provisions (released 19 April 2004)

The Findings:

• Skyguide - not known but many subsequent changes to procedures
• BFU - Error by the controller against a background of poor safety management at Skyguide and error by the flight crew of the Tu 154 in not following their TCAS RA. 19 Safety Recommendations were made.

The Criminal Prosecution

Persons Prosecuted: Employees of Skyguide

The Court: Bülach District Court near Zurich Switzerland after agreement with German Public Prosecutor

The system : Judge sitting alone

The Charge(s): Charges of Negligent Manslaughter and Negligent disruption of public transport were brought against eight Skyguide employees on 7 August 2006:

1. Three ATC Managers
2. The ATSEP Project Leader for maintenance work being carried out at the time of the accident
3. An ATSEP worker
4. The ATCO also on duty but on an approved break at the time of the accident
5. An ATC Supervisor
6. A Technical System Manager

The Trial: Commenced 15 May 2007

Plea(s): Not Guilty

Prosecutors Sentencing Request: Suspended prison sentences for all the accused of between 6 and 15 months

Significant aspects of the trial: none

The Judgement: Delivered on 4 September 2007. The three ATC Managers and the Maintenance Project Leader were convicted and the remaining four defendants acquitted on grounds including:

• that single controller operation was common practice at the time of the accident when light traffic prevailed and that
• the allegations of the controller involved not having access to sufficient information to carry out their task could not be proved.

The Sentence(s):

1. Three ATC Managers - one year prison sentence suspended for two years and court costs of SWF 25000
2. ATSEP Project Leader - A fine of SWF 13500 suspended for two years and court costs of SWF 25000

Appeal Lodged and Outcome: No

Related Facts

• In 2005, the Regulator decided to introduce a licensing regime for ATSEP.
• In February 2004, the controller who had been at the desk and had given the instructions which led to the initial loss of separation and the subsequent late change to one of the aircraft directly, was killed at his home by a Russian national who had lost family members in the crash.
• Skyguide made out of court settlements involving payments to the victims’ families during 2003/2004.
• The grounds for not bringing charges against the then Head of Skyguide were stated as their lack of awareness of the prevailing organisational circumstances and absence of "direct responsibility".

Related Articles

• Human Error in Aviation and Legal Process
• Just Culture
• T154 / B752, en-route, Uberlingen Germany, 2002: article covering the accident investigation.