B752/T154, Skyguide, Uberlingen Germany, 2002 (Legal Process - Air Traffic Controller, ATC Supervisor, Air Traffic Engineers)
From SKYbrary Wiki
and Legal Process
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)
- 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:
- Three ATC Managers
- The ATSEP Project Leader for maintenance work being carried out at the time of the accident
- An ATSEP worker
- The ATCO also on duty but on an approved break at the time of the accident
- An ATC Supervisor
- 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.
- Three ATC Managers - one year prison sentence suspended for two years and court costs of SWF 25000
- ATSEP Project Leader - A fine of SWF 13500 suspended for two years and court costs of SWF 25000
Appeal Lodged and Outcome: No
- 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".