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00:00A terrível colisão nos céus sobre o norte de Alemanha
00:07é visto por pessoas no fundo.
00:2371 pessoas estão mortos.
00:25Nós, como investigadores, não tínhamos ideia de o que exatamente aconteceu.
00:35Não faz sentido.
00:37O radar data apenas despeçou o mistério.
00:40Não está tentando tentar sair do caminho.
00:43Justo para usar os facilidades.
00:45Descente?
00:46Real?
00:46Vamos descente?
00:48Expedite, descente.
00:49To solve the mystery, investigators will need to disentangle a web of critical radio transmissions.
00:56The controller is guiding us down.
00:58A lot of things had to fall into place just the wrong way for this to occur.
01:02And really woke a lot of people up.
01:05D-Day, D-Day.
01:10Oh, stop.
01:133-8-1-0, 3-8-0, 3-8-0, 3-8-0, 3-8-0, 3-8-0, 3-8-0, 3-8-0, 3-8-0, 3-8-0, 3-8-0, 3-8-0, 3-8-0, 3-8-0, 3-8-0.
01:194-8-1, 3-8-0, 3-8-0, 3-8-0, 3-8-0, 3-8-0, 4-8-0, 3-8-0, 3-8-0, 3-8-0, 3-8-0, 3-8-0, 3-8.
01:28It's 11 p.m. in Switzerland, and airports across the region are closing down for the night.
01:40You're off.
01:42See you in a few hours.
01:44In the Sky Guide Control Center in Zurich...
01:47TIE, ENTER 933, procede para Algoi.
01:50Copy, procede para Algoi. TIE, ENTER 933.
01:54Air traffic controller Peter Nielsen is working the night shift.
01:59Variante 305, descend flight level 220.
02:03He's been on the clock for just over three hours and has six more to go.
02:12Tom Lawson is a former Sky Guide controller who worked with Peter Nielsen.
02:17The night shift in Zurich at the time had quite a lot of traffic.
02:24But around 11.30, 12 o'clock, it reduced to five to seven aircrafts an hour.
02:29And it was possible to do it alone.
02:32Top Swiss 935, proceed direct to Torpa.
02:35Direct to Torpa, Top Swiss 935, thank you.
02:40Nielsen manages the safe transit of all aircraft in his airspace.
02:44For further instructions, contact Padua 120.72. Bye-bye.
02:52Air traffic control is one of the most stressful jobs in the world.
02:56And a lot of it does hinge on decisions made by one person.
03:00Ah, Swiss radar, good evening. Tillman 611.
03:04Nielsen hears from another plane in his airspace.
03:10Just levelling at flight level 260.
03:15Dillman 611 is the call sign for a Boeing cargo jet owned by the courier DHL.
03:21It departed from Bergamo, Italy, and is flying through Swiss, then German airspace, on its way to Brussels, Belgium.
03:30Dillman 611, squawk 7524.
03:367524.
03:38611.
03:41Dillman 611, climb flight level 320.
03:47Nielsen clears the flight to climb to a higher altitude.
03:50Roger, climb flight level 320.
03:52And requesting 360, thanks, if it's available.
03:58Pilots ask for the most efficient flight level that they can fly at.
04:03And in this case, 36,000 feet is much more fuel efficient.
04:08Dillman 611, climb flight level 360.
04:13Climb flight level 360.
04:16Dillman 611.
04:16Nielsen clears flight 611 to 36,000 feet and tracks the change.
04:30You use flight strips to plan the traffic ahead.
04:35With the strips and flight screen, we have a good picture of what is going to happen.
04:40But at 11.30, Nielsen's night shift takes a turn.
04:49Zurich, good evening.
04:51Bravo, Tango Charlie, 2937.
04:53Zero, nine, one, one, three, five.
04:57Two transmissions come in together, one at the workstation beside him.
05:04There's an airbus on approach to Friedrichshafen.
05:07And another plane flying at a higher altitude in the upper sector.
05:14Aeroloid 1135, descending flight level 8-0.
05:20Nielsen briefly responds to the airbus now on approach.
05:24Aeroloid 1135, Roger.
05:26Uh, call you back.
05:31He needs to identify the aircraft now entering the upper sector.
05:37Station calling, say again, please.
05:40Ah, Zurich, good evening.
05:44The aircraft is a Bashkirian Airlines Tupolev 154.
05:51The Russian plane is slightly ahead of schedule, crossing from Moscow to Barcelona.
05:58Bravo, Tango Charlie, 2937.
06:00Level 3-6-0.
06:0940-year-old Oleg Grigoryev is Bashkirian Airlines' chief pilot.
06:15Tonight, he's evaluating the 52-year-old captain, Alexander Gross,
06:20who has more than 10 years' flying experience,
06:22but has flown to Barcelona only once before.
06:26Smooth enough for you?
06:28So far.
06:32A bit bumpy back here.
06:35First officer Murat Itkolov, 41,
06:38is the captain's second pair of eyes.
06:41Then you better tighten your belt, eh?
06:43The flight is carrying a group of students and some of their parents
06:53on a school trip to Spain.
07:00As Nielsen gives the Tupolev crew their transponder code...
07:05Bravo, Tango Charlie, 2937.
07:07Squawk, uh, 7520.
07:09The airbus crew on approach tries to confirm their landing instructions.
07:17Yes, I expect so. Call you back shortly.
07:23Aeroloid 1135, request Lowa.
07:31Aeroloid 1135, descend flight level 70.
07:35Descending flight level 70.
07:37Aero, aeroloid 1135.
07:40As the airbus gets closer to Friedrichshafen,
07:44Nielsen calls the tower controller to hand off the aircraft.
07:47The desired connection is not possible.
07:50But he can't get through.
07:52Find me a number for Friedrichshafen tower.
08:03He tries again.
08:05The desired connection is not possible.
08:07Please check the number.
08:08He's working out there.
08:12Aeroloid 1135?
08:14Aeroloid 1135, go ahead, sir.
08:18I lost my phone connection with Friedrichshafen.
08:20Can you please call them on 124.35
08:22and tell them you're coming ILS 24 with 20 miles now?
08:26Okay, will do.
08:28Thank you.
08:28With the approaching airbus handed off,
08:34Nielsen returns to his other aircraft,
08:37the Tupolev passenger jet that's westbound to Barcelona
08:40and the Boeing cargo jet northbound to Luxembourg.
08:51Nielsen notices that both planes are moving towards each other at 36,000 feet.
08:56Nielsen realizes that Tupolev is soon scheduled to descend to 35,000 feet.
09:10Bravo Tango Charlie 2937, descend flight level 350, expedite.
09:16I have crossing traffic.
09:19Descending an aircraft is an automatic response for air traffic controllers
09:24because descending is a lot easier than climbing.
09:27It's the easiest way to solve a conflict.
09:32Bravo Tango Charlie 2937, descend level 350, expedite descent.
09:38Expedite descent level 350, Bravo Tango Charlie 2937.
09:45Yes, we have traffic in your position now at 360.
09:50I'm sorry, from the Aeroloid 1135.
09:55Yes, go ahead.
09:55We've made contact with Friedrichshafen Airport.
10:00But then, as the Aeroloid flight signs off...
10:10Affirm, bye-bye.
10:12Bye-bye.
10:17The Boeing has disappeared from the controller's screen
10:21and the Tupolev's radar signal is lost.
10:34Bravo Tango Charlie 2937.
10:38Air traffic controller Peter Nielsen has lost contact
10:41with two planes flying over southern Germany.
10:46Bravo Tango Charlie 2937.
10:48He called the aircrafts and got no response.
11:07He must have understood that it was a collision.
11:12Near the town of Uberlingen, people watch as fireballs fall out of the sky.
11:34Huge sections of both planes have crashed to the ground.
11:51There is no shortage of witnesses.
11:53And then there was a short hit and then three glühende parts of the world
12:00have fallen out of the sky and are slowly moving.
12:08A very hot light flare, yes, and then it was already over.
12:11First responders are on site within minutes, and by dawn, crash investigators from Germany's Federal Bureau of Aircraft Accident Investigation, the BFU, are there too.
12:29At the accident site, you just document what the wreckage tells you.
12:36The wreckage of the Tupolev is spread over four distinct areas.
12:48There would be maybe 100 meters between some parts, so it clearly indicates that there must have been an in-flight breakup of the Tupolev.
12:57Most of the Boeing is found in a forest outside the village of Teisersdorf, but one section is missing.
13:07The only part of the Boeing that was missing was the vertical tail, and this later has been found together with parts from the Tupolev, indicating that the collision took place between the two aircraft.
13:22Seventy-one people are dead. Forty-five of them are Russian students from the city of Ufa.
13:37Investigators soon recover much of the wreckage, including the black boxes from both planes.
13:58Hey, over here.
14:05But before they get readouts from the black boxes, investigators start to reconstruct the collision.
14:12So this piece is interesting.
14:19We as accident investigators did not have an idea about the details of what exactly happened.
14:29This red paint could have come from the Boeing.
14:36And then over here.
14:38The main issue is to understand which aircraft part collide with the other one and which came from the impact to the ground.
14:47Okay, so I've marked all the areas where the red paint from the Boeing transferred onto the Tupolev, and we even found part of the Boeing's rudder embedded in the Tupolev right here.
15:06The only way this could have happened is if the Tupolev flew straight into the Boeing like this.
15:21The question is, how can it happen that two planes are at the same place at the same time?
15:44Thank you.
15:45Okay, so we've compiled all of the radar data from air traffic control.
15:52Okay, let's see what happened.
15:58Both planes are cruising at 36,000 feet.
16:03They both start descending.
16:05At exactly the same time.
16:11Neither one is trying to get out of the way.
16:1590 degrees at the same altitude is about as simple as it comes.
16:22A turn, a descent of one, a climb of one.
16:26So, how did we get to this point?
16:31It doesn't make sense.
16:33Why would both planes descend?
16:36We all were of the opinion that the air traffic control system in Europe would be very, very safe.
16:48So, it was really hard to understand that an accident like this could occur.
16:53Let's explore this.
16:55Look at the weather data.
17:01The basic way for pilots to avoid collisions is called see and avoid.
17:07The pilots look out the window, see the other aircrafts, and don't collide.
17:12It was a clear night.
17:15No moon at the time of the collision.
17:19The sky was pitch black.
17:21Even with anti-collision lights, judging altitude and distance would have been impossible.
17:28For jets operating at high altitudes, moving at seven miles a minute, finding some little dot even in a clear sky is nearly impossible.
17:44So, we can eliminate that.
17:49What about ATC separation?
17:51Can we interview the controller yet?
17:53We're making arrangements to speak with him about the accident.
17:56And where are we at with the TCAS recovery?
17:59I'll check.
18:05The TCAS, or Traffic Collision Avoidance System, uses transponders on the aircraft to transmit a plane's location.
18:13to others.
18:14If two aircraft appear to be on a collision course.
18:16Traffic.
18:18Traffic.
18:19An alarm sounds, warning pilots to change course.
18:24TCAS is intended for, when we need a last-ditch effort, to just keep them from hitting.
18:32Yeah.
18:33Thank you.
18:36We've got the two below TCAS, but no lock on the Boeing.
18:40It's too damaged.
18:43The major question for us, did the TCAS computer work as per design?
18:52The TCAS computer of the Boeing was destroyed completely.
18:58And that was the problem.
19:02If TCAS is at fault, it could threaten the safety of air travel throughout the world.
19:07Investigators looking into the Uberlingen mid-air collision examine the TCAS data from the Tupolev plane, to determine if it was working properly.
19:21Wait a sec.
19:22The Tupolev TCAS recorded data for both planes.
19:34There's an identical set of files for both flights.
19:39That was a big moment in the course of the investigation, and we were very happy about that.
19:52Investigators compare the TCAS altitude data with the radar data from both planes.
19:57The altitudes match perfectly.
19:58What instruction did TCAS give each plane?
19:59Start with the Boeing.
20:00Did TCAS provide each aircraft with the proper instructions to avoid each other?
20:16Tell them to descend.
20:21Which the Boeing did.
20:23Now the Tupolev.
20:27Investigators discover that TCAS correctly advised the Tupolev pilots to climb.
20:37But, they descended.
20:38Just like the Boeing.
20:39So, why didn't they follow the TCAS instruction?
20:44TCAS did what TCAS should have done.
20:58If pilots would follow the TCAS instruction, TCAS would have prevented the accident.
21:05Investigators turned to the Tupolev's cockpit voice recording, or CVR, to determine why the Russian crew disobeyed the TCAS instruction.
21:18Look here.
21:19On the VSI.
21:21There's a plane approaching on our left.
21:27They first became aware of the Boeing two and a half minutes before the collision.
21:35They're still more than 25 miles apart.
21:38It's ample time to avoid the Boeing.
21:40So, why didn't they?
21:43We have the same altitude.
21:49It's coming towards us.
21:54No.
21:55He has a parallel heading.
21:58For the next minute and a half, the crew discusses the Boeing's position.
22:08Here.
22:09Visually.
22:10This is showing us zero.
22:13Zero on the TCAS means there is no difference in altitude between them and the approaching Boeing.
22:21They seem unsure if the Boeing is actually a threat.
22:28Agreed.
22:29But TCAS should warn them if the Boeing is getting too close.
22:34Traffic.
22:35Traffic.
22:36There it is.
22:37Traffic.
22:38Traffic.
22:39Traffic.
22:40Traffic.
22:41Traffic.
22:42Traffic.
22:4350 seconds before impact, the TCAS issues the first aural warning when the oncoming plane
22:50is less than 10 miles away and closing fast.
22:54Traffic.
22:55Traffic.
22:56Moments later, the crew receives an instruction from air traffic control.
23:02Bravo.
23:03Tango.
23:04Charlie.
23:052937.
23:06Ascend flight level 350.
23:07Expedite.
23:08I have crossing traffic.
23:09Descent.
23:10Followed by a different instruction from TCAS.
23:15One.
23:16One.
23:17One.
23:18One.
23:19One.
23:20One.
23:21The crew got conflicting instructions.
23:27incares.
23:28The crew was going to rise to the plane toward над
23:39amoers.
23:41Need aكas told the crew to climb, the controller told them to descend.
23:48His controller,esen-clim, really?
23:49We're going to descend?
23:51The captain follows the chief pilot's command and puts the plane into a steep descent.
23:52Bravo Tango Charlie, 2937. Descend level 350. Expedite descent.
24:00Descend level 350. Bravo Tango Charlie, 2937.
24:07Yes, we have traffic in your position now at 360.
24:14Moments from disaster, TCAS issues a final command.
24:19Increase 1. Increase 1.
24:22But it comes too late.
24:43Well, there we have it.
24:46The chief pilot followed the controller's instruction to descend
24:50instead of the TCAS's instruction to climb.
25:03Each one of these guys got TCAS training.
25:08They should have known the TCAS is the final authority.
25:11So, why did the chief pilot listen to the controller instead of TCAS?
25:28Investigators of the Uberlingon disaster examined the TCAS training of the Russian crew
25:34to determine why they followed the ATC instruction instead of TCAS.
25:40Hey, I think I found something.
25:45TCAS 2000 is intended as a backup to visual collision avoidance,
25:49application of right-of-way rules, and ATC separation services.
25:52A backup?
25:54Look at this.
25:58For the avoidance of in-flight collisions, instructions issued by ATC is the most important tool.
26:09TCAS is an additional instrument.
26:11So, if it comes down to TCAS versus ATC, the Russian pilots go with the ATC's instructions.
26:22It seems that way.
26:23We asked Russian flight crews, and pilots told us, yes, it's a backup for ATC.
26:32And so, they explained that the flight crew of the Tupolev did what they should have done.
26:38But the Boeing crew followed the TCAS instruction.
26:44Descend.
26:45Descend.
26:46Descend.
26:47Descend.
26:49Descend.
26:51I wonder if they informed the controller they were descending.
26:56The final approach weeks for ILS runway 24.
27:00Did the controller know the Boeing was also descending?
27:03Call you back shortly.
27:07Let's have a listen to the cockpit voice recording.
27:11For the flight crews, there's a clear operating procedure.
27:15As soon as possible, they have to report it to ATC.
27:20That was the reason why we had to listen to the Boeing cockpit voice recorder.
27:24Ah, Swiss radar.
27:25Good evening.
27:26Tillman 611.
27:28Tillman 611, climb flight level 360.
27:33Climb flight level 360.
27:36Tillman 611.
27:38The flight is uneventful, right up until a minute before the collision.
27:43First officer Brandt Campione sees an opportunity to take a quick break.
27:50Just gotta use the facilities.
27:52Handing over?
27:53Okay, taking over.
27:54Captain Paul Phillips takes control of the flight.
27:58Anything can get you?
27:59No.
28:00I'm good.
28:01Traffic.
28:02Traffic.
28:03Traffic.
28:04Traffic.
28:05That's the TCAS's first conflict alert.
28:06Descend.
28:07Descend.
28:08Descend.
28:09Descend.
28:10Descend.
28:11Descend.
28:12Descend.
28:13Traffic.
28:14Traffic.
28:15Traffic.
28:16Traffic.
28:17That's the TCAS's first conflict alert.
28:20Descend.
28:21Descend.
28:22Descend.
28:23Descend.
28:24Descend.
28:25Descend.
28:26Traffic.
28:27Right there.
28:28Yup.
28:2950 seconds before the collision, TCAS warns the Boeing crew of the Tupolev's approach.
28:46Increase Descend.
28:47Increase Descend.
28:48Increase Descend.
28:49Increase?
28:50Increase Descend.
28:51Increase Descend.
28:52Increase Descend.
28:59Doma 600.
29:01TCAS Descend.
29:06No doubt about it.
29:07They informed the ATC that they were descending.
29:14Let's hear the rest.
29:16Microphone tägliche.
29:17Over and out of the ATC that I know.
29:19I need to talk to them.
29:20Too long.
29:22Oh?
29:23Don't worry.
29:24Ok.
29:25I know.
29:26Is that going to be a good pace?
29:28Let's go.
29:29I know I am.
29:30I am.
29:31I have to jump first.
29:32Where are they?
29:33No doubt about it.
29:34My gun is my gun.
29:35I am.
29:36I am.
29:37I am.
29:38Ok, então, a Boeing crew não fez nada errado.
29:59Eles seguem TCAS e informam o Contrôler.
30:03Mas o Contrôler instruiu o Tupolev de descendo duas vezes, warns eles sobre o tráfico de crossing, e aí, imediatamente, a Boeing reporta que está descendo.
30:20Ele ainda tem dois avanços na colisione.
30:23Ele já está falando com o Tupolev, então, por que ele não disse eles para mudar a colisione e clima?
30:33Se o Contrôler sabia que o Boeing estava descendo, por que ele deixou o Tupolev também descendo?
30:42A maior parte da investigação foi identificar o que o Contrôler fez e como ele performou o trabalho.
30:51O que ele fez o Tupolev de descendo?
30:53O que ele fez o Tupolev de descendo?
30:57Bravo, Tango Charlie, 2937, expedite descent.
31:00O que ele fez o Tupolev de descendo?
31:04Investigadores listened to Peter Nielsen's radio transmissions to determine how two planes on his watch could have collided over Uberlingen, Germany.
31:14Let's start 30 seconds before the collision, when the Boeing pilots informed the Contrôler of their descent.
31:21Descenting flight level 70, Aeroloid 1135.
31:30That sounds like the Contrôler was talking to a third aircraft.
31:34Just as the Boeing aircraft advised the Contrôler of their TCAS descent.
31:39Dome 600, TCAS descent.
31:41Aeroloid 1135.
31:43Yes, go ahead.
31:44The Contrôler received a simultaneous message from another aircraft.
31:49We've made contact with Frederikschefen Airport.
31:52So the call from the Boeing crew came in at exactly the same time as the Contrôler was dealing with the Aeroloid flight.
32:04When the Boeing pilots mentioned TCAS descent, he probably didn't even hear it, or it just was something that he didn't process as an issue,
32:12thinking that everything over on that airspace was already taken care of.
32:17But juggling three planes isn't unusual. There's got to be more to this.
32:25Investigators listen to earlier parts of the ATC recording.
32:30Zurich, good evening. Bravo, Tanko Charles, 0937.
32:41They hear the Tupolev and Aeroloid flights competing for Nielsen's attention.
32:47Aeroloid 1135, Roger.
32:50Good evening.
32:51Bravo, Tanko Charlie, 2937.
32:53Call you back.
32:57Station calling, say again, please.
32:59Ah, Zurich, good evening.
33:01Bravo, Tanko Charlie, 2937.
33:04Level 360.
33:06Aeroloid 1135.
33:11Aeroloid 1135, descent flight level 70.
33:14During the last five minutes before the collision, the workload increased very much.
33:23Investigators hear Nielsen having difficulty contacting the airport where the Aeroloid flight was due to land.
33:29The desired connection is not possible.
33:33Find me the number for Friedrichshafen Tower.
33:38How many times does he try calling Friedrichshafen?
33:43Seven.
33:45He spent a lot of time on something that should have taken seconds.
33:47The desired connection is not possible.
33:54Please check the number.
33:56This isn't working either.
33:58So, how did he end up in this situation in the first place?
34:05Normally, an inbound call is just a few seconds.
34:12But dealing with the communication system took a lot of time that then allowed the two collision aircraft to get ever closer at this very high rate of speed.
34:22Thanks for coming in.
34:29Investigators interview Peter Nielsen to assess his workload on the night of the accident.
34:37So, at the time of the accident, you seem to be working two different workstations. Why?
34:47There are two controllers on the night shift, but one controller always takes a rest as traffic decreases for the night.
34:53You're off. See you in a few hours.
35:07They come back in the morning when traffic picks up.
35:11And is that standard procedure?
35:14It's not written down anywhere in company policies, but management lets us do it.
35:23Okay.
35:25So, 13 seconds before the collision, the Boeing radio that they were doing a TCAS descent.
35:33Did you hear that transmission?
35:35No, I didn't.
35:37I guess I was dealing with the AeroLoid flight approaching Friedrichshafen.
35:42Couldn't get through to the airport. The phone was down for some reason.
35:48Is there anything else you can think of that might help us?
35:51Yeah. Normally, the computer system issues an alert well before two planes get too close together.
36:02But I never got that alert.
36:03The air traffic control radar system has what's called conflict alert system.
36:20It's looking at the airplanes and based on their current speed and altitude and heading is projecting out to see if airplanes are coming into conflict with each other.
36:30The controller was under very high pressure during the last minutes.
36:38Expedite descend. Level 350.
36:41Robert Angle Charlie 2937.
36:43It was, at the end for him, a really difficult situation.
36:47Was Peter Nielsen fully equipped to prevent the collision that cost the lives of 71 people?
37:00Investigators interview officials from Skyguide to find out why Peter Nielsen never received a warning of the impending collision above Uberlingen, Germany.
37:09Why were the control systems conflict alert and telephones both down?
37:20What's this?
37:22What's this?
37:23A work order for a computer upgrade.
37:30A new software was to be implemented on the main screen, which meant that the controller had to work on the backup system.
37:39The software in the telephone system also had to be updated.
37:43So, is this why there was no phone or visual conflict alert?
37:51Yes.
37:53But it doesn't say that anywhere.
37:59Was Nielsen warned about this before his shift?
38:03Not that I'm aware.
38:04One other thing.
38:07Why does management allow one of the controllers working nights to be on break most of the shift?
38:17It started when there were three controllers at night.
38:21But there are only two now.
38:25We didn't change the practice.
38:32Thank you.
38:35That was the way they did it.
38:39One controller on screen and the other was on break.
38:43And this was accepted by the management.
38:46Bravo Tango Charlie 2937.
38:49Descend flight level 350.
38:52Climb.
38:53It says climb.
38:55The controller is guiding us down.
38:57Descend? Really?
38:59We're going to descend?
39:01Investigators now understand.
39:04Bravo Tango Charlie 2937.
39:06Descend level 350.
39:07Expedite descent.
39:09Expedite descent.
39:11Level 350.
39:13Bravo Tango Charlie 2937.
39:15Why two flights...
39:17Descend?
39:19Descend forward!
39:21Ended in disaster.
39:22Ended in disaster.
39:23Embrace.
39:24No!
39:25Oh!
39:26No!
39:31No!
39:33No!
39:34No!
39:36No!
39:37...while completing their final report.
39:43BFU, hello.
39:49What?
39:54The story of the Uberlingen midair collision takes another tragic turn.
40:00On February the 24th, 2004, almost two years after the Uberlingen disaster, Peter Nielsen is murdered in his front garden.
40:16His wife and three children are witnesses to the crime.
40:21We couldn't believe it.
40:22We couldn't believe it because it was for us like a TV story and it was not a real life, but yes, it was real life.
40:38Did they catch the killer?
40:43Yeah.
40:45Apparently his family was on the troop alive.
40:52A Russian man, Vitaly Kaloyev, is arrested for Peter Nielsen's murder.
41:03Kaloyev's wife and two children were killed in the Uberlingen collision.
41:09He tells police he went to Nielsen's house seeking an apology.
41:13But Nielsen isn't found at fault for the collision in the BFU's final report.
41:34Instead, it concludes he was unable to safely carry out the tasks required of him.
41:43The BFU points to the fact that Nielsen was working alone as a cause for the accident.
41:54Bravo Tango Charlie 2937. Descend flight level 350. Expedite. I have crossing traffic.
42:01Descend.
42:03But the report also highlights deficiencies in aviation regulations that allowed for the Russian pilots' confusion over the use of TCAS.
42:12It says climb.
42:14The controller is guiding us down.
42:16Descend. We're going to descend.
42:19Climb. Climb. Climb.
42:23The BFU's most prominent recommendation is simple.
42:28Pilots have to follow the TCAS instruction, not to follow the ATC instruction, because TCAS is a safety net.
42:36Eventually, four Skyguide middle managers, who weren't even working the night of the Uberlingen disaster, are convicted of negligent homicide.
42:48This accident, it was really a watershed event.
42:56A lot of things had to fall into place, just the wrong ways for this to occur.
43:02And it changed a lot of things.
43:06A lot of the way people looked at ATC, collision avoidance, and it really woke a lot of people up.
43:11In 2005, Vitaly Kaloyev is convicted of the premeditated homicide of Peter Nielsen.
43:25Two years later, he's released from prison.
43:28Today, nine steel pearls, representing a torn necklace, mark the locations where victims' bodies were found.
43:48And a memorial inside Skyguide marks both the date of the collision and that of Peter Nielsen's murder.
43:585-528-648-948-746YG
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