The Vigilante and the Air Traffic Controller
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The airspace around Tokyo is busy. Another Japanese Airlines plane, Flight 958, is coming in from South Korea. It'll soon begin its descent. The flight paths of 907 and 958 are going to cross. That's not a problem, of course, as long as they're at different altitudes. But they're currently on course to be at pretty similar altitudes.

No need to panic. This kind of thing happens all the time. We simply need one of the planes to go a bit higher or the other to go a bit lower. As long as they don't both do the same thing, they'll be fine. Modern airplanes have an automated system for situations like this. It's called TCAS, the Traffic Collision Avoidance System. TCAS kicks in now.

In the cockpit of Flight 958, it tells the pilot to descend, descend, descend, descend. The pilot starts to descend. In the cockpit of Flight 907, TCAS tells the pilot to climb, climb, climb, climb.

But down on the ground, a 26-year-old trainee air traffic controller has also noticed that flights 907 and 958 are on a collision course, and he's issued an instruction of his own. JAL 907, descend and maintain flight level 350. Begin descent due to traffic. Hang on, 907? Isn't 907 the one that's supposed to be climbing?

Yes it is. The trainee air traffic controller has got his planes muddled up. He meant to say "958". So now the pilot of flight 907 has got a decision to make. On the one hand, he's got an air traffic controller telling him to descend. On the other hand, TCAS is insisting he has to "climb, climb, climb, climb". He decides to descend. This isn't good.

Both 907 and 958 are now descending, so there's a real risk that they're going to be at the same altitudes when their flight paths intersect. The trainee air controller supervisor sees the data and intervenes to put things right. JAL 957, climb and maintain flight level 390. Hang on, 957? There is no 957.

The boss meant to say 907, but confused her numbers. In the cockpit of flight 907, the pilot hears the message and thinks, that's not for me. Then he sees flight 958 through the cockpit window. It's alarmingly close, and he's heading straight for it. I'm Tim Harford, and you're listening to Cautionary Tales. CAUTIONARY TALES

In the cockpit of Japanese Airlines Flight 907, the pilot has another decision to make. And this time, he has just a split second to make it. How is he going to avoid smashing into Flight 958? He slams his plane into a nosedive. Back in the cabin, the passengers who've undone their seatbelts are suddenly hurled out of their seats.

Some of them hit the ceiling. So do the cabin attendants who are pushing the drinks trolleys. So do the drinks trolleys. Hot tea flies everywhere. A boy is catapulted over four rows of seats. A middle-aged woman breaks her leg. A hundred people are injured, nine of them seriously. But at least they're alive. It could have been so much worse.

Japan's Ministry of Transport asks its Accidents Investigation Commission to look into what had happened and what might be done to lower the risk that it happens again.

One problem, obviously, was that the trainee air traffic controller and his boss had got their flight numbers muddled up. But if you're a loyal listener to Cautionary Tales, you'll know that there's a common theme in stories about people screwing up. That theme is that people screw up. All of us, from time to time.

So if we want to reduce the risk of a repeat, we can't rely on saying to air traffic controllers, do better. We need to look at how they operate. Can we change anything to make it less likely that they'll screw up? And when screw-ups happen anyway, as they will, how can we make it less likely that they'll lead to tragic consequences? On that last point, think about the dilemma faced by the pilot of Flight 907.

He's got the air traffic controller telling him to descend and TCAS telling him to climb. Which one should he listen to? TCAS was new enough that this question simply hadn't come up before. But it turns out there's a clear right answer. He should listen to TCAS.

Like all automated systems, it's not infallible that when two planes are heading straight towards each other and there's less than a minute to keep them apart, TCAS is much more likely than a human on the ground to have the latest information and give quick and appropriate instructions. The Japanese investigators compile a report in which they'll recommend an overhaul in how pilots are trained so that in future, pilots will have no doubt that TCAS takes priority.

17 months after the near miss, the report is almost ready to be published. Meanwhile, in Moscow, 46 schoolchildren are boarding a plane to Barcelona. It's the 1st of July, 2002. The children, mostly teenagers, are excited. They're going to experience Catalan culture and hang out on the beach.

They've already travelled hundreds of miles from their home city of Ufa to the east in the Ural Mountains. But they're not the only ones on the flight. Svetlana Kaloyeva lives in Vladikavkaz, in the north of Setia Alania Republic. Her husband, Vitaly, is working as an architect in Barcelona. Svetlana is flying out to visit with their 10-year-old son and 4-year-old daughter. But they've missed their transfer in Moscow.

As luck would have it, there are plenty of spare seats on this charter flight from the kids from Ufa. Svetlana and the children get on board. The plane takes off from Moscow in the early evening. Three hours later, it's cruising over Switzerland.

Out of the cockpit window, the pilot and co-pilot see the strobing lights of another plane in the distance. It's hard to judge at night time how far away another plane is, or how high it is, or where it's going. But if they need to take evasive action, they'll be told. And sure enough, here comes a message from the air traffic controller in Zurich. Descend flight level 350, expedite, I have crossing traffic.

Flight level 350, that means 35,000 feet. They're currently at 36,000 feet. They start to descend. But then... Climb, climb, climb, climb. What to do? The pilot and co-pilot have both been properly trained in flying their plane, the Tupolev Tu-154. But even if they'd memorised the operating manual word for word, it wouldn't help them much.

One section prohibits initiating a manoeuvre contrary to a TCAS instruction. But another section stresses how important it is to follow the instructions of air traffic control and describes TCAS merely as an additional system. Taken together, that could be clearer. The manual for TCAS itself isn't much better.

One part says that if a TCAS instruction is inconsistent with current clearance from air traffic control, the pilot must not delay in following the TCAS instruction. But another part describes TCAS as a mere backup to air traffic control

So you can understand why the pilot and the co-pilot aren't immediately sure which voice to ignore. The automated voice of TCAS or the human voice of the Zurich air traffic controller? "Climb, climb, climb, climb." It's saying climb, but he's guiding us down. Descend? They keep descending. And here's the air traffic controller again repeating that instruction.

Descend level 350, expedite descend. Copy. Yes, we have traffic at your two o'clock, now at 360. The pilots descend even faster. But two o'clock? That means to the right. They look out of the cockpit window to the right. There's no sign of the other airplane. Where is it? Here on the left. Increase climb, increase climb, increase climb. It says climb. There are no more words recorded on the black box.

but it does record an action. A desperate tug at the control column, the pilots trying at last to climb, but it's too late. As they cross the path of the other plane, their wing slices into its tail. Their plane breaks up, the plane they hit catches fire. Both tumble from the sky. The wreckage falls over hundreds of square kilometres near Überlingen, just over the Swiss-German border.

There are no survivors. How could this happen? It seems incomprehensible. The next day, parents in Ufar receive the devastating news. In Barcelona, so does the architect and doting father, Vitali Koloiev. Cautionary Tales will return in a moment.

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Just 11 days after the crash over Uberlingen, the Japanese investigators publish their report on the near miss. Pilots' training needs to change, it says, so they know that TCAS trumps air traffic control when the two give opposing instructions. Now a German investigation team looks into the collision over Uberlingen.

Among other things, their report makes much the same point. The instructions for TCAS, they find, are not standardized, incomplete, and partially contradictory. The training and instructions have since changed. So no pilot should now make the same mistake. And in case they do, TCAS has changed too. It now monitors whether both pilots are obeying it and reverses orders if one is not.

In both Japan and Uberlingan, that would have kept the planes apart at the last moment. The pilot who'd been descending because TCAS told them to descend would now be told to climb instead. The pilot who'd been descending in spite of TCAS would now find TCAS telling them to keep doing what they were doing anyway. But let's not forget that these incidents weren't all down to TCAS. It's never just one thing, is it?

The flaws in TCAS came to light only because the air traffic controllers screwed up. In Japan, as we've heard, one was still in training. But what went wrong in Zurich? On the evening of July 1st, Peter Nielsen turns up for his night shift with Sky Guide, the company that runs Zurich's air traffic control.

Peter Nielsen is 35 years old. He's qualified and experienced. His colleagues, said the accident investigators, considered him to be a competent, knowledgeable and professional air traffic controller, a team player, a nice guy. The staffing level for night shifts in Zurich had recently changed. In the past, there'd always been three controllers on shift.

They'd take turns to go for an extended break in the middle of the shift and get a bit of sleep in the staff lounge. That was perfectly safe. There went enough planes in the dead of night to keep even two controllers occupied, and the third would return, refreshed, as traffic picked up in the morning. But Sky Guide had become short-staffed. They'd started putting only two controllers on at night.

The controllers continued their informal arrangement that one would go to the lounge for a snooze. That was considerably less safe. Yes, as long as nothing unusual occurred, one controller could get through the quiet nighttime hours easily enough. But if something out of the ordinary were to happen, the controller would have nobody to turn to for a sense check. And if the lone controller screws up, there's no colleague there to notice.

At quarter past 11, Peter Nielsen and his colleague agree that there'll now be few enough flights coming through that the colleague can retire to the lounge and return in a few hours. There is something unusual happening tonight though, and Nielsen is already aware of it. Technicians are doing maintenance work on some of the systems. They tell him those systems are now in fallback mode. That's fine, he says.

Nobody checks if he understands exactly what fallback mode means. It later transpires that he doesn't. Here's one thing it means: the radar screens no longer display a scale, and Nielsen has to monitor two screens which use different scales. Without the visual aid, there's more risk of misperceiving how far apart planes are.

Also, the screens aren't automatically showing which blip on the radar corresponds to which plane. And the short-term conflict alert system is partly disengaged. Normally, this system shows a warning on the radar screen with two minutes' notice if planes are on course to pass within a few miles of each other. Now, there'll just be an audible alarm if a collision is much more imminent.

None of these systems are critical. Nielsen should be able to compensate for their absence by making sure he pays a bit more attention, but he isn't really aware that he needs to. And what's this on his radar screen?

It's a plane he wasn't expecting to have to deal with, an Airbus that should have landed much earlier but got delayed. Nielsen and his colleague had completely forgotten that the Airbus would be coming along. If they'd remembered, the colleague would have stayed for another half hour to handle it. At half past eleven, the Russian plane enters Nielsen's airspace and the pilot checks in with him. It's flying at 36,000 feet.

The radar shows Nielsen that there's another plane at 36,000 feet, a cargo flight from Bahrain to Brussels. The planes are approaching each other roughly at right angles. They're still over 50 miles apart. It sounds like a lot, but they'll be upon each other in barely five minutes. If he'd been paying more attention, Nielsen would have told the Russian pilot to descend.

But with so many systems down, he doesn't notice. And now this delayed Airbus wants his attention. Nielsen has to move to a different workstation to talk to it and tune into a different frequency.

The Airbus wants permission to land on an alternative runway. That's a pain. Nielsen will need to phone the airport to check that it's okay. And the main phone system is yet another thing that's down for maintenance. There's a backup phone system that should still work, but for some reason Nielsen can't get through. That's weird. He dials again and again. It later turns out there's a software glitch with the backup phone system.

Nielsen doesn't know that. He assumes he must be dialling the wrong number. He tries seven times to get through. He's got half an eye on the radar screen, but it isn't showing any warnings. It would be, by now, if the short-term conflict alert system was working properly, but it isn't, and Nielsen doesn't know that. The airspace next to Zurich's is handled by another control centre in Karlsruhe, Germany.

The controllers there see the short-term conflict alert pop up on their radar screens.

Remember, that alert means two planes will be perilously close to each other in just two minutes. The Karlsruhe controllers could jump on the emergency radio frequency to talk to the two planes, but the rules say they shouldn't do that, for the very good reason that the planes aren't in their airspace. Instead, the rules say they have to contact Zurich, so they try.

But of course, the phone system in Zurich isn't working. They try again and again. They try 11 times. Nearly five minutes after the Russian plane entered his airspace, Nielsen suddenly realises the danger. Descend flight level 350 expedite. I have crossing traffic. The Russian crew don't respond. Why aren't they responding?

We know why. It's because the pilot and co-pilot are busy debating whether they should ignore Nielsen, telling them to descend, or TCAS, telling them to climb.

It hasn't occurred to Nielsen that TCAS will have kicked in. And now, the audible conflict alert sounds. The two planes are just half a minute from colliding. Nielsen leaps into action. Descend level 350. Expedite descend. We have traffic at your two o'clock, now at 360. Nielsen is stressed. He's not thinking straight. He doesn't realise that he's contradicting TCAS. But more than that, he said two o'clock when he meant ten o'clock.

10 o'clock. It makes the pilots look right when the cargo plane is to their left. And his radar display is out of date. The cargo plane isn't now at 360. It's been descending because TCAS has told it to. The next time Nielsen's radar refreshes, it shows the cargo plane level with the Russian plane and descending at the same rate.

The pilot of the cargo plane comes on the radio too to inform Nielsen that he's descending. But Nielsen doesn't see the radar refresh and he doesn't hear the cargo pilot's call. Because he thinks he's averted the danger, he's gone back to his other workstation to deal with the late running Airbus instead. In Karlsruhe, the air traffic controllers watch in horror as the two dots on the radar collide.

By the time Nielsen looks back at his screen, it's already happened. He tries to call the Russian plane. There's no response. Vitaly Koloyev knows his wife and children were on that plane. He hurries to Uberlingen, expecting the worst. But nothing could have prepared him for the horrors he was about to see. Rescuers are still searching for all the bodies. They're scattered over hundreds of square kilometres.

The body of Koloyev's wife, Svetlana, has landed in a cornfield. His 10-year-old son on asphalt near a bus shelter. The little body of his four-year-old daughter was found snagged up in a tree. When Koloyev searches the area, he finds her pearl necklace lying on the forest floor. Koloyev cleans the bodies and dresses them for the funeral. He also asks questions of journalists. The air traffic controller

What's his name? And where does he live? Cautionary Tales will return.

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The Swiss air traffic control company, Skyguide, had recently come up with new procedures that were meant to allow controllers to work safely alone when needed. Swiss regulators were already worried about those procedures. Were they too lax? Too risky? But Peter Nielsen wasn't even working under these new procedures. They applied only when there was officially just one controller on duty.

During night shifts, officially, two controllers were on duty at all times. The fact that one of them always spent a few hours asleep was just an informal arrangement, but it was an arrangement that the managers at Sky Guide knew all about. They'd already had to investigate one near-miss.

When Sky Guide came up with their new procedures for solo working, they assumed that if only one controller was on duty, they'd at least have a supervisor they could call on for help. But that didn't happen on the night shift, when one controller slept. There was no supervisor. Nielsen had to supervise himself. The procedures also assumed that the controller would have the short-term conflict alert system to rely on.

Taking that system offline for maintenance would have breached the procedures. But of course, Nielsen wasn't protected by these procedures. Procedures that the regulators already worried might not be safe enough. No wonder the investigation report comes across as pretty sympathetic to Peter Nielsen. He screwed up. Of course he did. But his employers had allowed a workplace culture to develop in which screw-ups were disturbingly likely.

Nielsen was not in a position to safely execute all the tasks he had been given, the investigators found. Nielsen was traumatised by his role in the collision. He was treated for shock, but after some time off, he returned to work. Nearly two years after the accident, Peter Nielsen was at home with his wife and three children when he saw a middle-aged man sitting in his front garden.

He went outside to find out who the man was and what he wanted. His children followed him out. He waved them back inside. We don't know for sure what happened next. We only have Vitaly Koloyev's side of the encounter. He says he tried to say the German words for, I am from Russia. He says he gestured to the front door to show that he expected Nielsen to invite him in.

He says he tried to show Nielsen photos of the bodies of his dead children. And he says Nielsen pushed his hand aside and the photos fell to the ground. In Koloyev's telling, what happened next is a blank. But Peter Nielsen's wife can pick up the story. She heard a scream. She rushed outside to find Koloyev walking calmly away with a switchblade knife.

and her husband lying in a pool of his own blood. It's never just one thing, is it? If Nielsen's colleague had stayed for another half an hour, if Nielsen had known that the alert system wasn't working, if the backup phone line hadn't had a software glitch, if the pilots had been trained to prioritize TCAS, maybe you can think of it as a series of dominoes falling, one toppling another, then another,

That's a metaphor one pioneering safety researcher came up with, Herbert Heinrich, in his 1931 book Industrial Accident Prevention. Or think of the Swiss cheese metaphor, developed more recently by the psychologist James Reason. Each slice of cheese is a layer of defence, and each has holes in. Accidents happen when you have a stack of slices and the holes just happen to line up.

Peter Nielsen's screw-up was one hole in a slice of cheese. But it wouldn't have mattered if there hadn't been other holes in other slices. Sometimes we can reasonably hold people responsible for gaping holes in a slice of cheese. A Swiss court fined managers at Sky Guide for having allowed a culture of negligence to develop in the workplace. At other times, there's really nobody at whom you can point a finger.

The people who train pilots or write operating manuals hadn't been sloppy or reckless. They simply hadn't foreseen that you might get dangerous circumstances in which TCAS is saying one thing and air traffic controllers are saying another. Once it became clear that this could happen, they changed the training and rewrote the manuals. That slice of cheese now has smaller holes. Still...

Even when there isn't anyone obvious to punish, people can get punished anyway. Remember the 26-year-old trainee air traffic controller in Japan who'd said, Flight 907, when he meant Flight 958?

Remember the supervisor who jumbled her numbers and said, It's the same kind of flub, you might think, that could happen to anyone and would hardly ever lead to tragedy. There'd usually be plenty of other slices of cheese to cover the hole.

The Tokyo Metropolitan Police Department wasn't so forgiving. It was professional negligence, they said. Prosecutors brought the pair to court. They demanded 18 months in prison for the supervisor. They cut the trainee a bit of slack. They wanted just 12 months for him. The case rumbled on for five years, during which both kept working at Tokyo Air Traffic Control,

At last, the district court delivered its verdict. Acquitted. On all counts. The controllers' legal ordeal seemed finally to be over, and they wrote an open letter to the International Federation of Air Traffic Controllers Associations to say thank you for all the support they'd received from their professional colleagues around the world.

The court recognised that it was an accident connected with a system rather than individuals, they wrote. We think the collision above Uberlingan might have been prevented if the causes that led to our accident had been properly clarified at an earlier stage and notified worldwide. This not guilty verdict is not only ours but also for all of those who supported us. But the prosecutors lodged an appeal. They weren't ready to give up yet.

Vitaly Koloyev walked back to his hotel, the Welcome Inn, near Zurich Airport. Having revenged himself upon Peter Nielsen, he was covered in the air traffic controller's blood. Somehow, the staff didn't see him make his way up to his king-size room. The next day, police came to the hotel to arrest him. The charge was murder. Peter Nielsen had bled to death.

Vitaly was held at first in a mental hospital, then tried and sentenced to eight years in a Swiss prison. Just two years later, he was out. An appeal court decided that he couldn't be held fully accountable for his actions. The most shocking thing about Vitaly Koloyev's murder of Peter Nielsen isn't the murder itself.

The most shocking thing was the public reaction to Vitaly Koloyev when he got out of prison and went home to North Ossetia. It was a hero's welcome. He got fan mail, letters of support, offers of marriage. If more people were like you, wrote one woman, the world would be a better place. He's a real man, said one local dignitary. What he did was an act of heroism. Journalists in Ossetia named him Man of the Year.

The government of North Ossetia supported Koloiev too. They even appointed him deputy minister for construction. When he retired, they gave him the Glory of Ossetia Medal, awarded, among other things, for maintaining law and order. One man's grief-fueled madness is understandable. The support from many others says something more troubling about the human condition.

In any accident, there are lots of lessons we might learn about how to make future accidents less likely. Rewrite instructions, change workplace culture, tweak automated systems. But punish people for getting in a muddle? I'm not so sure that helps.

The prosecutors in Japan took a different view. They pursued their case against the two air traffic controllers for another five years, until at last the Supreme Court handed down the final verdict, guilty. The sentences, at least, were suspended. They wouldn't go to prison, unless they committed some other crime, such as maybe mixing up their flight numbers again. But they wouldn't need to worry about that.

Because as convicted criminals, they lost their jobs. It's never just one thing. But shades of grey aren't satisfying, it seems. We thirst for black and white. We want villains. And we want vengeance. For a full list of our sources, please see the show notes at timharford.com.

Cautionary Tales is written by me, Tim Harford, with Andrew Wright. It's produced by Alice Fiennes, with support from Edith Russelo. The sound design and original music is the work of Pascal Wise. The show wouldn't have been possible without the work of Jacob Weisberg, Ryan Dilley, Julia Barton, Greta Cohn, Lital Millard, John Schnarz, Carly Migliore, Eric Sandler, Maggie Taylor, Nicole Murano and Morgan Ratner.

Cautionary Tales is a production of Pushkin Industries. If you like the show, please remember to share, rate and review. It helps us for, you know, mysterious reasons. And if you want to hear the show ad-free, sign up for Pushkin Plus on the show page in Apple Podcasts or at pushkin.fm slash plus.

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