「華人戴明學院」是戴明哲學的學習共同體 ,致力於淵博型智識系統的研究、推廣和運用。 The purpose of this blog is to advance the ideas and ideals of W. Edwards Deming.

2008年1月27日 星期日

Skyguide 空中撞機事故

我昨天在有線電視初次"重溫"一次著名空中撞機事故
其中為"系統失靈"和"人類感情因素"之互動的悲劇
特別列在這



Skyguide (official name: Schweizerische Aktiengesellschaft für zivile und militärische Flugsicherung; Swiss stock company for civil and military air traffic control. Official English name: Swiss Air Navigation Services Ltd) is the air traffic control corporation that controls Swiss airspace.

Skyguide is an air traffic control company that operates mainly from Zurich and Geneva, Switzerland. Skyguide is responsible for air traffic control over much of Switzerland as well as some parts of Italy, Austria, France and Germany.

The company was found partially responsible for the mid-air collision of Bashkirian Airlines Flight 2937 with a DHL Cargo Boeing 757 on 1 July 2002 over Überlingen.

External links


Information regarding the air accident at Überlingen on July 1, 2002

On July 1, 2002 two planes collided in the airspace controlled by skyguide above South Germany. You will find here information on this tragic accident.

White rose in the control centre of Zurich in memory of the Überlingen accident victims and of our colleague P. N.

On July 1, 2002 a Tupolev Tu-154M passenger aircraft of Bashkirian Airlines collided in mid-air with a Boeing 757-200 cargo aircraft of express mail carrier DHL. The accident occurred above the town of Überlingen in Southern Germany, in German airspace assigned to skyguide’s control, and resulted in the loss of 71 lives.

On 24 February 2004, the skyguide air traffic controller in service during the night of the accident was stabbed to death at his home.

On May 19, 2004 the German Aircraft Accident Investigation Bureau (BFU) published their report, which provides a detailed account of the events leading up to the accident. The report also cites the causes of the collision, and makes numerous recommendations for improving the safety of air traffic management activities. Ten of the report’s 19 safety recommendations relate directly to skyguide.

Skyguide had drawn lessons from the investigations into the accident before the publication of the final accident report, and has already enhanced its safety system. The errors which led to the accident were rectified in its immediate aftermath, and many of the actions recommended by the BFU have also already been taken. The safety management practised by skyguide complies with all national and international requirements, and will continue to be constantly refined. Skyguide’s 1400 personnel are also committed to ensuring that all the BFU’s recommendations are adopted and acted upon in full, to ensure that a tragedy of this kind cannot reoccur.

Useful links:

Inauguration of the sculpture in memory of July 1, 2002 and February 24, 2004:

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