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Printed page 5. PDF page 7.
climb. This manoeuvre was performed contrary to the generated TCAS RA. The following systemic causes have been identified: � The integration of ACAS/TCAS II into the system aviation was insufficient and did not correspond in all points with the systemOpen final report at PDF page 7BFU AX001-1-2/02: collision near Ueberlingen
Printed page 82. PDF page 84.
professionalism and competence. However, it is possible to draw a parallel relating to a systemic weakness when comparing this incident and the accident, in that both occurred when a sole ATCO was operating a sector. There was no human redundancyOpen final report at PDF page 84BFU AX001-1-2/02: collision near Ueberlingen
Printed page 104. PDF page 106.
not taken any actions to eliminate the defect. The BFU considers these deficiencies as systemic causal factors having led to the accident. The controller of ACC Zurich was in charge and responsible for the separation of the aircraft controlled byOpen final report at PDF page 106BFU AX001-1-2/02: collision near Ueberlingen
Printed page 106. PDF page 108.
standardised, incomplete and partially contradictory. The BFU considers these deficiencies as systemic causal factors having led to the accident. AX001-1-2/02 106Open final report at PDF page 108BFU AX001-1-2/02: collision near Ueberlingen
Printed page 110. PDF page 112.
climb. This manoeuvre was performed contrary to the gener- ated TCAS RA. The following systemic causes have been identified: � The integration of ACAS/TCAS II into the system aviation was insufficient and did not cor- respond in all points withOpen final report at PDF page 112BFU AX001-1-2/02: collision near Ueberlingen
Printed page Appendix 10, unnumbered first sheet. PDF page 10.
with the support and training they should have had. Some findings significant to the systemic nature of the accident and that are in the body of the report or in the Human Factors report are not carried through to SectionOpen official document at PDF page 10BFU appendices 2 and 4 to 10