The 1st July 2002 Mid-air Collision over Öberlingen, Germany: A Holistic Analysis

Abstract

On the night of 1st July 2002 two commercial aircraft collided over the German town of Oberlingen. This paper suggests that the accident originated in different understandings of the primacy of an aircraft-borne collision warning system (known as the Traffic Alert and Collision Avoidance System). It is ventured that these different understandings originated in national variations in the operationalisation of the system; in deference to a flight-deck cultural practice known to the UK's Civil Aviation Authority as ‘commander's discretion’; and in the failure of the world community to establish a single, authoritative rule-making body for commercial aviation. This paper suggests that the ability of states to ‘file a difference’ with the International Civil Aviation Organisation creates a ‘resident pathogen’ or ‘latent error’ (after Reason, 1990) within the global air traffic management system. This paper suggests also that—due to its partial membership—the new European Aviation Safety Agency may, like the body it will gradually replace (the Joint Aviation Authorities), fail to solve the problem of national variations in the operationalisation of the Traffic Alert and Collision Avoidance System. If they are to be effective, safety systems like this must be used in the same way by all parties. Variations in patterns of use create resident pathogens/latent errors. It is concluded that aviation's administrative arrangements must be sufficiently robust to eradicate national variations in the operationalisation of such systems.