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Цитаты из отчёта комиссии BFU AX001-1-2/02
Стр. 112, полное содержание пункта:

"3.2
Causes

The following immediate causes have been identified:
• The imminent separation infringement was not noticed by ATC in time. The instruction for the TU154M to descend was given at a time when the prescribed separation to the B757- 200 could not be ensured anymore.
• The TU154M crew followed the ATC instruction to descend and continued to do so even after TCAS advised them to 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 with the system philosophy.
The regulations concerning ACAS/TCAS published by ICAO and as a result the regulations of national aviation authorities, operational and procedural instructions of the TCAS manu- facturer and the operators were not standardised, incomplete and partially contradictory.
• Management and quality assurance of the air navigation service company did not ensure that during the night all open workstations were continuously staffed by controllers.
• Management and quality assurance of the air navigation service company tolerated for years that during times of low traffic flow at night only one controller worked and the other one retired to rest."

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