Mid-air collision over Brasil

[RatherBeFlying]

There are a large number of instructional books out there on obtaining an Instrument Rating in many languages and you need to do some serious reading on IFR flight plans and clearances. Go to your local pilot shop usually located at an airport with private airplanes or ask a local flight instructor to recommend a book.
Read the chapters on filing flight plans, obtaining clearances, adhering to clearances and lost communications procedures.

You will learn as has been said repeatedly by every IFR pilot on this thread that:
A flight plan proposes a route with requested altitudes at a requested speed at a requested time
A clearance is ATC's best effort to accommodate your proposal without conflicting with other traffic.
You DO NOT deviate from your clearance without permission from ATC except in an emergency.

As well, there's a good probability the Legacy pilots used a commercial provider to generate their flight plan by computer. Computers can be very particular about adhering to quadrantial flight levels when generating flight plans when ATC will normally prefer to simply assign a single cruising flight level.

[flyingnewbie10]

There are a large number of instructional books out there on obtaining an Instrument Rating in many languages and you need to do some serious reading on IFR flight plans and clearances.

Go to your local pilot shop usually located at an airport with private airplanes or ask a local flight instructor to recommend a book.
Read the chapters on filing flight plans, obtaining clearances, adhering to clearances and lost communications procedures.You will learn as has been said repeatedly by every IFR pilot on this thread that:

A flight plan proposes a route with requested altitudes at a requested speed at a requested time
A clearance is ATC's best effort to accommodate your proposal without conflicting with other traffic.
You DO NOT deviate from your clearance without permission from ATC except in an emergency.As well, there's a good probability the Legacy pilots used a commercial provider to generate their flight plan by computer. Computers can be very particular about adhering to quadrantial flight levels when generating flight plans when ATC will normally prefer to simply assign a single cruising flight level.


RatherBeFlying,

Is there any online source available (aviation organization rules, etc) or book you could recommend ?

From what I was told my conclusion is that the ATC is responsible for Flight Level setting as the flight plan is filed with them and therefore they know it.

The pilot is not supposed to check the plan and ask for clearance when he changes to an airway for which there is another assigned flight level by the flight plan. Instead, ATC has always to contact him and order a FL change.

It seems that in the Legacy case there was a contact with Brasilia but I don't know whether it was long before the Legacy hit the point where in the flight plan it was supposed to descend.

But in this contact ATC said something about the transp. identification and about mantaining FL370. I suppose that even if this contact happened a long time before the Legacy changed airway it proves that ATC brought the Legacy crew into error. As I said, the crew wasn't supposed to ask for confirmation of FL370 after changing airway.

And it seems there was another contact prior to this back in the start of the flight where the Sao Jose dos Campos ATC apparently told the Legacy to maintain FL370 until Manaus.

Again, it seems the pilots weren't supposed to confront this with their flight plan and ask clearance after passing by Brasilia.

[con-pilot]

Call it paranoia, but I really wonder just how much information that many professional pilots and Air Traffic Controllers that have posted on this thread, and Pprune itself, will be used in the trial.

The sudden removal of some the posts from some legal sounding people from Brazil makes me very curious.

However, there is hope in the fact that no matter how many time they asked the same question they always received the correct answer, not the answers they were wishing for.

Therefore, I believe that the professional pilots and professional Air Traffic Controllers all whom remained true to the Laws of the Air, ICAO and the world standard rules of Air Traffic Control deserves a pat on the back.

Well done all. :ok:


(Now all we have to do is wait for the trial.)

[RobertS975]

As I have said previously, the Legacy pilots should only agree to return to Brazil if granted immunity. We have already seen on this board that apparently intelligent individuals approach this case with a "confirmation bias" that will likely prevent truly fair proceedings.
To paraphrase Jack Nicholson in A Few Good Men, they can't stand the truth.

[marciovp]

Yes, before leaving São José the Legacy pilots had a written flight plan: 370 till Brasilia, then 360 till Teres, then 380 to Manaus. This was written and it can be seen.

After leaving São José the pilots were told by São José ATC to fly 370 to Manaus. Well, here is the controversy. Some say that they were not told
this. Some say they misunderstood. Some say that in Brazil clearance is given only to the next point, not for the whole flight as in other countries. Well there is a recorded tape of the conversation between the pilots and ATC in São José. I heard it one in a TV station and I think it was clear that the ATC said 370 to Manaus. But I would love to listen to that tape again. I don´t hear it around for a good while. I hope they still have it. The pilots said that they were cleared to Manaus by São José ATC.

Approaching Brasilia the pilots said to ATC here we are, at 370. ATC said OK, "have a good trip". Nobody said anything about changing altitude.

The radar screen in Brasilia showed for seven minutes after the Legacy passed Brasilia that the transponder was OK showing 370 but the software from Brasilia was showing 360. Software in Brasilia entered the original written flight plan not requiring that ATC talked and confirmed 360 with the pilots. The icon was showing 370:360. A discrepancy.

Then transponder OFF. There was clear indication in the radar screen in Brasilia that the transponder was off. A military primary radar entered the picture and sent information 360. The written original flight plan also was there. So 360Z360 (Z means unreliable). Also transponder OFF. For about one hour. No communication between ATC and pilots even the radio was working. The pilots also did not see the Transponder OFF sign, in small letter, in yellow in their screen.

Then the lack of communication, one trying to call the other more that a dozen times. When ATC was able to say something to the pilots it was nothing about altitude, and there was no concern. It was to tell them the frequency of Manaus.

Then the disaster.

It seems that both ATC and the pilots felt that everything was OK... until the disaster. Sad...

[flyingnewbie10]

Marcio,

I was not concentrating in this issue but in the TAM 3054.

After reading all information about the GOL 1907 accident I really reach the conclusion that the pilots blame in this case was minimal and their arrest (not their retention here for a reasonable time) was very unfair. A serious judicial abuse that nevertheless cannot be used to generally prevent any legal action in case of air accidents.

The brazilian media played an irresponsible role in all this (as usual).

The Brazilian ATC system had a key relevance in the accident. It seems that almost the entire "blame" should be put in the lack of adequate equipment and the "black holes" in the Amazon Region, although the ATC at Sao Jose dos Campos made a great mistake when it IFR cleared the Legacy at FL370 until Manaus as I was able to confirm.

There are new technologies coming (GPS, etc) in order to make AT more secure. We hope our dear government & airlines seek to upgrade ATC system accordingly. Brazilian pilots should demand it.

In the meanwhile, relatively to the unsufficient number of ATC personnel, the number of flights in Brazil should be reduced (at least the domestic ones).

We have to admit we have a deeply flawed ATC system indeed.

As to Lepore and Palladino I think they really should be declared not guilty before the facts I have now. Moreover after confirming that they tried to contact Brasilia ATC several times before the accident took place. :sad:

[lomapaseo]

It seems that both ATC and the pilots felt that everything was OK... until the disaster. Sad...

Not at all true. both were trying to contact the other but to no avail.

[marciovp]

Not at all true. both were trying to contact the other but to no avail.


Not so, this attempts were made later. The Legacy flew at 370 with the ATC radar showing 360Z360 for a good while and one did not try to contact the other. It was later that they tried to contact. I have no idea what the Legacy pilots wanted to tell ATC but when ATC finally contacted the pilots all he had to say was the frequency of Manaus (nothing about altitude). This is why I made the above statement.

From NTSB:


At 3:51 pm, an air traffic controller in the Brasilia ACC (CINDACTA 1) instructed N600XL to change frequencies to the next controller's sector. The crew of N600XL reported in on the assigned frequency that the flight was level at FL370. ATC acknowledged and instructed the crew to "ident"
(flash their transponder). Radar indicates that the ident was observed.

This was the last two-way communication between N600XL and ATC. At this time the airplane was approximately 40 nautical miles south of BRS.

At 3:56pm the Legacy N600XL passed BRS level at FL370. There is no record of a request from N600XL to the control agencies to conduct a change of altitude, after reaching flight level 370. The crew
made calls, but there is no communication in which they requested a change of flight level. There is also no record of any instruction from air traffic controllers at Brasilia Center to the aircraft, directing a change of altitude.

When the airplane was about 30 miles north-northwest of BRS, at 4:02 pm, the transponder of N600XL was no longer being received by ATC radar. A transponder reports a unique code, aiding radar
identification, and provides an accurate indication of the airplane's altitude. Additionally, the transponder is a required component for the operation of Traffic Collision Avoidance System equipment, commonly called the TCAS system.

Between 3:51 pm and 4:26 pm, there were no attempts to establish radio communications from either the crew of N600XL or ATC. At 4:26 pm the CINDACTA 1 controller made a "blind call" to N600XL. Subsequently until 4:53 pm, the controller made an additional 6 radio calls attempting to establish contact. The 4:53 call instructed the crew to change to frequencies 123.32 or 126.45. No replies were received.

There is no indication that the crew of N600XL performed any abnormal maneuvers during the flight. Flight Data Recorder information indicates that the airplane was level at FL370, on course along UZ6, and at a steady speed, until the collision. Primary (non-transponder) radar returns were received corresponding to the estimated position of N600XL until about 4:30 pm. For 2 minutes, no returns were received, then returns reappeared until 4:38 pm. After that time, radar returns were
sporadic.

Beginning at 4:48 pm, the crew of N600XL made a series of 12 radio calls to ATC attempting to make contact. At 4:53, the crew heard the call instructing them to change frequencies, but the pilot did
not understand all of the digits, and requested a repeat. No reply from ATC was received. The pilot made 7 more attempts to establish contact.

At 4:56:54 pm the collision occurred at FL370, at a point about 460 nautical miles north-northwest of BRS, on airway UZ6.

[PBL]

The Brazilian non-pilot position I think is slightly different.
to paraphrase their position:
1 - ........
2 - ........
3 - ........
4 - ........

Very well put, mm. That is indeed what some contributors seem to have been arguing, and this position seems to be contained in the citation from the CIP proceedings which has been unfortunately deleted by its poster.

You are also correct to observe that these principles violate ICAO ATC procedural norms.

I wish that those supporting these principles would address this issue of conformance and let us know what they think. For many non-Brazilians who fly there, whether ATC intends to adhere to ICAO norms or not is a question of the utmost importance for safety of flight.

PBL

[lomapaseo]

Not at all true. both were trying to contact the other but to no avail.

marciovp


Not so, this attempts were made later. The Legacy flew at 370 with the ATC radar showing 360Z360 for a good while and one did not try to contact the other. It was later that they tried to contact

Your source seems to relate only to ATC transcripts but with the radio silent on the ground from the Legacy does not mean that attempts were not being made in the air from the Legacy.

[marciovp]

Your source seems to relate only to ATC transcripts but with the radio silent on the ground from the Legacy does not mean that attempts were not being made in the air from the Legacy.


My source is the NTSB. You can go and look their site: www.ntsb.gov (http://www.ntsb.gov). The pilots confirmed this report. They did not try to contact Cyndacata in Brasilia before the attempts described in the NTSB report. They said that the radio was working fine because they would hear Cyndacta talking with other planes. I did not know why later they tried to contact Brasilia so many times, neither I read anywhere why they tried so hard at that
particular time. I am not sure if it was to discuss altitude. They did not understood the new frequency they were given for Manaus.

[Brian Abraham]

From AIN today

IATA Criticizes Brazil ATC System
In a report sent privately to Brazilian officials and airlines, the International Air Transport Association (IATA) says Brazil’s military-run ATC system is “unreliable, unsafe and inefficient.” Labor problems and other disruptions in ATC have “magnified the deficiencies of the ATC system,” the report states, since last September’s midair between an ExcelAire Embraer Legacy 600 and Gol Airlines Boeing 737-800 over the Amazon, killing all 154 aboard the airliner. IATA says the 2006 accident rate for Brazilian operators was 3.5 times higher than the world average and emphasizes that fixes must be made immediately. It wants to “establish a communication link” with the Defense Ministry, which runs Brazils ATC system, to set up monthly collaborative decision-making meetings to address aviation safety issues. Further, the group is asking for the Defense Ministry to implement a contingency plan to mitigate ATC problems; resolve ATC political-labor issues; comply with all ICAO rules; and ensure that all area control centers have adequate radar surveillance, ground-to-air communications and navigational aids.

[Thylakoid]

Well, anything run by the military in Brazil, is always inefficient and dangerous. Being like that since day one:E

[PBL]

Richard Pedicini ..... is your *reliable* source.

Well that's a nice piece of character assassination without any supporting evidence

Well, I'm not sure it is. Sdruvss is crediting this person with being the source for NTSB/CENIPA reports, published ICAO documents, and articles written in The Controller (under a pseudonym, of course) as a senior official/member of IFATCA; as well as being able to influence the views of the Flight Safety Foundation president, ditto mutatis mutandis for the Royal Aeronautical Society, the International Federation of Airline Pilots' Associations, the Civil Air Navigation Services Organisation; and last but not least able significantly to influence the deliberations of the Brazilian Parliament's CIP committees.

That is not character assassination, that is praise of the highest order for his political skills!

PBL

[bsieker]

That is not character assassination, that is praise of the highest order for his political skills!

he has a biased view of all facts. [...] he is out of his mind. [...] He has many identities.

Maybe this one is an (unsuccessful) attempt at it. Most other sentences are neutral or positive.


Bernd

[marciovp]

Perhaps the American pilots could or should have done things that would prevent the disaster. The final report will - I hope - inform us of their reponsibility share.

But what I can say, as a Brazilian, is that there is a lot of prejudice against the pilots here. You all know what is prejudice. We humans don´t seem to deal with people who are different, in this case nationality. I guess this could happen in any country. In the case of Brazil there is a lot of prejudices against the USA and the pilots were at the wrong time at the wrong place. Stvruss in a way represents the Brazilians´ average thinking...

From the beginning I was appaled when the Minister of Defense in TV was already blaming the Legacy pilots for "disconnecting the transponder in order to do stunts with the new plane". On that day I realized that I would have to do whatever I could to neutralize this venon. Well, with the black boxes, it then became clear that they flew all the time straight and level... So this version was shot.

Then it was repeated many times that they did not follow the written flight plan. This was said by people who should know better, that is, that the flight plan is always the last one cleared by ATC. But the press was always coming back to it. Well I am not going here into the conversation between the pilots and the ATC in San Jose: if there was a misunderstanding, if the ATC did not know how to speak english, if the pilots did not understand (this will become clear because the tape will not lie) but the fact is that the Legacy pilots felt that they were cleared to fly 370 to Manaus.

I am not going into why, but I am sure no pílot would disconnect a transponder voluntarily specially in a somewhat strange country. Yes, after seven minutes after passing Brazilia they were flying 370. Then with the transponder off they flew 370 until the disaster. Well... couldn´t ATC in Brasilia and Manaus help them out in this predicament?...

In Brazil there has been a mess...local police investigation, federal police investigation, CPI of the House, CPI of the Senate, Air Force blaming the controllers (who are also lower rank Air Force) and...of course CENIPA (that belongs to the Air Force too). All, except CENIPA have decided who is to be blamed...

The Legacy pilots, of course, where afraid to come to Brazil for deposition. I believe that for good reazons. So they are being tried without being heard...even though they offered to make depositions in the USA...to be sent to the judge in Mato Grosso. The judge did not accept this.

As for the informant for Mr. Sharkey I am not sure. But let´s not kill the messager of bad news... I recall that this man indeed was falsely accused in his school and had a very hard time dealing with it after the school was closed. He must be very sensitive to people being falsely accused of course.

As for Sdvruss I am glad he is expressing himself and is here in this forum.
I believe he means well.

[barit1]

Thank you marciovp for your enlightened view. Yes, I'm sure we all feel a little paranoia, a little xenophobia in a tragedy under such circumstance. And those who would exploit the same for political ends must be shown for what they are. (Many Norteamericanos will recall the 1979 ORD DC-10 crash in which an NTSB official, a day after the accident, infamously held up a broken bolt to announce he had found the "cause" of the disaster.)

Fortunately the international agencies (ICAO, IFALPA -- ) will serve to do the right thing and point to a better way. They are not perfect, but they still have the common goal of accident prevention and are less subject to local politics.

[marciovp]

Thank you barit1. This is my hope too, that the international agencies plus CENIPA and NTSB will arrive at the data without prejudices. I am hoping these agencies will be there.

Joe Skarkey is a north american NYTimes reporter who was a passenger in the Legacy. He has a blog talking about the disaster:
http://sharkeyonbrazil.*************/

It is interesting to notice that since the disaster the NTSB has published some directives to the effect that when a transponder goes off the pilots of any plane should be warned in sound and red color. In the case of the Legacy all that happened was a small warn in small yelow letters in the screen that was not noticed by the pilots. It is also of interest that the FAA has send a directive stating that in some Embraer planes, includingthe Legacy, the pilots should be carefull when resting the feet on the foot rest below the dash because this would alter the radio frequency and the transponder. And NTSB has sent a directive about the working hours of ATC and the times for resting. I suspect all of this related to the Brazilian disaster.

I am confident that eventually we will get there to prevent further disasters like this one.

I also suspect that the Brazilian Air Force should be less defensive and allow for investigation of its equipments and softwares since they are responsible for ATC in Brazil.

We are all citizens of a global community!

[PBL]

And NTSB has sent a directive about the working hours of ATC and the times for resting. I suspect all of this related to the Brazilian disaster.

I believe this last one is related to the Comair accident in Lexington, Kentucky.

PBL

[Brian Abraham]

Sdvruss????????? Here yesterday, gone today. What's he playing at?

[PBL]

Sdvruss????????? Here yesterday, gone today. What's he playing at?

I think anybody who considers replying to a post of his might do well to consider the phenomenon that all his previous posts have either disappeared or have had their content erased by him (see, for example, 1 Sept. at 20:13).

PBL

[shortfinals]

Here's a summary of what the IATA report says. It seems as if IATA is working with the Brazilian authorities but are refusing to pull their punches:

http://www.flightglobal.com/articles/2007/09/10/216666/iata-criticises-all-aspects-of-brazilian-aviation-safety.html

[lomapaseo]

(Many Norteamericanos will recall the 1979 ORD DC-10 crash in which an NTSB official, a day after the accident, infamously held up a broken bolt to announce he had found the "cause" of the disaster.)


It wasn't an NTSB official

and it really isn't that much different from what is going on today in Brazil regarding concentrating on blaming a turned off transponder for the crash. Lack of a working transponder don't causes crashes they simply fail to prevent them once other causal factors have occured

[Sdruvss]

I repeat bsieker words:
Most other sentences are neutral or positive.
I had a deep affinity with his thoughts, but he only sees one side of the coin. I deleted my post because PBL said something that doesn't express my will.

[RobertS975]

Seems like he has left the building! makes you wonder what he was up to!!!

http://www.pprune.org/forums/search.php?searchid=1828049

[bsieker]

I deleted my post because PBL said something that doesn't express my will.

Now that's a strange attitude if I ever saw one.

Why would you expect PBL to express your will??

I expect him to express his own thoughts and opinions, as we expect and respect you to express your own.

I find it regrettable that you deleted or erased most of your previous posts.


Bernd

[Sdruvss]

bsieker,

I'm trying again. I was trying to say, that I am for Pedicini cause, but he has a biased view. The same way YOU think about me. It's simple as that. If I have a biased view, he has too. I only reported facts published by news the same as him. I didn't do any "character assassination" as PBL said. Do you see that only with facts published by news may lead to wrong conclusions?

[ATC Watcher]

Sdruvss, good that you are again with us.
he has a biased view. The same way YOU think about me

We only have an opinion about you based on what you write here. We do not know you.
If you want to be understood and not mistaken, or wrongly understood, if would be good that you explain who you are and/or who you are representing, and what is your interest/ connections in this particular case..

You could fill up your profile for a start.

[bsieker]

I didn't do any "character assassination" as PBL said.

Before you say things, it might be a good idea to check who actually said what.

ORAC said what you wrote was character assassination (now also deleted),

PBL defended you and said you were praising Richard Pedicini's political skills.


Bernd

[ORAC]

I'm trying again. I was trying to say, that I am for Pedicini cause, but he has a biased view.

In the interest of clarity, an as a direct quotation, what Sdruvss, said about pedicini was as follows:

Richard Pedicini, an information technology professional and lotery consulting (???), was falsely accused, in 1994, of child sexual abuse by neighbors, a police officer, and rushed newspapers. He was in jail for nine days. Without any evidence, justice released him. Since then, his mission is to support what he believes to be falsely accused foreigners in Brazil. Although all Brazilians sympathize with his cause, he has a biased view of all facts. He sees Escola Base everywhere and he is out of his mind. Since Legacy/Gol accident, he gathers favorable news to the pilots and translates to Joe Sharkey. He creates many blogs, and he participates in many forums like this. A lot of Joe Sharkey references are Pedicini’s sites. He has many identities. He is everywhere at internet. He is your *reliable* source

[Sdruvss]

Parliamentary Commission of Inquiry (CPI) on the Sept. 29 crash and the crisis in Brazilian air traffic.

Richard Pedicini in Sao Paulo tirelessly translated this from the Portuguese, and has added Translator's Notes at appropriate spots to point out slips, errors and outright mistranslations in the Portuguese version of English radio transcripts from the American pilots.

Excelent translation!!!!

[marciovp]

Come to think about it...of course families who lost loved ones in the disaster want to sue. Then, to sue the Brazilian government (Air Force),
GOL Airlines (Boeing 737)... or Excell AIr that, as came out in the papers, has insurance for this contiongency, and has an airplane sitting there at Cachimbo Air Force Base, confiscated already by a Judge?... Perhaps this is why it becomes important for the pilots of the Legacy to be at fault... so that Excel Air can be sued...

Just a thought...

[ATC Watcher]

marciovp :
so that Excel Air can be sued...


Follow the money is always a good trail in investigations . But this time the family relatives should perhaps realize that the State of Brazil has far more funds that a small US company ( that could also declare that part operating the aircraft insolvent ) and I am not sure the Legacy impounded was paid cash in advance . If banks were involved they will certainly recoup their credits on it as well.

In the US , during the Cerritos trial, the Mexican lawyers representing the families preferred to attack the FAA ( which had little responsibility in that case but a lot of cash ) instead of the Pilot/owner of the Piper, whose assets were less that a Million US. They won by the way , and the FAA paid.

Sdruvss :
Excelent translation!!!!
thanks for the link, but I still do not know what you are after after this remark .

[Sdruvss]

ATC Watcher:Excelent translation!!!! thanks for the link, but I still do not know what you are after after this remarkHe did a very good translation job. He lives a long time in Brazil and he is American. No one could do a better translation. He translated everything (170pages!). And I don't know how he have access to the original. I haven't find it yet at internet, I had only part of it, but there is nothing but what we all already know.

[marciovp]

Follow the money is always a good trail in investigations . But this time the family relatives should perhaps realize that the State of Brazil has far more funds that a small US company ( that could also declare that part operating the aircraft insolvent ) and I am not sure the Legacy impounded was paid cash in advance . If banks were involved they will certainly recoup their credits on it as well.


I am not sure how long and how it will be to collect money from the Federal Government (Air Force) in Brazil. I suspect that a long time, if they collect, but I am not an expert in law, and really am not sure. Four controllers have been indiciated by the CPI of the House and the Federal Police. The Air Force has denied any software-equipment failures. I am not aware of any suits agains the Brazilian (Air Force) government.

Aeromagazine, just came out.
www.aeromagazine.com.br (http://www.aeromagazine.com.br/)
The last edition of the magazine Aeromagazine mentions again the two disasters Boing x Legacy and TAM in Congonhas. Since this is a thread on Boeing x Legacy, here is what they say:

It mentions that there is a controversy about the Legacy Transponder.
It says that the north-american authorities are questioning the local that the RMU (Radio Management Unit) in the jets of the family ERJ built by Embraer. The FAA (Federal Aviation Agency), aviation authority in the USA, published in July 3/07 a Security Alert for Operators (SAFO 07005) callingthe attention for the possibility of pilots who fly the models Legacy, ERJ-135, ERJ-140 and ERJ-145 modifying radio frequencies VHF or placing the Transponder in Stand By uintentionally during the flight. The FAA afirms that it found out during an investigation that pilots who had the habit of placing their shoes in the shoe rest located just below the instrument panel could unintentionally change the Transponder to Stand By . The study also shows the difficulties for the pilots to see that the Transponder was off because the indication "TCAS OFF" appear in the PFD (Primary screen) in small white letters that, according to FAA, are less perceived than warnings with colored letters.

Then the Embraer replies:
They acknowledge the note from FAA for the family EMB-145.. However in more than 11 million accumulated flight hours there has been no reports of TCAs being disconnected or going into Stand By in airplanes built by Embraer that have any relationship wit foot rest. All the technical analysis made by Embraer show that the normal use of the foot rests in the family EM-145 do not cause risks of the disconnection involuntary or accidental of the TCAs in these airplanes.

This subject is now being discussed between ANAC (Brazilian National Agency for Civil Aviation) and FAA, organizations that are reponsible for the certification of airplanes in Brazil and USA

So, so far...no conclusion on why the Transponder went off in the Legacy...

[PPRuNe Towers]

Confirmation via IFALPA:

http://www.ifalpa.org/sab/08SAB10_Inadvertant_transponder_and_radio_selection_on_ERJ14 5_family.pdf

[PBL]

If I understand it right, I believe that the Brazilian parliament committee CPI - Crise do Sistema de Trafego Aereo has recently issued a report in which they hold air traffic controllers and the Legacy pilots responsible for the midair accident.

I understand that this report has no direct legal implications.

I am also open to being contradicted if I have misunderstood the situation.

PBL

[broadreach]

Correct, PBL

CENIPA have not produced the final report yet, although the media says they're in the final stages and are leaking tidbits.

[ATCBob]

Approaching Brasilia the pilots said to ATC here we are, at 370. ATC said OK, "have a good trip". Nobody said anything about changing altitude.

The radar screen in Brasilia showed for seven minutes after the Legacy passed Brasilia that the transponder was OK showing 370 but the software from Brasilia was showing 360. Software in Brasilia entered the original written flight plan not requiring that ATC talked and confirmed 360 with the pilots. The icon was showing 370:360. A discrepancy.

Then transponder OFF. There was clear indication in the radar screen in Brasilia that the transponder was off. A military primary radar entered the picture and sent information 360. The written original flight plan also was there. So 360Z360 (Z means unreliable). Also transponder OFF. For about one hour. No communication between ATC and pilots even the radio was working. The pilots also did not see the Transponder OFF sign, in small letter, in yellow in their screen.

Then the lack of communication, one trying to call the other more that a dozen times. When ATC was able to say something to the pilots it was nothing about altitude, and there was no concern. It was to tell them the frequency of Manaus.That is interesting, because if U.S. controllers had the same equipment and same circumstances, our procedures would have detected the conflict and this "wouldn't" have happened. Which confirms all blame here is on Brazil's ATC, either the controller or their system. Modern ATC is set up to still work even with one aircraft's transponder failure, plus radio failure, plus confusion with assigned altitude, plus no TCAS... Brazil needs to catch up!

[PBL]

In the International Herald Tribune:
http://www.iht.com/articles/2007/10/03/america/03brazil.php

From flightglobal.com, the WWW presence of Flight International:
http://www.flightglobal.com/articles/2007/10/04/217780/gol-legacy-mid-air-collision-mistakes-leaked-to-press.html

PBL

[ATC Watcher]

How nice to see the names of the air traffic controllers published in the press. ( Herald Tribune link ) That is really important news !
Nobody seems to have learned anything from Ueberlingen.:rolleyes:

[ATC4US]

These news are about the military inquiry. That is why it doesn't metion the pilots charges. And those news doesn't mention:

"For the pilots, the following procedural failures can be listed, besides that indicated as determining:
• the lack of proficiency in the handling of the Embraer Legacy aircraft, especially in the operation of its avionics, characterizing incompetence;
not using the communications failure code on the transponder;
• not using the emergency frequency in due time when the communications failure
was characterized;
• conducting the aircraft in an imprudent manner and being negligent of security rules; and
• the low situational awareness of the Legacy’s crew."

About the clearance:

"An ATC clearance means an authorization by ATC, for the purpose of preventing collision between known aircraft, for an aircraft to proceed under specified conditions within controlled airspace. It is not autorization for a pilot to deviate from any rule, regulation, or minimum altitude nor to conduct unsafe operation unsage operation of the aircraft. The pilot-in-command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft. If ATC issues a clearance that would cause a pilot to deviate from a rule or regulation, or in the pilot's opinion, would place the aircraft in jeopardy. It is the pilots responsibility to request an amended clearance."

[barit1]

An ATC clearance means an authorization by ATC, for the purpose of preventing collision between known aircraft, for an aircraft to proceed under specified conditions within controlled airspace. It is not autorization for a pilot to deviate from any rule, regulation, or minimum altitude nor to conduct unsafe operation unsage operation of the aircraft. The pilot-in-command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft. If ATC issues a clearance that would cause a pilot to deviate from a rule or regulation, or in the pilot's opinion, would place the aircraft in jeopardy. It is the pilots responsibility to request an amended clearance.

Is this last sentence a Brazilian rule, or is it in accord with ICAO? If a pilot is not aware (and cannot be aware, unless informed by ATC) of a specific hazard, is he thus culpable?

[A310driver]

nope.....except, it appears, in Brazil.

[ATC Watcher]

ATC4US and Barit : the "clearance ' text mentioned is something taken out of its context to prove something, that was not intended to .
While it is indeed the pilot's responsibility to request an amended clearance if the initial instruction would put the aircraft in jeopardy ( think about a climb above max alt, or an unfeasible speed reduction , etc... ) it does not cover the FL changes according semi-circular.
What is very mean here, is that under the cover of technical knowledge, someone manipulates regulatory texts in order to influence the judiciary into believing that there is indeed some form of pilot responsibility in this..
Very dirty game ....

[ATC4US]

"4-4-1. Clearance
a. A clearance issued by ATC is predicated on known traffic and known physical airport conditions. An ATC clearance means an authorization by ATC, for the purpose of preventing collision between known aircraft, for an aircraft to proceed under specified conditions within controlled airspace. IT IS NOT AUTHORIZATION FOR A PILOT TO DEVIATE FROM ANY RULE, REGULATION, OR MINIMUM ALTITUDE NOR TO CONDUCT UNSAFE OPERATION OF THE AIRCRAFT.
b. 14 CFR Section 91.3(a) states: "The pilot-in-command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft." If ATC issues a clearance that would cause a pilot to deviate from a rule or regulation, or in the pilot's opinion, would place the aircraft in jeopardy, IT IS THE PILOT'S RESPONSIBILITY TO REQUEST AN AMENDED CLEARANCE."
(Federal Aviation Administration - Aeronautical Information Manual - Official Guide to Basic Flight Information and ATC Procedures)

Universal Weather, a global trip support services provider, made the Legacy flight plan taking in account fuel efficiency; best time to destination; adequate reserves; alternate ETOPS; airport weather considerations; RVSM airspace; navigation and communications requirements. This plan foresaw from São José dos Campos (SP) to Brasilia (DF), passing through Poços de Caldas (MG), the Legacy aircraft should travel via airway UW2, at 452 miles per hour, at an altitude of 37,000 feet. From Brasilia onward, the Legacy aircraft should have progressed via the UZ6 airway, at 456 miles per hour, at an altitude of 36,000 feet. From the Teres (virtual) compulsory notification point, the Legacy aircraft should have continued progressing on UZ6 airway, at 449 miles per hour, then changing, to the altitude of 38,000 feet. UZ6 airway has traffic in both directions. Aircraft that are traveling from north to south fly at odd levels (FL 290, FL 310, FL 330,... to FL 410), while those that are traveling from south to north fly at even levels (FL 300, FL 320, FL 340,... to FL 400). This plan was electronically submitted by Embraer to the traffic control center. An air traffic controller, in the Flight Plan Room, confirmed the insertion of the referred plan into the system and verified route conflicts by cross referencing it with the flight plans of the ACCs of the other FIRs. Before beginning a flight, the pilot-in-command shall familiarize himself with all available information appropriate to the intended operation. Although there is documentary evidence the crew had marked the flight route on an aeronautic chart of Brazilian air space, as far as everything has been seen, the probably is immense that the pilots did not even become aware of the originally presented flight plan, only coming to worry to about this after embarking on the aircraft, since there are no records of their presence in the AIS Room of the São José dos Campos Aerodrome. A clearance should contain clearance limit, departure procedure, route of flight, altitude data, and other information that are necessary. The clearance was: “November six zero zero x-ray lima, ATC clearance to Eduardo Gomes, flight level three seven zero, direct Poços de Caldas, squawk transponder code four five seven four. After take-off perform Oren departure”. It was clearly incomplete. It didn’t mention the complete route (Brasilia, Teres). The crew kept the route of the requested flight plan, but not levels. The crew acted with low situational awareness, not observing RVSM airspace and fuel efficiency provided by original flight plan.
(Note: this may be a bad translation)

[PBL]

The clearance was: “November six zero zero x-ray lima, ATC clearance to Eduardo Gomes, flight level three seven zero, direct Poços de Caldas, squawk transponder code four five seven four. After take-off perform Oren departure”. ........ The crew kept the route of the requested flight plan, but not levels.

It seems they were cleared to FL 370. What FL do you think they should have flown, given this clearance?

Please also give your justification, with reference to ICAO procedures.

PBL

[ATC Watcher]

Plus the fact that the crew was cleared later en route to climb to FL370 and reported to Brasilia sector 7 ( the sector in which the change to 360 was planned to take place , ) cruising at FL370.

They were replied to be under radar contact. Which mean in normal ATC operations everywhere in the world to maintain that level unless cleared otherwise.(*)

As they never were, the use of that " Flight plan regulations , incomplete or badly understood pre-departure clearance, or pilot's responsibilities to ask for an amended clearance , is total bulls... to explain why they stayed at 370 all the way.

It looks like someone uses this to hide the ground deficiencies later on .

(*) The only point which is still not clear for me is from which point/time an eventual radio failure can be established , and if so, which radio failure procedures did apply.

[ATC4US]

It seems they were cleared to FL 370. What FL do you think they should have flown, given this clearance?



Me? I don't know. I only read leaked reports, and translate to you. But for us, Brazilians, this clearance has a completely incorrect format. It should mention Brasilia and Teres. Experts say that the crew shouldn't have accepted this clearance, until ATC tell the complete route. The way it is, it seems that they should go straight to Manaus, FL 370, and not passing through Brasilia and Teres.

[bubbers44]

The crew read back and accepted the clearance properly. That is how 100% of clearances are received. I tried to get a full route readback out of CCS one day because our company had revised our original route because of a controller strike and after several attempts with ground control and tower ended up calling departure control on taxi out to see what radial they wanted me to intercept after departure to get out of there.

Everybody that flys down there knows how difficult it is to have a nonstandard conversation with ATC that isn't exactly what they are expecting to hear. Cleared to FL370 is it. Anything else in your flight plan is meaningless unless you have lost com. Lost com is fairly normal for short periods down there so changing altitudes would be very stupid.

[ATC4US]

As far as I know, nobody said that the crew didn’t read back and didn’t accept the clearance properly, and everybody said that they were indeed cleared to FL 370. As far as I know NTSB/CENIPA blames the crew (besides transponder issue) for “Before beginning a flight, the pilot-in-command of an aircraft shall familiarize himself with all available information appropriate to the intended operation.” and they didn’t. And “The Legacy crew failed to act with special caution, considering that the pilots had little knowledge, not only of the Legacy’s operation, but of Brazilian air space:
• when they did not question the authorization received, with level FL370 (37,000 feet) for the entire route, differently than in the original flight plan, which foresaw different levels than previously authorized;
• when they perceived, by the onboard documentation (and, if they did not perceive, they had the professional duty to have done so) that level FL370 (37,000 feet) on airway UZ6 provided for traffic in the direction opposite that in which the aircraft was proceeding.”

[PBL]

ATC4US,

has anyone attempted to show that these alleged failings of the Legacy crew were causal to the accident?

PBL

[mm_flynn]

"4-4-1. Clearance
a. A clearance issued by ATC is predicated on known traffic and known physical airport conditions. An ATC clearance means an authorization by ATC, for the purpose of preventing collision .... IT IS NOT AUTHORIZATION FOR A PILOT TO DEVIATE FROM ANY RULE, REGULATION, OR MINIMUM ALTITUDE NOR TO CONDUCT UNSAFE OPERATION OF THE AIRCRAFT.
b. 14 CFR Section 91.3(a) states: "The pilot-in-command of an aircraft ...
(Federal Aviation Administration - Aeronautical Information Manual - Official Guide to Basic Flight Information and ATC Procedures)

While US regulations have little direct relevance to the proceedings in Brazil, it is worth reading on in 14 CFR where it says § 91.179 IFR cruising altitude or flight level.
Unless otherwise authorized by ATC, the following rules apply—

(a) In controlled airspace. Each person operating an aircraft under IFR in level cruising flight in controlled airspace shall maintain the altitude or flight level assigned that aircraft by ATC.

This clearly says - 'maintain the last level assigned by ATC' (as all of the pilots keep saying. It would be interesting to know what Brazil's regulations are for IFR altitudes in controlled airspace are (I had naively assumed all countries required compliance with your last ATC clearance - other than in an emergency)

The prosecutors almost seem to be arguing that Brazil's ATC is not competent to assign an altitude!!

[ATC4US]

has anyone attempted to show that these alleged failings of the Legacy crew were causal to the accident?


The news (Agestado, Folha, Globo) say that the official Air Force documents (I understand that is Military Police Inquiry and CENIPA/NTSB investigation) produced until now on the investigation leave no doubts: despite the controllers performance having been a "contributing" factor in the accident, the "determining" factor in the tragedy was really the two North American pilots Joseph Lepore and Jan Paul Paladino. The Military Police Inquiry (IPM, has no legal effects to pilots), indicted the controllers for "carelessness" and "lack of diligence" and that the pilots had "neglect conduct". They say that the responsibility for navigation is that of the pilot-in-command of the aircraft and crew had to follow the indications on the aeronautic chart (I understand as the RVSM issue), which is a required document in the command cabin. They say the clearance was wrong (didn’t mention the route) and incomplete (they should had said “as filed”). Controllers said on their testimony that they knew that there was 3 different levels, but this is the way they use to do. They don’t say “as filed”. The conclusion that is reached is that the pilots considered that the current flight plan was one, while the flight controllers considered that there was another, as is explained: (1) A flight plan, requested and cleared, from the radio clearance, to the Legacy’s crew, which provided level FL370 from São José dos Campos to Manaus; (2) a flight plan, submitted and approved to and by ACC-Brasilia, which foresaw three different flight levels, obeying the flight plan originally submitted: level FL370 from São José dos Campos to Brasilia; FL360 from Brasilia to waypoint TERES; and FL380 from waypoint TERES to Manaus. The most relevant neglect conduct of the North American pilots is in respect to radio communication. They say neither they nor any other pilot in any part of the world needs controllers to know at what frequencies they should position their communications apparatus (Is this true?). The navigation charts register the frequencies sector by sector. Lepore and Paladino knew that in Sector 9, between São José and Brasilia, the frequencies are 125.05MHz 133.10MHz and 121.50MHz. On entering Sector 7, in Brasilia to Manaus, the frequencies are 123.30MHz, 128.00MHz, 133.05MHz, 135 90MHz and 121.50MHz. The frequency 121.50MHz appears in all of the sectors because it is the universal emergency band.

[mumbo jumbo]

About time IFALPA got to grips with the ridiculous nature of this 'keystone cops' Brazilian excuse for an investigation. Just reading the excuses put forward by the authorities in Brazil and the defense of their interpretation of the rules in the post above, we should be demanding that Brazil be blacklisted.

Just as we have done over the years where the aviation authorities were too ignorant and ineffective to get their airspace organised and made safer by upgrading equipment such as with Greece in the recent past, Brazil should be shamed by being awarded Black Star status. Until they get their ATC system and their ridiculous interpretations of Air Law sorted out, the flying public should be made aware of the deficiencies in Brazil and we as airline pilots who have to operate within and through their airspace should be demanding boycotts and avoidance.

The Brazilians obviously are proud of their aviation heritage but the time has come after reading the above translations of their various government organisations or lawmakers, to show them up for the buffoons that they appear to be. Boycott Brazil and their third world aviation infrastructure!

[ATC4US]

"However, to get around this problem, without being bound to the Federal Police’s conclusions in its inquiry into the accident, we will take some informative elements from it, principally the “Report on the Facts by Investigation Specialists”, registered under number DCA06RA076A, of the National Transportation Safety Board (NTSB)"
(...)
"The task of transcribing the Legacy’s Black Box was conducted by a team composed of a chairman and three members:
- Albert G. Reitan, Transportation Safety Specialist (CVR), National Transportation Safety Board (chairman of the group);
- Steven M. Demko, Air Safety Investigator, National Transportation Safety Board;
- Tony James, Air Safety Investigator, Federal Aviation Administration (FAA) which is part of the United States Transportation Department; and
- Greg Brinkman, Chief Operating Officer, ExcelAire Service, Inc."

[PBL]

ATC4US,

I thank you for some informative posts on what the current state of the investigation is. I also thank you for answering my questions directly!

I don't necessarily like what I read, but that is not to do with you, of course. Please keep us informed.

PBL

[ATC4US]

PBL,


I thank you for some informative posts...


You are wellcome.

That is what I READ. It is not what I think.

Regards.

[aviadornovato]

The Brazilians obviously are proud of their aviation heritage but the time has come after reading the above translations of their various government organisations or lawmakers, to show them up for the buffoons that they appear to be. Boycott Brazil and their third world aviation infrastructure!

First:

Our aviation infrastructure really appears to be a s... We have to admit that :bored:

Second:

I wanna see you pilots not only in websites as anonymous users proposing boycotts.
Do it openly face to face with your airline bosses !!!
Let's see how "machos" you are :E

[marciovp]

I am a proud Brazilian and Ii know a little about aviation. Perhaps I am repetitive but, unfortunatelly:

CENIPA is a branch of the Air Force, and the Air Force is responsible for Air Traffic Control in Brazil.

ATCs in Brazil, for the most part, don't speak English to carry on a conversation beyond the niddy griddy.

Either the Legacv pilots understood it wrongly or the ATC in Sao Jose told them wrongly but they were flying 370 to Manaus passing thorugh Brasilia.

The software in Brasilia showed them flying 370:360 (360 being the software that did not require confirmation with the pilots). This hapened for 7 minutes. Then the Legacy transponder went off ( see FAA commmunication) and stayed of for about one hour. The radar in Brazilia showed 360Z360, the first 360 coming from an unreliable military radar and the seconf from he software. It also showed cleaely that no info was coming from the transponder. In no moment Brasilia tried to talk to the Legacy pilots about this anormality. When they did was just to tell them the frequency of Manaus.

The Brazilian government and the Air Force have manteined that the Air Traffic Control equipments and softwares are of last generation and have no problems. The ATCs disagree.

I am wainting from a statement from NTSB.

[ATC4US]

Dear fellowcountryman marciovp,

The conclusions you are waiting for:

(...)
3. The occurrence of problems or functional failures in the software installed in the Air Traffic Control System, was not characterized, at the time of the accident;
4. The flight rules for Brazilian Air Space are correct by international standards, as prescribed by the International Civil Aviation Organization (ICAO);
5. The Air Traffic Control radiocommunication system, from an exclusively technical aspect, did not present failures, because other aircraft that flew over the region of the accident, including some close to the Legacy N600XL, did not have any communication problems; that the Legacy did not manage to communicate with ACC-Brasilia is linked to the use of differing frequencies on the part of the pilots and of some foreseen frequencies not being programmed in the console that controlled the Sector in which the aircraft flew;
6. The communications problems between controllers and pilots that occurred when the Legacy aircraft was cleared for takeoff, at the São José dos Campos Aerodrome, were not due to the low technical quality of the transmission, nor to the incorrect or deficient use of the English language in communication with the pilots: it was, essentially, due to the incorrect form in which the content was transmitted, which does not signify that there should not be investment in improvement of the flight controllers’ conversational English;
7. There were no incorrect indications nor the appearance of unknown signals on the radar screens of the air traffic controllers’ consoles; this does not indicate, however, that there does not exist the possibility of improving the system, such as by the inclusion of audio alerts to indicate exceptional circumstances;

[Rob21]

It is rare that we see so many mistakes (IMHO) on a single flight.

1. The clearance given to the pilots was incomplete. And this led to a misunderstanding about the FL. Normally, when a controler gives you clearance (in Portuguese), he starts giving you the destination and then the "details". So when the pilots got the FL (370) information, right after the destination (Manaus) and no other word on changing FLs, they read back FL 370 to Manaus and were not corrected.
The other instructions were related to the departure procedure, and that was understood.

2. The pilots did not familiarise themselves enough with the route to question the incomplete clearance. IMO, the pilots should have questioned the non standard FL for that specific airway. Allow me a simple analogy: You are on an interstate hwy, I-40, going west. Between Flagstaff and Wiliams there was an accident and the the traffic had to be deviated to momentarily accommodate westbound traffic in the "wrong" side of the road, facing (controlled) eastbound traffic. If the highway patrol (controllers) authorise you to go all the way to Los Angeles on I-40 east, something must be wrong. I would not question if I didn't know that I-40 was not a 2-way road.

3- The controller in Brasilia did not "remind" the pilots to change FLs. He probably thought the pilots knew what to do, and the pilot expected the controller to tell him what to do.

4- The pilots were not familiar with the Legacy avionics. It is too much of a coincidence that the transponder went off (or stand by) when the pilots were changing radio frequencies, and it's clear (per CVR) that they both were confused about operating the avionics.

5- The controllers did not notice the transponder was off.

6- The pilots, facing communication problems (not radio problems), did not try to call other traffic to try a "bridge" with Brasilia (or Manaus). They only did that after the collision, whith success. At that point, the transponder started transmitting again.

I am against criminal prosecution for these pilots and controllers. Maybe loose their licences, IF it is proven "reckless flying" and "reckless controlling" was the cause for the midair collision. Note I said IF...

[CDN_ATC]

These guys were American pilots.


American/Canadian pilots, and every other pilot on the planet at some point will fly through "Structured" airspace. Which means certain normally reserved eastbound/westbound levels are switched to accomodate heavy traffic flows.

It's up to the Controller to enforce those rules.

Also in the two major non-radar areas I work around, and they are the busiest non-radar areas out there, there is no such thing as a "Wrong-Way level"

For example in Gander Oceanic, and NY Oceanic (Two of the biggest and busiest non-radar areas on the planet) airplanes routinely fly what would normally be considered "WestBound" levels, eastbound and vice versa.

It has to be that way because of the required extra separation required, in order to accomodate the ever growing traffic volume. When they enter radar airspace, we identify them, and put them to a "Right Way" level.


What I'm getting at here is that flying at FL370 westbound would not be as strange to these pilots as some on this board seem to think, in fact if they're in and out of radar airspace, to them it would be routine I've never had a pilot ask me "Hey Center should we really be at this level?"


Let me also add that everyday I get professional pilots, from all the biggest majors in the world asking for an inappropriate level for no reason other than performance, so being a biz-jet and being cleared at a certain flight level, it would never cross their minds, or the minds of most pilots to question the flight level.

My opinion of course, and based on the few facts we have on the subject.

[ATC4US]

More about final CENIPA/NTSB report:

"Cenipa investigators also suggested more rigorous requirements (inspection) of foreigner pilots that operate in the country, requiring needed familiarity with Brazilian air traffic system. In this case, concluded that Legacy’s pilot-in-command didn’t have complete familiarity with glass cockpit technology, by which instructions of flight and operation of aircraft are virtually displayed in cockpit windshield. This partially explain the not intervention in the transponder, although alerts showed that it was off. One recommendation in this case is to reinforce the training for this virtual environment."


CDN_ATC,
Do you know how far is Manaus from Brasilia and how intense is the traffic in this airway? It's equal to crossing all Europe on wrong level. There is a chance of 100% to face another aircraft.

[RatherBeFlying]

Once ATC gives a crew a clearance and the crew accepts it, the crew's responsibility is to comply with the clearance.

Upon receipt of a flight plan, it is ATC's responsibility to determine a clearance that will not conflict with other traffic.

ATC's responsibility is separation.

Aircrews' responsibility is to fly in compliance with clearance.

ATC does not fly the airplane.

Aircrews do not tell ATC how to do their job -- If you see a green traffic light, do you first check to see that the traffic lights for the intersecting street are red before proceeding?

[applevid]

a green traffic light means you can go into the intersection ...IF IT IS CLEAR.

green doesn't just mean blindly go.

and one should keep the big picture in mind...ATC can make a mistake too.

[GlueBall]

Irrespective of the filed flight plan [a "plan" is not a clearance] with intended en route cruise level changes: It is is impractical reality for any airplane anywhere to change its last assigned Flight Level without talking to somebody.

Take this example: One day last year we were en route SIN-DXB. We were "cleared as filed" and over the Arabian Sea our "filed" flight plan had directed us to climb from FL340 to FL360. But Mumbai HF radio was dead on all frequencies. No other airplane over the Arabian Sea was able to contact Mumbai Radio. Needless to say, we maintained our last assigned Flight Level [thankfully as did all the other airplanes] until we had established VHF contact with Muscat Center. Between waypoints SUGID [Mumbai FIR] and PARAR [Muscat FIR], the radio outage lasted approximately 1 hour. It would have been suicidal for us to have followed our flight plan and to have climbed on our own in this busy airspace.

[ATC4US]

It seems to me that you people are forgetting that "the pilots considered that the current flight plan was one, while the flight controllers considered that there was another" and "the Air Traffic Control radiocommunication system, from an exclusively technical aspect, did not present failures, because other aircraft that flew over the region of the accident, including some close to the Legacy N600XL, did not have any communication problems". Your examples are very diferent of what really happened. GlueBall, for instance, imagine that in your filed plan you were supposed to climb from FL340 to FL350 over Arabian Sea because all planes in the same direction as you goes odd levels and against you came even. What did you do? Would you keep FL 340? I'm not a pilot, but I would never do that without ATC give me a good reason :)

[mumbo jumbo]

What did you do? Would you keep FL 340? I'm not a pilot, but I would never do that without ATC give me a good reason
Aha! And once again we have the ridiculous situation where we are forced, ad nauseum, to try and explain to these "non-pilots" what happens in the real world. Of course you "...would never do that without ATC give me a good reason..." because you are not a fcuking pilot and you don't understand the rules. Give us a break and go and get your licences and a job for a few years flying commercial airliners and then come back and tell us what you would and wouldn't do if ATC told you something. :rolleyes:

CDN_ATC has explained, very succinctly and to the point, what and how we as pilots deal with clearances. It is also explained very clearly to the "non-pilots" the difference between a flight plan and an ATC clearance. I have yet to fly anywhere in the world where the differences are not understood by professional pilots. Yet here, we once again are going to have to explain to "non-pilots" the differences.

If these few examples of Brazilian "non-pilots" way of thinking and lack of understanding of the rules of the air are anything to go by, and I assume that most of the people conducting these investigations are "non-pilots", then it's a foregone conclusion what the result is going to be. No need to hold anyones breath because the pilots are going to be blamed for the fcuk up of the Brazilian ATC.

Will you please stop trying to persuade us with your stupid comparisons of highway driving or traffic lights. If you are not a pilot then you should at least save us from your stupidity by expecting us to change what we all already know about the differences between clearances and flight plans. Brazil has shown us that they are not competent enough to deserve first world status when it comes to their airspace infrastructure and the way their accidents are investigated. Blacklist them. I have already discussed this with our flight planning department and we already have special procedures in place for any flights that cross Brazilian airspace.

It has been explained many times already on this thread the difference between a flight plan and a clearance. It has also been explained many times how we deal with differences between a flight plan and level changes once en-route, whether in a radar or non-radar environment. For the "non-pilots" to keep trying to tell us that we should have changed flight level because the flight plan said so only goes to prove to us that we are dealing with "non-pilots" who have no idea how we actually operate and for them to try and quote the rules to us is as insulting as me calling them incompetents and buffoons because of their total lack of comprehension and understanding.

The above is not meant to insult those "non-pilots" who are experts in their fields of aviation incident and accident investigation and at least have an understanding of what is being explained about the differences between flight plans and clearances. Unfortunately, their cause is not helped by the "non-pilots" who are trying to persuade us that they somehow know better than us how to fly a clearance.

[lomapaseo]

The above is not meant to insult those "non-pilots" who are experts in their fields of aviation incident and accident investigation and at least have an understanding of what is being explained about the differences between flight plans and clearances. Unfortunately, their cause is not helped by the "non-pilots" who are trying to persuade us that they somehow know better than us how to fly a clearance

If we leave out the judicial aspects of this discussion, then the only thing that counts is the resulting recommendations to prevent future accidents with similar causal factors. This will require uniformity or better understanding within the aviation infrastructure. Driving on the road on the ground has nothing to do with this.

[ATC Watcher]

Not going to continue on this silly discussion about "what the pilots should have done or not " waste of time . Everything has already been said by professionals here. Let's move on .

What I really find interesting , is those " leaks" in the CENIPA reports posted here ( if indeed they are leaks, this is Internet after all )

I especially like this one :
More about final CENIPA/NTSB report:
"Cenipa investigators also suggested more rigorous requirements (inspection) of foreigner pilots that operate in the country, requiring needed familiarity with Brazilian air traffic system.

in conjunction with that one :

4. The flight rules for Brazilian Air Space are correct by international standards, as prescribed by the International Civil Aviation Organization (ICAO)

An admission that Brazil ATS system is not what the rest of the world do, even if it is not in contradiction with ICAO SARPS ?

As to the Communications :
5. The Air Traffic Control radiocommunication system, from an exclusively technical aspect, did not present failures

Ah ! so it does has failures which are not exclusively technical ? :E
This is perhaps why they keep on transferring a/c to other sectors always giving an alternate frequency ? :hmm:

[pilot-br]

Aha! And once again we have the ridiculous situation where we are forced, ad nauseum, to try and explain to these "non-pilots" what happens in the real world.

Who asked you to explain us anything? We, Brazilians, are just reporting you NTSB/CENIPA conclusions published by the newspaper, and it seems that they don’t agree with you. And, it seems that many of you, as PBL ("I don't necessarily like what I read, but that is not to do with you, of course. Please keep us informed."), like to know them in advance. You don't need to loose your time if you don't want.

Ah ! so it does has failures which are not exclusively technical ?

Yes, there is a lot of them, such as:

"
(...)
5. The Air Traffic Control radiocommunication system, from an exclusively technical aspect, did not present failures, because other aircraft that flew over the region of the accident, including some close to the Legacy N600XL, did not have any communication problems; that the Legacy did not manage to communicate with ACC-Brasilia is linked to the use of differing frequencies on the part of the pilots and of some foreseen frequencies not being programmed in the console that controlled the Sector in which the aircraft flew;
6. The communications problems between controllers and pilots that occurred when the Legacy aircraft was cleared for takeoff, at the São José dos Campos Aerodrome, were not due to the low technical quality of the transmission, nor to the incorrect or deficient use of the English language in communication with the
pilots: it was, essentially, due to the incorrect form in which the content was transmitted."



Unfortunately, their cause is not helped by the "non-pilots" who are trying to persuade us that they somehow know better than us how to fly a clearance.


The point is how a real pilot here deals with an undoubtly wrong clearance, and not persuade you of anything. We apologyse, if this is what you are thinking.

[ATC Watcher]

Pilot br :
on communications :
5. The Air Traffic Control radiocommunication system, from an exclusively technical aspect, did not present failures, because other aircraft that flew over the region of the accident, including some close to the Legacy N600XL, did not have any communication problems; that the Legacy did not manage to communicate with ACC-Brasilia is linked to the use of differing frequencies on the part of the pilots and of some foreseen frequencies not being programmed in the console that controlled the Sector in which the aircraft flew;

If I read this , and having seen the IFATCA report on the Brasilia centre VHF and radar coverage. I can deduct that the coverage of the VHF frequency they were last given was not for the whole part of their route through that sector , and that now, in the report the pilots are accused of not having selected an alternate/spare one .
Am I correct in this interpretation ?

If yes, then I want to add , that in " normal ATS procedures " (*) it is up to ATC to initiate transfer of communications and frequency changes. Unless , (like in Oceanic for instance ), ATC says , " make your next position report ( in 20 or 30 minutes ) on xxx,xx Mhz, if no contact, alternate is XXX,xx MhZ .etc..

I did not read any of this in the Brasilia R/T transcript published by the NTSB.
For me, they were on a given sector frequency, and the boundary of that sector was until close to the point they collided, and they had no reason to select another one.
------------------------------------------------------------------------

(*) " that is what the rest of the world I know , do.

Is there something specific to Brazil mentioned in the Bazilian AIP ?

[mumbo jumbo]

...and it seems that they don’t agree with you.
Of course it doesn't agree with me or anyone else that flies professionally for a living for that matter. Based on the information we have received so far from all the leaked reports by the Brazilians tasked with investigating this collision we are now told that the pilots were responsible for not correcting a bad clearance or adhering to a flight plan. :ugh:

This just stinks of a smear campaign to incriminate the pilots because of deficiencies in the Brazilian ATC system. We, the professional pilots are, according to the leaked information, expected to read back a clearance which is then accepted on read-back and then analyze it for inconsistencies AFTER it has been accepted. On top of that, the Brazilians expect us to then go fly and whilst en-route, in a supposedly radar environment, to change flight levels whether or not we can talk with ATC even though the clearance we read back and was accepted on read-back, stipulated no level change.

Please, spare us the anguish at being berated for just being the messengers of this daft information. It reeks to high heaven of a corrupt, inept and downright dangerous administration of a third world, tin-pot air traffic system. Banana republic attitudes to blaming the 'foreigner' for the ills of their own inherently dangerous failings in some belated attempt to deflect blame or scrutiny.

Just so as it has a remote chance of sinking in... we read back a clearance and unless the controller points out that our read back is wrong we then have to assume that it was given correctly in the first place In addition, if we are cleared to our destination and only given one flight level then we stay at flight level until ATC advise us otherwise. We do not start climbing willy nilly just because the flight plan said so. That's all it was... a flight plan. The clearance from ATC is the final instruction on what to do and if they fcuked it up and didnt catch it on the read-back from the pilots then it is ATC who are at fault.

No amount of argument, especially from "non-pilots" with absolutely no grounding in aviation law and the day to day operation of jet aircraft will convince anyone else on here who happens to make their living by flying aircraft professionally, to change their minds. Even those with ATC experience are pointing out the holes in the leaked reports which make it even more obvious that there is a corrupt attempt to cover up the deficiencies in the Brazilian ATC system and to lay blame elsewhere. Pathetic. :=

[pilot-br]

For me, they were on a given sector frequency, and the boundary of that sector was until close to the point they collided, and they had no reason to select another one.


The following affirmative was published by Folha (biggest Brazillian newspaper) and all Brazilian newspapers as an extract of NTSB/CENIPA final report (It's not my words, it's not my opinion. Don't kill the messenger!):

"The most relevant neglect conduct of the North American pilots is in respect to radio communication. They say neither they nor any other pilot in any part of the world needs controllers to know at what frequencies they should position their communications apparatus . The navigation charts register the frequencies sector by sector. Lepore and Paladino knew that in Sector 9, between São José and Brasilia, the frequencies are 125.05MHz 133.10MHz and 121.50MHz. On entering Sector 7, in Brasilia to Manaus, the frequencies are 123.30MHz, 128.00MHz, 133.05MHz, 135 90MHz and 121.50MHz. The frequency 121.50MHz appears in all of the sectors because it is the universal emergency band."

The collision occurred in Sector 7 shortly before entry into FIR Amazônica.


The clearance from ATC is the final instruction on what to do and if they fcuked it up and didnt catch it on the read-back from the pilots then it is ATC who are at fault.



This is not in dispute by anyone. That is why controllers were indicted and besides that, for "lack of diligence".

[pilot-br]

One more no-pilot stupid question: If they were cleared to Manaus why they deviated to Brasília instead of going by Goiania :confused:

[pilot-br]

This just stinks of a smear campaign to incriminate the pilots...


I think that there is no "sides" here. It's a factual debate.

[aviadornovato]

Banana republic attitudes to blaming the 'foreigner' for the ills of their own inherently dangerous failings in some belated attempt to deflect blame or scrutiny.




Hey Dude,

Try to keep your conversation on-topic. If you have any adiction to dick measurement contests this is not the place for you to be.


By the way:

What are the special measures your company adopted regarding Brazil. Do they include a boycott, Dude ?

[A310driver]

Of course, you know that "cleared as filed" refers to route only and does not include altitude/level even if requested in flight plan. The only change that can be effected without an ATC clearance would be to comply with an MEA under lost-comm conditions where the previously cleared altitude is lower than the MEA and no EFC was issued for a higher altitude at the appropriate point.

[pilot-br]

Of course, you know that "cleared as filed" refers to route only and does not include altitude/level even if requested in flight plan.

Please also give your justification, with reference to ICAO procedures.

[pilot-br]

Not necessary, I've found:

"f. Cleared to (destination) airport as filed” does NOT include the en route altitude filed in a flight plan. An en route altitude will be stated in the clearance or the pilot will be advised to expect an assigned or filed altitude within a given time frame or at a certain point after departure. This may be done verbally in the departure instructions or stated in the DP."

[Rob21]

Lost comm procedures should not include changing the transponder code?

The argument that the Legacy didn't loose radios, that is why they didn't change the transponder code, does not make any sense to me. A radio that does not have a 2-way communication, is not a "functional" equipment. If you call, and have no answer, to me this is a non working radio. The fact that the Legacy' pilots could hear radio "chats", but could not establish a 2-way communication, for me is enough to change to "lost radio" transponder code.

[pilot-br]

Rob21,

If you call, and have no answer, to me this is a non working radio.


Legacy called ATC only a few minutes before accident, so radio was ok until that moment, but ATC called Legacy 30 minutes before collision and had no answer!!! This would be the moment, for ATC, to start lost-comm procedures, and they didn't. And, they should have called them before that, when transponder went off!!

[pilot-br]

It seems that Asia are facing same issues as us:

International Civil Aviation Organization
The Seventh Meeting of the Regional Airspace Safety Monitoring Advisory Group (RASMAG/7)
Bangkok, Thailand, 4 – 8 June 2007
(...)
Summary
This paper provides the definition of Large Height Deviation (LHD) and its causes for flight operations in the RVSM airspace.
(...)
1. Introduction
1.1 For the past meetings of the RVSM implementation in the Asia Region, the issue of LHD has been discussed in great details due to the significant number of occurrences, especially in the RVSM airspace of Western Pacific/South China Sea (WPAC/SCS).
(...)
2.2 The causes of LHD occurrence include:
• Operational errors (aircraft operating at a flight level other than the assigned flight level due to ATC/Pilot loop errors and incorrect clearance), which is categorized into three causes:
- Flight crew not following the correct ATC clearance
- ATC issuing an incorrect ATC clearance
- Receiving ATC unit unable to apply the separation standards during a transfer of control responsibility between two ATC units
• Aircraft contingency events occurring in situation where the pilot cannot initially follow normal contingency procedures and is forced to climb/descend through flight levels before diverting from track,
• Deviation due to the effect of high level meteorological condition, and
• Deviation due to Technical Collision Avoidance System (TCAS) advisories, which includes:
- Flight crew correctly following the TCAS Resolution Advisory (RA)*,
- Flight crew incorrectly following the TCAS RA, and
- Any vertical displacement not conforming to the resolution advisory.
2.3 It is important to note that the LHD resulting from actions complying with the TCAS RA would not reflect risk in the RVSM airspace since it is a proper remedial action of flight crew to prevent the possible mid-air collision between aircraft. Nonetheless, it is strongly recommended that all LHD occurrences related to TCAS advisory be reported to the responsible RMA for detailed airspace safety analyses.

[Rob21]

pilot-br,

Our government should be ashamed for allowing the airspace over Brazil get in to this mess.

I heard a rumor saying some international airline pilots are being instructed by their Ops to fly on the "shoulder" of the airways when over Brazil's airspace.

I imagine how nice is to have TCAS. But Gol 1907 had a nice and working TCAS and didn't save all those people...

[ATC Watcher]

pilot-Br. Caution not to mix things up !!

LHDs are monitored to verify the target level of safety of RVSM operations.This does not explain the problems Brazil ATS currently faces.

In your case the Legacy was flying exactly at the altitude it was set to fly : 37.000 ft, and so was the GOL 737 . Should one of them had an altitude deviation , not even a large one , as it is meant in this WP , they would have missed.
The Brazil collision has nothing to do with RVSM operations or LHDs.
The collision would have occurred the same below 290.

[pilot-br]

ATC Watcher,

Are you saying that we are not facing "ATC issuing an incorrect ATC clearance?". I thought we were :rolleyes:

Just remembering:
"It is worth clarifying that the “UZ6” airway has traffic in both directions, as if it were a “two way street”, with levels distributed from FL290 to FL410. Aircraft that are traveling from north to south fly at odd levels (FL 290, FL 310, FL 330,... to FL 410), while those that are traveling from south to north normally fly at even levels (FL 300, FL 320, FL 340,... to FL 400). This vertical space from FL290 to FL410 is reserved for RVSM - Reduced Vertical Separation Minimum – flights, with separation between aircraft being 1,000 (one thousand) feet."

I thought that when we clear a aircraft to fly a few hours northwest at level FL370 is not correct, or at least it is not the best. It's very difficult to put way all traffic that are coming odds to southeast. It seems that a better clearance would be 360 or 380, don't you think? And it seems that it is even more incorrect when we want to clear only the first leg and we clear all route. We don't know even the correct phraseology:bored:

[Brian Abraham]

From AIN today

IFALPA to Brazil: Don’t Criminalize Midair Collision
The International Federation of Air Line Pilots’ Associations (IFALPA) late last week called on the Brazilian government “to return to agreed international standards and principles in the investigation” of the midair collision of a Gol Airlines Boeing 737-800 and an ExcelAire Embraer Legacy 600. The September 2006 accident, which killed all 154 aboard the airliner, focused attention on Brazil’s air transport system, as well as the Legacy’s American pilots–Joe Leopore and Jan Paladino. In the letter to Brazilian authorities, IFALPA said it has “serious concerns” about the government’s indictment and possible criminal prosecution of the Legacy pilots and air traffic controllers. The pilot group is also disturbed that the legislative inquiry and federal police investigation have been conducted before CENIPA, Brazil’s safety board, could publish its independent technical investigation. Accordingly, IFALPA wants the Brazilian government to suspend the legislative inquiry and the Justice Ministry to adjourn criminal proceedings. Instead, IFALPA said, Brazil should focus on applying “any lessons and recommendations made in the [forthcoming] CENIPA report that will improve air safety.”

[aviadornovato]

IFALPA wants the Brazilian government to suspend the legislative inquiry and the Justice Ministry to adjourn criminal proceedings.



IFALPA will keep "wanting" those things.

First because the legislative inquiries are both already over (Senate and Chamber of Deputies).

Second because Brazil is not a dictatorship anymore and thus only the legislative itself and the Judiciary could respectively stop the legislative inquiries and "adjourn" the criminal proceedings.

The Justice Ministry only controls the Federal Police, not the Federal Prosecutors, which are independent and cannot be dismissed by the Executive Branch.

IFALPA should learn more about the countries to which it issues its recommendations

[barit1]

ATC Watcher correctly notes:

... the Legacy was flying exactly at the altitude it was set to fly : 37.000 ft, and so was the GOL 737 . Should one of them had an altitude deviation , not even a large one , as it is meant in this WP , they would have missed.

A few decades ago, autopilot and navigation accuracy were "loose" enough that a significant (albeit imperfect) additional layer of separation redundancy existed. Two aircraft on the same route at the same altitude had only a small probability of occupying exactly the same space at the same time. History will never tell us how many near-GOL-1507's happened and went unrecognized.

Autoflight refinement, RVSM, GPS ad inf. have stolen this last slice of the cheese from the aviator's safety net. Two aircraft cleared on the same route at the same altitude have a much higher probability of exchanging paint.

[barit1]

per aviadornovato - IFALPA should learn more about the countries to which it issues its recommendations

Many of us will see it the other way around. Countries inclined to pursue criminal procedings against pilots should learn more about international civil aviation law and practice. :rolleyes:

(thinks: Do Brazilian pilots have to follow different rules when they leave Brazilian airspace? Are the rules that different?)

[con-pilot]

(thinks: Do Brazilian pilots have to follow different rules when they leave Brazilian airspace? Are the rules that different?)

Excellent point barit1, if in fact true, the posters here that are blaming the Legacy pilots for the accident for not changing their FL without ATC approval are proved totally wrong or Brazilians pilot would have been being violated by every country in the world.

Of course they are not, because Brazilian pilots are very professional.



(The real one's anyway.)

[pilot-br]

IFALPA and IFATCA are non-governamental organization, that talks in the name of the defendants. They should know better the Constitution and the laws in their own countries:

US Code of Federal Regulations:

§ 91.13 Careless or reckless operation.
(a) Aircraft operations for the purpose of air navigation.
No person may operate an aircraft in a careless or reckless manner so as to endanger the life or property of another.



Phillip J. Kolczynski, American attorney in “Criminal Liability in Aviation”:
Some states have established criminal liability for unintentional homicide with an offense they call ‘criminal negligence’. Other states punish negligent homicide as a form of ‘manslaughter’. This charge is often called ‘involuntary manslaughter’. These criminal charges require more than just simple negligence. In fact, most well-written state laws require more than ‘gross negligence’ for a criminal prosecution.

Why is the NTSB, which now knows precisely what happened, is sitting on its hands, citing procedure, when two American pilots are being criminally accused?

[aviadornovato]

Many of us will see it the other way around. Countries inclined to pursue criminal procedings against pilots should learn more about international civil aviation law and practice.


Barit,

Let us let "countries" out of this topic.

I am one of those who are against the criminal proceeding against the pilots. However I cannot tolerate this "Brazil bashing" talk. This is pure prejudice and nothing else. Kind of "dick measurement contest".

If pilots are unhappy with the behaviour of the Brazilian Judiciary, WHICH IS AN INDEPENDENT BRANCH, so please direct the complaints against the right person: The Judge and the Federal Prosecutor in charge. This is the only reason why I am intervening here.

If a foreigner told you that any Judiciary absurd that happened in the United States was a proof of Americans not knowing anything about this or that international law how would you react ?

[pilot-br]

the posters here that are blaming the Legacy pilots for the accident


Are not (only) the posters here that are blaming. Are NTSB, CENIPA, almost all pilots in Brazil, all controllers, all newspapers and all magazines.

[pilot-br]

PS:
I, personally, blame the pilots bosses -- that were in the Legacy as passengers and almost lost their lives-- and controllers bosses -- that were in controlling room -- and didn't give them correct training.

[aviadornovato]

Our government should be ashamed for allowing the airspace over Brazil get in to this mess.

I heard a rumor saying some international airline pilots are being instructed by their Ops to fly on the "shoulder" of the airways when over Brazil's airspace.



Ok, Rob21. I agree with you.

But just to put some "pepper in the sauce", I would sugest you read the whole story of the Uberlingen collision back in 2002...

[pilot-br]

I don't know why people here are worried about finding ONE cause (ONE guilty). ALL of them have their responsabilities: pilots, controllers and their bosses.

[pilot-br]

Con Pilot,

Excellent point barit1, if in fact true, the posters here that are blaming the Legacy pilots for the accident for not changing their FL without ATC approval are proved totally wrong or Brazilians pilot would have been being violated by every country in the world.


No Con Pilot, NTSB/CENIPA is blaming the pilots, besides transponder issue, for not requesting an ammended clearance when they received a clearly incorrect (FL370 in UZ6) and incomplete clearance (CRAFT: Clearance limit, route, altitude, frequency, transponder).

[GlueBall]

Under the circumstances of lost contact with the Legacy, the correct ATC procedure would have been for Brasilia Center to have called Manaus Center [by telephone] and alerted them about the Legacy's altitude [FL370]. Then Manaus Center would have contacted the GOL B737 and have it vacate FL370... :ooh:

[pilot-br]

Glueball,

When Brasilia lost transponder signal, 1 hour before collision, and this was displayed at their ATC screen, they immediately should have called Legacy, ... and they didn’t. 30 before collision, when Brasilia lost radio communications, they should adopt all applicable procedures (bridge between planes, using emergency frequency, …), ... and they didn’t. After failing all of these procedures, they should put away all traffic against the Legacy because they didn’t know its altitude due to the transponder failure, ... and they didn’t. All errors after Brasilia, besides the transponder issue, are controllers procedures errors.

The accident was in a ACC-Brasilia sector, and Gol flight was already under control of ACC-Brasilia, and in ATC mind, Legacy were in FL 360, ATC didn’t guess that Legacy was FL 370. That it is why they didn’t guess that there was a mid-air collision risk at that moment. They assumed that it was just a transponder mistaken code issue.

[pilot-br]

This is the reading of testimony of the controller who issued the wrong clearance at Senate. Maybe it helps to understand what happened:

SENATOR DEMOSTENES TORRES: “Sergeant Felipe S.R. were not heard on this CPI (Parliamentary Commission of Inquiry). He affirmed – he is one of the indicted – as was published by press, that would not talk about the accident and his professional conduct. His intention of stay in silence was confirmed when he was requested to testify at CPI of the Chamber of Deputies (in Brazil there is two chambers – Deputies and Senate). If he said nothing to Chamber of Deputies, it became clear in his testimony to police officer Sayao, there is no doubt that his conduct was relevant to the accident. He said to police officer... So, this testimony is important for what? Because he didn’t came here to testify and even in the Chamber he stayed quite, that is why we didn’t request him to testify, but for the police officer he said: “That, when he transmitted the flight plan – who was this sir, sir Felipe S.R.? Or who is he? On that moment he was the person in Brasilia, who was in charge of approving the plan and transmit the plan to Sao Jose dos Campos – and, by the occasion of transmitting the plan of N600XL aircraft, of planning room in position “S1 assistant”, the declarant was occupying this position; That the air traffic in that moment could be considered of low intensity; That he received only the “electronic strip” that indicated the flight plan only of the sector of the declarant-S1; That he didn’t have, in that occasion, the declarant, the information that the aircraft intended, in their plan, modify its fly level at Brasilia, neither in Teres position, because those information is not displayed in the “electronic strip”; That the subsequent information regarding the flight plan in the sectors after of the declarant, could be accessed by a special function key, but since it was an ordinary flight plan and an ordinary clearance and since the responsibility of the declarant was only Sector 1, the declarant didn’t understand necessary to access them – he didn’t access all information; That in his training, the declarant learned that flight plans clearances, that have several levels, were issued by the first sector assistant specifying only the flight levels of his sector, due to the lack of information in the “strip”. That, for that reasons, the declarant, indeed, when received the call of São José dos Campos tower – that requested clearance for aircraft N600XL flight plan, issued this clearance mentioning the level 370 and direction necessary to the aircraft intercept the intended airway; That when asked if this clearance was complete or partial, answered that his clearance was of the essential information, and didn’t mention complementary information and that was a partial clearance; That when was read the transcription of phone communication between Brasilia and Sao Jose dos Campos, by which this clearance was issued and asked again about the partial aspect of this clearance, the declarant assured that his clearance foresaw level and direction to be flown in the airway until Brasilia, and ends in Brasilia, and this way, couldn’t be understood as a complete clearance; That the extract that says “São José – Eduardo Gomes” was interpreted by the declarant, as a way to identify what flight and aircraft he was referring to and not the complete extension of the clearance; That he knowledge and understand that he didn’t infringe what is put in ICA-100/12, item 8.4.9 and item 8.4.10.1 (clearance)”.
(THIS IS MY TRANSLATION, AND I’M NOT A GOOD TRANSLATOR)

He and four other controllers were indicted. What surprises me is that how many thousands of clearances were issued this way? IFATCA believes that this is not a human fault, and it is not a training issue. They believe it’s a equipment failure.

[Tarq57]

Actually, Pilot-br, If I am to understand your translation correctly this is normal, and, as far as I know, the way clearances are issued all over the world.
An ATC clearance is a somewhat "fluid" authorization, in that it is expected that amendments occur enroute , and for the approach phase. This is necessary because it is impossible for the issuing controller to know in advance, or even with prior coordination, what the next controller along requires, and the next, and the next...
In our ATC manual, and I expect, all others, a clearance is defined in this manner.
-----------------------------------------------------------
Said this before in this thread, I'll say it again, thousands of flights are cleared, daily, at initial levels that are subsequently amended enroute for various reasons, including fuel efficiency as the aircraft burns fuel off and wants to climb, unavailability of existing level due other traffic, weather, and quadrantal rule (the case here.)
From what I've learned of this accident, I believe it is more an equipment issue, too.
When the transponder return was no longer received by ATC, the symbol-which is not large, nor I imagine particularly attention grabbing - changed. That was the clue available to the controller/s. Against that clue, the information in the datablock reverts not to the last assigned ATC level (370) but to the flight planned level (360). A counter-clue.And, in human factors terms, a deadly one. In addition, the radar system used in Brazil triangulates the position of the aircraft and offers an approximate level, which is displayed. This displayed level, at the crucial time, was also 360.
So yes, there are things the controllers might have noticed, and perhaps should have done, particularly when communications were interrupted, but I for one can easily understand, given the incorrect clues displayed, why the controllers might have believed that the flight was at 360. Had any controller had doubts about this, and no communication with the aircraft, they would have made darned sure the Gol aircraft was moved laterally away from the flight path of the Legacy.

[pilot-br]

barit1

(thinks: Do Brazilian pilots have to follow different rules when they leave Brazilian airspace? Are the rules that different?)


The answer is no, but the airways are different and Brazilian pilots should know the airways rules of the airspace they are flying.

[pilot-br]

Markjoy,

From what I've learned of this accident, I believe it is more an equipment issue, too.



Please, let me repeat CENIPA conclusions:
"7. There were no incorrect indications nor the appearance of unknown signals on the radar screens of the air traffic controllers’ consoles; this does not indicate, however, that there does not exist the possibility of improving the system, such as by the inclusion of audio alerts to indicate exceptional circumstances;"

Transponder fault was clearly seen in controllers screen (360Z360). The Z indicates that there is no information of actual altitute due to transponder failure, and the left or right (I'm not sure) 360 was the flght plan level.


...the way clearances are issued all over the world


Without clearance limt? Without route? Only "essencial informations" as controller said? What surprises me is that all Brazilians pilots and foreigners that operates here understands this is a clearance until Brasilia and then "as planed", and Legacy understood until destiny, as forsaw in ICAO regulations.

[Ace Rimmer]

Ask yourself these questions: Is Brazil a Contracting State of the Chicago Convention?
If so, why is it failing/refusing to comply with the standards set out in Annex 13?
Answers: Yes and you tell me...
As I see it, IFALPA is calling for in this case is for the Brazilian government to remind the Judiciary and so forth of the nation's obligations the treaty. Which is the same thing it has been saying for the last year.
BTW: IFALPA doesent have a country. It is an international organisation comprised of 97 member associations, including, and this may be significant, the SNA.

[pilot-br]

Ace Rimmer

...why is it failing/refusing to comply with the standards set out in Annex 13?
Answers: Yes and you tell me...



Because Constitution and the Parliamentary Commission of Inquiry supersedes Annex 13. Annex 13 applies only to NTSB/CENIPA investigation, and criminal negligency must be investigated by justice, it's the law almost everwhere, including USA. It doesn't matter if it is a car crash, a bridge that falls or a plane that has an accident, which is the same thing it has been saying for the last year.

[pilot-br]

Ace Rimmer,

BTW: IFALPA doesent have a country.

That is why I said "They should know better the Constitution and the laws in their own countries"

[Ace Rimmer]

The question is then how to establish any liability without waiting for an independant technical investigation to be completed first?

If this investigation finds evidence of wilful negligence by any party then procecute away...BUT this is NOT the case here. The prosecution proceeds without the benefit of the full report by CENIPA.

[pilot-br]

Ace Rimmer


The question is then how to establish any liability without waiting for an independant technical investigation to be completed first?


Liability was not estabilished yet. No one was convicted, hearings are just starting. No one, controllers and pilots, will be condemned without independant technica investigation be completed. You can be sure of that. Brazil is a country that usually doesn't make justice, but injustice is rare.

[Ace Rimmer]

But that is exactly my point, the indictments have been made, the hearings have started WITHOUT the CENIPA report.

[pilot-br]

But that is exactly my point, the indictments have been made, the hearings have started WITHOUT the CENIPA report.


But Ace Rimmer, this is the law and Constitution, everywhere. And CENIPA doesn't have justice power. If someone don't want to talk to CENIPA, they may, and justice may cite them, justice can even arrest them if someone deny to testify. CENIPA may not do that.


If this investigation finds evidence of wilful negligence by any party then procecute away...BUT this is NOT the case here


Don't you think that a transponder off and wrong clearance is not a strong suspicion of criminal negligency? One (pilots) is blaming the other (ATC) of criminal negligency. Pilots says they were cleared, ATC says they were not. It was the pilots that accusated ATC of criminal negligency. Someone in this history acted with criminal negligency. And remember, CENIPA won't blame anyone, as forseen in Anex 13. The facts emerged in CENIPA investigation will tell who is telling the truth, in the timely moment. The process can't stop until there. A process don't stop because the technical investigation is not ready. And it's not necessary that the negligence be "wilful".

PS: I'm being blocked to post in this forum. Why do you think they are doing that?

[lomapaseo]

The facts emerged in CENIPA investigation will tell who is telling the truth, in the timely moment.

I doubt that.

The interpretation of the truth will still be left to the eyes of the reader against their already made up mind.

Cenipa will simply cite causal factors (including some that are possible but not confirmed) and recommendations for prevention of these possible factors coming together again.

It would be a shame if we (in aviation) continue to polarize ourselves about who is right and wrong, rather than fixing the causal factor linkages.

The criminal part of this is a legal matter and while decried by many under Annex 13 it will not be solved outside of Brazil.

[pilot-br]

lomapaseo,

I doubt that.


We are entering in a wider debate about justice, and I totally agree with you that truth depends on the eyes of the judge, in EVERY judgment, and not only aircraft accident judgment. The accident was here; it was Brazilians who died, so Brazil has the right to judge it, the same as if the accident were in USA, the judge would be American. I’m always trying to concentrate in the facts, but this accident is different from others we are used to see. No equipment failure was proved until now, although a lot of people insisted on this theory. And that is why I insist in the facts, and the documents I’m dealing with are the same as Joe Sharkey in their blog, but we (Brazilians) have different interpretations. It's well known that we have radar and radio covertures holes, old equipments, our airspace is in a mess, but all of these facts, that is totally true, was not possible to be related to this accident. All the radar records show all the movements of all aircrafts flying in the region. All radio conversation was recorded by other aircrafts in same region, even the Boeing recorded the messages sent to Legacy. All that was proved, until now, and it is not necessary that CENIPA tell us, points to controllers and pilots procedures faults. It is enough their testimonials and independent technical expertise point of view to we make our mind. There was conflicting testimonials of pilots and controllers. It’s not necessary that CENIPA reveals CVR to we know it. Unfortunately, there were fatalities, and then, it’s not the professionals involved (pilots, controllers and their unions) that would be the judge. Professionals are heard thru their technical investigation, but then justice goes on. It’s the same with doctors, hospitals, engineers, attorneys, drivers and all professionals that have lives on their hands. Take the doctors as example, when there is a medical malpractice doctors are heard but are not them and their classes associations that will judge, and it is not their associations that will ask justice to stop the process until they have their findings. I’m not here to convince anyone. I’m here to tell you what Brazilians think, how our justice system is. I think that a lot of people here are willing to hear us, as I am willing to hear you.

[ATC Watcher]

Pilot-br :
Are you saying that we are not facing "ATC issuing an incorrect ATC clearance?". I thought we were

From your alias here I initially thought you were a commercial pilot. Having seen your posts now, I began to realize that you are most probably a lawyer, or at least someone knowledgeable with the law rather than in Aircraft operations and ATC.

So , for the sake of closing our debate let me just say that in our case above , the Bangkok WP on RVSM you quoted refers to height deviations to measure RVSM compliance and target Level of safety(TLS) Using this WP to prove something in a Brazil accident is not very wise.

Your vision of this case is that of a justice person : someone must have made an error, so by looking for the individuals , and punishing them we will ensure peace.( and the good name of our Country )

In Aviation accident investigation we are interested in finding the causes, and issue recommendations for the accident not to happen again .
Legal procedures and fears of prosecution should not enter the equation. If they do people are not talking and we learn nothing.

In our case here, errors have been committed of course, as always . But why is far more interesting than by who.
Restoring radar coverage and VHF coverage on all frequencies in Brasilia for instance would be one of those things a proper investigation would be looking at recommending. ( read the Fohla on line article of last monday (15 Oct) on this issue, very, very interesting)

If you take a flight tomorrow with your family between Sao Paulo and Manaus, the implementation of proper technical investigation recommendations will be 1000 times more effective in ensuring your family safe flight than sending 4 controllers and 2 pilot in jail.

Incidentally, after the Tenerife crash in 1977, one of the additional recommendation in one of the 3 reports was to warn about the " fear of prosecution " inhibiting many actors to tell the truth to the investigators then.

Unfortunately nothing has changed 30 years later.

[pilot-br]

ATC Watcher,

You are arguing that airspace safety improvement and criminal liability are mutually exclusive, and they aren't. We want our skies safer, we fly here, so I am more interested than everyone in this forum. And I am not a lawyer, not an attorney, not a pilot, and it is not a MS flight simulator pilot that pretend to be a pilot that will give me lessons. I want to know why 154 of my friends died.

[lomapaseo]

And I am not a lawyer, not an attorney, not a pilot, and it is not a MS flight simulator pilot that pretend to be a pilot that will give me lessons. I want to know why 154 of my friends died.
We continue to hear the same plea from the survivors of TWA800 and the SA295 Helederbeg accident in post after post on their internet sites. Collectively there are just as many believers as there are non-believers in any theory or causal factor linkages in these accidents, including the published final report from the chief investigating agency. It's clear to me that neither a Final technical Report nor even a judicial finding will satisfy all that the truth has been found.

For the survivors with little aviation knowledge or understanding they may feel consoled by a jury of peers or a judge. For those of us interested in continued flying with our families we are consoled by the technical understanding, the lessons learned and the adoption of the recommendations that follow.

[pilot-br]

ATC Watch:

read the Fohla on line article of last monday (15 Oct) on this issue, very, very interesting

Folha:

Of four frequencys that Legacy’s pilots could have used, two were unavailable to controllers and one not operational.
(…)
Complete transcriptions of radio conversation between ATC and aircrafts in accident region, obtained and analyzed by Folha, also prove that Cindacta-1 received and ignored at least three calls of Legacy before collision .

This is not new and was mentioned by leaked report of CENIPA, as:
19:48:13s to 19:52:07s (three minutes before collision): the Legacy tried twelve times, always without success and always using different frequencies, to make contact with Sector 7 of ACC-Brasilia, according to the following list:
19:48:13 to 19:49:30: 3 attempts - Frequency: Unknown
19:50:09 to 19:50:27: 2 attempts - Frequency: 123.30 Mhz
19:50:45 to 19:51:21: 3 attempts - Frequency: Unknown
19:51:42 : 1 attempt - Frequency: 133.05 Mhz
19:52:07 to 19:52:56 - Frequency: Unknown
In the previous list, the frequencies, when determined, signify communications that were received by ACC-Brasilia, but were not heard by the controller responsible for Sector 7, since these frequencies were not programmed on his console. The information registered as unknowns were not received by ACC-Brasilia, having been collected from their appearance on the Legacy’s CVR.

Folha:
The frequencies that must be used, indicated in the aeronautical chart for that sector, are: 123.30 Mhz, 128.00 Mhz, 133.05 and 135.90. Each sector has its own list. Pilots should be informed by Cindacta which of them they should use (Neither they nor any other pilot in any part of the world needs controllers to know at what frequencies they should position their communications apparatus. The navigation charts register the frequencies sector by sector – Agestado), whereas controllers listen and transmit on until six simultaneous frequencies in their consoles (workstation). At September, 29 of 2006, however sector 7 controllers had only frequency 135,90 Mhz available. The other five were of sectors 8 and 9, that they were watching that day
Sorry, but what is the new here? Sectors 8 and 9 are much more crowded, so if controllers allocate just one frequency for sector 7, always will have just one frequency operational.

And Folha conclusion:

These revelations don’t exempt responsibility of controllers for proved failures raised in investigations: to clear a collision altitude for the jet, to neglect surveillance of Legacy and don’t put in action foresaw lost communication procedures that could avoid the accident. Not even remove the responsibilities of pilots Joseph Lepore and Jan Paladino for flying with transponder (equipment that feeds anti-collision system) turned off.


lomapaseo:

For those of us interested in continued flying with our families we are consoled by the technical understanding, the lessons learned and the adoption of the recommendations that follow.

I respect that.

I think that all of us, Brazilians and you, understood what happened. We are only worried about some facts, as the mess of our airspace, our safety issues, that are being published by blogs and forums, althought be true, but are not cause of this accident, but just intended to baffle us and you.

[pilot-br]

Just one more provocative reflection: That day, a dozen of aircrafts received clearances of the same format as Legacy received, and for years they are receiving this kind of clearance, as the controller Felipe S.R. said in his testimony. All of these pilots understood that this format of clearance is partial and presumed they were cleared only to the first sector. Legacy was the only one aircraft that followed the rule and kept same level until destiny. Could you imagine if all of those pilots had followed the rules? God bless them by disobeying the rules.

[bsieker]

ATC Watcher,
You are arguing that airspace safety improvement and criminal liability are mutually exclusive, and they aren't. We want our skies safer, we fly here, so I am more interested than everyone in this forum. And I am not a lawyer, not an attorney, not a pilot, and it is not a MS flight simulator pilot that pretend to be a pilot that will give me lessons. I want to know why 154 of my friends died.

For a concise argument about why criminal prosecution and the conduct of an accident ninvestigation aimed at finding causes and improving safety are conflicting, I refer you to the Joint Resolution (http://www.flightsafety.org/pdf/resolution_10-06.pdf) by various organisations involved in aviation safety.

To quote its key points:

[...]

Recognizing that information given voluntarily by persons interviewed during the course of safety investigations is valuable, and that such information, if used by criminal investigators or prosecutors for the purpose of assessing guilt and punishment, could discourage persons from providing accident information, thereby adversely affecting flight safety;

[...]

1. [...] By identifying the “what” and the “why” of an accident, aviation safety professionals will be better equipped to address accident prevention for the future. Criminal investigations can and do hinder the critical information gathering portions of an accident investigations, and subsequently interfere with successful prevention of future aviation industry accidents.

2. [...] The benefit of gaining accurate information to increase safety standards and reduce recurring accidents greatly outweighs the retributive satisfaction of a criminal prosecution, conviction, and punishment. Increasing safety in the aviation industry is a greater benefit to society than seeking criminal punishment for those “guilty” of human error or tragic mistakes.

[...]



Bernd

[Rob21]

1- If it was possible to file a flight plan maintaining FL 370 all the way to Manaus, why they chose to file a more "complex" and less fuel efficient plan?

2- I believe all pilots know (in Brasil also) that what you get from the tower at the airport of origin is an initial clearance. And if it is a "small" airport, you normally activate your flight plan AFTER take-off. So normally what pilots get from tower is the clearance for the BEGINNING of the flight, like the TO procedure, speed liberation, altitude and route. Destination is included as per regulations, but this does not mean that you shall fly all the way to the destination following departure instructions.

3- So my question is: Did the Legacy activate their flight plan?.
4- After take-off, leaving ATZ, since they understood they were cleared all the way to Manaus, did they inform their intentions (fly 370 all the way) to the control center?

[ATC Watcher]

Pilot -Br , in quoting the Fohla you seem to have missed ( unintentionally I hope ) the crucial NEW information in the report ( in bold ) :

The complete transcriptions of the radio conversations between
control and the aircraft in the region of the accident, obtained and analyzed
by the Folha, also show that Cindacata-1 received and ignored at least
three calls from the Legacy before the collision.
The motive is linked to the equipment's limitations: of the four
options of frequencies that the American may have used, according to the
Brazilian aeronautic chart, two were unavailable for the controller and another wasn't even in operation.
In summary, there was only one possible frequency and the American pilots
never received instructions to tune to it, as has already been released.
Also do not forget that we have not yet seen the CENIPA report,as you seem to have. For me this information was new and explains quite a lot.

you said later :
No equipment failure was proved until now, although a lot of people insisted on this theory
Playing with the words again . I would argue for equipment design failures both in the ATC system ( e.g assigning automatically Flight plan altitude, replacing Mode C altitude with military height finders average height, etc.. . and in the Embraer aircraft avionic suite ( e.g ability to switch off transponder ( and TCAS) in a single key stroke without adequate warning to the crew ) .
I consider those TO BE major technical issues and failures.

I will not even go into the facts of assigning frequencies in areas with known coverage shortcomings, and applying radar procedures in known areas with no radar coverage, placing transfer of control/communications in those black out areas, and so on.
you said :
our airspace is in a mess, but all of these facts, that is totally true, was not possible to be related to this accident.

I agree with the mess, I disagree strongly with the fact that it is not related to this accident.

[marcosCR]

TO PPRuNe members:
The administrators are deleting all messages of this thread, without saying a word. All of today posts where deleted. Shame on you.

[marcosCR]

TO PPRuNe members:
The administrators are deleting all messages of this thread, without saying a word. All of today posts where deleted. Shame on you.

[Lost in Saigon]

"Legacy was the only one aircraft that followed the rule and kept same level until destiny. Could you imagine if all of those pilots had followed the rules? God bless them by disobeying the rules."

NO. You are wrong. Dead wrong. On that day, the Legacy was the only aircraft to have both a transponder failure and communication failure at a critical point in their flight. I am quite sure that most of the other aircraft flying that day could have fallen into the same trap.

As pilots we are very careful to maintain the last assigned altitude unless cleared by ATC. Even if radio contact is lost.

What if GOL had just been cleared to 36,000'? What if the Legacy pilots had taken the initiative to change altitude to 36,000' on their own because they had lost radio contact? Can you just imagine the outcry if they then collided at 36,000'.

The fault here is totally with Brazilian ATC...... They were unable to maintain separation in a very straightforward situation. Many parts of the world have no radar at all. Many parts of the world have gaps in radio coverage. It is not difficult to seaprate aircraft in these situations if you follow some very basic rules.

The way I see it, Brazilian ATC has very lax procedures, poorly designed equipment, and it was just a matter of time before an accident like this happened.

Just pray it won't happen again.

[marcosCR]

Lost in Saigon:

NO. You are wrong. Dead wrong.

NO. YOU are wrong. Dead wrong. Read controllers testimonials, they use to do that for years. It seems you are lost in the world, not only in Saigon.:ugh:

[ATC Watcher]

marcosCR : (re?) joined today and already aggressive, again , and wrong in your assumptions, again.

What lost-in-saigon said makes a lot of sense to most of us here. .

What do you expect with this? You know something in Aviation that we don't ?

[marcosCR]

ATC Watcher,
It seems that Lost in Saigon missed the following. Copy before administrator delete.

It is well known, that an aviation accident is not the result of an isolated failure. It is always the result of a succession of inter-related factors, what we call, here, determining factors and contributing factors. In the collision between the two aircraft under consideration, indubitably, the determining factor is identified as the turning off of the transponder/TCAS system by the Legacy’s crew.
It should be perceived that, even if all the mechanisms of the Brazilian Air Space Control System had failed, or even, if neither radars of any other form of communication existed, the accident would not have happened if the transponder/TCAS system had been on.
As contributing factors, we point to all sorts of procedural failures on the part of the Legacy pilots and of some air traffic controllers.
For the pilots, the following procedural failures can be listed, besides that indicated as determining:
• the lack of proficiency in the handling of the Embraer Legacy aircraft, especially in the operation of its avionics, characterizing incompetence;
• not using the communications failure code on the transponder;
• not using the emergency frequency in due time when the communications failure was characterized;
• conducting the aircraft in an imprudent manner and being negligent of security rules; and
• the low situational awareness of the Legacy’s crew.
For the air traffic controllers, in an overall way, can be listed the following procedural failure of a contributing type:
• flight clearance solicited and granted in an incorrect form, indicating for the Legacy cruising level FL370 (37,000 feet) from São José dos Campos to Manaus;
• the existence of deactivated radio frequencies on the controller’s console;
• not adopting the prescribed measures as soon as it was detected that the Legacy’s transponder was not functioning;
• not adopting corrective measures as soon as it was detected that the Legacy aircraft was proceeding against traffic on Airway UZ6; and
• not adopting the prescribed measures when the failure of bilateral communication was characterized.
Of the responsibilities of the Legacy crew One of the crucial questions through which the whole investigative proceeding passes is that of what was the valid flight plan was for the Legacy N600XL’s trip, and the conclusion that is reached is that the pilots considered that the current flight plan was one, while the flight controllers considered that there was another, as is explained in detail below:
- a flight plan, requested and cleared, from the radio clearance, to the Legacy’s crew, which provided level FL370 (37,000 feet) from São José dos Campos (SP) to Eduardo Gomes Airport, in Manaus (AM); and
- a flight plan, submitted and approved to and by ACC-Brasilia, which foresaw three different flight levels, obeying the flight plan originally submitted: level FL370 (37,000 feet) from São José dos Campos (SP) to Brasilia (DF); FL360 (36,000 feet) from Brasilia (DF) to waypoint TERES; and FL380 (38,000 feet) from waypoint TERES to Eduardo Gomes Airport, in Manaus (AM).
This fact, especially, has served as an argument for those who take up the defense of the North American pilots, as they understand that the current flight plan corresponds to the verbal authorization provided them on the departure from São José dos Campos, and in which, considering the procedural rules, they have reason on their side. However, in at least two moments related to this fact, the Legacy crew failed to act with special caution, considering that the pilots had little knowledge, not only of the Legacy’s operation, but of Brazilian air space:
• when they did not question the authorization received, with level FL370 (37,000 feet) for the entire route, differently than in the original flight plan, which foresaw different levels than previously authorized (sic);
• when they perceived, by the onboard documentation (and, if they did not perceive, they had the professional duty to have done so) that level FL370 (37,000 feet) on airway UZ6 provided for traffic in the direction opposite that in which the aircraft was proceeding. Although there is documentary evidence the crew had marked the flight route on an aeronautic chart of Brazilian air space, according to the indictment presented by the Federal Prosecutors’ Office against the pilots, as far as everything has been seen, the probably is immense that the pilots did not even become aware of the originally presented flight plan, only coming to worry to about this after embarking on the aircraft, since there are no records of their presence in the AIS Room of the São José dos Campos Aerodrome.
The lack of greater caution in the conduct of the aircraft can be observed by reading the transcription of the conversation between the crew, as per several transcripts presented in previous chapters of this same report. In truth, one verifies, yes, an evident carelessness in their conduct, allied to a lack of proficiency in handling the aircraft which they crewed, proving that the qualification formally documented does not correspond to the qualification in fact required.
Here is appealed to, as corroboration, the opinion of Commandant GEORGE WILLIAM CÉSAR DE ARARIPE SUCUPIRA, President of the Association of Aircraft Pilots and Proprietors, who testified to this CPI:
“(...)
It is difficult and not recommended that you emit an opinion on an accident before analyzing all of the causes that led to it. But, in summary, the attitude of the airplane was so contrary to any kind of regulation that there’s nothing to say. That is to say, the primary blame is the airplane’s for being on an incorrect altitude, and the airplane not respecting the flight plan that was done.
(...)
and they only noticed that they had the TCAS turned off and the transponder in the stand by position, after the blow they took. And they didn’t know what it was (...)”

[lomapaseo]

Legacy was the only aircraft to have both a transponder failure and communication failure at a critical point in their flight. I am quite sure that most of the other aircraft flying that day could have fallen into the same trap.

I agree that both the loss of communications and the transponder failure are both layers of swiss cheese that were nibbled at or perhaps even devoured whole. I would like to understand just how important so I'm looking for some relavancy here.
I'm sure that there are some individual statistics on communication failures as well as transponder failures. Are these airways so crowded that if these two failure conditions combine together the flight is doomed?
Or do we have yet another ingedient or two that makes this accident stand out?
Else we had to have just a random roll of the dice where several ingedients had to combine together?

[rafaelMX]

PPRuNe,
You like to play games. Me too. Be prepared. People will know who you are and this will not contribute to your cause.

[Lost in Saigon]

I don't consider either the transponder failure, or the communication failure to be very important factors in this accident. Transponders and radios do sometimes fail.

In some situations, an aircraft can be allowed to takeoff without a functioning transponder and/or TCAS system. There are many examples of this.

Temporary loss of communications are EVERYDAY occurrences all over the world. Many things can cause this. It can be as simple as the pilot turning the volume too low. An earpiece falling out of your ear. Stuck microphone blocking transmissions. Out of range stations. It happens every day. In fact it probably happens on every flight.

An ATC system must be designed to be failsafe. This is not the case in Brazil

[leduardoR]

I don't consider either the transponder failure, or the communication failure to be very important factors in this accident. Transponders and radios do sometimes fail.



What do you mean? How ATC will help us without our FL?

(Sorry but are you a real pilot?)

[lomapaseo]

Lost in Saigon

quite a provocative post following my straight lead-in!!!

I wonder what all the diversionary fuss is about then in the press

[Lost in Saigon]

What do you mean? How ATC will help us without our FL?
(Sorry but are you a real pilot?)

Yes, I am a pilot with over 30 years experience in every part of the world except Africa.

On first contact, the primary way for an air traffic controller to establish the altitude of an aircraft is at is to simply ask him on the radio. He then takes a pen and checks off a little strip of paper to verify he is at the correct altitude.

If there is no contact, then the aircraft is at the last cleared altitude that was received and acknowledged by the pilot.

This is universal all over the world.

This is what failed in Brazil.

[leduardoR]

This is universal all over the world.


Sorry, dude, but it is not.

[aviadornovato]

An ATC system must be designed to be failsafe. This is not the case in Brazil

I wonder if the same was said about Europe (mainly Germany/Switzerland) after the Ueberlingen collision... A single controller on duty, no phone lines, etc, etc...

[Tarq57]

Quote:
This is universal all over the world.
Sorry, dude, but it is not.
I don't know about "all over the world", I've only worked in NZ, but this is pretty much ATC-101.
If one can't be certain about the level the flight is at, and there is a loss of comms, you apply a bit of lateral separation.

[con-pilot]

Sorry, dude, but it is not.

Well, hum, I have been flying all over the world, including Africa, for 40 years. Except Brazil.

In every country and Air Traffic Control Systems I have flown in the first call when entering a new sector, new area, crossing any and all boundaries is;

1. Who you are.
2. Where you are. (If not in radar contact.)
3. What level you are. (Or what level you are transiting to and from.)

If there is no response from ATC you stay at the last assigned altitude (level) you were last assigned.

Now, just where is this not the procedure?

Inquiring minds desire to know.

[aviadornovato]

Our ATC either commited mistakes or was a victim of system failures. This with no doubt.

I am against a criminal procedure against the pilots in this case as I don't see enough evidences of gross negligence in this case, at least to support a criminal conviction.

But some questions remain:

There is a talk about a transponder failure being caused by the use of the footrest.

The first question is: Is that technically proved ? If so, Embraer should immediatelly fix it.

The second question is: Was this the cause for the Transponder to be innoperative in the Legacy aircraft ? Or did the pilot confuse switches ?

Third question: Should the absence of an aural warning after the Transponder was shut off be accepted as a justification for the crew not having turned the device on again ? Shouldn't the crew monitor the a/c instruments ? Shouldn't it be trained to do so ?

Right after the collision, the PNF (I suppose) asked the PF if the transponder was off... The PF promptly confirmed it...

[con-pilot]

aviadornovato, now those are very good questions and from what I have read and heard the manufacture is changing things so that cannot happen again.

Of course they are not admitting that was the problem in the first place.

[leduardo.R]

He then takes a pen and checks off a little strip of paper to verify he is at the correct altitude.

Oh, now I got, You are joking. :)
That is why you are talking those thinks. I thought that you was talking serious.

[lost.in.saigon]

Do you believe in something here?

[Tarq57]

Quote:
He then takes a pen and checks off a little strip of paper to verify he is at the correct altitude
.

Oh, now I got, You are joking.
That is why you are talking those thinks. I thought that you was talking serious.
leduardo.R is offline Report Post Reply
The little piece of paper is called a flight progress strip. This, and the Bic ballpoint pen (black or blue) are the ultimate Air Traffic Control tools.
Recorded levels, headings, clearances etc are written on those strips. The strips are retained for a set minimum time after finished with and filing: they are legal documents.
This is not a joke.

[poorwanderingwun]

Been looking in here periodiacally hoping to learn of something new transpiring... instead it's like jumping aboard a carousel... the engine of which is being fueled by a few people who know as much about aviation procedures as I know about nuclear fission.

[ATC Watcher]

he engine of which is being fueled by a few people who know as much about aviation procedures as I know about nuclear fission.

Very well said, I also think now that perhaps the " few" people could be one with many aliases, whether it is in Brasilia, Timbuktu or now Lisbon.
I for one, fell into the trap.

I initially thought that there were a group of law people in Brazil that believed Pilots in IFR under radar control would change frequencies by looking at what is written on a chart, and change altitude according to their flight plan, and thought it was worth educating them.

Now , if someone wants to explain Procedural control to him ( or her ) , you' re welcome, but I am out.

I' d say : Let's wait for the final CENIPA report ( due any week now) to restart an interesting debate here .:hmm:

[Tarq57]

ATC watcher and poorwunderingwun,
thanks for the sanity check. Think I'll follow suit. (It's just so annoying........)

[joernstu]

I wonder if the same was said about Europe (mainly Germany/Switzerland) after the Ueberlingen collision... A single controller on duty, no phone lines, etc, etc...


In the Ueberlingen Mid-Air there was a trial in Switzerland, in which ACC Zurich managers were sentenced for failures to ensure ATC operations. So, it was said.

[lomapaseo]

I' d say : Let's wait for the final CENIPA report ( due any week now)

Don't hold your breath

Lot's of questions remain unanswered that need to be in the report. ATC is only one part of the report.

[aviadornovato]

Very well said, I also think now that perhaps the " few" people could be one with many aliases, whether it is in Brasilia, Timbuktu or now Lisbon.
I for one, fell into the trap.


Of course I am not from Timbuctu but I am not ATC4US.

And please answer my questions about the transponder without bypassing the subject.

Regards.

[Radar]

ATC WAtcher,

I was wondering how long your patience would hold :bored::bored:. Regardless of the junk you were dealing with, thanks for some very interesting posts.

[Lost in Saigon]

And please answer my questions about the transponder without bypassing the subject.

I am not familiar with the Legacy aircraft but most aircraft are the same.
If the transpnder fails, you will get a warning, but it is VERY easily missed.
If you turn off the transponder, then there will be no warning.

There is speculation that the crew accidently turned off the transponder.
This is not the cause of the accident. Aircraft experience transponder malfunctions every day. Some of these malfunctions are simple "finger problems".

[aviadornovato]

There is speculation that the crew accidently turned off the transponder.
This is not the cause of the accident. Aircraft experience transponder malfunctions every day. Some of these malfunctions are simple "finger problems".

Thanks for directly answering. I deleted my previous post. One cannot so easily answer to provocations of some junk minded people (not your case).

But anyway, shouldn't the crew monitor the a/c instruments, moreover when they are related to navigational information ?

What I am just trying to say is that this accident was caused by a series of mistakes from both the legacy crew and the Brazilian ATC. However I disagree with ATC4US when he says that the legacy crew should be responsible for not having changed its FL.

[Lost in Saigon]

No, flight crews do not continually monitor transponder operation. It is not a navigation instrument.

If it fails or is turned off, usually ATC will be the first to notice and ask the aircraft to confirm it is on.

[marciovp]

No, flight crews do not continually monitor transponder operation. It is not a navigation instrument.

If it fails or is turned off, usually ATC will be the first to notice and ask the aircraft to confirm it is on.


As far as I know it was clear to the ATCs in Brasilia that the Legacy transponder was off and that the data they were reading were not trustworthy. This lasted for almos one hour and...no attemps were made to cintact the Legacy and informing them that their transponder was off. I agree with you.

Insofar as the Legacy pilots, in hindsight (pay attention...hindsight...) they could have done two things that could prevent the disaster: question the change in the flight plan to 370 to Manaus and see in their flight data screen the small yellow letters saying that the transponder was off. I said..in hindsight...knowing what happened...

We can´t make a statement that any ATC in every country will need the ATCs of planes to prevent air collisions... The system should be able to avoid collisions without ATCs...

[Lost in Saigon]

Many years ago I used to fly in uncontrolled airspace in northern Canada. All pilots gave position reports and provided their own separation. It worked very well.

Today the responsibility of separation lies solely with Air Traffic Controllers on the ground.

It is not the responsibility of the pilots to question an assigned altitude. Altitudes are assigned by ATC after giving consideration to all the traffic in the area. Often aircraft are temporarily assigned "wrong way" altitudes in order expedite the flow of traffic.

Aircraft warning systems are designed to give different levels of warnings to the pilots. Some warnings are very important and other warnings are not so important. The "transponder off" warning is a very un-important or non-critical warning. As a result it is very easy to miss.

These pilots were busy trying to establish radio contact and it is easy for me to understand why they missed a non-critical warning.

It is non critical because a transponder does not affect the ability of the aircraft to stay in the air. The aircraft will fly all day long without a transponder. The transponder does not separate traffic. It is only a tool that makes the job of an Air Traffic Controller a little easier to separate traffic. Again, it is the Air Traffic Controller's job to separate traffic and no one else.

These pilots did nothing wrong and it makes angry to see people with very little practical knowledge of Aviation and Air Traffic Control try to speculate on what should have been done, or what could have been done by these pilots.

[aviadornovato]

These pilots did nothing wrong and it makes angry to see people with very little practical knowledge of Aviation and Air Traffic Control try to speculate on what should have been done, or what could have been done by these pilots.


You can be angry at your will. We are very sorry but we just want to clear all doubts on why 154 of our fellow citizens died that day.

I am sure the same would happen if those 154 were, say, Canadian or US citizens.

[barit1]

aviadornovato, the reason 154 died is perfectly clear:

1) the two aircraft were assigned the same altitude, which is a normal and temporary occurrance when the two are hundreds of miles apart;

2) as they became closer, ATC should have reassigned one or the other to a clear altitude;

3) ATC could not contact one of the aircraft, and then failed to reassign the other.

The pros in this forum understand this sequence very well. There are a dozen other side issues (why the radio & transponder failures, etc.), but when ATC fails to act to assure clearance, the negligence is obvious.

[Rob21]

barit1,

I agree that pilots understand very well the sequence you've posted.

I also assume pilots understand a couple of other simple things:
1- ATC can make mistakes. Be sure you master the operation of your aircraft and the environment you are flying (terrain, weather, routes, etc...).

2- Other pilots can make mistakes, so if you don't understand the "chat" on the radio (foreign language), double check with ATC if you are doing OK.

We all know cases of controllers saving pilot's a##es and also cases of pilots questioning a controller instruction. And I believe this happens a lot.

IMHO, we don't see more midair collisions because of good controllers catching pilot's mistakes and good pilots catching controllers mistakes. When none of this works, we have TCAS. Now, when we have ATC mistakes, poor aircraft operation and poor environment awarness all together, then luck comes in. Good luck, and you are home thinking how close that one was. Bad luck, if you are home thinking that all those people maybe wouldn't have died if you had "read" the book or learned that "international sh#t"...

[LimaHOIQ]

barit1

The pros in this forum understand this sequence very well.


Yes, I agree with you. It's a shame NTSB doesn't agree with us.

[Halfnut]

As one who will be interfacing up close and personal with ATC tomorrow I see it completely as a failure in the Brazilian ATC system. Now the big question is what will the people of Brazil demand next; a cover up or to use this tragedy to drag their country into the twenty-first system with a modern ATC system with well paid professional controllers. Along with this comes a modern judicial system that doesn’t go out on witch hunts looking for scapegoats but a judicial system that realizes the only way to fix problems like this that do occur is to encourage people to come forward to tell their side of the story without punishment.

It is now up to the people of Brazil to fix their ATC system.

[aviadornovato]

Along with this comes a modern judicial system that doesn’t go out on witch hunts looking for scapegoats but a judicial system that realizes the only way to fix problems like this that do occur is to encourage people to come forward to tell their side of the story without punishment.



Let's not use this case generically. I really don't like the way you put this specific thing.

Probably both controllers and pilots should not be prosecuted in the GOL/Legacy collision case but pushing for a generic immunity in any circumstance is very irresponsible IMHO and doesn't happen anywhere in this world.

As to the rest of your statement you are completely right: We should not cover up the problems with our ATC.

Nor should americans cover up the problem of pilots unfamiliar to a given A/C flying without sufficient training and putting the lives not only of Brazilians but of US citizens in danger too, no matter the eventual lack of correlation with the accident itself.

[ATC Watcher]

aviadornovado ( and others ):

If you have a few minutes check this, It is not long:
http://www.atwonline.com/channels/safetySecurity/article.html?articleID=1815

If you are still there after reading it , then check this : ( a little bit longer, but not that much. )
http://www.lusa.lu.se/upload/Trafikflyghogskolan/TR2003-01_Errorsinunderstandinghumanerror.pdf

Then come back and debate with us.

[Rob21]

A couple of questions for the pros here.

1- Is it possible to obtain a clearance to fly direct to your destination, in a route with no direct airway, above FL 240?

2- If 1 is affirmative, it seems to me that the Legacy was cleared direct to Manaus, not passing trough Brasilia. The only waypoint mentioned on the clearance was Poços de Caldas. So why the Legacy pilots understood they should go through Brasilia, if the clearance didn't mention that?

[PBL]

I am glad to see that the moderators are taking an interest in the thread and deleting pure rubbish. Let me say that I hope they leave it open (as opposed to the peremptory manner in which they closed the Congonhas thread).

My take is as follows. Our Brazilian colleagues on this thread (as, before it was closed, on the Congonhas thread) are seriously trying to figure their way through two horrendous accidents that have occurred in the last year. I have today downloaded the 713-page final report of the parliamentary committee (CPI) of the Chamber of Deputies concerning what they officially term the "Crisis in the Air Traffic System". The report of the Senate committee is yet to come. The information was given to me by someone who has been "banned" from discussing these events in this forum, although I judge he has resurfaced under another name.

I am gratified to find my slight contributions to this debate (through one of the newspapers, Folha) considered on p210. I haven't read the complete document (it was enough for me to print it out today!)

This is a serious discussion, with two sides that are having a very hard time understanding each other. It is very noticeable that our Brazilian professional pilot colleagues are saying absolutely nothing. There is a reason for this.
We are debating with Brazilian lawyers and concerned others. It is very worrying to me that what are (by us) regarded as international air traffic control standards were apparently not followed, and that the consequences of that event are being drawn differently by Brazilians that by non-Brazilians. This indicates to me a significant cultural discrepancy that needs to be bridged.

The clearest statement of the non-Brazilian view has to my mind been given by [email protected]:11.56. I must say I agree with this view completely.

I appreciate the citation by ATC Watcher of work by Sidney Dekker. Sidney is one of the most persuasive purveyors of the view that when competent operators screw up, one should look for the faults inside the system design rather than in the operators' mental states (which, as he and I would argue, should be accounted for in any system which requires human operators essentially). Another advocate of this view is Don Norman. Don does not deal much with airplanes (he is more into door handles, tea kettles and coffee machines) but he is very readable and his insights translate.

PBL

[broadreach]

PBL
You and many others have been extremely generous of your time on this thread. ATC Watcher!

In an anecdotal vein, some of the responses from the Brazilian end remind me of when I was stopped by a policeman while driving the wrong way up a one-way street where the traffic sign had been knocked down. “Sorry, officer, it’s not signposted”. “But everyone knows this is a one-way street, your fault for not knowing”.

You’ve mentioned the need to bridge a cultural discrepancy regarding the way Brazilians and non-Brazilians see the consequences of not following international ATC standards. I think your interpretation has a lot to do with the absence of contributions by Brazilian pilots and other professionals on here, which you’ve also mentioned. Had there been such contributions, I suspect they would echo those of the international community very closely.

The real discrepancy is more related to Brazil’s Portuguese legal and cultural baggage, which tends to surface in situations where it’s easier to apportion blame and decapitate the offender than to absorb the tragedy and apply whatever lessons might be learned from it to avoiding similar ones in future.
That, alongside a military ATC system where most of the professionals are long-serving subalterns and the “managers” are heirarchically superior but less experienced.

Were Brazilian commercial pilots and controllers to post here I do think the views expressed would be much closer to Barit1’s posting of 22 Oct.
As to why they haven’t come forward, I’d venture a few guesses, the main one being that they can be fairly easily identified. For all the size of Brazil’s air transport network, it’s still a small community. There are hundreds if not thousands of pilots wanting flying jobs and it’s not an economy where, if you’re not flying you can easily get a well-paying job doing something else. Speaking out can damage one’s career prospects. For the controllers, there’s military discipline and, usually, a linguistic challenge.

As to what happens now, post CPI, whew, I wonder. The air force seem to have been successful in rebuffing attempts to take ATC away but it would be inconceivable to presume they’d not absorbed some of the lessons. The CENIPA report will throw some light on that and I expect it will be at least moderately self-critical. After publication there will be a response from the air force and corresponding signals from the executive, and we might see some gradual changes.

For now, part of the CPI report is scathing toward Infraero, the airports authority, recommending the indictment of over twenty managers and directors on grounds of corruption. The executive response, apparently not related but in reality very much so, via the president’s chief-of-staff, has been “we’d like to see airports privatised.” Piano, piano...

For anyone else who might like to download the CPI final report, the 12.5mb pdf file (in Portuguese) can be found at:
http://www2.camara.gov.br/internet/comissoes/temporarias53/cpi/cpiaereo/CPIAEREO_RelFinal_REVFinal1.pdf

[Rob21]

And for the ones who did not have the chance to read the Legacy's CVR trancription (in English) and maybe after reading this will see that the pilots were not confortable in that cockpit.

http://www1.folha.uol.com.br/folha/especial/2006/voo1907/20070512-legacy-2.pdf

[GlueBall]

Rob21 . . . can you get us the GOL-B738 CVR transcript please. Obrigado.

[Rob21]

GlueBall,

Info I had here (via press only) from the Gol Boeing 737-800's CVR was:

1- The crew had no problems with radio communications.

2- No voice sounds were recorded after impact. No screams, indicating the crew and passengers went unconscious as a result of the high rate of roll.

3- CVR stopped recording at 6.000 ft.

Sorry if I can't get you more info. I heard that the families of the victims are "demanding" access to the recordings, just like the families of the TAM accident had.

[aviadornovato]

aviadornovado ( and others ):

If you have a few minutes check this, It is not long:
http://www.atwonline.com/channels/sa...articleID=1815 (http://www.atwonline.com/channels/safetySecurity/article.html?articleID=1815)

If you are still there after reading it , then check this : ( a little bit longer, but not that much. )
http://www.lusa.lu.se/upload/Trafikf...humanerror.pdf (http://www.lusa.lu.se/upload/Trafikflyghogskolan/TR2003-01_Errorsinunderstandinghumanerror.pdf)

Then come back and debate with us.



I read both texts and again I think that the approach is too generic.

What do those guys want, after all ? If they think that a given action or omission that causes an accident is not a consequence of gross negligence or any other criminal behaviour they just have to provide the correspondent reasoning IN THAT SPECIFIC CASE.

Why such generic and imprecise statements against criminal persecution in aviation ? Wouldn't a specific approach like saying "it was just an error not negligence in this case" or "he wasn't expected to do that much in that specific situation" work better ?

It is important to point out the contradictions:

In the first article one can read as follows

"At the same time, FSF points out that even an organization that promotes a "no blame" culture cannot tolerate irresponsible or careless acts, such as those involving a number of pilots being caught on the flightdeck under the influence of alcohol."

So the discussion should rest only on what could be seen as irresponsible and careless acts or not, shouldn't it ? The issue is wrongly addressed...

BTW, all the cases cited in the first article where icons of the wrong application of criminal law.

In the Linate accident, for instance, there was an obvious gross negligence from the directors of the airport.

A ground radar should be FULLY installed a long time before the accident but it wasn't. The guidance signs didn't follow the rules and were misleading.

But instead of convicting who was really to blame for the tragedy (yes, to blame: it was gross negligence) the Italian Judiciary at the end of the day put the blame on the only guy that should be spared: The ground controller Paolo Zacchetti.

This specific event is a typical case of Judiciary error. The wrong person is paying the price for the really guilty ones.

But this fact should not support a "no-blame" culture in aviation: It should only be a reminder that if there are any careless acts that cause an accident then the real perpetrators of such acts (or omissions) are the ones to be convicted and not to be spared in place of a scapegoat. Just so.

[PBL]

I read both texts and again I think that the approach is too generic.


I think it is about right, for the reasons below.

Why such generic and imprecise statements against criminal persecution in aviation ?

There are two main points, which are generic, but not at all imprecise.

The first is that pursuing accidents with criminal proceedings ensures that accident participants, who could otherwise contribute to safety prophylaxis by sharing their knowledge of what went on, will first concentrate on their defence (or avoiding prosecution in the first place) and not share that otherwise invaluable knowledge.

This is not conjecture. This is fact. It is a phenomenon not only in aviation, but also, say, in rail travel. My colleagues at IfEV in Braunschweig, who are involved in many proceedings concerning rail accidents in Germany, say it is a pervasive problem and have specific examples to show it.

And this hinders learning from accidents. There is a very specific example from the Brühl railway accident in my talk at the Bieleschweig 9 Workshop in Hamburg in May 2007 (see http://www.rvs.uni-bielefeld.de
-> Bieleschweig Workshops -> 9th Workshop, Hamburg, May 2007
for the slides).

The second is that if criminal proceedings in the wake of accidents persistently and pervasively miss the mark, as we know they do from many other cases besides Linate, then there is a case for a general moratorium on criminal proceedings until there is some means of ensuring that the "wrong" people do not get blamed. This is why, for example, the Governor of Illinois, while a death-penalty supporter, instituted a moratorium on executions until the courts can be sure that no mistakes are made.

It is important to point out the contradictions:


There are no contradictions (I speak from authority).

So the discussion should rest only on what could be seen as irresponsible and careless acts or not, shouldn't it ? The issue is wrongly addressed...

This is a very important point. But I don't think one can establish that the issue is wrongly addressed. There are specific models as to who is reponsible, and these models differ. For example, in the U.K. there is a new legal concept of corporate manslaughter, whereby a company can be held responsible for unlawful killing, and thus the directors suffere the consequences. Contrast this with, say, the Maglev accident, in which, despite significant concerns about the safety design of the system, the people who will appear before the courts are, as usual, operators on duty and associated people "at the pointy end".

Were the U.K. model to be applied to the GOL/Legacy midair, then the Air Force top command would be busy preparing their defence.

So I don't think one can legitimately claim that the issue is wrongly addressed, rather that the issue is differently addressed in different jurisdictions and the question is who has got it right. And if there is no way of settling the matter who has got it right (and it does seem to me to depend to some extent on different views of the polity), then it can be argued that a moratorium is an appropriate response.

PBL

[rmac]

Just a small thought to add on the "changing the system" line of thought.

If transponders are an important part of the safety chain in airspace when related to separation, why not make the warning of a transponder failure/disconnect similar to that of an autopilot failure/disconnect ?

[PBL]

If transponders are an important part of the safety chain in airspace when related to separation, why not make the warning of a transponder failure/disconnect similar to that of an autopilot failure/disconnect ?

I was about to say that such options are being seriously considered as a consequence of the NTSB recommendation, but then I actually looked it up. NTSB A-07-37 recommends to make pilots aware of loss-of-transponder annunciations, but doesn't go as far as to suggest modifying the warning.

The recommendations can be found at http://www.ntsb.gov/recs/letters/2007/A07_35_37.pdf
and the
EUROCAE WG49 Working Paper (Aug 2007) at http://adsb.tc.faa.gov/SC209_Meetings/Mtg07-2007-0820/WG49N11-13-Action%20A-10-17%20-K%20Hallworth%20NTSB%20Recommendations-Update%20of%20ED%2073B%20%2011%2008%2007.pdf

PBL

[aviadornovato]

The second is that if criminal proceedings in the wake of accidents persistently and pervasively miss the mark, as we know they do from many other cases besides Linate, then there is a case for a general moratorium on criminal proceedings until there is some means of ensuring that the "wrong" people do not get blamed. This is why, for example, the Governor of Illinois, while a death-penalty supporter, instituted a moratorium on executions until the courts can be sure that no mistakes are made.



PBL,

The debate is indeed very interesting.

I think that part of the problem has its roots in the lack of an effort (or visibility of such an effort) for a sufficiently extensive, precise and continuosly improved (in its objectiveness and clarity) set of rules to be followed by controllers, pilots and aviation industry managers in general.

It might seem wrong by some but if people in the Judiciary don't see a quest for accountability and clear delimitation of responsabilities in such a safety critical industry like aviation then we unfortunately will continue to see this trend of excessive "criminalization" of conducts after each accident.

Prosecutors and judges will keep forcing the industry to seek clear rules for the delimitation of the responsabilities of all parties involved. I very much doubt that a moratorium on criminal prosecutions would be accepted by those guys.

I think the best solution would be a continuous effort of delimitation of responsabilities through regulation. The directives should be more detailed on the procedures and ON THE RESPONSABILITIES of all the players envolved regarding those procedures.

This would prevent irresponsable criminal lawsuits when a given situation wasn´t foreseen by such very precise and exact regulations.

I will give you an example that relates to the GOL 1907/Legacy collision:

a) Controllers should give exact, standardized and CORRECT (as to altitude, etc) clearances to pilots on departure and ask for confirmation. If there is some change in a previously filed flight plan, then they should make this circumstance explicit;

b) Pilots should ask for confirmation and question non-standardized clearances;

c) Depending on the number of monitored a/cs, parallel situations, etc, a controller should have a maximum time allowed for the delay to order a necessary FL change (when an a/c enters a giver airway, for example) AND NOT KEEP WAITING UNTIL THE TWO A/Cs ARE TOO CLOSE AND CONTACT WITH ONE OF THEM IS LOST AND HE CAN´T ORDER A FL CHANGE TO EITHER AIRCRAFT BECAUSE HE IS NOT SURE ABOUT ONE OF THE ACs FL ANYMORE AS ITS TRANSPONDER IS OFF (AND AS STATED HE CAN´'T CONTACT THIS A/C BY RADIO TO CONFIRM ITS FL THE OLD FASHIONED WAY - excuse me for the capital letters ) ;

d) ATC authorities should provide a minimum infraestructure regarding personnel, hardware and software as well as the organization of ATC itself (don't you ask me to put the details here, but it should be detailed);

e) The a/c crew should have a minimum knowledge of a given aircraft and constantly monitor the warnings given by the a/c system, like those relating to transponder and TCAs activity. This should be extensive detailed for a given a/c model;

f) The a/c crew should be given a set of frequencies (including alternative ones) to use in a given sector and should keep and use it when necessary;

etc.

If the regulations established those specific and detailed procedures and "duties" in the future (if they are pertinent or not is another story) then everything out of such circumstances would be likely to block any criminal procedure.

The problem now is that it seems that the rules aren't clear and detailed enough and, what is even worse, it seems that people out there in the aviation industry are not that concerned with it as they should be. :ugh:

[PBL]

I think the best solution would be a continuous effort of delimitation of responsabilities through regulation. .............
I will give you an example that relates to the GOL 1907/Legacy collision:

Well, I sympathise with your suggestion that a clearer delimitation of responsibilities might help against criminalisation, but in such a project I would worry that the systems science would be overridden by political considerations. For example, in the German legal system there is a clear delimitation of responsibilities: the people at the "pointy end" of the Lathen Maglev accident are being prosecuted, whereas the managers who decided against incorporating service vehicles into the technical protection system are not being prosecuted. But whichever way it goes, someone is still being prosecuted.

Your specific suggestions in the wake of the GOL/Legacy collision suffer, if I may say so, from a significant lack of understanding of how air traffic control operates. This is not the place for me to write a tutorial on ATC, but please bear the following in mind.

* I have been flying IFR for 23 years (although not recently). In this time, I have almost never had a "cleared as filed" pre-take-off clearance, and I cannot recall ever flying the clearance I was given pre-take-off; there are always en-route changes. The idea that a pilot can be given a pre-take-off clearance that will take himher to the destination free of modification is a pipe dream. It is also unnecessary, as the next point shows.

* The system in the U.S. deals with 85,000 movements a day, which amounts to some 25-30 million movements a year. Let's assume that has grown from (I guess) 15 million movements in, say, 1987. That is of the order of 10^9 movements total since 1987, *without a collision between two aircraft flying under IFR*. (There have been collisions between IFR and VFR aircraft, but that is a different matter, since we are talking here about revising the system of clearances). That is an *extremely good safety record* by any standards (O(10^9) is the Holy Grail of highly-reliably-system designers). One simply doesn't propose to change such a system radically, as you are. One proposes to bolster its identified weaknesses.

* Some of the suggestions you make just don't seem to make sense (for example, what is a "correct" clearance? A clearance is an ATC promise to keep a certain block of airspace clear of other controlled aircraft for a certain period of time; what is a "correct" promise? Accepting a clearance is likewise a promise to maintain one's AC in that block during that time). Others are impractical (not only imagining that the system can be managed quasi-statically, but also imagining that pilots can check whether the clearance they get conforms to local ATC procedures, which can be very complicated: that is why controllers are licenced for specific control jobs).

PBL

[GlueBall]

And what to do when your tpx/tcas goes on vacation en route? It's not a situation where you'd be landing at the nearest suitable airport, nor vacate your RVSM airspace without talking to somebody. A "warning" annunciation of a tpx/tcas failure in flight wouldn't have been a cause for the Legacy crew to have changed route or altitude on their own. One option in case of known system failure would be to offset cruise flight level by 150 feet.

[aviadornovato]

For example, in the German legal system there is a clear delimitation of responsibilities: the people at the "pointy end" of the Lathen Maglev accident are being prosecuted, whereas the managers who decided against incorporating service vehicles into the technical protection system are not being prosecuted. But whichever way it goes, someone is still being prosecuted.



Maybe the people at the "pointy end" really didn't do what they had to independently of the management having refused to incorporate service vehicles into the technical protection system.

I believe that in German Law the managers you mentioned COULD have been prosecuted if their conduct clearly showed an injustified disregard for safety. We should ask the german prosecutors why they weren't.

Not all prosecutions are unfair or irresponsible. My point was that prosecutions tend to be broader and many times exaggerated if there isn't a clear delimitation of responsabilities by a given industry.

As for the examples of regulation and clear delimitation of responsabilities, they were just given to show what this clear delimitation of responsabilities would be.

Asking the pilot to ask for a standardized IFR clearance, for instance, just means that he should know whether or not he should try to contact ATC to ask permission to change his FL if he doesn´t get the expected clearance to change FL a considerable time after he enters another airway in which he is expected to change said FL.

Asking the pilot to follow his fight plan and to know what are the FLs he was supposed to fly in each airway would help to prevent accidents. If he is not contacted by ATC, he should at least ask for confirmation of his (supposedly wrong) FL from ATC.

You might say that it could represent an overburden to controllers (answering requests from pilots in such circumstances) but it also could work in the opposite direction as pilots (or crews) would act as a backup to ATC. And increase the likelihood of net being killed themselves

Anyway, the main point is:

If (IF !!) those were the rules, and they weren´t followed, then we have a prosecution. If all the regulations were followed, however, no matter the conduct of pilots or controllers we won´t have a criminal lawsuit.

(P.S.: I am refering to future rules on this matter, not specifically to the GOL/Embraer collision)

[marciovp]

From the NTSB:


Therefore, the Safety Board believes that the FAA should require, for all aircraft required to have TCAS installed and for existing and future system designs,14 that the airborne loss of collision avoidance system functionality, for any reason, provide an enhanced aural and visual warning requiring pilot acknowledgment. This is an important consideration for the development of runway incursion collision avoidance systems, as well. Without aural and visual warning requiring pilot acknowledgement, there would be a loss of runway incursion avoidance system functionality if a system on an individual aircraft were to fail or be inadvertently turned off. Therefore, the Board believes that the FAA should evaluate the feasibility of providing enhanced aural and visual warnings for future systems that may provide ground collision avoidance functionality. If feasible, require that future design criteria include such warning functionality

[ATC Watcher]

Aviatornovato : Your vision on how ATC should be regulated and performed is just that : a vision, a concept, based on 100% safety at all times trying to take into account all possible failures and multiple failures combinations. It is laudable, if applied traffic would be reduced to such an extend that it will not be economically viable.
Safety in Aviation is always a trade off . In ATC, safety is first, but expediting the traffic and providing capacity to cater for the continuous traffic growth is a very close second.
As an EASA ( European Aviation Safety Agency )top official recently said : Safety must not restrain the market "
You have to understand that a pre-departure clearance , past the first altitude, point to be flown to and SSR code becomes more a " wish list" than a contract set in stone.
Arguing a criminal case against pilots or controllers based on incomplete or incorrect pre-departure ATC clearance will be easy to wipe off technically.

On the transponder issue : More an more ANSPs are declaring their airspace SSR only ( Portugal for one ) making a loss of Transponder a real safety issue. I would think that to pass a proper safety cases States relying on SSSR only for their ATC , a proper warning in the cockpit that SSR has failed would be an mandatory item.
I am surprised that after this accident the NTSB only " believes that the FAA should require" i a warning . For me, and there I agree with you, the lesson to this accident should be asking for a modification .
And I am not adding the TCAS issue.

[aviadornovato]

Safety in Aviation is always a trade off . In ATC, safety is first, but expediting the traffic and providing capacity to cater for the continuous traffic growth is a very close second.
As an EASA ( European Aviation Safety Agency )top official recently said : Safety must not restrain the market "
You have to understand that a pre-departure clearance , past the first altitude, point to be flown to and SSR code becomes more a " wish list" than a contract set in stone.
Arguing a criminal case against pilots or controllers based on incomplete or incorrect pre-departure ATC clearance will be easy to wipe off technically.



ATCWatcher,

I proposed adherence to Flight Plans on the grounds that airways should have predefined FLs between waypoints in order to avoid collisions and also predefined rules on FL in case of lost communication. So a clearance that didn´t adhere to a filed flight plan would have to be avoided IMHO.

I will stress that my instance for adherence to flight plans derives mostly from the possibility of a communication loss. If the possibility of a communication loss is considerably reduced then I think that predefined FLs really would not have that importance.

BTW I read some posts in the "TCAs philosophy" thread and I think the main issue was the potential discrepancy between a TCAS RA and a FL change ordered by ATC.

Well, maybe if we had predefined rules regarding FL changes given a certain airway and A/C direction equally applicable to RAs and ATC ordered FL changes then this might (might) not be an issue anymore.

I really don´t know if such changes would increase or reduce the costs of ATC. I am not even 50% certain they would be really helpful but I would like to see some discussion about.

Regarding the NXL600/GOL1907 collision, after reading the data from the Brazilian Chamber of Deputies Commission Report I concluded that the main cause was Brasilia ATC simply "forgetting" the NXL600 flying at the wrong altitude even though THEY HAD ALL DATA to order the appropriate FL change when the aircraft entered the UZ6 airway and before the Legacy´s transponder went off and contact with the A/C was lost.

So the problem wasn´t exactly the wrong clearance given at S. Jose dos Campos.

[barit1]

So the problem wasn´t exactly the wrong clearance given at S. Jose dos Campos.

No, that clearance wasn't wrong at all - it was an initial clearance, pending updates according to later traffic conditions.

[ATC Watcher]

Aviadornovato :
many points in your post above deserving long answers, but due to lack of time , I will only take the first one :
you said : I proposed adherence to Flight Plans on the grounds that airways should have predefined FLs between waypoints in order to avoid collisions and also predefined rules on FL in case of lost communication. So a clearance that didn’t adhere to a filed flight plan would have to be avoided IMHO.
That is a correct assumption if we were talking about Procedural control, i.e not radar control. In a radar control environment the minimum separation criteria is 5NM or 1000 ft. How to achieve this is dynamic, and flexible ( i.e. radar vectoring, anticipating or delaying planned climbs or descents, etc.. ) Therefore in radar control airspace you can ( and many do ) use all the altitudes at your disposition regardless of Flight plan or predefined altitudes on the airways or tracks.
Radar control also imply full 2 way radio telephony capability at all times.
So if we were in a full radar environment the clearances issued by the Brasilia Controllers were not abnormal, nor " wrong ". The problem lies in the fact that , in our case, both radar and VHF communications were lost.
Now, and there it is my own interpretation : As far as I can see, in CINDACTA 1 , for whatever reason ( having to do perhaps with national pride or for hiding the fact that the military are not being able to cover the whole Amazonas ) is providing radar service and separation in deficient areas. We learned that there are large areas declared " radar area" which in fact are areas of poor or no VHF radio coverage and no civil radar coverage.
In those areas , procedural control should have been in place , i.e altitude separation and 10 minutes between aircraft.
Procedural control is totally different from Radar and need different training. We are not sure that the staff in CINDACTA 1 are procedurally trained.

Comm failures :
We have not been able to asses yet which procedure apply in Brazil in case of radio communication failure : the US one or the worldwide ICAO one .

Now about your statement that the system was showing the right Flight level, this is incorrect ,and is part of the main cause of this accident . Nobody willingly “ forgets “ an aircraft or the level at which it is in reality. A combination of technical and human factors led someone to believe that the Legacy was 1000 Ft higher that in was in reality.
Eliminating that from happening again is the issue. Looking for controllers or pilot “errors” will only delay the corrections that will prevent another accident.

One thing is for sure, if the system is not changed, it is only a matter of time until you have another accident.

[songbird29]

Avia wroteI proposed adherence to Flight Plans on the grounds that airways should have predefined FLs between waypoints in order to avoid collisions and also predefined rules on FL in case of lost communication. So a clearance that didn’t adhere to a filed flight plan would have to be avoided IMHO.
ATCwatcher respondedThat is a correct assumption if we were talking about Procedural control, i.e not radar control.

Avia's thinking is not a correct assumption, under no circumstance. An ATC system bases on fixed adherance to the flightplan is always impossible, also in a procedural system. In this context, the only difference between radar and procedural is the time/distance of separation, 5 NM or a number of minutes. Also in a procedural ATC system aircraft may end up being in conflict with each other on the basis of their static flightplans. It is the dynamic system of ATC, be it procedural or radar based, which resolves these conflicts by telling the pilot to climb or descend to another confict-free flightlevel.

In fact, it's the old discussion with people who think in terms of a fixed railway system where trains can be put to a standstill. If it's a mess on the railway tracks, one could eventually stop all trains. Not very nice for the train passengers, very awkward indeed, but nobody will get killed in trains which are not moving anymore. In the air you cannot stop a single aircraft. They need to keep moving, for obvious reasons.

[ATC Watcher]

Songbird :An ATC system bases on fixed adherance to the flightplan is always impossible,
I disagree. Of course you may be right in the absolute , especially if you look at today's Procedural environement , when some procedural airspace ( e.g the NAT) move much more traffic that way than some radar airspace ( e.g Albania ).
But what I understood "aviadornovado" said was not that : I think he refered to FL allocation , and there, this is true , this method can be used to separate conflicting traffic procedurally from one another, both on crossing, and when on dual-directions tracks or aiwrways.

In the 1970,s there were aispace ( e.g Greece , pre-radar times or Siberia if you want some examples among many others) which had some airways restricted to a few FL only (250 280 and 350 for instance,) 15 minutes longitudinal. With a system like this you move 10 a/c an hour but it was sufficient and safe enough in those days. If Brazil has opted for a basic system like this on the Amazonas to compensate their lack of radar coverage, we would not be here today discussing their collision.

But then of course , Brazil would not move that many aircraft around as in the current system .

[songbird29]

I disagree. Of course you may be right

:confused:

No, ATCwatcher, you mix up procedural control with a Flight Level Allocation system, which is not the same.

Procedural control is applied where radar is absent. Under procedural control any level may be used in accordance with the semicircular system. Flightplanning is similar in both radar-based and procedural systems. ATC interventions to provide separation are also similar. Strict adherance to the flightplan during flight is never the case, impossible in fact as I have argued.

A Flight Level Allocation System as a method to strategically separate aircraft may be applied both in procedural as well as in radar control.

Aviadornovado may indeed have thought of FL allocation in his reasoning. FL allocation is indeed a method to strategically separate aircraft, in order to reduce the need and workload for tactical separation by the controller. As far as I've understood (but here I stand for correction since you have followed the Brazilian collision and its aftermath much closer) FLAS was not the case in Brazil.

In the Amazonas it looks indeed like the application of procedural control for those parts of the flights going through non-radar areas. Nothing wrong with that. Any region out of radar range where ADS is not yet applied is controlled in this manner. E.g Northern North Sea until the day of today and indeed south-eastern Europe, not only Greece, in the 70s. In those days the Austrians had to bear the brunt over Villach VOR where for eastbound traffic the longitudonal separation had to be changed from some 10 NM radar to 10 or 15 minutes procedural. The difficulties of this changeover from a radar based area in western Europe to procedural control for traffic to the southeast led to Flight Level allocation in that area, and also to Flow Control which was later organised and improved to present-day Flow Management by the CMFU in Europe.

This brings me to say that "new" ATC-overloaded areas like Brazil and India are in dire need of a Flow Management System to safely cope with their problems.

[Rob21]

In a region where radar coverage is sometimes lost (i.e. Black Holes over the Amazon), it doesn't make sense to have a 2-way airway.
I've seen airway modifications due to pressure from pilots and airlines.

Navigation nowadays is so accurate, why do we need a 2-way airway over the Amazon? One way between virtual waypoints, routes can be paralel...

Just a thought...

[ATC Watcher]

Songbird :
Your English is far better that mine, aso you explain this shorter an better. (I indeed beleived Mr Aviatornovado was refereing to FLAS in his questions)
No disagreement anymore with your reasoning.

From what we have learned in Brazil , it would appear that the semi circular is used as a form of FLAS in the known-to-them non-radar areas, but remember this whole airspace is declared full radar everywhere by the military. So for the outside world , radar procedures apply ( and any non-Brazilian pilot would not be alarmed to keep its last assigned altitude ,even if it contradicted the published semi-circular )
This is for me one of the contributing factors of this collision , among many others of course.

Rob 21 :
Yes indeed , introducing dual tracks in what most of us are doing in busy airspace. Not only safer , but far easier to control the traffic. And today with RNP5 it is dead easy to do so. I would not be surprised if either the CENIPA/NTSB report do not mention this in their recommendations, or if quietly, the Brazilians did not introduce this in the meantime.

[RatherBeFlying]

aviadornovato and others have suggested that flight levels should automatically change if a route segment in the flight planned route changes direction between easterly and westerly tracks from the last route segment.

Doing this would create substantial extra workload for ATC.

Consider an a/c at FL200 that has to change from an even altitude in a westerly segment, say 350 degrees, at waypoint X to an odd altitude in the succeeding easterly segment, say FL210 at 010 degrees.

An opposite direction a/c approaching X at FL200 tracking 190 degrees (westerly) has to change from even to odd altitude, say FL210, when changing track to 170 degrees (easterly).

ATC has to ensure that both a/c are past each other before clearing them to trade flight levels.

ATC also has to ensure that the climb and descent do not conflict with following a/c. There are some casino dealers who can shuffle a deck with great efficiency, but this is not something ATC would want to do.

Workload is far more manageable with a/c remaining at their cleared altitude.

[Richard_Brazil]

Here's an update on the situation of the investigation in Brazil. I'm not a pilot, or a lawyer. I try to pay attention, though.

The aviation investigating commission held a general meeting at the end of November 2007, which should have started the clock on the 60-day comment period. However, in December, the Legacy pilots and the ATC controllers agreed to speak to the investigators. Which put the final report on hold. Col. Rufino, heading the investigation, was in the U.S. in December 2007, but schedule conflicts prevented a meeting with the pilots. Information from the January 17 Folha de S.Paulo.

The criminal trial in the Sinop, Mato Grosso, federal court is awaiting a decision by a superior court on whether that court or a military court has jurisdiction to try the air traffic controllers. Over a year ago the Military Prosecutor-General said on the radio that it's a matter for the common, not the military, courts, so it's hard to see this as a knotty legal question.

In the U.S., over a hundred civil suits have been unified into a single case in the Federal Court in Brooklyn, under judge Brian Cogan. Lawyers had until just about New Years to submit additional documents and arguments on whether the suits should be heard in the U.S., or sent to Brazil. He is to decide the question around the start of April. U.S. courts would award a multiple of what Brazilian courts would, so it's by far the most important question in the suits. The Brazilian lawyer with the second-largest number of clients in the accident says he expects the cases to be heard in the U.S. He admits his fees would be higher if that's the case, so he may be engaged in wishful thinking.

Questions were asked here on the Gol 1907 black box. The last minute or so of the black box were played on Brazil's TV Record on December 9. You can find the clip online on the network's site, although I can't find a way to link directly. The site is http://www.mundorecordnews.com.br/record.jsp . Put your mouse on "TV Record", then "Domingo Espetacular", click, and a menu of clips appears, some forty pages' worth. Currently it's on page 18. The title of the segment is "9/12 Os minutos finais do acidente da Gol", and currently it's on page 18. Easiest is to put "18" in the lower-rightmost field on the screen, click on the arrow, and browse from there. It's nine minutes, 15 seconds.

It is, of course, in Portuguese.

The recording is accompanied by a CGI simulation that's inaccurate to the point of fraud. It shows the airplane reaching the treetops almost intact. Four times. At 3:47, 4:48, 6:49 and at 8:31. The flight recorder stopped at about 7,800 feet, as the plane came apart. The debris was scattered in a 500 meter arc, and bodies, their clothes ripped off by the wind, were found atop the first fragment discovered. The cockpit was intact, though, with the pilots' bodies found inside.

The clip also included commentary by a Brazilian pilot, who after doing instant, and inaccurate, analysis of a series of Brazilian airplane accidents, starred in one in January. You can read about him here: http://sharkeyonbrazil.*************/2008/01/aviation-know-it-all-crashes-his-plane.html

The Brazilian says he has no doubt the American pilots are to blame for the crash. He also says that the Gol pilots lowered the landing gear to slow the plane, although the lever in the cockpit was in the retracted position. And that most of the passengers reached the ground alive, if they had their seatbelts fastened. Despite the fuselage being scattered over half a kilometer of the Amazon forest.

The one I like best though, is where he says the pilots turned the engines off to bring the Boeing to the ground in a glide. While I am not a pilot, that seems to cross the line from the ridiculous to the absurd.

The CPI, or parliamentary commission of inquiry, that looked at the aviation crisis including the Gol crash proposed a bill on the manner in which aviation accidents are investigated. This page http://www.camara.gov.br/internet/sileg/Prop_Detalhe.asp?id=377306 says the bill "Legislates on the System for the Prevention of Aeronautic Accidents (SIPAER), the inviolability of the secrecy of its investigations and other measures."
The progress of the bill can be followed at the address above, but it will probably be like following continental drift.

The bill seems to be heavily influenced by the accident investigation bureau, CENIPA. It attempts, for example, to explain that when an investigation finds something that might have been a factor in the accident, and therefore could be a factor in a future accident, recommendations are made to fix the problem. But that doesn't mean that the factor actually played a role in the accident being investigated.

While the bill attempts to maintain the independence and primacy of aeronautic investigations, it does not take a stand on criminalization. On black box recordings, the accompanying explanation says that the flight recorder would go to Cenipa, and then to the police. The police might have to make their own transcription, despite the additional cost, as a way of insuring the independence of the Cenipa investigation.

From the point of view of pilots, however, the bill says that if you are involved in an aviation accident in Brazil, the black box will go to the police. And, based on experience, it will then be leaked to the press and the public at large.

- Richard

[Richard_Brazil]

I have just looked over the past five months of posts. There are some bits of news from Brazil that are misleading or simply false. Some of them are lies, that is the authors made up "facts" which they assumed posters here would not or could not check.

Things seem currently quiet, so this seems a good time for some clarifications, before things heat up with the eventual release of the Cenipa report. So here goes:
The CENIPA draft report has not been leaked.
While the House CPI preliminary report accused both the Legacy pilots and the controllers, the final report accused only the pilots. That was not a technical but a political decision, according to the official House news agency:The report referee of the Aviation Crisis CPI, congressman Marco Maia (PT-RS), accepted, shortly before approving the report, a suggestion by congressman Miguel Martini (PHS-MG) to remove from the text the typification of the supposed crimes committed by the air traffic controllers. The removal was an agreement among all the congressmen on the commission. The report still carries the names of the five controllers, but without characterizing crimes. Maia explained that the Prosecutors' Office has already concluded the investigation of these controllers, and it was the CPI's political position to not indict them. (http://www2.camara.gov.br/internet/homeagencia/materias.html?pk=111308)
The House CPI preliminary report was 170 pages, in translation, and dealt exclusively with the Gol 1907 tragedy. The final report, 713 pages, dealt also with the TAM Airbus crash and the aviation system in general, and seemed to include the portion related to Gol 1907 largely unchanged. I didn't compare the two reports page by page, but looked at minor errors such as "level" where "limit" was meant, and found them uncorrected, so I've assumed the rest was not revised. Only the conclusions changed, by political decision. The English version of the preliminary report can be found at js.biztravelife.com/preliminary.pdf
Regarding the initial clearance given to the Legacy pilots, it was given and properly confirmed by the pilots as 37,000 feet to Manaus. That's on page 54-55 of the translated report cited above.
The CPI report makes clear that Brazilian controllers had a habit of giving only the first level in the clearance, as was done with Legacy N600XL. The report says on page 38:From everything that has been set out, it may be concluded that the issuance of a message with partial authorization for an aircraft’s flight is a procedure without any grounding in rules and procedures.
In other words, the controllers were following habits, not the rules. Unfamiliar with Brazilian airspace, the Legacy pilots followed the published rules. That's what rules are for, and that's why they're published. So everyone can know what they are, and follow them.

The radio problem is far clearer with a sector map, and alas the sector map in the preliminary report compressed to illegibility. But, let's look at Page 71:Combined with information from Technical Report 1.187/07-INC: the Legacy is leaving ACC-Brasilia Sector 5, and entering ACC-Brasilia Sector 7, receiving instructions from the Sector 5 controller to change radio to frequency 125.05 in the new sector.
Frequency 125.05 is correct for Sector 9, which the Legacy never entered, and which was aft and starboard of it at that moment, and got father aft as it flew. The frequency could be heard for perhaps another 120 nautical miles beyond Brasilia, but the Legacy had passed beyond reach by the time the Sector 7 controller first attempted to call it.
The Legacy continued to hear chatter in Portuguese though, never going more than seven minutes without some radio traffic, but not knowing the language was unaware it was hearing only the air portions of conversations. By great misfortune, just before the collision as the co-pilot was calling Brasilia, he heard a message from Brasilia to him, with exactly the words "in blind" inaudible, and assumed he was being answered. The pilots were not required to make contact until the handoff to Manaus, just about the time of the collision, and had no reason to believe they were out of contact.
Of the non-emergency frequencies listed on the navigation chart for Sector 7, three of four were disabled at the controller's console. Control center tapes captured calls by N600XL to two of the three frequencies, and on the ground soon after the collision the copilot testified he'd tried the third. ATC tried only one frequency to reach N600XL.
The Federal Police investigation of the Gol 1907 accident relies heavily on a translation of the Legacy's voice data recorder. That transcription was leaked to the press on Sunday of Carnaval last year. The Federal Police translation is criminally poor. Even numbers are mistranslated. See page 70 of the preliminary report for three incorrect numbers (The gray background is the PF's Portuguese on the left, with equivalent English to the right; the white background has original English on the right, with an accurate translation on the left.)

Some phrases widely quoted are so incorrect as to suggest bad faith. One of the pilots was quoted on the front page of the leading newspaper as having said after the collision, the Portuguese equivalent of "So what if we hit someone?" In fact what he said was "What if we hit something?"There is a tendency in the Brazilian press to assume that everything is an opinion, that there are two sides to every question, and that if the Federal Police translate 17,000 pounds of fuel as 1,700 pounds of fuel, well that's an official view that has to be respected. That's a load of hooey. 15,300 pounds' worth.

- Richard

[marty1468]

Oi Richard,

Tudo bem?

I have been keeping a keen eye on this topic as i was in Brazil with my wife (who is from Sao Caetano Do Sul) when this crash happened.

I'm a little amazed at the corruption going on but my wife says this is very normal. I guess you have to expect that sort of thing when the military runs your airspace. I dont like the chances of Brazil getting the american pilots back for a trial so i guess that lawyer with the most clients probably wont be getting his huge (expected) fee huh?

Anyway thanks for the update.

Marty

[varigflier]

Marty,

Don't come and fly here. After living in the states for most of my life, all I wanted to do was to come back and fly for the airlines here. 2 years later, I am ready to get out of here and not come back for a long time. The country is great to visit on vacation but living here and flying here sucks. You would not believe the type of captains we fly with here. People who barely know the difference between left and right, yet they think they are GOD because they have the 4 stripes. FOs get no respect here at all. CRM is 0% and ATC.....well I don't think I need to say anything about that. Maintenance is ok, accidents happen because of human error, mostly captain error, as FOs aren't allowed to do much, let alone have an opinion on the flight.
Not too long ago, our chief pilot and another captain high up almost killed everybody in EZE as they almost ran out of fuel and to cover it up, they ripped the pages off the a/c log. These are the same people who demand knowledge and a high degree of technical skills from FOs, yet they can't even manage their fuel burn and hold times. I'll take the worse airline in the states anyday over these idiots.

[marty1468]

WOW! It is really THAT bad huh? Thanks for the tip. I'll show my wife. I love Brazil and the people there but it's probably not the best place to get a job flying. Thanks for the tip Varigflier

[varigflier]

No problem Marty. Unfortunately it is really bad. I wouldn't want people to make the same mistake I made. Had I gone somewhere else, I would've been better off today. For the first time in my life I dread going to my flying job and can't wait to get out of here. Things have gotten worse since the accidents and if people don't do something about it, another one will come, it's just a matter of time.

[DA7X]

Hey Varigflier, I've been flying in Brazil for the last 32 years. I've come up the ranks, from F/E to Captain, your view is a very biased one, there are jerks (Capt and F/O) anywhere you go in this world. As the old saying goes "the grass is always greener on the other side", so my advice to you is go, get out of here fast, :D you are "too good" for us mortal brazilians.

[Richard_Brazil]

On November 11, 2007, the Gol 1907 accident investigation commission issued an official statement on the Legacy transponder. It hasn't been posted here, so here's a link and a translation.

The statement doesn't say what caused the transponder to be disconnected, instead it lists several possibilities that have been discarded.

I am not a pilot, but I did have the opportunity in December to sit in the left-hand pilot's seat of a Legacy. I tried using the footrest, as warned against by the FAA. I couldn't push the fourth button on the RMU that way, and don't see how anyone else could. It's my personal and unprofessional opinion that the accident commission and not the FAA is correct on this, it wasn't the footrest.

- Richard

http://www.fab.mil.br/imprensa/Noticias/2007/11_nov/2611_voo_1907_comissao.htm (http://www.fab.mil.br/imprensa/Noticias/2007/11_nov/2611_voo_1907_comissao.htm)

Flight 1907 – Commission clarifies on transponder

Because of the release of information, on the part of organs of the domestic and international press, on the accidental interruption of transponder transmissions in the case of the Flight 1907 accident, which provoked the non-functioning of the anti-collision system, the Aeronautic Accident Commission of Investigation informs that:

1) Up to now, there are no indications that there occurred an intentional act on the part of the crew of aircraft prefix NX600L in the sense of interrupting the transponder's transmission (STAND BY mode) ;

2) Ergonometic studies, CVR (Cockpit Voice Recorder) data, and reconstructions demonstrate that:

- The interruption of transponder transmissions occurred during a period of silence in the cabin, lasting 1 minute and 43 seconds, while the pilots of aircraft NX600L performed flight planning calculations for the next stage of the trip, with the pilot on the right using a laptop;

- According to the report of the reenactment flight, there is no way that a laptop resting on the lap of the pilot on the right can touch the button on the RMU (Radio Management Unit) control screen twice, in less than 20 seconds, to put the transponder in STAND BY mode;

- There is no way to utilize the footrest during the flight with the seat in the normal piloting position. It would be necessary to move it back. The movements of the seat positions are registered on the CVR and there is no register of movement (cabin noise) during the period in which the transponder ceases operation;

- The footrests have a protection which impedes a shoe sole from directly contacting the panel;

- If this occurs by an action by the pilot on the left, flexing and contorting his right foot, the buttons reached would be the first two, from top to bottom and on the left side of the RMU control panel, which have as their function the changing of the radio frequencies, and not the fourth button, which would permit changing the transponder mode (if it were touched twice in succession, in an interval of less than 20 seconds);

- Only the pilot on the left can, observing the description in the previous item, place his foot on the left side of the RMU);

- On the CVR, there is a commentary by the pilot on the left recommending not putting feet up in the cabin during the flight.

From all the evidence presented, the Commission reiterates that the conclusions aired by some organizations and press organs, domestic and international, on the use of the laptop or of the "footrest" on the flight in question, do not have any technical support in the work of the Aeronautic Accident Commission of Investigation, which is responsible for the procedure aimed at prevention.

Source: Aeronautic Accident Commission of Investigation / CENIPA

[410]

How long has it been since this easily avoidable tragedy? If the primary cause had been something of a technical nature, we would have seen a technical instruction from the manufacturer or the regulator demanding the problem be fixed post haste before the aircraft type concerned was allowed to continue flying.

Yet, despite everyone who flys the line knowing with utter certainty that if even only one of the two aircraft involved in this tragedy had been flying offset, the whole sorry episode would have amounted to nothing more than a filed and forgotten Air Safety Report (if that!!!), almost nothing has been done (granted, NATS are now 'encouraging' pilots to use offset not just for wake avoidance and Chinese ATC are leading the way in sometimes telling aircraft to fly offset), and we contine to fly right down the centreline of airways with ultra accurate navigation equipment.

An outsider - or a litigation lawyer - might ask why in the world we and every regulatory authority worldwide haven't seen the light and made enroute offsetting mandatory everywhere.

[Blip]

Here here 410!! :D

We offset when we drive a car down a country road don't we? Makes perfect sense. Why should it be such a big deal when flying an aeroplane?

All that has to be done is to define an air route with a horizontal dimension, say 1 nm either side of the centreline, and allow aircraft to pick a random fraction of a mile offset right of centreline e.g. 0.2 nm, or 0.7 nm right ( rather than a set distance of 1.0 nm just incase some idiot in the opposite direction enters an offset 1.0 nm left of centreline.)

Here in Australia we have first class ATC but I still prefer to offset just 0.2 nm right of track when flying trans-continental and out of radar coverage for this very reason.

[Wiley]

Blip, what equipment to you fly that allows .1nm offset?

[Blip]

Hello Wiley.

B737 NG

I also wanted to mention that there are serious ATC shortages here in Australia at the moment, to the point where we are being forced to use TIBA procedures for hours at a time during normal business hours in airspace surrounding some of our main cities!

The pressure our poor ATCer's must be working under. I hope the issues can be solved soon!

PS I just noticed the thread started by 410 about making offsets standard procedure and am reading though it now.

[Richard_Brazil]

The cover story in the January 25 issue of Época magazine, the number two Brazilian newsweekly, is titled "WORRY" and claims that nothing has been done to fix the ATC system, citing several incidents.

This cannot be taken at face value. For example in one incident of close approach or near collision (June 12, 2007, 15:30, São Paulo Guarulhos airport, Alitalia Boeing 777 AZA677 and Beechcraft King Air F90 PT LYZ. ) Época has a drawing of the planes separated by only 30 meters of vertical distance, and that's what is says in the text. However, the planes were also 1.2 nautical miles apart. The Air Force said it clarified that. Época says well, the air force confirmed the 30 meters, and it just disregarded the 1.2 nautical miles as being another subject. Right. :ugh:

Two other incidents related are in the same region as the Legacy/Gol 1907 collision. One, on June 3, 2007, at 02:30 (UTC) as Air Canada flight 091 from Guarulhos in São Paulo to Toronto neared Manaus airspace at 32,000 feet, it couldn't make contact with ATC, and began to circle until it could establish communications. However, radar was out and it couldn't be seen by ATC. Momentarily it appeared on the screen, and ATC diverted American Airlines Flight 950 from Guarulhos to JFK and Delta Flight 120 also from Guarulhos to JFK, which were coming close behind at the same altitude.

There's also a reference to radar screens giving incorrect data on flights, again in the Sinop/Cachimbo region where the Gol Boeing went down. That can best been seen in the diagram accompanying the text, available (in Portuguese) here:
http://epoca.globo.com/infograficos/506_aviacao.html

Below, a partial translation of the Época article.

- Richard

Unpublished Air Force documents reveal that the risk of aviation disaster has not diminished

25/01/2008 - 23:18 | Issue no. 506

Cover Story:
WORRY

Unpublished Air Force documents reveal situations with high accident risks in Brazilian air space. Weren't two tragedies enough?

Wálter Nunes with Matheus Leitão
On June 12 of last year, the Presidency of the Republic's Airbus 319, known as Aerolula, took off from Guarulhos International Airport at about 15:30. President Luiz Inácio Lula da Silva had participated in the 7th CUT National Congress of Metal Workers and was returning to Brasilia. Every time the Presidency of the Republic's airplane turns on its motors, air traffic control increases its alertness. The distances between airplanes are increased and the controller begins to treat as a priority the airplane which appears on the control screen with the tag FAB01, the principal plane of the Brazilian Air Force fleet.



On that day it was no different. Aerolula was the center of attention. Until a breakdown in the Guarulhos control room blacked out three of the four consoles, the devices that allow the visualization of aircraft. With only one of them working, the controller responsible for the security of the Presidential aircraft began to monitor another 13 airplanes. At that instant, an Alitalia Boeing 777, call sign AZA677, which was taking from Guarulhos on its way to Italy, was rapidly approaching a private bimotor, call sign PT LYZ. [It seems to be a Beechcraft King Air F90, belonging to Ícaro Taxi Aéreo.] There was a high risk of collision. The air traffic controllers, perceiving the possibility of an accident, altered the trajectory of the Italian plane. But, as the two aircrafts' routes foresaw a curve soon ahead, the alteration determined wound up throwing one plane into the other. Only 30 meters separated the belly of the Alitalia plane from the roof of the bimotor. It seems like a long distance. For airplanes at an average velocity of 550 mph, it's not. The minimum safety margin, determined by international standards, is 300 meters.



The FAB (Brazilian Air Force) internal report classified the incident as serious, with a critical collision risk. The the Air Force internal investigation's conclusion is a synthesis of the problems of Brazilian air traffic control: equipment fails, the controllers work in improper conditions and are overloaded. The controller, with 14 airplanes on the same screen, one of them being Aerolula, erred. And almost caused a tragedy.

It was not the only case of a near accident in recent months. Internal Air Force documents, to which ÉPOCA had access, show hundreds of records of air traffic control failures. They go from breakdowns in equipment and maintenance failures to the existence of locations in Brazilian air space that the radars don't manage to monitor. They are failures similar to those that contributed to the accident with the Gol Boeing in September of 2006. After the collision with the Legacy jet, the Gol airplane crashed, killing 154 people. During the investigations of this tragedy, the country was alerted to the problems of air traffic control personnel and equipment. And began to have doubts about the true safety conditions of Brazilian aviation.

A second large-scale accident reinforced the trauma. On trying to land on a rainy day, in July, a TAM airplane overshot the runway, collided with one of the airline's warehouses and exploded, killing 199 people. Seventeen months after the aviation crisis began, doubts remain. Is traveling by air in Brazil safe? For Air Major-Brigadier Ramon Borges Cardoso, director-general of the Department of Air Space Control (Decea), "In terms of safety, we continue very well." According to him, the country was always safe. It has one of the best controls of air traffic in the world. The opinion is the opposite of that of the Swiss president of the International Federation of Air Traffic Controllers (Ifacta), Marc Baumgartner. "A new aviation accident in Brazil is a question of time", he says.

Some of the documents that the Air Force keeps secret seem to support Baumgartner. There, there are reported cases in which disasters were narrowly averted (see table). There are critical incidents - when one aircraft comes closer than it should to another. There are serious equipment failures, such as a radar that informs incorrect position and velocity for an airplane. And there is a record of a trainee participating in the monitoring of aircraft on his first day on the job.

"The number of incidents in Brazilian air space is similar to Europe, where there are ten times more passengers"

[...]

On this point, it's important to clarify what sort of risk this is. In the two aviation disasters of recent months, 353 people died. Accidents on the country's roads and highways kill 36,000 people a year. Diseases linked to cigarettes, more than 200,000. It is much less dangerous to fly than to drive a car on a street. But, historically, society accepts fewer risks when dealing with flight.

One of the problems indicated by pilots and air traffic controllers is the recurring failure of radars (which allow seeing the flights' location and information) and of the communication frequencies by which airplane and tower stay in verbal contact. Internal Air Force reports show that errors can cause accidents. Such as that involving a Canadian airplane which was flying across Brazil on its way to Toronto, on June 3 of last year. An Air Canada Boeing 767-300 was leaving the region controlled by Cindacta 1, in Brasilia, to enter the area controlled by Cindacta 4, in Manaus. Without managing to make contact the the flight control centers, the Air Canada pilot began to circle in Brasilia air space, but did not appear on the controllers' screens. He was mute and invisible. Two North American aircraft, belonging to American Airlines and Delta Air Lines, flew in the direction of the Canadian airplane at the same altitude, 32,000 feet. Suddenly, the image of the Air Canada plane appeared on the screen of the Brasilia flight controller - and quickly vanished. Unable to contact the Canadian plane, the Brasilia controller detoured the two American planes and avoided a tragedy. In the Danger Report, a document the controller filled out soon after the incident, he affirmed that luck saved everyone from "a large difficulty". But warned: "Luck isn't always on our side".

Publicly, Air Force officers deny that the equipment problems are serious. Internally, the failures are recorded in detail. A report by aviator major Eduardo Yoshiaki Toda is an example. He investigated a breakdown in the information of of the radars that monitor the region between the city of Sinop and the Serra do Cachimbo mountain range, in Mato Grosso. On March 27, 2007, the radars showed mismatched information on the altitude, velocity and direction of flights TAM 3749 and GOL 1641. Until the anticollision alarm went off. The image on the monitor showed that the two aircraft were at the same altitude and position. The accident signal was a false alarm. The controller only knew that the airplanes hadn't crossed and that the information on the screen was wrong, after contacting both pilots by radio. According to aviator major Eduardo Toda's report, the controller was removed from work [NT: it's ambiguous as to temporarily or permanently] after panicking, thinking he had been part of a tragedy involving two large airliners. Toda's document emphasizes the "danger of the psychological factor" resulting from technical problems. If failures such as these are common, flight controllers may start to not believe important information coming from the radar and "one day be surprised by a real accident", said the report. It was in this same region that the Gol Boeing collided with a business jet, killing 154 people. Pilots and controllers dubbed the region "blind spot" or "black hole" because of the constant failures of radio frequencies and radar. The Air Force always denied that there are points in Brazilian air space not covered by radar.
[...]

[Richard_Brazil]

http://www.fab.mil.br/imprensa/Noticias/2008/02_fev/0702_boletim_voo_1907.htm

BULLETIN ON FLIGHT 1907 ACCIDENT - FEB. 7, 2008


Seeking to inform public opinion on the progress of the investigation into the Flight 1907 accident, this Center releases the following information supplied by the Center for the Investigation and Prevention of Aeronautic Accidents (CENIPA):

1) The CENIPA investigation, in accordance with Annex 13 of the Chicago Convention, does not have the purpose of placing blame or leading to criminal or civil responsibility. The investigation has as its sole objective the identification of contributing factors, to issue safety recommendation that can help avoid new aeronautic accidents;


2) In December of last year, the Commission of Investigation was sought out by representatives of the pilots of aircraft prefix N600XL, when the work was in the last stage of producing the final report. In the face of the importance of this testimony, which had not been undertaken previously by the crew's own decision, a meeting was set with Brazilian representatives of CENIPA. It is important to observe that information in this type of investigation is supplied voluntarily;


3) Between the 29th and 31st of January, members of the Commission heard the two pilots, in individual interviews, at the headquarters of the NTSB (National Transportation Safety Board), in Washington, in the United States. Three representatives of that American investigative body participated in the depositions. Until then, the crew of aircraft call sign N600XL had supplied information through the NTSB, responding to questionnaires sent by the Commission;

4) The pilots heard the two hours of audio recording registered on aircraft N600XL's black box (CVR) and responded to a long questionnaire elaborated by the Commission of Investigation on the accident;

5) Accompanied by a lawyer, the pilots affirmed that they did not perform any intentional act to interrupt the functioning of the transponder, and consequently, of the aircraft's anticollision system, as well as also not perceiving or remembering having done something that could have caused the interruption, accidentally, of the cited pieces of equipment;

6) The information supplied is important for the clarification of relevant points in the investigation, by being cross-referenced with other data already found, and for the formulation of possible scenarios which could lead to the non-functioning of the transponder. Evaluations made by the Commission show that the equipment was in usable condition, however was not in operation at the moment of the collision;

7) The Commission of Investigation made a final effort to hear the controllers, but on the advise of the lawyer for the defense, they persist in the position of not participating in any interview with the goal of helping in the work of investigation. This fact is due to fear of the utilization of information from the technical investigation, contrary to what is recommended by Annex 13 of the Chicago Convention, in criminal trials that are underway; and

8) Finally, it should be informed that the investigation is in its final phase and the new information collected will be introduced in the final report.

AIR FORCE CENTER FOR SOCIAL COMMUNICATION

Source: CECOMSAER [Acronym for Air Force Center For Social Communication]

[HarryMann]

I have not read all 70 odd ages diligently, but a hell of a lot of the salient discussion here... may I add a couple of observations?

When ATC knows that 'two Americans' (better still, two strangers) are flying in their airspace, and might even know or suspect that they are 'one-time' visitors... wouldn't it be good manners, as well as good stewardship of airspace, to take a bit more care and diligence over guiding their flight safely through what may be unknown territory? A slightly more watchful eye than a regular national flight for instance.. ?

Ok shoot me... but that's another kind of human factor one would think might be factored into ATC thinking.

Offsetting... I've read the lot. And yes, as a non-pilot (in your terms at least), I'm still gobsmacked that airways haven't long since been segregated laterally and that no aircraft should be on the centreline for long... The implications of increasing traffic and the introduction of GPS systems should surely have been thought through years ago.

I hate to criticise but a lot of the 'What if' thinking I thought was embedded in every aspect of aviation appears to have gone missing.

And for that ATC radar set to revert to 360Z360 , some non-aviation thinking there, that doesn't quite tie up with last known good height

For the sake of all those lost souls, the stubborness of thinking and tendency to not take high account of unusual circumstances and human factors in some areas of aviation, must be shifted aside...

[Brian Abraham]

From Aviation International News today.

Trial Stalled for ExcelAire Pilots
The Brazilian criminal court case against the two U.S. pilots–Joseph Lepore and Jan Paladino–and four air traffic controllers involved in a fatal midair between an ExcelAire Legacy 600 and a Gol Airlines Boeing 737-800 above the Amazon jungle in September 2006 has stalled while a judge decides whether the case will be heard in a military court or a federal criminal court. The conflict about who should hear the case arises from the fact that the air traffic controllers are civilians who function within a military organization. Brazil’s Superior Tribunal of Justice, the highest court for non-constitutional issues, is expected to make that decision next month. Lepore and Paladino, who safely landed their damaged Legacy, face charges under the Brazilian criminal code that they unintentionally endangered an aircraft through negligence by somehow disengaging the transponder. Last month, they spoke to Cenipa investigators for some 20 hours over the course of three days at the NTSB offices in Washington, D.C. Cenipa, Brazil’s aviation accident investigation agency, said inspection of the equipment showed that the transponder was in working order but not operating at the time of the collision. Joel Weiss, the pilots’ lawyer in the U.S., says that they didn’t do anything to turn off the transponder.

[Richard_Brazil]

There are two different issues at the STJ, Brazil's second highest court, holding up the judgment. One is, as described above, the jurisdiction on judging the controllers - civil or military?

The most recent news on that is a week old: http://www.sonoticias.com.br/mostra.php?id=62160 and they say "maybe February 27", which is tomorrow.

While the federal trial judge wrote 8-10 pages on the issue when accepting the indictments (out of a total of maybe 12 pages, if I recall correctly), for a non-lawyer it doesn't seem that complex. The military prosecutor-general said on the radio in December of 2006 that the controllers could be tried in common courts. In a recent newspaper interview, the president of the highest military court described how when both civilian and military criminal codes apply, the military are usually judged in civilian courts. Though he didn't refer specifically to Gol 1907.

The newspapers haven't noted that while the civil court indicted four controllers, the military inquiry brought charges against five. But people go into journalism because they can't count.

Pilots should keep a special eye on that fifth controller, though. If he hadn't been forcibly retired, he'd be working toward his third airliner. Cough.

Another problem there is that the military court sent the indictment back to the military prosecutors, claiming it was "inept". Not an entirely unreasonable contention, as one controller was charged with violating Air Force Regulation something-or-other, said regulation being the Aeronautic Code and three hundred pages long. The charge lacked specificity, to put it mildly.

There's a second issue, which is that the pilots are asking to be allowed to testify in the U.S., as they did for Cenipa. There's a habeas corpus pending on this, also in the STJ. The judge who will write the opinion has just been switched, this news from a day or two ago.

So both these issues may be decided in the next few days. May be. However, a judge in Brooklyn, Brian Cogan, will decide in early April whether or not the civil suits are more appropriately judged in Brazil than in the U.S. That makes a big, big difference in the value of verdicts or settlements, so the lawyers may be trying to keep anything from happening in Brazilian courts until that decision is made.

[CDN_ATC]

I get a kick out of all of this talk of off-setting on airways and how it's going to "save the day"

At least in my airspace it is far more common to have crossing track conflicts than opposite track conflicts, offsetting will never help the vast majority of near-misses.

Lets not forget two airplanes meeting crossing is going to be just as disasterous as opposite direction.

Yes a SLOP would eliminate that specific possibility of occuring on that specific airway, and I agree pilots should implement it, but be advised ATC should be advised if you're doing so.

[barit1]

...far more common to have crossing track conflicts than opposite track conflicts

An argument, I presume, for SVOP as well as SLOP.

[1xxxxx1]

DCN_ATC this is a thread about an accident were more than a hundred people died. And you write; “I get a kick out of all of this talk of off-setting on airways and how it's going to "save the day"

In this case it would have saved the day !

I can recall plenty of collisions that were head on with aircraft on the airway. But very few collisions from crossing traffic, these happen normally in a terminal aria. This is a different problem. Let’s solve one at a time.

Maybe it is against your work ethic that some pilots fly off set to be safer?
A safety that ATC is responsible for and sometimes not provides!

But my understanding is an airway should not be a line with zero margin. Today with GPS and RVSM it is. And how wide is an airway? Not 0NM
Anyhow I fly offset when enroute surely when in a non-radar environment and this without informing ATC. (we all would be very busy calling ATC every time)

And I lobby heavily for all pilots to do the same. I wrote it into our company SOP and train our pilots to do the same.
Finally my passengers and I are safer this way; it does not matter if by 1NM or 2 NM when the opposite traffic is doing the same or not.
You keep watching the crossing traffic but do not worry I will help as we have TCAS now. All this might save your day.

[barit1]

You keep watching the crossing traffic but do not worry I will help as we have TCAS now
Let me remind you that in the present case, TCAS did not (and could not) function. :uhoh:

[Wiley]

I get a kick out of all of this talk of off-setting on airways and how it's going to "save the day"

At least in my airspace it is far more common to have crossing track conflicts than opposite track conflicts, offsetting will never help the vast majority of near-misses.

Lets not forget two airplanes meeting crossing is going to be just as disasterous as opposite direction.CDN ATC, it's not a dick measuring contest, OK? You seem to share the opinion of many ATCOs that somehow, flying offset is an insult to their professionalism. Your comment about crossing traffic conflicts may well be true, but for two aircraft in a crossing conflict to actually collide, they must BOTH reach that point of crossing at exactly the same time - a period of a few seconds, possibly a minute if the tracks cross at an angle that is not acute. An opposite direction conflict, (as in the tragic - and easily avoidable - Brazilian accident), and especially since the advent of ultra accurate GPS, can remain 'in place' - exactly - for many, many hours.

Taking that into account, most people would agree that the opposite direction problem far outweighs the crossing problem.

Unless, (it would appear from your comments), you are an ATCO.

[Tarq57]

Wiley, covered quite well, I thought. Very true. Somewhat analogous to the relative risk of shooting a red light at a quiet intersection, vs driving the wrong way down a quiet motorway, I think. The former may result in an unlucky meeting of metal, the latter almost certainly will.
Except for the last sentence, sorry.
I'm an ATCO, and think a fair bit about separation issues, how to mitigate against/recognize hazards etc. And although it is true that the consequences to myself are rather less dire than to the aircraft occupants, don't for a moment think that any ATCO is less likely to dwell on such matters than a pilot.
FWIW, in NZ we have approved lateral offsets promulgated, for oceanic airspace (not sure about domestic) and IIRC, no advice to ATC is required when doing same, up to a certain distance. I think the maximum is about 2nm.

[Brian Abraham]

In the Australian FIR you may offset up to 1NM right of track when OCA and not in radar controlled airspace. No need to advise ATC.

[Blip]

And why is the same latitude not given across continental Australia when not radar identified. And *&^#@$ it, why not even when you ARE identified when not in the terminal area, say 30 nm from the major airports?? What is the big deal if you are 0.5 nm off the airways centreline.

Would an Aussie ATC'r please explain what the big deal is? If an airways was defined with a lateral area of 1 or 2 nm either side, why can't you simply add that to whatever lateral limits there are with other aircraft diverting from adjacent airways??

What do we have to do to get the ball rolling on changing the status quo?

[barit1]

I'm not sure that this (http://www.guardian.co.uk/world/2008/mar/07/brazil) is pertinent, but it may offer some clues. :confused:

[broadreach]

Barit1

Yes it probably is. From this perspective it sometimes seems that Brazil has more lawyers per capita than any other country, although I know the US wins hands down in that miserable ranking.

On the other hand, even the simplest legal cases here can go on for decades so you might go through several generations of lawyers (as well as claimants) so perhaps young Joao Victor is onto something.

Many private universities are in it only for the money so the bar in this case could well have been lower. I once sat on the examining board of one, judging final-year foreign trade students' oral defenses. Once was enough: I didn't pass a single one.

[Capt Fathom]

Blip:Would an Aussie ATC'r please explain what the big deal is?

You're barking up the wrong tree!
ATC don't make the rules, they just apply them!

I'm sure they would accommodate your half-mile; if you ask nicely...:hmm:

[Brian Abraham]

From Aviation International News today
Legacy Midair Pilots Can Now Testify in U.S.
Joseph Lepore and Jan Paladino–the two U.S. pilots of an ExcelAire Legacy 600 that collided with a Gol Airlines Boeing 737-800 over Brazil’s Amazon jungle in September 2006, killing all 154 aboard the airliner–will now be allowed to testify in a criminal trial from the U.S. A Brazilian federal court judge reversed his previous decision based on new case law from the Federal Supreme Court, which decided that two North American flight attendants, in similar circumstances, would be allowed to testify in their own country. According to Theo Dias, the pilots’ criminal lawyer in Brazil, a U.S. legal body such as a state attorney will be selected to hear the pilots’ evidence, probably in their home state of New York. However, with the need to translate questionnaires and legal documents and decide which court will hear the proceedings, this process is likely to take a while. “It may take three months or more before the pilots can be heard,” said Dias. The two pilots already spoke to Cenipa investigators in January for some 20 hours over the course of three days at the NTSB offices in Washington, D.C.

[aviadornovato]

I'm not sure that this (http://www.guardian.co.uk/world/2008/mar/07/brazil) is pertinent, but it may offer some cluesOh, no, it is not pertinent.

If it were, what to say about the US who put a two year old boy in the Presidency ? :E

[stator vane]

with the mental capacity of a two year old!!!

[Basil]

First time I saw this thread I thought it said "Mid-air collision over Basil"
Got such a fright!

OK just in from pub.
Hat, Coat, Door >>>>>>>>>>>>>>>>>>>>>>

[Brian Abraham]

From Aviation International News today.
Midair Collision Civil Suit Moves to Brazilian Courts
Wrongful-death suits brought on behalf of family members of passengers and crew killed in the 2006 midair involving a Legacy business jet and a Brazilian Gol Airlines Boeing 737 were dismissed last Thursday by New York District Court judge Brian Cogan based on his opinion that the Brazilian courts are a more appropriate venue. Among the defendants are Honeywell, which provided the avionics for the Legacy; the aircraft operator, Long Island-based charter and aircraft management provider ExcelAire; and pilots Joseph Lepore and Jan Paladino, who were in control of the Legacy at the time of the accident. The crash of the Gol airliner following the midair killed all 154 passengers and crew aboard the Boeing. The initial lawsuit on behalf of those whose families died in the crash was filed in November 2006. In making his decision, Cogan observed, “On the whole, this court’s inability to compel testimony or evidence from potentially unwilling witnesses located in Brazil, compared to the Brazilian courts’ likely access to all the evidences, weighs in favor of dismissal.” While the pilots have agreed to provide testimony to Brazilian courts, Brazilian air traffic controllers and other Brazilian entities might choose to provide no evidence at all to a U.S. court, explained Cogan. The decision also took into consideration an agreement by all defendants to consent to the jurisdiction of the Brazilian courts with regard to the civil actions, with certain exceptions. ExcelAire agreed to all conditions except the toll of any applicable statute of limitations. The Legacy pilots agreed to the domestication of any Brazilian judgment against them; they also agreed to appear for videotaped or transcribed depositions taken in the U.S., and to provide evidence in response to interrogatory requests by the Brazilian courts.

[Richard_Brazil]

I have a copy of the judge's decision if anyone needs it.

For the relatives to sue in Brazilian courts, there are three possible statutes of limitations, in the Code of the Air, the Civil Code, and the Consumer Code. The shortest is in the Code of the Air, two years.

The families have an incentive to sue in the Brazilian courts, instead of betting the bank on an appeal of this decision, which will push them beyond the two years. At least one of the leading lawyers expects a flood of work on this before September 29, 2008. (Because I talked to his secretary just after the decision came out, that's how I know.)

The American lawyers have said they plan to appeal. Their incentive is different than that of the relatives: Brazilian courts will award the families lower damages, but based on past experience will enforce no fees for American lawyers. The lawyers have everything to gain by betting on an appeal, and nothing to lose if they miss a Brazilian filing deadline.

I've been told that the National Geographic Channel documentary has been aired. I've also heard that the aeronautic investigation report is done or very close.

Four air traffic controllers are on trial in the federal court in Sinop, Mato Grosso, and five have been indicted in the Military Courts. The fifth controller is the explanation as to what caused the collision, as opposed to what failed to prevent it. The Brazilian press fails to question the discrepancy, though.

- Richard

[ATC Watcher]

Richard, thanks for sharing this with us.Very interesting.

The fifth controller is the explanation as to what caused the collision, as opposed to what failed to prevent it. The Brazilian press fails to question the discrepancy, though.

Could you elaborate a bit more on this point ?

[Richard_Brazil]

Could you elaborate a bit more on this point ?I got a note last year from an air traffic controller who retired with over 30 years' experience. He draws some extraordinary similarities between the September 29, 2006 accident and a September 19, 1886 disaster ( http://www.planecrashinfo.com/1986/1986-46.htm), both with planes on their maiden flights from Embraer to the United States - and both with incorrect instructions given by the very same air traffic controller.

Here's part of his note:
We will examine the occurences:

1) On September 19, 1986 Embraer delivered to the American company Atlanta Southeast Airlines a Brasilia aircraft, registry N219AS. The aircraft took off from São José dos Campos with The United States as its destination with a stop in Manaus and collided with the Serra da Mantiqueira mountains, killing 5 people.

The aircraft with an American crew collided with a mountain range covered by clouds at 700 feet from its crest, maintaining an altitude of 5,000 feet or FL050. The flight was instructed by the controller to climb to FL280 on radius 253 of the São José VOR, however, for unknown motives, remained at 5,000 feet on radial 012.

The final report on the accident detected as a contributing factor, among other, the improper phrases used by the São José TWR controller on instructing the aircraft to climb to level 280 and informing "crossing" FL050 instead of "passing" FL050. When the American pilot read back crossing FL050 the controller responded "roger" (understood) and the pilot stayed at crossing, awaiting a new authorization to climb and collided. That occurrence generated a safety recommendation by CENIPA to take care with English phraseology, but there was no investment made that yielded improvement in the controllers' English.

2) On September 29, 2006 Embraer delivered to the American company ExcelAir a Legacy aircraft registry N600XL. The aircraft took off from São José dos Campos with the United States as its destination with a stop in Manaus and collided in flight with a commercial aircraft of GOL (B737-800) near the beacon TERES at the boundary between FIR Brasilia and Amazônica, killing 154 people.

"Déjà vu!" - 20 years later, coincidentally in the month of September of 2006, the scene is repeated. A new Embraer aircraft was delivered to American pilots, with doubtful technical capacity in the aircraft, badly oriented by DOV, received incomplete clearance from TWR São José, flew over Brasilia, presented communications problems, there was a failure in RADAR communications, stayed at a level that was incorrect, although that determined in the clearance and collided with GOL 1907. The initial investigations turned to the pilot's difficulty in understanding the Brazilian controllers' instructions, not only because of the language, but also because of the different interpretations existing among the FAA, the ICAO standards and the Brazilian terminologies.

The saddest and most decisive evidence of this episode is that "disgracefully" besides the coincidences of situations, the valuable principle of SIPAER (System for the Investigation and Prevention of Aeronautic Accidents) was confirmed , because the controller was the same who participated in the 1986 occurrence.

And that's the fifth controller.

- Richard

[ATC Watcher]

Thanks for your clarification Richard. I have not read the previous crash report you refer to,but from what you tell us, I guess that the phraseology issue was a possible contributing factor, definitively not a cause.

From your description , I believe the departure was a non-radar one and the aircraft was clear to fly a VOR radial. Under those circumstance it is the responsibility of the pilot to avoid terrain, not the controller ( he cannot see where the aircraft is at which altitude) . If , as you described , the pilot leveled off on the wrong radial below minimum altitude, it is not the controller responsibility.
Also the difference between " passing" and " Crossing " a FL cannot be understood as leveling off. There must be more to the story.

Therefore I do not see any link between the 2 accidents , other than they were delivery flights operating by US crews in a unknown environment.

[Richard_Brazil]

The January issue of Vanity Fair will have a 13-page article on the collision.

The article is already up on the web site at William Langewiesche on the Amazon air crash: About Us: vanityfair.com (http://www.vanityfair.com/magazine/2009/01/air_crash200901) The Web article includes black-box audio of both the Gol Boeing and the Legacy 600.

The Legacy recording starts some four minutes before the "BEGINNING OF RECORDING" in the transcriptions that have turned up in court filings. It has some dialog that seems to have been elided from the transcripts. Also, the phrase, "Yes, the TCAS is off", which on a recording leaked to TV seemed to be "Yes, the TCAS in on", seems to just have a very broad New York accent. About 1:26:02.

One question the recording does answer is why the phrase "in blind" wasn't hear in Brasilia's last transmission to the Legacy before the collision. There's a burst of static on the recording then, at 1:20:20. On the Gol's black box, the phrase appears at 26:02, but the pilots are talking over the transmission.

I am not a pilot, and my sound equipment is utterly basic. Someone else can make more sense of this than I.

As to the article itself, its main technical source seems to be Megaron, who is an Indian chief.

- Richard

[grizzled]

Richard,

Thanks so much for your contributions, especially the link to the Vanity Fair article. In the more than 35 years I have spent in the aviation business that is the most accurate, informative, and well-written article I have ever seen in the mass media. Langewiesche has done a masterful job of telling the story in terms that all readers can understand, and he did his research exceedingly well. Most importantly he succeeded in the most difficut task for any writer of non-fiction: humanising a story without using hyperbole, and without glorifying or degrading anyone.

Thanks again for that,
Grizz

[Golf Charlie Charlie]

Langewiesche is indeed good. He wrote a superb piece about the Egyptair 767 flight MS990 some years ago, I think in the Atlantic Monthly magazine.

[Carrier]

Langewiesch is clearly prejudiced against corporate aviation and those connected with it. Just look at the phraseology he uses. The article is a disgraceful example of biased journalism.

[Richard_Brazil]

Today's Brazilian press carries articles claiming the final report on the accident will be released this week, and giving what are purportedly the report's conclusions.

The accident investigation was done by CENIPA, which is part of the Brazilian Air Force. The Air Force released a statement on the accident report this afternoon.

In reading this, keep in mind that the reports in the media say the report concludes the pilots turned off the transponder. There is a small group of relatives of the accident victims who are determined to find some way to blame the American pilots for the crash. These people have repeatedly told lies in the past. They have not "spun" or "shaded" or "given their side", they have repeatedly and consistently made statements that are factually untrue, and known to be untrue.

Below, the complete Air Force statement.


http://www.fab.mil.br/portal/capa/index.php?mostra=2051

06/12/2008 - 13h40
Note: Final Report Flight 1907
In relation to the material published in the press about the FINAL REPORT ON THE FLIGHT 1907 ACCIDENT, the Air Force Center for Social Communication (CECOMSAER) clarified that this document will be presented to the victims' relatives on December 10, 2008, at 13:00, at the Center for the Investigation and Prevention of Aeronautic Accidents, in Brasilia, according to an invitation issued on Friday, yesterday, 5/12. Only after fulfilling this commitment to first inform the relatives, will the content be presented to the press in general.

Additionally, this Center confirms that CENIPA held a meeting with victims' relatives, on August 9, 2008. At that meeting, the relatives saw segments of the reconstruction of the accident, based on the voice and data records of the black boxes of the aircraft involved in the accident. They also received information about the work done up to that point by the Commission, however they were informed that the conclusions will be presented in the final document.

The principal points presented in the meeting with the families, already supplied to the press, were the following:
1) No errors were found in the design or integration of the communications, transponder and TCAS (anti-collision) equipment of aircraft N600XL (the Legacy);

2) Between January 29 and 31, the two American pilots were heard, in individual interviews, at the headquarters of the NTSB (National Transportation Safety Board), in Washington, in the United States. The pilots heard two hours of audio recorded by the black-box (CVR) of aircraft N600XL and answered a long questionnaire elaborated by the Commission of Investigation about the accident;

3) The pilots said that they did not undertake any intentional act to interrupt the functioning of the transponder and, consequently, of the aircraft's anti-collision system, as well as not having noticed or remembered having done anything that could have caused the accidental interruption of the functioning of that equipment;

4) Some rules and procedures were not correctly followed in the occurrence, which led the Commission to analyze the reasons for this having happened, with the objective of elaborating flight safety recommendations. These considerations will be made in the final report;

5) In the accident no indication was found of influence of radar coverage, through inefficiency or deficiency in air traffic control communications and surveillance equipment;

6) Additional information on the technical investigation will be supplied at the end of the work, with the conclusion of the final report. Air Brigadier Antonio Carlos Moretti Bermudez
Head of the AIR FORCE CENTER FOR SOCIAL COMMUNICATION

Source: CECOMSAER

[ATC Watcher]

Thanks for this double information Richard, very interesting.

Carrier : The article is journalism, made for the masses, it is not an accident investigation report. With this in mind I find it rather good, even if there are some innacuracies and perhaps incorrect assumptions, I particularly like the last sentence. The lateral offset debate can go on.

I am curious to see the tone of the CENIPA report next week. However , looking at the Air force statement one can see already the pressures that were applied :
1) Honneywell and Embraer are off the hook .
5) The Brazilian air force wanted all in Brazil to believe that, and they apparently won.

Wait and see for the full report before commenting further.

[Brian Abraham]

From Aviation International News today

Report Blames U.S. Pilots, Controllers for Brazil Midair
According to reports in several Brazilian newspapers, U.S. Legacy 600 pilots Joseph Lepore and Jan Paladino and Brazilian controllers will be blamed for the September 2006 midair in which an ExcelAire-owned Embraer Legacy 600 collided with a Gol Airlines Boeing 737-800 over Brazil’s Amazon jungle, killing all 154 aboard the airliner. A final accident report, leaked to the Brazilian press over the weekend and expected to be officially issued tomorrow at noon by both the NTSB and Brazilian aviation safety agency Cenipa, claims the Legacy’s transponder was “inadvertently turned off by the hand of one of the pilots,” which was the “central point in a chain of errors” leading to the collision between the Legacy and Boeing 737 at FL370. A transponder turned off or set to “standby” mode also places its TCAS into “standby” mode. The controllers will be taken to task for failing to note the drop in transponder returns from the Legacy, miscommunication about the Legacy’s altitude and failure of communication between the crew and ATC. ExcelAire executive vice president David Rimmer said, “The transponder is a distraction from the true cause of the accident: ATC put two airplanes on a collision course for about an hour. It was compounded by multiple catastrophic errors and weaknesses within the ATC system.”

[GroundProxGuy]

Nation & World | Pilots outraged by release of cockpit recordings in crashes | Seattle Times Newspaper (http://seattletimes.nwsource.com/html/nationworld/2008490368_apeupilotscockpitrecording.html)

IFALAP's statement expressing outrage at Vanity Fair for publically releasing full CVR audio of a fatal accident.

I have downloaded both files and listened to the 2+ hours of ExcelAire CVR in its entirety. As someone who works in aviation safety I find it most interesting to hear with my own ears the ATC comms and try for myself to make sense of what they heard.

That said, I agree with IFALPA's position.

[Roadtrip]

Even if the transponder was inadvertently turned off and the aircraft was under radar control, the ground controllers must inform the flight crew who would have recycled the transponder.

Either you are under radar control or you are not. Brazil can't have it both ways.

[ATC Watcher]

Even if the transponder was inadvertently turned off and the aircraft was under radar control, the ground controllers must inform the flight crew who would have recycled the transponder.

Agree, but for this you need all of the following :

a) a controller watching his display all the time
b) an ATC system that indicates clearly that the transponder failed
c) 2 way (VHF) communications

let's wait if the report will answer those basic 3 questions.

[broadreach]

One issue the Gol accident highlighted was the difference between a job and a profession.

With ATC being an essentially military function in Brazil, it’s difficult to know what improvements were put in place. Difficult here, let alone outside Brazil. One thing I’m pretty sure of – and BR aircrew on this forum might confirm or deny – is that substantial changes have occurred and that the airforce didn’t just hunker down and wait for the PR storm to pass but that they quietly lobbied for and got whatever they felt they needed to improve. And I doubt very much that whatever they got was limited to a handful of English lessons.

The overwhelming question, and one I suspect ATC Watcher may already have a notion as to the answer, is whether the corporate ethos has changed in any way.

[Richard_Brazil]

The final report is available online at: http://media.folha.uol.com.br/mundo/2008/12/10/relatorio_voo_1907.pdf

I hear rumours that the NTSB will make an English version available. This is, of course, in Portuguese.

Local news reports show heavy ";spinning&amp" with vocabulary used only by lawyers, and frequent comments from "the families", which are always the same two or three individuals. Always intent on attacking the pilots.

There is some interesting new information. Up to now, only CENIPA knew which RMU turned off the transponder (the left one). Missteps by controllers are more clearly detailed; for example the Legacy was handed off to Brasilia Sector 7 very early, when still well inside Sector 5. The Jeppesen chart had an invalid frequency, 134.70 MHz, not foreseen on Brazilian charts.

The file, a total of 277 pages, includes from page 262 onward, a response by the NTSB, disagreeing with certain conclusions. Some of those are related to the automatic altitude chance function of Brazilian ATC software. An audit of the system by the independent Federal Court of Audit (TCU), in August, agrees with the NTSB. Interestingly, one of the objections made by the Air Force in the TCU report was that the controllers could use the criticism of the function as a legal defense in the Gol 1907 case.

As to the optimism on changes in ATC management expressed by Broadreach, I have seen no reason to share it, but agree with him that the forum would benefit from first-hand reports, instead of what I can offer second-hand.

- Richard

[GroundProxGuy]

fixed link:

http://media.folha.uol.com.br/mundo/2008/12/10/relatorio_voo_1907.pdf

[broadreach]

Richard,

You have been the prime source of news on this thread, for which my thanks and, I'm sure, those of many others.

If I might quibble over your last post, it’s not just optimism although I suppose that does enter. More, perhaps, an awareness that, despite outward appearances to the contrary, things do change here, and I am constantly reminded of that in my own industry, shipping; frequently two steps forward, one back, but the overall direction is still in the desired one.

What I was getting at earlier was, I suppose, whether the airforce has been able to instill a more professional attitude amongst their ATC people. By professional, I mean “this is my vocation” as opposed to “this is my job for the next two years”. Not the easiest of challenges for a hierarchical organisation. If I’m at all optimistic it’s that brains within the airforce and without - politics aside - will be discussing the issue and find a way forward.

[kappa]

Joe Sharkey, who writes for a number of U.S. newspapers, has posted three more blogs (http://joesharkeyat.*************/) commenting on the latest matters.

Edit to say I'm trying to fix the link

Here are three links:

http://joesharkeyat.*************/2008/12/brazil-crash-key-charge-dropped-against.html

http://joesharkeyat.*************/2008/12/more-on-brazil-crash-charges.html

http://joesharkeyat.*************/2008/12/brazil-crash-was-primarily-caused-by.html

If they don't work, try joesharkeyat.*************

[Machaca]

... available from NTSB:
CENIPA Draft Final Report (http://ntsb.gov/Aviation/Brazil-CENIPA/Midair_Collision_Final_Report_1907_%28English_version%29%5B1 %5D_Redacted.pdf)

NTSB Detailed Comments (http://ntsb.gov/Aviation/Brazil-CENIPA/US_Detailed_Comments.pdf)

[ATC Watcher]

Finally got time to go through (most) of the 300 pages .
Nothing really new , basically confirming what was reported before by IFATCA /The Controller magazine in their special issue of the collision in March 2007.

But what I find interesting are some of the safety recommendations (pages 15-19),
which infirm some "official statements" .

Rec 266A06 for instance orders the Brazilian authorities ("shall immediately") to propose off-set procedures in regions which present communications/radar coverage deficiencies .
These deficiencies have been reported by IFATCA but until now fiercely denied by the Brazilian air force.

Similarly :
Rec 267 orders the ATS software to be changed to alert controllers of Mode C loss.
Rec 122 : about lack of 121,5 coverage.
Red 81 about (lack of) proficiency evaluation/training of controllers
Rec 77 about bad staff selection and staff shortages.

All these recommendations ( and some more) point out the real deficiencies of the Brazilian ATC system. Hopefully those recommendations will be followed.
Betters selection and training of controllers in sufficient numbers to operate a better designed ATS system , and correct the VHF coverage “deficiencies” will do a lot to rectify the situation. But , for this the BAF needs to recognize that ATC is a profession and not a military “ specialty” that need proper training and recognition. Recruiting off the street, giving them 3 months training , the grade of corporal or sergeant and pay them 250 USD a month will not contribute to that. If this is nor addressed , they the Brazilian controllers will continue to have another job ( even 2 ) on the side to make ends meet, and leave the ATC job at the first opportunity they get.

On the airborne side, Rec 204 about Pilot training requirements for international operations ,: I find personally this recommendation very pertinent in the general sense, especially in conjunction with the imminent arrival of the VLJs worldwide .

The rec 206 about certification of RMUs and the position of instruments is very relevant to this case. The report main text spends some time on the position of feet rests and crew training on how to use those feet rest whereas the real problem is the design of an RMU that allows to stand by the transponder (and disable TCAS) with a simple touch that can remain unnoticed by the crew.
Honeywell is apparently of the hook legally , but the problem remains in all EB135/145 family and might kill again one day.

Will something change in Brazil after this report ? Maybe our Brazilian friends here can answer that one.

[RatherBeFlying]

Left to themselves engineers can come up with brittle human interfaces.

ATC software that quietly changes cleared flight level is one obvious invitation to disaster that has been well discussed.

Device control is changing wholesale from single function knobs to multi function buttons. We don't know exactly how the xpdr got flipped to standby, but I would not be surprised if a corner of the laptop contacted the button. That a single inadvertent button push can silently put the xpdr into standby is not a design philosophy that allows for human error. Perhaps an audible click would have alerted the crew that a button had been pushed. The other question is whether xpdr mode selection should have remained controlled by a knob.

Displaying TCAS Off in white is reasonable on the ground, but needs to be more attention getting in the air. The message likely would have been caught if either crew had an eye on the PFD when it first displayed, but the report shows that they were busy working the numbers for the landing and subsequent takeoff from the reduced length runway at Manaus.

Same deal for the display of standby in the RMU -- in the air a case could be made for it to be flashing.

Losing TCAS in the air would seem to merit a chime and a line in the EICAS message list. It's worth as much attention as losing a hydraulic system.

[A-3TWENTY]

This brazilian report is a joke. They try in all manners two things:Accuse pilots and controllers

1They say that Brazilian airspace didn`t contribute to the accident, because the lack of communucation in that area is just "sporadib" .Lie,lie,lie.I`ve flown there for many years (I`m brazilian).

2. They spent almost the whole report trying to accuse the pilots and their flight preparation and the fact they turned the xponder off.
1. Pilots could be last one week preparing the flight, but at the moment they are cleared to Fl370 throught out the route..
2.They are in controled airspace so they can`t change a flight level by themselves.

3.TCAS is just a secondary way to avoid midair colisions.The very first one is ATC .

4. If pilots did the flight with just 5 simulation hours,is because law permits that. They are under the law. So guilty here is the guy which did the law.

To me, the first one cause of this accident was brazilian airspace infra structure and controllers( who are poor guys who have to work in dailybasis with poor equipment and very poor working conditions).
Pilots had just a small contribution to the accident when hey turn the xponder off.If they effectively did that.

A-3TWENTY

[Heilhaavir]

How about implementing SLOP in that region too, just like over the North Atlantic and the Chinese RVSM ...

[marciovp]

In Brazil ATC and Cenipa are runned by the military. From the beginning they made sure that the ATC was out of the loop. Finally they are blamming the controllers (not the equipment, the software, etc) and the US pilots. Yes, the controllers did not see what was clear in the screen, the Transponder was off close to one hour! And yes, the US pilots did not notice either that the Transponder went off. Nobody know why. But the software gave wrong information (370) and the transponder off signs are now going to change to produce an alarm when a Transponder goes off. But this will take months. I agree, the ATC abandonned the pilots of the Legacy despite all the signs that they were without a Transponder and heading for a disaster. And, again the ATC is runned by the military,

[broadreach]

A few observations on the report, with a proviso: my knowledge is more of the maritime variety, so I look at the report as if it were a maritime collision case. Sealanes are not centrally controlled but the politics and other aspects are very much alike.

First, the report is not the whitewash many expected. I was happily surprised to note how far Cenipa went in its criticism of the existing ATC system and not at all dismayed at its criticism of the Legacy crew. ATC Watcher and RatherBeFlying go the nub of each aspect.

Re ATC, “being run by the military” is almost immaterial. The issue is whether it’s run professionally for its clients, or as a side issue which ensures revenue or some other advantage for the corporation, e.g. prestige or a bargaining chip in influencing political decisions related to budget allocations. Up to this accident it’s been the latter. The accommodations necessary for this situation to change are, I believe, already well underway, but you don’t change a corporate culture overnight. The process will be slow and the public won’t hear about the final result as it affects ATC until well after it’s happened. An indication of change though, is the recent discussion of airport privatizations and of new defense kit for the airforce.

Regarding the Legacy side, I wonder if one of the biggest holes in the cheese might not have been the very fact that ATC appeared to be working reasonably well in Brazil, its deficiencies being of the type we all work around in our day-to-day business, aviation, maritime or in any other industry. In hindsight, a "Tips, Tricks and Traps" for the Legacy men might have helped but who would have written it, a dozen AA, UA and TAM/Gol crew?

[bubbers44]

Had a situation over Swan Island over the Carribean one day in the clouds at FL350. We reported Swan Island on the hour at 350. One minute later World reported Swan Island at 01 at 350. I asked them to confirm their position report and they confirmed it. I then asked them what direction they were going and they were on a 130 heading. We were on a 180 heading so knew we were clear. A few minutes later the controller cleared them to FL370. No reports were filed but things like that happen a lot down south. TCAS is a wonderful thing down there.

[100BMEP]

Bubbers:
I'm impressed! You too remember it as Swan Island instead of Isle de Cisne!
It is a different world down south. It was not too long ago no one had enroute radar..so everyone would 'report traffic in sight' to get a climb or descent. Time have changed for the better...sort of!

[Blip]

If everyone simply made it a habit of offsetting a fraction of a mile to the right, ESPECIALLY those guided by GPS, no opposite direction aircraft would come close enough to hit each other.

Why does it have to be such a big deal to off-set say 0.2 or 0.3 of a mile (or even 1.2 nm to protect against those aircraft that are not GPS equipped)??. At least then if there is a collision, it is by chance rather than by design!

[ATC Watcher]

AH Blip ! just search this forum with the words " lateral offset" and you will have enough reading material for the whole of the Christmas period !

It is one of these old idea where everyone is for ( IFALPA ATS committee previous 2 chairman had seriously lobbied and tried to have it ) but the idea does not pass the mathematical model .
Without going into too much details, embedded ( i.e. inside the FMS ) offset is the solution, 0.1 NM right of track will be enough , but 1 NM was retained for the mathematical model. Result: offset increases the risk of collision at intersections. Then there was also the notion that voluntary decreasing precision of navigation goes against some other principles, therefore ICAO will not pursue the matter. There are other problems as well.

I see that Brazil says in the report that they will look into the matter, but little chance of getting anywhere I fear, unless they do it alone and file an ICAO difference.

The solution is not offset it is dual one way tracks/airways . This is what was finally done in Europe.( very easy to do with RNP5 and without loss of airspace ).It also increases capacity as all levels can be used if necessary on both sides.