Mid-air collision over Brasil
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EASA, would you be so kind as to elaborate WITH PROOF that the TCAS was deliberately turned off? Thank you.
The words "is the TCAS on?" were mentioned AFTER the collision, as the bewildered flight crew tried to make sense of what had happened.
I can't believe the Brazilians are blaming the pilots. Clearly this was Brazilian ATC error, and this was proven. We also cannot rule out the fact that some of the victims' relatives seem to be connected to persons of high standings involved in the investigation.
The words "is the TCAS on?" were mentioned AFTER the collision, as the bewildered flight crew tried to make sense of what had happened.
I can't believe the Brazilians are blaming the pilots. Clearly this was Brazilian ATC error, and this was proven. We also cannot rule out the fact that some of the victims' relatives seem to be connected to persons of high standings involved in the investigation.
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What a bunch of face-saving political B.S.
Lets see, a Brazilian made aircraft involved in an accident in Brazil in which Brazilian lives were lost, in which the aircraft - made by a Brazilian company involving thousands of Brazilian jobs - could be found faulty.
Blame the pilots and give them a nice jail sentence - voila, swept under the rug - or blame the faulty aircraft, possibly involving a huge lawsuit against Embraer, airworthiness directives, and God knows what else that could put Embraer at a huge loss.
This is shades of TWA 800 and AA 587 all over again. Can't blame the aircraft manufacturer now, you see, when pilots could always be blamed.
Anyone else see the political B.S. conflict of interest?
Unreal. Those ATC controllers should bear 100% of the blame for absolute INCOMPETENCE.
Never felt safe flying in Brazil ever since then. Sorry but that's just the way it is.
Lets see, a Brazilian made aircraft involved in an accident in Brazil in which Brazilian lives were lost, in which the aircraft - made by a Brazilian company involving thousands of Brazilian jobs - could be found faulty.
Blame the pilots and give them a nice jail sentence - voila, swept under the rug - or blame the faulty aircraft, possibly involving a huge lawsuit against Embraer, airworthiness directives, and God knows what else that could put Embraer at a huge loss.
This is shades of TWA 800 and AA 587 all over again. Can't blame the aircraft manufacturer now, you see, when pilots could always be blamed.
Anyone else see the political B.S. conflict of interest?
Unreal. Those ATC controllers should bear 100% of the blame for absolute INCOMPETENCE.
Never felt safe flying in Brazil ever since then. Sorry but that's just the way it is.
Last edited by aa73; 16th Mar 2013 at 15:08.
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Debatable. And ok, maybe that was over the top as ANY controller can screw up no matter where. So i take back the "not feeling safe in Brazil" part. Lets jus say i feel very strongly about the cover up going on in Brazil over this tragedy. Simply disgusting. All to protect the interests of a powerful aircraft manufacturer (sound familiar?)
Last edited by aa73; 16th Mar 2013 at 17:33.
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JazzHands, I think aa73 was already alluding to the US with his sound familiar comment. I took that as a comment about the current battery situation.
I won't comment on the overall safety of ATC in Brazil, however, the history of this incident is indeed disturbing. From the beginning there was a strong bias towards blaming the American pilots (eg claims of showboating, not maintaining their altitude, which all turned out to be measurement error of the altitude by military radars).
Ultimately, the root cause was controllers clearing two airplanes to the same altitude. There were many contributing factors: poor radar coverage, poor representation of unknown altitude on the controller's display, controllers not being aware of or not noticing that indication, controllers not monitoring the airplane to discover the lack of transponder, transponder being inadvertently switched off, alleged poor cockpit layout that allowed inadvertently disabled the transponder. But none of that would have mattered had the controllers properly separated airplanes. TCAS is meant as a last ditch desparate save, not the primary method of separation.
From my admittedly limited perspective, the investigation seems to have avoided facing the real issues here, the real problems that need to be improved: controller training/competency, and equipment. There seems to have been such a bias towards blaming the foreigners (or somebody other than those in charge of ATC) that they have missed to opportunity to fix these issues. They've missed the primary purpose of aviation incident investigation -- system improvement rather than blame.
I won't comment on the overall safety of ATC in Brazil, however, the history of this incident is indeed disturbing. From the beginning there was a strong bias towards blaming the American pilots (eg claims of showboating, not maintaining their altitude, which all turned out to be measurement error of the altitude by military radars).
Ultimately, the root cause was controllers clearing two airplanes to the same altitude. There were many contributing factors: poor radar coverage, poor representation of unknown altitude on the controller's display, controllers not being aware of or not noticing that indication, controllers not monitoring the airplane to discover the lack of transponder, transponder being inadvertently switched off, alleged poor cockpit layout that allowed inadvertently disabled the transponder. But none of that would have mattered had the controllers properly separated airplanes. TCAS is meant as a last ditch desparate save, not the primary method of separation.
From my admittedly limited perspective, the investigation seems to have avoided facing the real issues here, the real problems that need to be improved: controller training/competency, and equipment. There seems to have been such a bias towards blaming the foreigners (or somebody other than those in charge of ATC) that they have missed to opportunity to fix these issues. They've missed the primary purpose of aviation incident investigation -- system improvement rather than blame.
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Thank you YRP, yes, my comment had to do with aircraft manufacturers and governments pulling out all the stops to ensure the manufacturer never gets blamed. After the DC10 fiasco of the 1970s and the resulting chaos, we have seen a trend in which blame somehow always gets shifted away from the manufacturer. TWA 800, AA587 come to mind. In the 787 case I think there is no way for Boeing to avoid blame. This Brazil tragedy is a classic case of a government protecting its assets at whatever cost.
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For what little my opinion's worth, I'm not sure I see it that way. If anything, I think the fallout from the DC-10 "Gentlemen's Agreement" forced the manufacturers to pull their socks up and get things as right as possible.
If I recall correctly, the outcome of the TWA800 investigation led to a tightening of wiring inspections on older aircraft and a push to find a way of inerting fuel tanks when empty. Where do you see a move to deflect criticism from Boeing? I'm also pretty sure that the NTSB report on AA587 made mention of some of the A300's quirks regarding rudder pedal movement. The fact remains that had those rudder deflections occurred in that manner on any large aircraft with that tail/rudder configuration (e.g. B767), the vertical stab would still have come off. Ultimate Design Load means just that.
Back on-topic, The Brazilian government knows that ATC was a
shoot the way it was being done. Jail sentences were definitely overkill, but even if TCAS was disabled accidentally, it was still a breach of the rules to have it off.
If I recall correctly, the outcome of the TWA800 investigation led to a tightening of wiring inspections on older aircraft and a push to find a way of inerting fuel tanks when empty. Where do you see a move to deflect criticism from Boeing? I'm also pretty sure that the NTSB report on AA587 made mention of some of the A300's quirks regarding rudder pedal movement. The fact remains that had those rudder deflections occurred in that manner on any large aircraft with that tail/rudder configuration (e.g. B767), the vertical stab would still have come off. Ultimate Design Load means just that.
Back on-topic, The Brazilian government knows that ATC was a
shoot the way it was being done. Jail sentences were definitely overkill, but even if TCAS was disabled accidentally, it was still a breach of the rules to have it off.
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The fact remains that had those rudder deflections occurred in that manner on any large aircraft with that tail/rudder configuration (e.g. B767), the vertical stab would still have come off.
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Is this the explanation as to why the transponder of the Legacy dropped offline?
Report: LOT E170 near Varna on Jun 30th 2015, transponder inadvertently off results in near collision with business jet
The Transponder of an Embraer ERJ-170 dropped offline over Europe causing another near collision. The Bulgarian AAIU describes the failure mode of the transponder in detail leading to the transponder dropping into standby mode while in flight ...
Report: LOT E170 near Varna on Jun 30th 2015, transponder inadvertently off results in near collision with business jet
The Transponder of an Embraer ERJ-170 dropped offline over Europe causing another near collision. The Bulgarian AAIU describes the failure mode of the transponder in detail leading to the transponder dropping into standby mode while in flight ...
Pegase Driver
Yes and no . No: There was no reset in the Legacy in Brasil , they just pushed a button on the side of the screen ( presumably by the shoe or by opening the laptop screen of the F/O during cruise) which turn the SSR to SBY, and they did not notice as there is no real warning of this ( just small letters at the bottom of the screen) .
and Yes like now the reset put the SSR on SBY and the crew did not notice.
There has been at least 2 other similar incidents with ERJs : one in France and one in Switzerland,and one also led to a close call.
It is an Honeywell/ Embraer problem , they know it , I naively thought that they had fixed it by now.
and Yes like now the reset put the SSR on SBY and the crew did not notice.
There has been at least 2 other similar incidents with ERJs : one in France and one in Switzerland,and one also led to a close call.
It is an Honeywell/ Embraer problem , they know it , I naively thought that they had fixed it by now.
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Yes and no . No: There was no reset in the Legacy in Brasil , they just pushed a button on the side of the screen ( presumably by the shoe or by opening the laptop screen of the F/O during cruise) which turn the SSR to SBY, and they did not notice as there is no real warning of this ( just small letters at the bottom of the screen)
What strikes me in the new report of Bulgaria now is, that the NIM (Network Interface Module) restart takes 5 seconds while the last transponder operating mode is stored only for 3 seconds, in other words, any NIM restart would drop the transponder into Standby. This result was stated in a SB of Dec 13th 2007 - obviously in response to the accident of GOL-1907 and the Embraer Legacy.
Hence, is it possible, that this service bulletin of 2007, so far unknown here as far as I recall, actually identified why the Legacy's transponder dropped into standby, even without any pilot inadvertent action?
The indications to the crew are another matter of concern indeed, again proven by the near collision over Bulgaria in 2015
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Simon ,indeed , the inadvertent push of the left button that turned the SSR to SBY was never 100% established but was seemed the most obvious at the time . If there had been a NIM restart the investigators would have seen this in the FDR/QAR no ?
Also I think there are more things that go blank during the restart and surely the crew would have registered that , and there would have been evidence in the CVR .
Or the crew was busy with something else and did not notice the restart?
Would be interesting to see what actually a NIM restart does in a simulator .
Also I think there are more things that go blank during the restart and surely the crew would have registered that , and there would have been evidence in the CVR .
Or the crew was busy with something else and did not notice the restart?
Would be interesting to see what actually a NIM restart does in a simulator .
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If there had been a NIM restart the investigators would have seen this in the FDR/QAR no ? [...] Or the crew was busy with something else and did not notice the restart?
In the Black Sea near-midair the LOT pilot who had 3300 hours in type and the co-pilot with 1026 hours in type, didn't notice the message for half an hour, and only switched the transponder back on after ATC told them it was off.
So, it wasn't that inexperienced pilots overlooked the message, the message was easily overlooked, even by the experienced pilots.
It is an Honeywell/ Embraer problem , they know it , I naively thought that they had fixed it by now.
Without rereading through all the stuff back of 2006 and following years I seem to recall, that the cause of why the transponder went into the standby was never fully established, an inadvertent contact by the crew was suspected but not proven (whether inadvertent or not was the major reason of conflict between Brazilian and US investigators).
There were specific units of the avionics that were installed in N600XL after having shown defects when installed earlier in other Legacies on the assembly line.
The original Black Sea report is well worth reading, though it takes some effort. Three parallel time lines are given, but you have to watch for the time stamps jumping back near the top of pp. 9 and again at the top of page 11.
For example, the original flight plan called for LOT7293 to enter Bulgaria at FL350, and an automatic message was sent which routed to Varna East Lower (the lower/upper division is FL355). A eventual, late, transfer from the wrong sector in Romania gave the LOT pilots the frequency of Varna West. Meanwhile, LOT7293 entered Varna East Upper, which didn't get a message, automatic or by radio.
Bulgaria ATC did warn the Falcon of unknown traffic, the Falcon did see LOT7293, but identified its altitude as FL400, so in that sense, the fallback of "look for it" didn't work, either.
How many things can go wrong in series is impressive. And the Romanian ATC operators had from 11 to 30 years of experience.
Bulgarian ATC straightened it out five minutes after LOT7293 entered Bulgarian airspace, but the moment of closest approach was four minutes after entry. If bad luck had put the Falcon and the Embraer in the same place at the same time, it would have been too late. The Legacy and Gol 1907 were on a head-to-head collision course, and there it was a question of when they'd be at the same point at the same time, rather than there being a single critical point where paths crossed, as above the Black Sea.
Pegase Driver
Thanks you Richard for the Brazilian Court case inside info.
For the Bulgarian case , we are all flabergasted to learn that the Modification was apparently not done on this aircraft despite teh history of problems and a collision .
Around the same time as the GOL there was a carbon copy that occurred on an Air France ? Regional Embraer ( cannot recall if it was a 145 or another model) . From memory , it lost its SSR over Italy and disappeared for 20 or 30 min from civil ATC radar displays , it reappeared over France . I could not find the report back on the French BEA site . maybe someone here remembers the date/occurrence and can find the report.
To understand ATC reactions : the problem is when the aircraft cross the boundary to another country with a different ATM system and data base. the correlation in the new system is the SSR code. In absence of it , no label, no visualization, but you can generally still see it on the previous system in the previous country,as the flight plan is tracked . hence no alarm .This is what happened in Brazil also by the way , the flight plan label remained, just a symbol changed, and was not spotted ..
For the Bulgarian case , we are all flabergasted to learn that the Modification was apparently not done on this aircraft despite teh history of problems and a collision .
Around the same time as the GOL there was a carbon copy that occurred on an Air France ? Regional Embraer ( cannot recall if it was a 145 or another model) . From memory , it lost its SSR over Italy and disappeared for 20 or 30 min from civil ATC radar displays , it reappeared over France . I could not find the report back on the French BEA site . maybe someone here remembers the date/occurrence and can find the report.
To understand ATC reactions : the problem is when the aircraft cross the boundary to another country with a different ATM system and data base. the correlation in the new system is the SSR code. In absence of it , no label, no visualization, but you can generally still see it on the previous system in the previous country,as the flight plan is tracked . hence no alarm .This is what happened in Brazil also by the way , the flight plan label remained, just a symbol changed, and was not spotted ..
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Fly Offset
Across vast land masses and oceans without adequate ATC radar coverage, peace of mind suggests tracking .5 or 1 mile right of the airway. It's practical reality. 
