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 (...)”