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Blip
22nd Dec 2008, 17:07
offset increases the risk of collision at intersections. Well I'm not in a position to challenge that statement, however I my intuition says that the risk would be for all practical purposes the same.

But OK lets say the risk of collisions at intersections is twice as likely, no lets say it is ten times more likely!, 10 x one in a million is still only one in one hundred thousand, yet by doing this, you reduce the risk of a collision such as the one in Brazil, from almost certainty (one in two) to one in one hundred thousand. (That is to say, two aircraft flying in opposite directions on the same air route, at the same altitude, navigating with the assistance of GPS which is capable of determining position to within a metre or so is going to mean they WILL end up at the same place at the same time, yet if the tracking of one of the aircraft is offset by 0.1 nm (180 metres) they are highly unlikely to collide. Even more so if they both offset (180 metres x 2 equals 360 metres).

I'd say that is a very good trade in risk!!

Of course I just made the numbers up but it illustrates the point I am trying to make.

I think in the end, common sense should prevail.

Redesigning the air routes so that they are all one way traffic may be the answer, but in the mean time while two way air routes still exist, I can think of no better technique to mitigate the current risks.

The simple fact is, if either one of these planes had offset 0.1 nm, this particular thread would not exist!

ATC Watcher
22nd Dec 2008, 19:19
I think in the end, common sense should prevail.

I could not agree more ! I also am of the opnion that 0.1 Nm enbedded right offset would be invisible to ATC and marginal in the mathematical collison risk model .
However I am not a mathematician ans was not a member of the ICAO Working Group that killed off the idea, but the fact is they won the issue.

CMS
23rd Dec 2008, 00:57
Well I've just spent the evening reading the whole report. I have been getting increasingly incensed at the consistent criticism of the American pilots' "airmanship".

They made a mistake; they failed to notice the mistake. ATC, on the other hand should have (a) advised them of the mistake and (b) if not corrected, kept other traffic at least 2,000' away from them.

Yes, the mistake was a contributing factor; yes the poor software was a contributing factor but the clear and single cause was a series of errors by ATC starting with an incomplete clearance, continuing with losing communication and failing to give increased vertical separation and culminating with effectively instructing two planes to fly into one another. Compared with that lack of competence and that criminal negligence, the crew's "lack of airmanship" is minute.

Of course, the really sad thing is that undoubtedly some poor, undertrained controllers will lose their jobs or even their liberty whilst their managers who permitted the atmosphere of negligence to exist go free.

Cliff.

gonebutnotforgotten
23rd Dec 2008, 09:13
I attended a meeting of a Separation Assurance Sub panel meeting earlier this year with the express intention of getting small, micro, offsets back on the agenda. There was no opposition and considerable support, and a State Letter was promised in the near future. Since then things seem to have got stuck, so maybe another visit to Montreal will be needed soon.

The proposal is to permit random offsets of 0.5 NM or less right of track. This also covers the unidirectional airway case where otherwise everyone gets stacked neatly on top of each other, with obvious potential consequences (cf the A330/A340 near miss over the Atlantic in October 2000).

I am still baffled by the difference in the official response to the GOL accident compared to Uberlingen. The latter produced paroxysms of activity, not all of it very relevant; the latter has produced, er, nothing despite the obvious mitigation.

kappa
27th Dec 2008, 18:56
There is controversy in the U.S. over an article in Vanity Fair (http://www.vanityfair.com/magazine/2009/01/air_crash200901) magazine about the Brazil mid-air.

In it you will find a link to the actual audio on the CVR of both the Gol 737 and the ExcelAire Legacy aircraft.

A widely read blog Cranky Flier has posted comments by an airline pilot (http://crankyflier.com/2008/12/18/a-pilots-view-on-the-brazilian-golexcelaire-accident-guest-post/).

There seem to be two points of contention:

1) Should the CVR audio have been released; and
2) Were the actions by the Legacy crew appropriate.

Warning: The VF link is a long read, The audios are long download time MP3 files, the language spoken on Gol audio is Portuguese and the Legacy audio is in English but very long.

aguadalte
27th Dec 2008, 19:43
How about implementing SLOP in that region too, just like over the North Atlantic and the Chinese RVSM ...I fly a lot to Brasil and I must say that my company uses SLOP at all times. As a matter of fact, we use SLOP for all North/South Atlantic and Africa routes.

There is also a procedure I feel would be very important for ATC and pilots awareness: Common phraseology and language. English all times! I know that legislation allows you to speak the country's language and English, but for the sake of Safety, one should only use English as the aviation communication language.

songbird29
29th Dec 2008, 16:22
I am puzzled by a discussion point in the NTSB report on page 8 :

There is no direct discussion of flight path offsets in the report or any discussion about the role that a lack of offset procedures played in the accident. Also, because the word “offset” is capitalized in the report, it would seem to need a definition somewhere.

However, I have not found any mentioning of OFFSET in capitals in the CENIPA report.

Have I overlooked something or am I misinterpreting?

marciovp
7th Jan 2009, 21:25
Translation in a hurry:

Flight 1907: The final report

After more than two years after the crash between the Boeing from GOL and the Legacy from Excelaire, the Cenipa (Center of investigation and prevention of Aviation Accidents) issued a final report of the factors that contribuited to the acciudent that killed 154 persons, in September 2006.According to the document , there were errors from the ATCs in Manaus, Brasilia and Sao Jose dos Campos and from the American pilots Joseph Lepore and Jan Paladino, that were commanding the Legacy of Excelaire. The Cenipa investigations were made in collaboration with the NTSB (National Transportation Safety Board), the American agency that also helped in report, following the recommendations of Oaci (International Organization of Civil |Aviation). But despite the collaboration, the conclusions of the two agencies give different weight to explain the same fact. For example, the NTSB emphasizes that the greater responsibility for the accident belongs to the problems in the structure of the Brazilian ATC, especially in Sao Jose dos Campos that authorized the flight plan for the American pilots. The aAmerican agency makes it relative the fact that the Legacy pilots did not complete the flight plan correctly - the airplane should fly to Brasilia at 370 and then descend to 360 and later climb to 380 and remaining there until Manaus. The pilots kept 370 for the whole flight until the collision. The NTSB also doesn´t mention that the transponder was switched to OFF during the flight even if this was unintentional.

My comment: If Sao Jose gave the pilots the new flight plan why should the follow the old? Makes no sense!

chuks
14th Jan 2009, 05:29
has written a recent article for Vanity Fair about this crash. He's a professional pilot and a professional writer and the article, while written for the layman, is worth a read, I think.

kappa
15th Jan 2009, 03:06
The Vanity Fair article has already been referred to and linked in my post #1476 above.

But there is a very new comment by Joe Sharkey (http://joesharkeyat.*************/2009/01/brazil-mid-air-collision-report.html), one of the pax on the Legacy aircraft.

In it he cites The International Federation of Air Traffic Control Associations (IFATCA), in a statement to be released today, expresses "disappointment" with the lengthy Brazilian report, compiled by an aviation investigations panel called CENIPA, which operates under the aegis of the Brazilian Air Force -- which runs that country's long-troubled commercial air-traffic control system. If you want to read the entire statement, go to IFATCA (http://www.ifatca.org/) and look on the right for 'Position Statement - Brazil - A Missed Opportunity'. Click on it and a PDF file will appear or download.

RatherBeFlying
15th Jan 2009, 04:29
As a programmer of some decades, I am well aware of the tendency of software projects to add features without appropriate consultation with those at the coalface.

What often happens is management gets a bee in its bonnet and puts a feature in the specifications, but Joe Programmer never gets an opportunity to check out how the feature will affect those at the coalface.

Management tells the programmers what they want in the software without bothering to run it by the coalface workers -- asking coalface workers their opinion and acting upon it is something too many managements feel is beneath their station:mad:

Mind you, programmers are quite capable of dropping in a feature without bothering to inform either management or coalface workers:}

aguadalte
15th Jan 2009, 18:32
12 January 2009
POSITION STATEMENT
BRAZIL: A MISSED OPPORTUNITY
The final accident report of the mid-air collision in Brazil involving flight GOL 1907 and
N600XL which occurred on September 29, 2006 at FL 370 was published on 10
December 2008 by the Brazilian aviation accident investigation bureau CENIPA (Centro
de Investigação e Prevenção de Acidentes Aeronáuticos.
IFATCA notes that whereas the inquiries in regards to the events in the cockpit of the
Legacy private jet seem to have received a lot of attention and were done with rather
detailed care by CENIPA, the same cannot be said for investigations on the ATC-side.
The Federation notes with disappointment that the well-evidenced failures and safety
problems of the Brazilian ATC-system, including its contributions to the fatal chain of
events of the accident, have not received the required attention and detailed scrutiny
from CENIPA. This is disappointing as in the aviation community there was hope that
the final accident report would shed a neutral light on the problems and shortcomings of
the Brazilian ATM-system, in particular on these elements that were part of the chain of
events leading to the mid-air collision of 2006.
The final accident report admittedly focuses on some events and problems on the ATCside,
but these items do not lead to clear conclusions. They also do not lead to the
issuance of safety recommendations as a logical consequence. Rather, the "Analysis of
the Surveillance" section, starting on page 253 of the report, ends on page 255 with the
following paragraph:
"The pieces of equipment involved in the scenario of the occurrence did not
present design failures, since they functioned within their specifications on the
day of the accident, removing the possibility of a contribution of the
Communication and Surveillance Systems and Equipment."
IFATCA's Human Factor Specialist, Bert Ruitenberg, co-author with Dr. Anne Isaac of
the book that was cited several times in the final accident report of CENIPA, says
"However the mere fact that equipment 'functions within its specifications' doesn't mean
the specifications were well-designed! In order to identify design failures, the content of
the specifications needs to be looked at - not how a system functions relative to its
specifications"
INTERNATIONAL FEDERATION OF
AIR TRAFFIC CONTROLLERS’ ASSOCIATIONS
1255 University Street, Suite 408, Montreal (Quebec) H3B 3B6 CANADA
Tel: +1 514 866 7040, Fax: +1 514 866 7612, Email: [email protected]
Page 2 of 4
On 24 November 2006, two months after the accident occurred, IFATCA included the
following statements in our press release:
"IFATCA has been very much surprised by what was seen when visiting the
ACC [Area Control Centre] in Brasilia after the accident in early October
2006. The cleared flight level ("nivel autorizado") on the aircraft label, as it
appeared on the radar screen, was not only fed by controllers into the system
(once the clearance was transmitted by radio to the aircraft, and the aircraft
had correctly read back the clearance), but there were occasions when this
was done automatically by the system itself without any direct input from the
controllers. This automatic change did not show prominently on the aircraft
label as it should (both the fonts and the colours of the label remained the
same as before). The "explanation" given by the [Brazilian] authorities was
that this FL was actually the Flight Plan Level of the flight and so it was
"normal" to change it automatically when an aircraft passes over a fix (or
[navigation]-aid) where a change of flight level is requested by the flight plan."
"In many ACCs of the world, this crucial information of the cleared flight level
("nivel autorizado") is fed by the controllers into the system once the
clearance is transmitted by radio to the aircraft (and this has been correctly
repeated by the pilot = read-back). This "feeding of the system" is sometimes
done by hand-writing on paper strips, while other systems work electronically
whereby the input is done directly onto the label of the flight that appears on
the radar screen at the CWP (Controller Working Position). What is very
important, even crucial, is that the ground ATC system and the aircraft cockpit
always dispose of the same information."
"IFATCA believes that operators in the air (the pilots), and on ground (the
controllers), fell victim to unacceptable systems traps brought on by 'non-error
tolerant', and 'bad system design' of air traffic control and flight equipment in
use. We are confident that our statements concerning this equipment are
accurate, and said equipment is responsible for starting the fatal chain of
events of September 29, 2006, and therefore, contributed to the mid-air
collision."
The automatic level changes by the ATC software are mentioned, investigated and
explained to a certain degree in the report, and the CENIPA considerations clearly hint
to several safety issues related to this tool, yet CENIPA does not issue any safety
recommendation for this controversial feature. This is surprising, as it is a known fact
that the United States' National Transportation Safety Board (NTSB) had already in
2006 issued a safety recommendation related to this same system and in particular the
automatic level changes.
In accordance with international standards, the NTSB in 2008 was given the opportunity
to comment on the final report by CENIPA before its publication, and the comment is
included in the report as Appendix 2. The NTSB inter alia states the following:
Page 3 of 4
"[…] the use of the automatic "cleared altitude" field change has the potential
to mislead controllers, is a poor human factors design, and is a clear finding
of risk. In fact, this event was one of the first that is directly tied to the
accident scenario. This feature has the undesirable effect of making the ATC
automation "lead" the actual clearance issued to the flight crew. A basic tenet
of ATC is to have a double check of clearances. The automatic change takes
away a method for the [controller] to reinforce the proper clearance in his
mind. If the controller makes the entry, the action of keying in the numbers
helps to confirm that he has issued the correct altitude and that the pilot has
read back the clearance correctly. Therefore, the automatic change of the
datablock field from "cleared altitude" to "requested altitude" without any
indication to, or action by, the [controllers] led to the misunderstanding by the
sector 7 controller about what altitude clearance was issued to N600XL.
[Conclusion]"
"We recommend modifying the software to make it clear to controllers
whether this field of the datablock is displaying a requested altitude or a
cleared altitude. At the least, a "reminder" feature should be distinguishable
from a display that reflects the actual clearance status of the aircraft. This
feature has been discussed in worldwide ATC publications, and the report
must address the issue completely. A detailed assessment of this feature
should be conducted, and, if the feature is not changed, the assessment
should completely demonstrate why retaining the
feature is desirable. Such an assessment must specifically show training and
procedures that fit with the feature and support correct issuance of clearances
in accordance with ICAO document 4444. [Recommendation]"
These and other statements from the NTSB 2008 comment in the CENIPA report
confirm the statements made by IFATCA in our November 2006 Press Release. What is
more, they say with so many words that "poor human factors design" is applicable to a
key aspect of the ATC system in Brazil, i.e. the display of flight information to controllers
in the data label on their radar screens. "[...] A design in which two distinctly different
pieces of information (that is,
requested altitude and cleared altitude) appear identical on the display is clearly a latent
error", according to the NTSB comment.
IFATCA notes that in late 2008 CENIPA have issued a new Safety Recommendation
that requires the installation of the CLAM-tool (Cleared Level Adherence Monitoring tool)
for all en-route control centres of Brazil. Whilst IFATCA supports the installation of a
CLAM tool, it must be noted that CLAM is a "safety net" to alert controllers of a possible
problem. It is not a solution for the inherent design flaw of the operating system that
allows the displayed level to be changed without knowledge and input from the
controllers.
In conclusion, IFATCA thinks the identified shortcomings in the CENIPA report are a
missed opportunity for the Brazilian aviation authorities to restore trust and safety in the
Page 4 of 4
national aviation system. This final accident report could have served as the starting
point for an extensive and desperately needed healing process, the trigger event to
reorganize and restructure the national ATC-system that received a lot of criticism and of
which the safety is openly questioned. This has unfortunately not occurred, as CENIPA
(an integral part of the same Brazilian Air Force that is responsible for the provision of air
traffic control) has chosen to put the main responsibility for the mid-air collision of 2006
on the frontline operators only. This CENIPA decision appears driven by a reluctance to
expose staff and departments situated in its own organization.
IFATCA has noted with satisfaction the dissenting opinion expressed by the NSTB. The
Federation notes that the NTSB comes to very similar conclusions in regards to the
Brazilian ATC-system, and the points and features that have played a role in the mid-air
collision of September 2006. IFATCA agrees with the NTSB that these problems and
issues still continue to exist, and that they mostly likely will not be addressed and fixed
by the clean-up process initiated by the Brazilian authorities,. Even after the CENIPA
accident report the deeply rooted structural and organizational problems and - issues of
the Brazilian ATM-system continue to exist. Indeed a missed opportunity, yet hopefully
not a lost opportunity: after all, safety improvements can also be made without the
guidance of a CENIPA recommendation!
www.IFATCA (http://www.IFATCA) is the worldwide organization reipfartecas.eonrgt ing more than fifty thousand air traffic
controllers in over 130 countries. Amongst its goals are the promotion of safety,
efficiency and regularity in international air navigation and the protection and
safeguarding of the interests of the air traffic control profession.
International Federation of Air Traffic Controllers' Associations (http://www.ifatca.org)

Richard_Brazil
17th Jan 2009, 01:52
The most comprehensive article in the Brazilian press was by Leila Suwwan, in O Globo. When she was at the Folha de S. Paulo, Leila did a lot of coverage of the aviation sector, and even went to an IFATCA conference in Istambul.

I haven't translated her article, as Joe Sharkey covered the IFATCA statement and everyone here can read the full original. And due to other demands on my time (another American pilot falsely jailed in Brazil was finally released yesterday night, after more than a year in prison.) Here's what the Air Force had to say in response to Leila's article.

RESPONSE TO THE NEWSPAPER O GLOBO, ON JANUARY 15, 2009

In relation to the O GLOBO newspaper article, on January 15, 2008, titled “Controllers criticize Brazilian conclusion on Gol Flight 1907 accident”, the Air Force Center for Social Communication (CECOMSAER) would like to clarify some points that, apparently, passed unnoticed in the journalistic investigation by this distinguished communication vehicle.

The Brazilian air traffic control system does not present a “clear risk” directly linked to that collision (flight 1907). It is worth remembering that the features of the X-4000 software which were at the center of the controversy, have been in use in the country since the 1980s, deriving from the French system that had served Brazil. Air traffic controllers are not only trained to use X-4000, but have also participated directly in the modernization of the software, seeing as they are the product’s end users.

The Federal Court of Audit itself, which evaluated the features of the X-4000 program, clarified in a decision, “there is no way to affirm that the system is unsafe for supplying air traffic control services”. In fact, the Final Report concluded that the air traffic control system in itself was not a contributing factor in the accident’s occurrence.

In parallel, on consulting the Table of Contributing Factors in Civil Aviation Accidents from 1998 to 2007 (source: :: CENIPA - Centro de Investigação e Prevenção de Acidentes Aeronáuticos :: (http://www.cenipa.aer.mil.br) , link PPAA), it can be verified that. of the more than 20 factors that contributed to accidents in the country, air traffic control stands out by being the factor that least appears, with only 0.8% (it is the lowest index!).

It is worth pointing out that in Montreal (Canada), during the 36th Session of the ICAO General Assembly, which was held from September 18-28, 2007, specialists from several countries ratified Brazil in the elite group of countries with the best capacity to administer their air traffic.

As it relates to the Final Report on the GOL accident, it is worth emphasizing further that the main product of the technical investigation is not this document, but rather the safety recommendations (RSVs) it contains. What does this mean? A Flight Safety Recommendation is the establishment of an action or group of actions that could be directed to the public in general, to specific groups of users or to a determined public or private organization, referring to a specific circumstance that demands attention, looking to the elimination or control of a risk condition. In sum, it is the final result of the countless actions that are taken for the prevention of aviation accidents and, in this sense, the principal tool used to improve the level of operational safety.

Among the 60 Flight Safety Recommendations formulated because of this accident, all available in the Final Report, half were addressed to the Department of Air Space Control (DECEA).

Therefore, the Air Force Command understands that the investigation of this accident was opportune for presenting recommendations to the Department of Air Space Control (DECEA), exactly with the view of improving the Brazilian Air Traffic Control System.

Air Brigadier Antonio Carlos Moretti Bermudez
Head of the AIR FORCE CENTER FOR SOCIAL COMMUNICATION

RatherBeFlying
17th Jan 2009, 15:44
Re: RESPONSE TO THE NEWSPAPER O GLOBO, ON JANUARY 15, 2009

Thank you, Air Brigadier Antonio Carlos Moretti Bermudez
Head of the AIR FORCE CENTER FOR SOCIAL COMMUNICATION for this excellent example.

lomapaseo
17th Jan 2009, 15:57
I am having some difficulty in deciphering the weasel words in the Airforce statement. For this I look to others for help

Are they saying that the software is fine and that since there were no direct recommendations by the commision against the use of this software by the controllers that everything is fine on their end?

Richard_Brazil
17th Jan 2009, 22:52
Lomapaseo asked for clarification of the Air Force's statement.

Brigadeir Kersul of Cenipa, Brigadier Bermudez of the press office, and Brigadier Ramon of DECEA, all report to the Air Force High Command. This is a simple statement of fact, and any conclusions you may draw are your own.

The X-4000 ATC software normally shows on the radar screen an aircraft's exact height from the transponder via the secondary radar, an equal sign, and then the cleared altitude. If the transponder or the secondary radar fails, a "feature" of the software switches the number on the left to the altitude given by the primary radar, inexact and not approved for civil air traffic control, and the number on the right is changed to the altitude in the filed flight plan, which may not be the same as the current clearance given by ATC.

That explanation is based on the NTSB report. The NTSB further explains that the software changes not only the source of each number, but its meaning, calling this bad user interface design.

The TCU (Tribunal de Contas da União) is sort of like the U.S. Congressional Budget Office, but specialized in post-mortems. One of its roles is to supply expert advice on technical issues to the government. The TCU report was discussed about halfway through this article: Brazil Midair Marks Second Anniversary with Open Questions: AINonline (http://www.ainonline.com/news/single-news-page/article/brazil-midair-marks-second-anniversary-with-open-questions/) and some aspects of the TCU report might cause some to question what the Air Force's priorities are on this issue.

I am neither a pilot nor an air traffic controller. I am, however, a computer programmer, which gives me a rare chance to emit technical opinions here. I endorse RatherBeFlying's comment, but will speculate in more detail.

My own view is that a programmer, facing the question of what to do when one of his data sources disappeared, came up with the clever idea of using another. He probably repeatedly tested the notion, and confirmed that what his test radar screen showed, matched what his test flight plan database recorded. His idea kept everything in synch.

He forgot that the map is not the territory; that what is important is that where the controller thinks the pilot is, and where the pilot thinks he ought to be, must be the same.

He automatically changed the altitude, skipping the controller's instruction to the pilot. He switched the data souce from one that was accurate to one that wouldn't show that there was a problem: it was neither clearly wrong nor clearly missing, it provided only the illusion of information.

Regarding marciovp's contention that My comment: If Sao Jose gave the pilots the new flight plan why should the follow the old? Makes no sense! my understanding from reading the various reports is that there is a difference between FAA and ICAO in rules for communications failures. Under FAA rules you stay at the last assigned altitude; under ICAO rules you revert to the filed flight plan.

Here again, the programmer may have run a simulation, where automated models of "pilots" always realized immediately that they had lost communications, and where they were correctly programmed with ICAO rules. Pilots, however, are not computers, and loss of communications is not an instant, black-and-white event. That may be obvious to people who work in cockpits, but it is not clear to people who work in cubicles. RatherBeFlying explained about that.

Regarding the Vanity Fair article, there are major errors on critical issues, but I'll confine myself to two trivial examples based on the local knowledge I do have, rather than the aviation knowedge I don't. Langewiesche misspelled the very common Brazilian name "Pereira", which is like getting "Smith" wrong. Second, he takes at face value Indian chief Megaron's contention that Air Force soldiers stole watches and such. I've never met Megaron, but I have neighbors who have (they do anthropological documentaries), and they say the first time they met him, he tried to steal their canoe.

RatherBeFlying
18th Jan 2009, 00:15
Richard_Brazil's scenario is a reasonable programming / system design possibility.

A conscientious programmer or designer will give careful consideration to cases where the data source disappears and, quite naturally, solicit substitutes. The low level guy generally kicks such use cases (quite possibly with a proposed solution) upstairs to the lead designers who will run them by the client.

Note that the Brazilian side reports that the software performs to specification; so, we can be sure that this element of the spec was accepted by the client, the Brazilian Air Force.

That would not be by any means the first time that a stupid specification was accepted by a client - think millions:}

Brian Abraham
11th Feb 2009, 01:46
From Aviation International News today

Brazilian Prosecutors Appeal Dismissed Pilot Charges
Prosecutors in Brazil are appealing the dropping of some accusations in the 2006 midair collision between a Gol Airlines Boeing 737-800 and an ExcelAire Embraer Legacy 600. The airliner crashed into the Amazon forest, killing all 154 aboard, while the business jet made an emergency landing at an Air Force base. Judge Murilo Mendes recently dismissed accusations that the American Legacy pilots, Joe Lepore and Jan Paladino, were negligent in not taking emergency steps for communications loss, ruling that nothing suggested an emergency situation. He also dropped charges against two of the air traffic controllers involved, accepting as normal the fact that they weren’t alarmed by another failure of an ATC system “characterized…by poor functioning, by repeated defects.” The judge’s downgrading of charges against another controller was not appealed, leaving no defendant facing a penalty greater than four years. Additionally, last week the Supreme Court in Brazil ruled that defendants can’t be jailed until all appeals are exhausted, a process that can take more than six years. Even if convicted, there is now little chance any of those accused in the accident will serve time.

punkalouver
19th Feb 2009, 13:03
This is a very long post(actually two posts). But I believe it to be very important to write this.

I have finally completed reading this accident report and was very disappointed. In my opinion, the Brazilian Aeronautical Accident Investigation and Prevention Center(CENIPA) is not impartial and has gone out of their way to put as much blame as possible on the Legacy pilots well beyond what blame should have been apportioned to them.

Over and over they come up with all kinds of nitpicking stuff that is normal everyday airline type activity and used these examples in an unfair attempt to portray the pilots as having poor airmanship. I have many examples but there are more that I have not commented on. I have also posted my own comments on the many examples that make this a very poor accident investigation report.

CENIPA says “The crew was operationally unprepared to fly the equipment.
Such operational unpreparedness refers to the fact that they had not flown together before the trip to Brazil; that they had studied the new aircraft together, but not deeply enough (in detail”)(pg 193) This is because the captain was new on the aircraft and the F/O had been a captain on very similar Regional Jet version but was newly hired and trained on the Legacy version. Yet it is not out of the ordinary for a crew to have never flown together before or both pilots to be new on an aircraft. We see this with the first arrival of new A-380 at various airlines for international flights.

CENIPA states “Considering that the item “Flight Plans” of the “Air Carrier Operations Manual” mentions that it is the responsibility of the PIC the opening and closing of an FPL through the nearest Flight Service Station (FSS) or Aeronautical Information Service (AIS) facility, it can be observed that the PIC did not comply with this determination, as he transferred this responsibility for the FPL to the SIC.” (pg 94) and “…the PIC allowed the crew to separate at one of the crucial moments of the mission: the elaboration of the FPL (including the planning of the flight), and at the conduction of the pre-flight of the airplane, during the phase that preceded the departure.”(pg 94) It would appear the investigators they never heard of delegation before. That is a sign of a good piloting technique and CRM. Delegating the SIC to open or close a flight plan does not mean the PIC is any less responsible for it. A good example in the aviation industry is the PIC normally delegates a walkaround to another crewmember. The fact that they were not together for the “Elaboration of the FPL” is irrelevant as the crew followed all ATC clearances.

CENIPA states “The PIC decided to stay in the cockpit of the N600XL airplane, to continue with the flight preparation phase (pre-flight execution) and data insertion into the FMS, while the SIC was in the Embraer Delivery Management sector dealing with the planning and studying the weight and balance calculation software. By then, the pilots should have inserted the navigation into the FMS of the aircraft together. They were about to start a long duration flight, and for the first time without the assistance of an Embraer pilot (Safety Pilot)”.(pg 94) How many pilots out there have entered a flight plan into the FMS’(s) while the other pilot is busy with other activities? This is normal occurrence. There is nothing to suggest that the route in the FMS was not confirmed before departure. It is just more nitpicking of a real world scenario where some issues have been delegated by the PIC and is extremely unlikely to have had any effect on whether they would have noticed later on that ATC had not cleared them to the filed flight level.

Under reasons for a lack of preparation CENIPA says:
“Even the mentioned delay in delivering the flight plan and other data of the planning on the part of Embraer, alleged by the pilots, does not excuse them from their responsibility to forecast and manage possible delays in the preparation of the flight, especially for being in a place and under circumstances they had never experienced before”.(pg 191) So even the fact that of the late delivery of the “flight plan and data of the planning” from Embraer is now the pilot’s fault. Notice how they say “alleged by the pilots, a term typically used in criminal cases and a term used more than once by CENIPA on the pilots statements including the reason for being in the washroom by the captain.


CENIPA makes the statement of “The crew was OPERATIONALLY UNPREPARED to fly the equipment” on page 193 with reasons given below:

“Such operational unpreparedness refers to the fact that they had not flown together before the trip to Brazil; that they had studied the new aircraft together, but not deeply enough (in detail); and that they were not aware that the repositioning of the new aircraft, which the PIC had never flown before, would not be a routine flight..”

“The coordination of the cockpit preflight procedures contributed to the pilots not acquiring a perfect situational awareness, relative to the flight plan which had been submitted to the airspace control units.”

“They got to the moment of departure with doubts and expectations relative to the functioning of the system of fuel transfer from the extra tanks of the aircraft, a feature that was not present in the simulator used in their training”.

“At the moment of departure, they had not duly evaluated the consequences of the weight and balance on account of the reduction of the runway length available at the destination airport, informed by a NOTAM, something which was highly distracting to them during the flight, in detriment of the monitoring of the aircraft systems with which they were not well familiarized.”

“These factors made the pilots focus their attention on the fuel system, since it was a long distance flight, a considerable part of which over the Amazon rainforest. Consequently, they decided to configure the fuel system on the MFD screens of both sides.” With the exception of the NOTAM oversight, I believe CENIPA is making up excuses to blame the pilots. Never having flown together before is an everyday reality in the aviation industry. The pilots knew their flight plan and flew it as filed and amended by ATC. Concern about the fuel system(which was different from their training) was to be expected. There is nothing to indicate that they did not operate the fuel system properly and it showed good airmanship to be concerned about it.(keep in mind that it suspected that the transponder ceased operation during fuel system inputs of the Radio Management Unit RMU box of the integrated avionics system)

CENIPA goes on about this saying on page 192 “…It is not common for pilots who intend to fly an aircraft with which they are not accustomed, to be trying to solve doubts up to the last moment before departure, to the detriment of the time necessary to study the planning for the conduction of the flight to be initiated.” Actually it is quite common for a flight crew to be trying to solve doubts up to the last moment of departure and seeing as the crew filed and flew their flight plan as cleared by ATC this shows once again blame being put on a crew for an aspect of flight done properly.



Another example of unjustly accusing the pilots of poor airmanship is when the crew passed over the BRS VOR, the aircraft changed heading as it joined a new airway. This is when the aircraft started flying an airway at a wrong way altitude for direction of flight, though it was the altitude they had been cleared to maintain by ATC. Keep in mind that one of the pilots was using a laptop at this time for performance calculations at destination as it was discovered in flight that a NOTAM indicated a runway length reduction. The report notes that there was no verbal mention of the heading change over the VOR and “No dialog between the crewmembers was recorded in the CVR that could indicate that the flight was being monitored by any of them”(pg 80).
And
“As observed from the transcripts of the CVR, during this period of time, when the recordings indicate the use of the laptop, the crew focused on the calculation of the performance, without any conversation or comments that might suggest that the pilot in command was checking the information of the flight instruments at intervals. These circumstances denote a poor situational awareness on the part of the pilots.”(pg102)
On page 209 the report calls this poor airmanship. I would like to ask how many of you out there verbally note whenever a heading change is made by the autopilot while enroute? Since when does a lack of conversation indicate a lack of monitoring or poor situational awareness or airmanship? Assumptions like these destroy the credibility of CENIPA and make me wonder if they had any investigators with piloting experience.

At some point after passing the BRS VOR and flying out of range of ATC, the transponder stopped operating without the pilot’s knowledge. It is mentioned on page 229 about the “conspicuous” STANDBY indications on the aircraft as if it would just jump out at a crewmember if only time was taken to look in that direction. I’m sure it was to the investigators when they knew to look for such an indication. However it ignores the obvious reality that these standby indications won’t be obvious someone when they are unaware that it is there and buried in among a lot of other information. In fact, it took me a significant amount of time to find the TCAS FAIL annunciator in Fig. 31 on page 92 even when specifically looking for it.


The attacks on the pilots in the report become ridiculous when it criticizes a crewmember for not adhering to the standard English phraseology when he said “six souls on board” in response to a question from ATC about the number of persons on board.


Here some more quotes from the report.

“It is not good practice to be involved, while flying, in any type of task that demands too much attention that, otherwise, would be paid to the adequate operation of the aircraft systems or to the navigation being conducted.”(pg199) This is real world stuff. Crew members do actually perform other tasks in flight whether it is consulting an MEL, looking at performance charts and many other tasks including sleeping if approved. There is no evidence that the flight crew was not keeping a general overview on the flight deck during this period. It is just CENIPA using any excuse it can to blame the pilots.

“As was confirmed in an interview given by the pilots a year after the accident, more attention was paid to the lateral navigation than to the vertical navigation (levels). As already commented, this is common in the programming of the FMS for long routes. However, the lack of pre-established procedures on the part of the company for this type of operation contributed to the pilots’ diminished attention to this aspect.”(pg 199)
And
“When one considers the different versions about the moments and preparations prior to the flight, one gets to the conclusion that the pilots did not work methodically enough, did no to prepare themselves for tasks they had to do by themselves, and transferred the responsibility for those tasks to other people. Contributed to this the fact that the operator did not have standard procedures established to cover all the nuances that involved the receipt of a new aircraft, mainly in the case of executive flights, in which the scenarios are varied.” (pg 191). Does CENIPA really believe that an SOP can be written to cover as the report says “all the nuances involved in the receipt of a new aircraft”? How is an operator going to do that with a type not even in their fleet yet? Perhaps by hiring a person experienced on similar type to be a crewmember as Excelaire did with a complete initial course on type including international operations.


Under Organizational influences, it is stated:
“It was also observed that the company had two contracts with training centers for the execution of annual trainings of the CRM, as well as refreshers, and that the training for the operation of the N600XL was provided to the crew by EMBRAER, at the FSI. The difficulties presented by the crew at the pre-flight and at the ferry flight indicate that the mechanisms developed by the company to supervise the efficiency of the training taken up by the pilots were inefficient regarding the prevention of the performance deficiencies shown by the crew of the N600XL.”

“The validation of a training program takes place as the knowledge acquired by the pilots proves sufficient for the execution of all the functions necessary for the accomplishment of the mission, as well as makes it possible to detect any problems with the necessary anticipation for the implementation of corrective actions.”(pg 168)
Does CENIPA really believe that a training provided for an aircraft will prepare pilots for “any problems with the necessary anticipation for the implementation of corrective actions”. Have any pilots out there ever gone onto a new plane with complete and total knowledge of their aircraft and navigation systems and how to properly deal with any and every scenario they faced with “with the necessary anticipation for the implementation of corrective actions” and could have done so on their first flight. This is a ridiculously high expectation of perfection and a complete disregard of the reality that we learn a lot of stuff once we start flying the aircraft.

An example of the efforts by CENIPA over and over to paint the crew as not properly paying attention properly based on nothingness are given here on page 197. “Two minutes later, the ground controller made two calls to the aircraft, which was
taxiing, but there was no reply.”
This leads CENIPA to conclude that
“While they were taxiing, a low situational awareness could be observed on the part of the pilots, possibly due to their paying attention to other tasks in the cockpit, without being attentive to the radiotelephony.” This is something that has nothing to do with the accident, something that happens every day to many flights, and something that fails to take into reality that there is more going on in the flight deck than just listening out to ATC.

Concerning the long period of time that the crew did not talk to ATC before making repeated attempts to do so just prior to the collision leads to this conclusion
“The little concern with the lack of communication, mainly if one considers that it was a flight in a foreign country, denotes a low level of airmanship, professionalism and concern with the situational awareness on the part of the crew. However, it is worth pointing out that the fact that they were under radar surveillance and could hear the radio transmissions between the other aircraft contributed to their unconcern.”(228)
CENIPA says the pilots are unprofessional, lacking in airmanship and have a low situational awareness because of their lack of communication with ATC. In reality, you can see that they admit that they could hear radio transmissions and guess what? They are in Portuguese so it is that much more difficult to realize that you are out of range of ATC when you are in reality, tuning out these foreign language transmissions. How many of us have gone out of range of ATC on a flight? Were you unprofessional because of it? Another unrealistic expectation of perfection. These things happen very frequently.


There are of course many other small pointed remarks attempting to paint the whole mission by the pilots and Exelaire as unprofessional woven throughout the report.

punkalouver
19th Feb 2009, 13:06
Here is the clearance to destination as given by ATC(Eduardo Gomes is the destination airport):
“NOVEMBER SIX ZERO ZERO X-RAY LIMA, ATC CLEARENCE 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 is quite obvious that aside from any other restrictions from ATC that they are cleared to maintain FL370 all the way to destination, yet CENIPA tries to fault the crew saying on page 198 “A clearance delivered in an incomplete manner, and pilots that did not have enough time to analyze the flight plan filed, on account of a lack of proper anticipation of the procedures concerning the preparation for the flight, the N600XL ended up departing with situational awareness incongruent with the plan activated by ACC BS.” In fact they questioned ATC about the initial altitude to maintain and flew exactly as cleared by ATC. CENIPA complains that the pilots are basically incompetent based on every little thing it seems, yet after years of evaluation cannot figure out what the definition of a clearance limit is.

The NTSB has a 14 page report at the end of the Brazilian final report which criticizes CENIPA’s investigation. Among many things, the NTSB critique states the following:
“At numerous points in the report, there is discussion and analysis of the initial ATC clearance issued by São José ground control and the pilot’s understanding of portions of the clearance. Specifically, the terms “clearance limit” and “cleared as filed” appear to be misunderstood. “Clearance limit” is defined in ICAO document 4444 as “the point to which an aircraft is granted an air traffic control clearance” and in the FAA Pilot/Controller Glossary (P/CG, part of FAA Order 7110.65 and the Aeronautical Information Manual) as “the fix, point, or location to which an aircraft is cleared when issued an air traffic clearance.” However, numerous times this phrase is associated with the altitude portions of a clearance. The report correctly notes that the initial clearance issued to N600XL before departure from São José dos Campos did not follow the correct format for an initial clearance. However, we believe that the ground controller’s statement “clearance to Eduardo Gomes,” could not realistically be interpreted as anything other than the “clearance limit” item of the clearance. Furthermore, numerous statements in the report imply that issuance of a clearance limit, whether for the intended destination or an intermediate navigational fix, correlates with the assigned altitude. Section 4.5.7.1 of ICAO document 4444 describes the relevant application of a clearance limit, which in no way affects the assigned altitude of the airplane. The report cites section 11.4.2.5.1 of ICAO document 4444, which reads as follows:

Clearances shall contain the following in the order listed:
(a) aircraft identification;
(b) clearance limit;
(c) route of flight;
(d) level(s) of flight for the entire route or part thereof and changes of
levels if required;
Note. If the clearance for the levels covers only part of the route, it is important for the air traffic control unit to specify a point to which the part of the clearance regarding levels applies whenever necessary to ensure compliance with 3.6.5.2.2 a) of Annex 2.
(e) any necessary instructions or information on other matters such as SSR
transponder operation, approach or departure maneuvers, communications
and the time of expiry of the clearance.

This section is quite clear that the note referring to en route level changes applies to the “altitude” (levels) portion of the clearance. A common application of this procedure would be the issuance of a crossing restriction, as in the example in ICAO 4444 11.4.2.5.2.2b. Therefore, we submit that, although the initial departure clearance was incomplete and in a nonstandard format, the issuance of a clearance limit did not contribute to any misunderstanding. It is possible that, if the initial departure clearance had been stated as discussed above, it may have served as a reminder to the flight crew; however, any intervening altitude assignment by the en route controllers would be in force unless amended.
These instances include, but are not limited to, pages 39, 40, 54, 97, 197, 198, 201, 217, 250, 252, and 256.”

ON page 253 the CENIPA says “When the pilots noticed that they were having difficulties contacting the control units, they did not either attempt any calls on HF frequencies or follow the international rule concerning the use of the code 7600 in case of communications failure” Since when is being out of range of ATC a com failure justifying a squawk of 7600? How many pilot’s reading this have squawked 7600 as they were using their properly operating radios to find a new ATC frequency? In fact they even did receive a transmission from ATC shortly before the collision. Their comms did not fail.

No doubt CENIPA looked desperately for any regulatory infraction that the pilots may have made. Yet all they could find was that when the captain went to the washroom, the copilot did not have his oxygen mask on. A complete non-issue in this accident and something that is done all the time. Yet the Gol pilots get no criticism and are treated as shining stars. But oddly, hidden away in the final report recommendations on page 18 is this statement directed at Gol Airlines: “To reevaluate the SOP, “General Index of Chapters” / 1- General Procedures / 1.8 – Conversation in the Cockpit (Sterile Cockpit), and set up a protocol for cell phone utilization by crew members, when they are in the command cockpit of the aircraft.” If the Excelaire pilots had done the same as this recommendation hints happened in the Gol cockpit, it would have been just another example seized upon by CENIPA as incompetent.

As well, important issues have not been covered properly if at all:

One of these issues is the ATC radar display format played a significant role in misleading the controllers as to the actual altitude of the Legacy aircraft. There are no recommendations on changes to this. Fortunately the NTSB recognized this obvious danger and recommended changes.


Another is the fact that the report is unable to fully investigate or publish all the available information available because as is repeatedly stated, many involved parties refused to cooperate with the investigation. “On account of the legal processes in progress in Brazil, the Excelaire attorneys instructed all the company’s employees(which would include the pilots) to not give any interviews directly to the Brazilian investigation commission, and only give clarifications to the NTSB, which would then pass the interviews to the CIAA”(pg 78).
and
“The company that trained the Legacy pilots, Flight Safety International refused to receive the visit of the CIAA at the unit of Houston-Texas and brought considerable difficulties for the investigation of the instruction given to the pilots in the simulator”(pg 262).
and
“The fact that the controllers of Brasilia ACC involved in the accident refused to take part in the interviews hindered the precise identification of the individual aspects which contributed to the occurrence of active failures (attention, memory, motivation, expectations, attitude, knowledge, etc.). As a result, those aspects remain in the field of hypotheses”(pg 171).

And most importantly

“The authorities responsible for the judicial processes aiming at the verification of the criminal liabilities requested all the material gathered by this commission until then, when two months had elapsed after the accident. For this reason, the attorneys representing the controllers instructed their clients not to give any declarations, even after it was exhaustively explained that the purpose was to prevent the occurrence of further accidents”(pg 240).

Yet despite all this hinderance to the investigation, an obvious safety hazard, there are no recommendations to the Brazilian government to not criminalize aircraft accidents.

This whole criminalization procedure brings us to an issue central to the investigation. The non-operation of the transponder. The transponder stopped operating over 50 minutes before the collision probably due to being inadvertently disabled. Less than three minutes after the collision there is discussion about the TCAS. While nothing is specifically said about doing something to turn on the transponder, tests on the equipment revealed no faults so it would seem that the transponder was accidentally shut off and then turned back on after the collision. This unintentional error by the crew would be a contributing factor to the accident.

Yet the pilots denied having reactivated the transponder. Why would they do this when aside from the astronomical odds of the transponder having done all this by itself, it seems to be the only logical explanation?

This is why:

After the accident there was a public outcry to put the pilots in jail along with many false accusations based on limited information. They were accused of intentionally turning off the transponder and flying at different altitudes. The pilot’s claimed that they were at the altitude cleared by ATC(now a known fact). Yet Brazil’s Defense Minister called that “ a frivolous statement ... It was irresponsible” and in the same interview denied ATC responsibility. Given the above statement in the report of “The authorities responsible for the judicial processes aiming at the verification of the criminal liabilities requested all the material gathered by this commission until then, when two months had elapsed after the accident.”, who is going to tell the honest truth about an error made, especially when you look at page 266 and see two signatures authorizing the final report. They are the Chief of General staff of Aeronautics and the Chief of CENIPA. Both are Brigadier Generals. The Air Force run accident investigation board was investigating an accident with the Air Force run ATC involving a highly emotional event in Brazil. And all the statements are being taken for the judicial process where the pilots are facing many years in jail.

My opinion is that in the end, the military knew they couldn’t escape criticism of obvious ATC fault but made sure that as much blame as possible was put on the pilots in an attempt to escape much of the blame.

I highly recommend that anyone reading about this accident confine themselves to the NTSB section of the report. Here are some highlights.

“we believe that the ground controller’s statement “clearance to Eduardo Gomes,” could not realistically be interpreted as anything other than the “clearance limit” item of the clearance.”


“Hemispherical altitudes such as those shown on the index of an IFR chart or in the Aeronautical Information Manual, although used as conventions by ATC, are only a requirement when operating in uncontrolled airspace. The implication that a crew should somehow observe hemispherical altitudes while being positively controlled by an ATC facility is incorrect.”


“We do not agree that the analysis is sufficient to support any deficiency in the conduct of the flight, which can be related to planning. The crew flew the route precisely as cleared and complied with all ATC instructions. The crew’s awareness of their current altitude and its relation to the hemispheric convention applicable to the course of flight north of Brasilia is entirely independent of the requested level in the flight plan. The implication that a crew should somehow observe hemispherical altitudes while being positively controlled by an ATC facility is incorrect”.

“ATC did not issue an amended clearance; therefore, the crew had no reason to
change altitudes and could not unilaterally do so.”

“N600XL proceeded for an inordinately long time without two-way communication”

“they did have a long term opportunity to note a nonstandard situation and request clarification or confirmation from ATC”.

“Contributing to this accident was the undetected loss of functionality of the airborne collision avoidance system technology as a result of the inadvertent inactivation of the transponder on board N600XL”.

”Further contributing to the accident was inadequate communication between ATC and the N600XL flight crew.”

punkalouver
30th Mar 2009, 20:53
I found it quite interesting to discover the parallels between the Brazilian midair and another midair between large jets back in 1993 detailed below.

German Air Force TU-154 and USAF C-141 on Sep 13, 1997:

Synopsis: The mission was returning from a UN support mission to Namibia . Shortly after level off, the aircraft collided with a German Air Force Tu-154. The nine crew members aboard the C-141 and 24 crew and passengers aboard the Tu-154 were killed.

The C-141 had flown from Ascension Island to deliver UN humanitarian supplies to Windhoek Namibia , in southwestern Africa . They were scheduled to return that evening.

The German Air Force Tu-154 had departed Cologne for Capetown South Africa, with stops in Niamey Niger and Windhoek Namibia . The Tu-154 crew had filed a flight plan, in Niamey , requesting an initial cruise altitude of FL350 with a subsequent enroute climb to FL390. They received a small reroute while transiting the airspace of Gabon . The crew never requested the enroute climb and remained at FL350 for the duration of the flight. Passing western Africa , the course of the Tu-154 changed from westerly to easterly, requiring a change in flight level to comply with international air traffic control procedures. Neither the Tu-154 aircrew nor African air traffic control agencies requested a change in altitude.

The C-141 crew departed on the return leg for Ascension Island at 1611 local time (1411 GMT). Shortly after level off, at FL350, the C-141 collided with the Tu-154, approximately 80NM off the coast of Namibia . Cockpit voice recordings, from the Tu-154, indicated that someone in the German airplane spotted the Starlifter just moments before the collision, but not in time to maneuver away. The Tu-154 struck the C-141 in the lower fuselage.

A French Air Force aircraft, in the vicinity, heard a single "mayday" distress call. A US reconnaissance satellite reported a bright flash at position 18.8° South, 11.3° East at 1510 GMT, approximately one hour after the C-141 departed.

At 1600 GMT (2 hours after the scheduled takeoff), when they did not receive a departure message for the C-141, ATC personnel at Ascension attempted to verify the aircraft’s departure. For the next 15 hours they made 50 phone calls attempting to contact Namibian authorities. At 1055 GMT, they finally notified AMC TACC that the aircraft was overdue. AMC declared the aircraft missing at 1100 GMT, nearly 20 hours after the collision.

The Namibian Air Traffic Control Agency reported that they were controlling the C-141. They also claimed that they had not received a flight plan for the German aircraft. They were unaware that it was in their airspace. The German aircraft had just entered the Namibian FIR but had not yet made radio contact with the Namibian ATC, at the time of the collision. Investigation revealed that the Aeronautical Fixed Telecommunications Network (AFTN) was inoperative. Luanda ( Angola ) ATC had not contacted Windhoek , as required by ICAO procedures. The South Africa Air Line Pilots Association had labeled the Angolan airspace as "critically deficient". SAALPA had recorded 77 near-midair collisions over Africa , in 1996.

Reports indicate that at the time of the mishap weather conditions were VMC. The sun was low in the northwestern horizon (within 30 degrees of the horizon) and, within 30 degrees of the C-141 flight path, making visual clearing for traffic difficult. Local sunset occurred approximately one hour after the Starlifter’s departure from Windhoek . Neither the C-141 nor the TU-154 was equipped with TCAS (Traffic Collision Alert System). At a press conference on September 16, Brig. Gen. Duncan McNabb was questioned on why only VIP aircraft of the 89th AS were equipped with TCAS; he replied that Air Force pilots are trained "to always be looking outside". The Air Force subsequently equipped a small number of C-141s with TCAS.

Also: ASN Aircraft accident Lockheed C-141B Starlifter 65-9405 Namibia (http://aviation-safety.net/database/record.php?id=19970913-1)

ATC Watcher
30th Mar 2009, 21:50
punkalouver : Caution . It is a bit more complicated than what this short report says . The way the Flight planning of the Tu154, was done, the single plan with 2 legs ( non ICAO standard) and the subsequent non-rerouting of the 2nd leg of the PLN by Niamey due faulty AFTN were critical to the accident. They also apparently ( suggested in the German AF verbal briefing in March 1998) decided , because they could not contact Luanda, to change their route to avoid Angola airspace , and go over the sea to re-join Windhoek. Luanda and Windhoek did not had their Flight Plan.
Flying (way) off route, at the wrong altitude not talking to anyone and expecting to see and avoid at 450 Kts was streching the odds a bit too far.
Totally different from the Gol/legacy collision.

punkalouver
31st Mar 2009, 02:52
I'm sure there were significant differences. It just seemed in many ways to be similar. Have never seen a report on the accident.

ATC Watcher
31st Mar 2009, 07:24
The written report was never made public ( to my knowledge at least , but it is over 10 years now, if someone knows of it I would be for one very interested to read it )
Both aircraft were military, so the investigation do not fall under ICAO , and Annex 13 recommendations do not apply here .
There only was a joint satement by USAF and GAF end of March 1998,and a verbal briefing done in Bonn by the GAF for the Press end March or early April 98.

GXER
31st Mar 2009, 11:13
@punkalouver

I highly recommend that anyone reading about this accident confine themselves to the NTSB section of the report.

I think I would prefer to read the whole report and make up my own mind.

Yet the pilots denied having reactivated the transponder. Why would they do this when aside from the astronomical odds of the transponder having done all this by itself, it seems to be the only logical explanation?

This is why:

After the accident there was a public outcry to put the pilots in jail along with many false accusations based on limited information. They were accused of intentionally turning off the transponder and flying at different altitudes. The pilot’s claimed that they were at the cleared by ATC(now a known fact). Yet Brazil’s Defense Minister called that “ a frivolous statement ... It was irresponsible” and in the same interview denied ATC responsibility. Given the above statement in the report of “The authorities responsible for the judicial processes aiming at the verification of the criminal liabilities requested all the material gathered by this commission until then, when two months had elapsed after the accident.”, who is going to tell the honest truth about an error made, especially when you look at page 266 and see two signatures authorizing the final report. They are the Chief of General staff of Aeronautics and the Chief of CENIPA. Both are Brigadier Generals. The Air Force run accident investigation board was investigating an accident with the Air Force run ATC involving a highly emotional event in Brazil. And all the statements are being taken for the judicial process where the pilots are facing many years in jail.

Hmm. I suspect the pilots realised they were at least to some degree resonsible for the inop transponder. That is the obvious conclusion from the reported discussions with ATC. I doubt they had in mind the organisational structure of CENIPA at that time.

Yet the Gol pilots get no criticism and are treated as shining stars. But oddly, hidden away in the final report recommendations on page 18 is this statement directed at Gol Airlines: “To reevaluate the SOP, “General Index of Chapters” / 1- General Procedures / 1.8 – Conversation in the Cockpit (Sterile Cockpit), and set up a protocol for cell phone utilization by crew members, when they are in the command cockpit of the aircraft.” If the Excelaire pilots had done the same as this recommendation hints happened in the Gol cockpit, it would have been just another example seized upon by CENIPA as incompetent.

Puhlease! You're clutching at straws. There is no indication that the GOL pilots were anything but completely blameless. You accuse CENIPA of "nitpicking" but make a vague slur against the GOL crew in the same post. A double standard methinks.

I suspect you're quite right that the report is not - impartial - but neither is your defence of the Embraer crew. My impression was that they were underprepared and that their professionalism, in a number of areas, was some distance away from "irreproachable".

punkalouver
1st Apr 2009, 01:52
Thanks for taking the time to read my critique. It took a long time to prepare.






I think I would prefer to read the whole report and make up my own mind.

Understandable. My statement should be directed at people unfamiliar with aviation but looking for answers such as the Brazilian public.


Hmm. I suspect the pilots realised they were at least to some degree resonsible for the inop transponder. That is the obvious conclusion from the reported discussions with ATC. I doubt they had in mind the organisational structure of CENIPA at that time.


Going from memory, the pilots were interviewed about a year later by Cenipa after having made initial statements through the NTSB no doubt after being briefed in detail by lawyers about the investigative process in Brazil. I would guess they were well aware of the structure of Cenipa(ie the Air Force investigating itself)

Puhlease! You're clutching at straws. There is no indication that the GOL pilots were anything but completely blameless. You accuse CENIPA of "nitpicking" but make a vague slur against the GOL crew in the same post. A double standard methinks.

I suspect you're quite right that the report is not - impartial - but neither is your defence of the Embraer crew. My impression was that they were underprepared and that their professionalism, in a number of areas, was some distance away from "irreproachable".

I believe that the Gol pilots were blameless. However I suspect based on this recommendation to Gol about cellphone use in the cockpit(of which there is no detail in the report) that this happened on that flight. My point is as stated earlier ie. a suspicion that if the Embraer pilots had done this, Cenipa would have crucified them over it instead of not detailing it at all in the report.

I'm not sure where you feel that I am impartial or where the Embraer pilots were unprofessional. Please detail.

It is obvious that they made some errors such as accidentally turning off the transponder and not noticing a NOTAM about runway length at destination and therefore trying to confirm that the could meet performance limitations after departure. Making an error is not unprofessional.

In my view their transponder mistake was a contributing cause to the accident but ATC error was the primary cause.

Richard_Brazil
1st May 2009, 16:44
David Rimmer, an ExcelAire executive who was aboard the Legacy, spoke to an Aviation Week reporter at an aviation safety conference in April:

Bus Av Now Blog Article (http://www.aviationweek.com/aw/blogs/business_aviation/index.jsp?plckController=Blog&plckScript=blogScript&plckElementId=blogDest&plckBlogPage=BlogViewPost&plckPostId=Blog%3a2f16318d-d960-4e49-bc9f-86f1805f2c7fPost%3a25bbb34f-ec3e-4c37-833c-4eb916e4740a&plckCommentSortOrder=TimeStampAscending)

He speaks of "disappointment" at the inaction of the Consulate, and "disappointment" at the Cenipa report. Some interesting analogies to the treatment of the TAM crash. Also, he thinks Brazil finds survivors/witnesses inconvenient.

He emphasizes the role of the media in the case.

Aviation International News has an interview by Robert P. Mark with Roger Cox of the NTSB:
Brazil Midair Underscores Value of Thorough Research: AINonline (http://www.ainonline.com/news/single-news-page/article/brazil-midair-underscores-value-of-thorough-research/)Brazil Midair Underscores Value of Thorough ResearchBy Robert P. Mark
May 1, 2009
Accidents
Operational threat identification and risk mitigation remain a primary concern for those who operate internationally. NTSB senior air safety inspector Roger Cox, the lead investigator on the Gol Airlines/ExcelAire Legacy midair, used the accident as an example of why international operators should take the time to fully understand what may be asked of them in less than normal situations in another country.
[more at site]

The ATC errors seem to have resulted from a combination of flawed systems, understaffing, and poorly trained and inexperienced controllers.

The flaws in the software were pointed out not only by the NTSB (as in the article above) but by Brazil's own TCU, a sort of equivalent to the Congressional Budget Office.

The officers of the air traffic controllers' association (not a union, most of the ATCO's are military, and can't unionize, though they can associate) are among the most experienced controllers. One, who was on duty (though not involved) the night Gol 1907 went missing, immediately reviewed the control center tapes and knew there had been a collision. Last I heard, he was out of the control tower and at a desk in the Air Force Ministry. Another controller with over 20 years' experience now reports every day to an Air Force base, where he is given nothing to do all day long, and studies books on breeding dairy cattle.

Many other experienced controllers have retired, discontent with the current situation.

Meanwhile, training has been abbreviated, allowing new controllers to be put in front of radar screens more quickly. Formerly only five sergeants (the military controllers are mostly sergeants) were promoted to officer every year, but know it's fifty. On the surface that's good, because it finally puts them close to a living wage. However, the goal may be maintaining control over the workers. In a casual conversation, there's a feeling that those being promoted to officer are not the best qualified, but those fastest to salute. "If you don't trust him as a controller, will you trust him as a supervisor?" was one comment.

While in much of the world the recession has brought a drop in air travel and bought time, in Brazil the airlines expect "only single-digit growth" for commercial traffic this year. That's not a breathing space, merely a reduction in the pressure.

I hear that grave incidents continue to be frequent, 125 in Brasilia in January.

The lawyer for the Brazilian Air Traffic Controllers' association, Roberto Sobral, spoke at the IFATCA convention in Croatia in April. I have not yet obtained a copy of his speech.

- Richard

ATC Watcher
2nd May 2009, 06:49
The lawyer for the Brazilian Air Traffic Controllers' association, Roberto Sobral, spoke at the IFATCA convention in Croatia in April. I have not yet obtained a copy of his speech.

He basically confirmed what you say above. He said many experienced controllers have left, new mainly very young shortly trained with basic English levels are in.
Even more worrying he said serious incidents are now filtered out as controllers are prevented to file Occurrence reports.
He also announced that FEBRATCA ( the federation of Controllers Associations in Brazil) has decided to prosecute individually every chief of the Brazilian airforce, and a court case on that is expected before the end of the year.

barit1
2nd May 2009, 19:48
For any sane operator in Brazilian airspace, SLOP must be STRONGLY considered. You wouldn't drive down the centerline of a two-lane road.

rmiller774
10th May 2009, 16:03
Am I that naive to assume that if there were no traffic control at all, flying down the "middle of the road" would not result in a collision IF both aircraft had TCAS on?

broadreach
10th May 2009, 21:14
This isn’t entirely off-thread; please bear with me for a few minutes.

The Gol/Legacy accident – and later the TAM tragedy, gradually revealed some of the worst things about Brazilian politics, e.g. the way in which parastatal organisations like Infraero, the airports authority, are carved up to serve political parties in exchange for congressional support. They also helped shed some light on how the military have to share bedding with politicians to get the funding they require – or think they do.

Infraero went through several audits in 2007-8. Unsurprisingly, it was found to be riddled with corruption and the staff bloated with political appointees. The entire board was replaced – with new political appointees, new names to the same chairs.

Nelson Jobim took over as Defense Minister in 2007, a week after the TAM Congonhas accident. Since then my own impression is that he’s been mainly occupied with damage control, i.e. keeping the military off the front pages, and in working out arms deals.

Recently, though, something seems to have changed. Over the last few weeks the political appointees, all (or perhaps most – I haven’t checked the political affiliations) of them members of Jobim’s own PMDB party, have been dismissed and there’s a general management cleanup in process.

I’m not sure how to read this – it may be the air force reaction to the threat of airport privatization, “just get the politicians out of our hair and at least give us a chance to run the thing properly”. Whatever the reason, it shakes the system up and makes it a little more transparent, neither of which can be bad. Richard_Brasil will surely have a better view on what’s happening.

barit1
10th May 2009, 23:30
Am I that naive to assume that if there were no traffic control at all, flying down the "middle of the road" would not result in a collision IF both aircraft had TCAS on?

If TCAS were "prime reliable", never failed, then you might come to that conclusion.

But competent ATC plus TCAS gives an additional layer of Swiss cheese, less likely the holes will line up.

SLOP adds yet another layer, permitting the system to tolerate some degradation in one of the first two. I fail to see why ALL layers are not utilized.

TOFFAIR
11th May 2009, 00:29
Have you been flying in Brazil lately? Infrastructure is bad, from ground to air, no complete radar surveillance and bad radios added to lack of parking positions, bad runways, etc... do you believe safety is improved by pilots flying where they want instead of where they should?

barit1
11th May 2009, 01:49
Let's use this thread as an example. According to the GOL/Legacy case, both aircraft were "where they should" be - that is, where ATC assigned them. How did that work out?

Safety is improved by pilots using all the separation tools available to them. :ok:

Finn47
26th Sep 2009, 15:34
The widow of one of the GOL victims is now suing the Legacy passenger Joe Sharkey for allegedly insulting the honour of Brazil :hmm: The plaintiff seeks (at least) a public apology from him, to be published in the New York Times as well as on air by some TV & radio stations which interviewed him...

the suit is based on a Brazilian law that allows any citizen to claim damages for an alleged insult to the dignity or honor of Brazil in any case involving a crime.

Freelance US journalist sued for defamation in Brazil | AlterNet (http://www.alternet.org/rss/breaking_news/92671/freelance_us_journalist_sued_for_defamation_in_brazil/)

barit1
26th Sep 2009, 19:18
She wants to shoot the messenger... :rolleyes:

Ct.Yankee
26th Sep 2009, 21:47
How about uniting the people of the world by getting rid of lawyers?
I believe Shakespeare promoted this concept in one of his works
years ago!

Richard_Brazil
26th Sep 2009, 22:24
http://oglobo.globo.com/pais/noblat/posts/2006/12/05/no-pais-do-buraco-negro-44738.asp


Articles
Sent by Demóstenes Torres -


Dec 5, 2006 03:15 AM


In the country of the black hole


The New York Times journalist Joe Sharkey is a survivor of Brazil's worst aviation disaster. He was one of the passengers on the Legacy that collided with the Gol aircraft. Sharkey was the first reporter to denounce the pantomime of the Brazilian authorities in the management and safeguarding of the country's air space. At first he injured our patriotic spirits with the arrogant and ethnocentric tone of a Caucasian from the metropolis predisposed to disdain this third-world cane field. However, each new article published by the Brazilian media on the deficiencies of the air traffic control system has shown the North American to be right.


Joe Sharkey feeds his blog almost daily with caustic articles on the Brazilian tragedy. It's clear that he has taken on the mission of freeing the two pilots of the Legacy, after all, they saved his life. Until the investigations are concluded no one can be blamed, but the pilots showed extraordinary airmanship in landing the Embraer jet after the collision. That's because the pilot of a cargo aircraft, who spoke fluent English, oriented them on the position of the Air Force base in the Amazon jungle, since they were unable to communicate with the Brazilian controllers.


The journalist considers that the pilots are being maintained in a condition analogous to hostages, when they should be treated as heroes and sent home in first class, which seems inevitable considering the follies of the Brazilian government. The collision of the two aircraft was caused by a set of human and equipment failures, but wound up as a tragedy foretold because the government did not react promptly. Evasions and denials will not resolve the crisis of confidence in a public service that Brazilians were sure was one of the best in the world, especially after the billions invested in Sivam.


If it's true that the radars didn't work, that aircraft disappear in black holes and that there there's a shortage of air traffic controllers it's needful to admit that flying in Brazil is almost asking to die. Brazilian air space is equivalent to the country's precarious roads and what does the government do? Deny the evidence of the aviation blackout and promise that everything will be improved with a pothole-filling operation that will be done by summer. As Sharkey calls him, the Minister of Defense, Wonderful Waldir, lives with his head in another orbit: now he says that he wasn't informed of a certain problem, now he simply denies that there is a black hole, obsolete radar or impounded resources. As José Simão says the only things that's flying in Brazil is the Minister of Defense.


The problem, Minister, is that in this uniformly blue sky, not even passenger airliners are any longer seen. And what disrespect to the families of the dead of the Flight 1907 accident! The Air Force, Infraero, and ANAC knew that there were no survivors, but waited 48 hours to give the news. So it's a function of the State to create expectations so that suffering is less painful? I wrote in this blog that the delays would be assimilated by Brazilians and become normal. That's what's happened, to the surprise of a Dutchman who put up with a three-hour delay to make a connection at Congonhas Airport. What most intrigued the citizen accustomed to European composure was the cheer that the passengers in the chaotic departure concourse sent up for each flight confirmed. A full platter and more to reinforce Joe Sharkey's arguments.




Demóstenes Torres is a prosecutor and senator (PFL-GO)

alemaobaiano
27th Sep 2009, 10:51
Richard Brazil

The Minister of Defence is no longer Waldir Pires, and that article is from almost three years ago, so the comments of the good senator might be a little out of date. The comments of Joe Sharkey may well be accurate (or not) but when delivered in a tone of inherent superiority they will not be well received. He is, in the eyes of many Brazilians, a typical loud mouthed, opinionated gringo. IMHO many of his points ARE valid, but nobody will listen because of the delivery. I don't agree with suing him, but there are many who feel very strongly about him, and their views are not positive.

There has been time for change, but this being Brazil the following will probably have happened, much like the TAM accident at Congonhas (in which I was involved in the immediate aftermath).

1. Accident happens.

2. Public outcry about infrastructure failures.

3. Politicians promise to fix everything, if only we give them more money.

4. Time passes.

5. More time passes.

6. Public forgets, another accident happens for example.

7. Nothing is done.

8. Same accident happens again.

9. Go back to step 1.

Bem vindo ao Brasil

punkalouver
27th Sep 2009, 12:02
He is, in the eyes of many Brazilians, a typical loud mouthed, opinionated gringo. IMHO many of his points ARE valid, but nobody will listen because of the delivery. I don't agree with suing him, but there are many who feel very strongly about him, and their views are not positive.

There has been time for change, but this being Brazil the following will probably have happened, much like the TAM accident at Congonhas (in which I was involved in the immediate aftermath).

1. Accident happens.

2. Public outcry about infrastructure failures.

3. Politicians promise to fix everything, if only we give them more money.

4. Time passes.

5. More time passes.

6. Public forgets, another accident happens for example.

7. Nothing is done.

8. Same accident happens again.

9. Go back to step 1.

Bem vindo ao Brasil

Which explains the delivery from Sharkey. I suspect people being unwilling to listen has more to do with him being a terrble Gringo than anything else. There is a massive problem, if more people over there are upset at the truth being told by Sharkey in a direct, no holds barred approach as opposed than what is posted above. Pride overcomes lives once again and I have no time for aviation safety once again compromised by stupidity.

alemaobaiano
27th Sep 2009, 19:57
Which explains the delivery from Sharkey. I suspect people being unwilling to listen has more to do with him being a terrble Gringo than anything else. There is a massive problem, if more people over there are upset at the truth being told by Sharkey in a direct, no holds barred approach as opposed than what is posted above.

I disagree, a complete lack of sensitivity in the way he was communicating his ideas was evident from the very beginning. He does have good points to make, but as a journalist he should surely be aware of the need to understand the target audience? As it is, he practically guaranteed that no-one here was prepared to listen to his "direct, no holds barred approach". He could have expressed himself better, and had his ideas accepted on merit.

Pride overcomes lives once again and I have no time for aviation safety once again compromised by stupidity.

That seems to be a fairly widespread phenomenon.

TTFN

JammedStab
27th Sep 2009, 20:33
Then the Brazilians have condemned themselves to the 9 points you listed. While in the U.S., harsh words about their own system after recent accidents will lead to changes and hopefully a safer system.

Safety is an attitude.

Richard_Brazil
27th Sep 2009, 21:31
I disagree, a complete lack of sensitivity in the way he was communicating his ideas was evident from the very beginning. He does have good points to make, but as a journalist he should surely be aware of the need to understand the target audience? As it is, he practically guaranteed that no-one here was prepared to listen to his "direct, no holds barred approach". He could have expressed himself better, and had his ideas accepted on merit.

I have to disagree with alemaobaiano on this.

While I am not an aviation expert, I am an expert on the Brazilian press, and they jump rapidly to a conclusion as to who are the heroes and villians, and it seems no amount of evidence, expressed in any terms whatsover, will cause them to listen to sense.

I posted above a column by senator Demosthenes Torres, published two days before the Legacy pilots left Brazil, in which he acknowledged the correctness of Joe's blog posts.

The problems was not the tone, but the message: blaming the American pilots for the tragedy provided convenient scapegoats, appealed to anti-Americanism, and allowed people not to bother their heads with troublesome details such as poorly designed software. Anyone who insisted on pointing out facts became rapidly unpopular.

The third anniversary of the tragedy is coming up Tuesday, and some ordinarily serious newspapers have published nonsense put out by a group that calls itself the "Association of Friends and Relatives of the Victims of Flight 1907". They claim to represent the families of 154 victims; in fact they represent the families of somewhere between a tenth and a fifth of that number.

The Brazilian press learned that, the last time this lynch mob howled for blood, but that was close to a year ago, and press memories are short, and the unwarned reporter always sides with whoever calls themself a victim.

The groups "facts" are wildly inaccurate; they have an "accident expert" with whom I spoke and who astonished me by saying that he'd been hired not by the lawyers, but by the group's press agent.

They lost their loved ones, and I sympathize with that, but they also lost their love of truth, if they ever had it. And they are dangerous to others.

Those most interested in the investigation of the Gol 1907 accident are not the relatives of the victims. Rather, it is those who will live or die depending on whether the causes of this accident are found and fixed - or not.

Joe Sharkey spoke the truth, early and often, and the Association has never issued a press release without a glaring error or a bald-faced lie.

Why is Joe criticized, and this Association blindly believed? It is neither the quality of their information, nor the tone in which they communicate. It's that what Joe says isn't what the press wants to hear - and the Association provides the easy-to-swallow lies that lazy reporters eat up.

alemaobaiano
28th Sep 2009, 09:59
Richard

I think this needs to be separated into two audiences, if you will.

There are aviation professionals who understand exactly what Joe Sharkey has been saying, and agree with him. They would very much like to correct the multiple failings in aviation infrastructure here and know what needs to be done. However, they face a serious problem.

The public at large, fed by the sensationalist press and encouraged by self-serving politicians (I wouldn't put Demosthenes Torres in that group, BTW) who don't want to know about the problems. As you say, in the immediate aftermath the press blamed the American pilots, without the slightest shred of evidence. The official report received virtually no coverage in the general press, and so the public still believes that original impression. The politicians like to keep that going, as uncovering problems would reflect badly on their record in office.

I'm sure you saw the recent report on the promised changes at Congonhas following the TAM crash. Despite all of the wonderful promises, ABSOLUTELY NOTHING has been done.

The point I'm trying to make is that if Joe Sharkey had put his ideas in a different way they would have had a wider acceptance and probably have contributed to an improvement if flight safety in Brazil.

TTFN

flyboyike
28th Sep 2009, 15:12
I find even the concept (let alone the reality) of Brazillians calling anyone else (Gringo or otherwise) "loud-mouthed and opinionated" quite laughable.

punkalouver
28th Sep 2009, 16:09
There are no shortage of self-serving politicians in plenty of other countries, including ones with excellent aviation safety records. As well as sensationalist press.

If the way Mr. Sharkey comes across in a blog or newspaper article prevents a country from improving its safety record or as you say "Despite all of the wonderful promises, ABSOLUTELY NOTHING has been done.", I think you are looking at the wrong location for blame.

Change will only come from within, when the people demand it. If they don't particularly care, then the status quo will continue....for aviation safety and so much else.

broadreach
29th Sep 2009, 02:38
Have to agree with Alemaobaiano regarding Joe Sharkey's contribution. His commentary from the coalface was very informative, moreso than any other source could have been, but in reflecting only the views of the sole survivors of that accident, he contributed substantially to the early polarization.

Mr Sharkey's a journalist and he had an incomparable scoop on his hands. A very difficult situation and, in hindsight, suggesting he might have been more diplomatic, or reserved in judgment, sounds naive. But I wish he had been so and that he had responded less energetically or, better, not at all, to what the Brazilian media were spinning out of silly, ass-covering statements by the then minister of defence and others.

As for the "defamation of national honour" suit brought against him, ah well; the imagination of ambulance-chasing lawers knows no limits, nor, for that matter, national boundaries.

alemaobaiano
29th Sep 2009, 09:49
I think you are looking at the wrong location for blame.

punkalouver, I know exactly where the blame lies, and it isn't with Joe Sharkey. I just believe that this was a missed opportunity.

Change will only come from within, when the people demand it. If they don't particularly care, then the status quo will continue....for aviation safety and so much else.

Brazil in a nutshell.



TTFN

Rob21
29th Sep 2009, 12:43
The other day I heard a remark from some Director of ANAC when asked about the latest survey on world safety records, which ranks Brazil at a "scary" position, in comparison with other countries.

He said something like this: If those two accidents (Gol and Tam) didn't have happened, Brazil's safety record would be similar to the U.S.

With this stupid attitude, I don't believe we will see any changes...

Flying over Brazil ?
Check your TCAS...

Good luck to us all (pilots and passengers).

Rob

kappa
29th Sep 2009, 19:48
Joe Sharkey today posted comments on the law suit and also authored a column in Editor & Publisher in which he summarizes the events and his blogged comments (http://www.editorandpublisher.com/eandp/columns/shoptalk_display.jsp?vnu_content_id=1004016119). He has a link to the actual wording of the papers he was served. They are both ridiculous and almost hilarious.

{Link to Sharkey blog appears to be broken. As pointed out below, Google: Joe Sharkey + High Anxiety}

[Edited in attempting to to fix broken links]

augustusjeremy
29th Sep 2009, 20:24
Joe Sharkey today posted comments (http://joesharkeyat.*************/2009/09/brazil-mid-air-collision-three-years_29.html) on the law suit and also authored a column in Editor & Publisher in which he summarizes the events and his blogged comments (http://joesharkeyat.*************/2009/09/brazil-mid-air-collision-three-years_29.html). He has a link to the actual wording of the papers he was served. They are both ridiculous and almost hilarious.She is spending her own money to promote a guy that otherwise would be just another one among so many irrelevant journalists.

I find even the concept (let alone the reality) of Brazillians calling anyone else (Gringo or otherwise) "loud-mouthed and opinionated" quite laughable.

My opinion about some americans is reciprocal.

broadreach
29th Sep 2009, 20:37
Kappa,

The link you've included doesn't work - lots of asterisks - but if one googles joesharkeyat.************* one gets there.

The first thing one sees is a photo of the tail empennage of an aircraft, with the caption "Wreckage of Gol Flight 1907 in the Amazon, found several days after the collision".

However, the wreckage is - I'm pretty sure - that of a King Air which crashed on landing at Trancoso in northeast Brazil some months ago.

kappa
29th Sep 2009, 22:36
Broadreach, in going back to the JS blog in my attempts to repair the link, I note that he has removed the original picture.

Brian Abraham
20th Jan 2010, 02:00
From Aviation International News today

Legacy 600 Midair Pilots Still Entangled in Legal Jungle
American charter firm ExcelAire and pilots Joe Lepore and Jan Paul Paladino remain entangled in Brazilian legal battles more than three years after the midair on Sept. 29, 2006 between their Embraer Legacy 600 and a Gol Airlines 737-800 that resulted in the deaths of all 154 aboard the airliner. A Brazilian federal appeals court last week overturned the summary dismissal of negligence charges against the American pilots, while upholding complete dismissal of charges against two controllers and reducing charges against two others. The pilots again face those charges, linked to communications failures, along with other charges that were never dismissed. The controllers, sergeants in the air force-controlled ATC system, are also on trial in the independent military court system. Last month, a Mato Grosso state civil court ordered ExcelAire Services to deposit a 175,000 Real ($98,600) per plaintiff bond in several suits for damages brought by victims’ families. The same court had denied the bond request in similar cases the previous day. Meanwhile, a bill is pending in Brazil’s congress to limit the use of safety investigation information in the courts.

bubbers44
20th Jan 2010, 02:16
Justice system in Brazil is an oxymoron. They win and you lose.

Finn47
7th May 2010, 11:26
Some Brazilian congressmen have demanded that the FAA revoke the licenses of the Legacy pilots. The FAA has politely refused to do so.

Aero-News Network: The Aviation and Aerospace World's Daily/Real-Time News and Information Service (http://www.aero-news.net/index.cfm?ContentBlockID=620e9acd-441e-4c7c-a979-8619ec8ca724&)

Richard_Brazil
24th May 2010, 18:06
The usual - extracts from twisted translations of black-box dialogs, etc.

23/05/2010 21:53 - Updated 23/05/2010 21:53
Brazilian who traveled on Legacy tells how Boeing accident was

Ex-employee of Embraer left upstate SP and moved to the USA.
To Fantástico, he remembered how the crew reacted to the tragedy with the Boeing.


By G1, with information from Fantástico


Three years and seven months after surviving one of the worst tragedies in the history of Brazilian aviation, Daniel Bachmann decided to break his silence. The ex-employee of Embraer was on the Legacy jet that collided over the Amazon forest with a Gol Boeing that was going from Manaus to Brasilia. The accident, which occurred on September 19, 2006, left 154 dead.

The plane was piloted by Americans Joe Lepore and Jan Paul Paladino. Bachmann was accompanying the clients and an American reporter on the delivery of yet another Embraer business jet. He and the others who were traveling on the aircraft did not see when the Boeing 737 that was coming in the opposite direction hit the left wing of the Legacy 600. “What the devil was that?”, said one of the pilots. The question was preserved on the voice recordings of everything that happened in the cockpit during the trip.

The Embraer ex-employee said that he did not imagine at that moment that the problem had been caused by a collision. They only thought of surviving. "There was the sound of an alarm, the map had fallen on the floor. That was when we looked out the window and saw a piece of wing missing." In the following minutes, from the passenger cabin, Bachmann saw a sudden change of command. It was the first time that Joe Lepore piloted a Legacy. "The co-pilot said: ‘Then I'll take over’".

Jan Paul Paladino prepared for an emergency landing and everyone prepared to die. "The wing was opening, the sheet on the top was coming up, the rivets were coming out and fuel was running over the wing", the Brazilian remembered. The improvised decent at the Serra do Cachimbo air base was wobbly and shortly after the landing the news of the tragedy arrived.
Moving
Bachmann moved from São José dos Campos, in upstate São Paulo, where Embraer's headquarters is, to the small town of Owasso, in the state of Oklahoma, in the coumtryside of the United States. It was in his family's new home that Bachmann received Fantástico for an exclusive interview. Married, three children, he wants to start life over.

In Brazil, he did not feel free to give an interview. He remembered the accident all the time, had cardiac problems and was worried about winding up as a scapegoat, especially after Congressmen said that he had lied to defend the pilots.

“I don't know the specific details of the procedures each pilot does. When I arrived, the airplane was running, ready to take off and I was getting on board along with the clients", he said. Despite this, Bachmann evaluates the communications problems between the Legacy's cockpit and the Brasilia airport tower (sic). “Perhaps, during the communication that they (pilots) had, when they received from Brasilia "maintain", they interpreted it as maintaining the order they received in São José to go to Manaus at 37,000”.

“Maintain”, according to the pilots' interpretation, was to maintain the altitude of 37,000 feet on the leg between Brasilia and Manaus. But "maintain", according to the controller, was to maintain the original flight plan and to change altitude, which would have removed the Legacy from the Boeing's path. The ex-employee reveals that the failures persisted to the last minute. "There was also a communications failure between the controller of the Serra do Cachimbo tower and the pilot. A question of English and of measurement, the length: 2600 feet or 2600 meters of runway, then the pilot had to assume the shorter of the two, in doubt", he said.
Trials
Pilots Joseph Lepore and Jan Paul Paladino were accused for a series of incompetencies and negligences during the flight procedure. In the Brazilian courts, they were even absolved in the trial court and were greeted as heroes in the United States. But the Association of Relatives and Friends of Victims managed to reverse the decision on appeal and further asked for a new technical examination of the airplane's black boxes. And the result led to the opening of a new legal case against the American pilots.

According to expert Roberto Petrarka, the Legacy's black box revealed that they never even turned on a piece of equipment that's fundamental for flying, known as the T-CAS. The T-CAS is an anticollision system and the pilot's sight. At velocities and high velocities, the pilot's vision can't manage to see another plane coming. And the T-CAS does this in 360 degrees, from any position that the airplane is coming, that could signify a risk of collision.

Inside the cabin, one of the positions came to ask if the T-CAS was turned off. “Turned off”, the other confirmed. And the Legacy's black box registers from the aircraft's movement on the ground to moments before the collision.

In April of this year, the information of the new expert exam were sent to the agency which controls American civil aviation, the FAA, with a request that Lepore and Paladino have their pilots' licenses canceled. The body's response was that it would take no measures in relation to the two pilots.

In October of 2009, another two American pilots had their licenses immediately suspended by the same body, because they passed the landing position and continued another 230 kilometers because they were completely distracted.

“The 154 people who died are nobody?”, asked Roseane (sic), relative of one of the victims. Rosane's husband was aboard the Gol Boeing. The couple's daughter, who is now 7 years old, still keeps his cologne and slippers in the corridor. “This wound will only close when those responsible for these deaths pay in the form of the law for this crime they committed.”

Only 23 of the 154 families have still not reached an settlement over the indemnification for the tragedy. If they are convicted, the penalty for Jan Paul Paladino and Joe Lepore is from one to three years of detention.

Richard_Brazil
26th Oct 2010, 22:59
This controller and one other continue on trial in Federal court along with Legacy pilots Joe Lepore and Jan Paul Paladino.

For those without a scorecard, Jomarcelo is the one who was at the console when the transponder went off, though not without first showing for seven minutes that the Legacy was at a different altitude than he expected, without him noticing. In his defense, he had flunked the controllers' exam four times, so perhaps the question is not what he did or failed to do, but who the Hell sat him in front of a console?

On the others, another Embraer plane on its maiden flight with an American crew had followed one of João Batista's clearances into a mountain, according to persistent rumor. That the crash took place, and for that reason, is true; whether it was him I still lack proof, though he was on the duty roster that month.

There may be other news on the case in the next week or so.
G1 - Justiça Militar condena controlador de voo pelo acidente da Gol - notícias em Brasil (http://g1.globo.com/brasil/noticia/2010/10/justica-militar-condena-controlador-de-voo-do-acidente-da-gol.html)

26/10/2010 17h57 - Updated 26/10/2010 18h06
Military Court condemns air traffic controller in Gol accident

Accident between Gol airliner and private jet killed 154 people in 2006
Sargeant was sentenced to 1 year and 2 months for manslaughter


Débora Santos of G1, in Brasilia



The Military Courts this Tuesday (Oct 26) sentenced to one year and two months for manslaughter (homicide when there is no intent to kill), sergeant Jomarcelo Fernandes dos Santos, a light controller who was on duty controlling air traffic on the day of the Gol 1907 accident, which left 154 dead four years ago. An appeal to the Superior Military Tribunal (STM) is possible.
The accident happened on September 19, 2006, when the Gol aircraft collided in midair with a Legacy jet. The sergeant was sentenced by 4 votes to 1.

Another four controllers - João Batista da Silva, Felipe Santos Reis, Lucivando Tibúrcio de Alencar and Leandro José Santos de Barros – were absolved. They had been indicted by the Military Prosecutors' Office (MPM) for negligence and for not observing military safety rules.

ATC Watcher
27th Oct 2010, 07:07
This will surely improve ATC and safety in Brazil !. Condemning/Sending a few sergeants in jail absolve in the eyes of the public the responsibilities of the top brass who put this system in place.

But in the background a lot is changing fortunately. The ATC system flaws have been corrected, Flight plan processing and display adapted to fit the rest of the world, and procedures tightened.
What has not changed unfortunately is the fact that the Military still run the show, and treat their controllers like low class workers, with the same basic training and lack of motivation.
It might take another wake up call, hopefully without casualties, for them to change that.

Daermon ATC
27th Oct 2010, 07:30
Slightly off-topic

For those who do not know it, I absolutely recommend the documentary "Fuerza aérea SA" which shows the deeply entrenched corruption, negligence and mismanagement in the argentinian air navigation.

Seems to me Brazil wouldn't be too far away from that.

Here is a link to the movie (in spanish, sorry, but I'm sure there are a english translations)

YouTube - Fuerza Aerea SA parte 1 (http://www.youtube.com/watch?v=IJJIaNDbJrM)

Richard_Brazil
28th Oct 2010, 18:07
Legacy jet that collided with Gol Boeing will be returned to USA Aircraft remained at Serra do Cachimbo Air Base, in Pará, since 2006.


Parts that will be used in court cases on accident remain in country.


Glauco Araújo of G1, in São Paulo
28/10/2010 13h49 - Updated 28/10/2010 15h20





http://s.glbimg.com/jo/g1/f/original/2010/10/28/legacy.jpg
Legacy jet remianed at Serra do Cachimbo Air Base, in the south of Pará, since the accident with Gol Boeing (Photo: Release/FAB)
The Legacy jet involved in the accident with the Gol Boeing, on September 29, 2006, will be returned to the company Cloudscape, Inc, in the United States. The measure was authorized, on August 27 of this year, by judge Fábio Henrique Fiorenza, of the Federal Court of Sinop, in Mato Grosso. The aircraft's return will be done by the Brazilian Air Force (FAB). The airplane is at Serra do Cachimbo Air Base, in the south of the state of Pará, where it has been since the collision with the Gol aircraft. None of the 154 passengers and crew of the Gol aircraft survived.

According to the Federal Court of Mato Grosso, the pieces related to the cases on the accident, such as the black-box, the T-Cas and transponder, for example, will remain in the power of the Federal Police (PF).

The request for restitution of "seized object" was submitted by the American company on August 13, 2008 and sent to the Federal Prosecutor's Office (MPF) which gave a favorable opinion on the restitution on August 20 of this year.

After the Federal judge's authorization, a dispatch was sent to the Air Force to advise that the aircraft could be returned. The Air Force did not inform when the Legacy will be ready for flight.

[Repetition of news on controllers' conviction]

G1 - Jato Legacy que bateu no Boeing da Gol será devolvido aos EUA - notícias em Brasil (http://g1.globo.com/brasil/noticia/2010/10/jato-legacy-envolvido-em-acidente-da-gol-sera-devolvido-aos-eua.html)

G-V
30th Oct 2010, 14:42
It’s a little bit off topic:

Every time I fly in a non-radar environment I prefer to set an offset to the right of the airway.

Just had an argument in the cockpit about it. The other guy believes that it is "to look for trouble" to set up even a quarter mile offset in non-radar environment flying over the East Africa's best: Tanzania, Kenya, Somalia, Yemen.

It is always good to add a layer of a Swiss cheese if you can.

BR

Green Guard
30th Oct 2010, 15:28
1/4 NM OFF Track setting should be used EVERYWHERE...
Even for 1 NM you'll never get any remark from any ATC all the way down to APP.

For those "robot" pilots who insist on absolutely on track all the time,
even perhaps Mr. 411,
1. I would ask them if they drive their cars over the middle of the two-lane opposite-direction road ??
2. What harm can be done by 1/4 NM Offset to anybody and anything ??

aterpster
30th Oct 2010, 16:26
Green Guard:

1/4 NM OFF Track setting should be used EVERYWHERE...

Yes, good for oceanic and remote, non-radar land areas. But, most definately not good everywhere. In domestic, conjested airspace, if the equipment will support 1/10 of a mile offset, that would be far better for en route than 1/4.

Even for 1 NM you'll never get any remark from any ATC all the way down to APP.

I am not sure what you mean by "APP" in this context; initial approach segment? Intermediate segment up to the FAF? Offsets should not be used in any phase of an instrument approach procedure.

For those "robot" pilots who insist on absolutely on track all the time,
even perhaps Mr. 411,
1. I would ask them if they drive their cars over the middle of the two-lane opposite-direction road ??

Apples and oranges.

G-V
30th Oct 2010, 22:16
In my aircraft, even if you selected offset enroute, it will be auto canceled before you reach the first STAR or approach fix. You cant select offset for SIDs either.

BR

Richard_Brazil
31st Oct 2010, 02:22
Folha de S. Paulo reports the Legacy is in Manaus on its way to Ft. Lauderdale.

Brazilian pilots' board says arrived Friday afternoon; scheduled to leave this afternoon but did not.

Still missing the left winglet and "very dirty" by report, parked far from where photographers can snap it.

Tomorrow is Brazil's presidential election, and Tuesday a holiday, a good moment to softly and silently vanish away.

Green Guard
31st Oct 2010, 08:20
it will be auto canceled before you reach the first STAR or approach fix.

It will also be auto canceled any time you select "direct to" any fix (WPT),

You cant select offset for SIDs either.

and you forgot to mention: it can't be selected during T/O, taxi and landing.
:cool:

ATC Watcher
31st Oct 2010, 08:29
Green Guard : 1/4 NM OFF Track setting should be used EVERYWHERE...


Lateral offset has been discussed here before extensively in tech log, and in ICAO . IFALPA ATS past chairman went on a personal crusade with it but lost. because numbers show that with offset you mathematically increase the collision risk. (check ICAO doc if you want the details and the formulaes)

Even for 1 NM you'll never get any remark from any ATC all the way down to APP
Wrong in RNP 5 and RNP 1 airspace, ( most of Europe dense continental, and I suspect parts of the US as well)
Offset make sense in areas with no surveillance ( parts of Africa, Oceanic, remote desertic, polar , etc..) but definitively not Everywhere.

For info the part of the Amazon where the collison occurred was declared a radar controlled airspace by the Brazilian airforce. The final reports says otherwise.

Green Guard
31st Oct 2010, 10:01
because numbers show that with offset you mathematically increase the collision risk. (check ICAO doc if you want the details and the formulaes)

Please send me some details how to find these ICAO formulas.

Wrong in RNP 5 and RNP 1 airspace

Why is it wrong in RNP5, even in RNP1, if 1/4 NM off-set is used, ( IF any of these RNP make you follow an AIRWAY) ?


PS. In any airspace where radar vectors, or direct to somewhere are flown, Off-Sets make no logic and are canceled anyway.

When I wrote "anywhere" I meant anywhere along AIRWAYs...

Capn Bloggs
31st Oct 2010, 15:51
Every time I fly in a non-radar environment I prefer to set an offset to the right of the airway.

Just had an argument in the cockpit about it. The other guy believes that it is "to look for trouble" to set up even a quarter mile offset in non-radar environment flying over the East Africa's best: Tanzania, Kenya, Somalia, Yemen.

Surely you jest. Has the other guy seen how close aircraft are when they cross, opposite direction, on the same airway? The Australian AIP officially allows offsetting in oceanic controlled airspace (probably similar to non-radar African airspace?) by 1 or 2nm and recommends it when operating at non-standard levels.

barit1
31st Oct 2010, 16:12
ATC Watcher:

Lateral offset has been discussed here before extensively in tech log, and in ICAO . IFALPA ATS past chairman went on a personal crusade with it but lost. because numbers show that with offset you mathematically increase the collision risk. (check ICAO doc if you want the details and the formulaes)

We can easily assess the result of applying this rule on the highway; My neighbor (bless her soul) drives down the centerline, and all the other cars are off in the ditch! :D

ATC Watcher
31st Oct 2010, 20:04
Relax, don’t shoot the messenger ! I am not against lateral offset , just telling you it won’t be mandated , and if you do it in controlled airspace where it is not authorized ( e.g RNP1-5) you are not legal. Now if you are above or in an area with no surveillance and are using GPS for nav,, I would recommend it .A few States do authorize it . But this is not what ICAO mandate and not something your insurance company will support.

I have not the will nor the time to look for the old paperwork, if you are really interested contact ICAO or IFALPA. The IFALPA ATS Comm chairman at the time ( Capt Foreman, a brilliant guy) started the discussion this after the mid-air collision in Sioux look out (Canada) in 1995, they aimed first at voluntary off set, then FMS-embedded. Both did not work for various reasons , but the final blow was given by the “mathematicians group report “ of ICAO which demonstrated that with offs set especially on crossing tracks you increased risk.(using rather basic geometry if my memory serves me well) This combined with the fact that not 100% of aircraft will ever be able to offset automatically, and the very complex transition from off-set airspace to precision APP, killed the project.

Now you can take my word for it, or look for the Working papers and reports for yourself .

Now for the ½ or ¼ NM that ATC will not see : in RNP 1 or 5 , many tracks are separated by 5 NM and you are expected to be on centerline, if not you will set off a lot of alarms , STCAs, etc.. on the ground. Read the RNP guidelines.

Lastly, this is at thread about the Brazil collision, not about offset, If you want to reopen the investigation , read first all the relevant posts here, then read the final report ( 266 pages plus the annexes) Then we can discuss if there is something new. I’d love it . But even if offset would have been mandated in 2006 , it would have been only in remote areas with no surveillance ( radar or ADS). It would not have been mandated above the Amazon, because this was (still is afaik) declared radar controlled airspace. So in fact not really relevant to discuss it here.

aterpster
1st Nov 2010, 09:50
ATC Watcher:

Now for the ½ or ¼ NM that ATC will not see : in RNP 1 or 5 , many tracks are separated by 5 NM and you are expected to be on centerline, if not you will set off a lot of alarms , STCAs, etc.. on the ground. Read the RNP guidelines.

Do you know of something more stringent than ANP being within 1xRNP 95% of the time?

Lonewolf_50
1st Nov 2010, 12:22
The T-CAS is an anticollision system and the pilot's sight. At velocities and high velocities, the pilot's vision can't manage to see another plane coming. And the T-CAS does this in 360 degrees, from any position that the airplane is coming, that could signify a risk of collision.

1. We are either dealing with a translation issue, or this reporter has no idea what he is talking about, and hasn't talked to any pilots or controllers to understand the system.

2. Why would one not turn on TCAS if one has it equipped?

3. Interesting to see an issue arising out of a communication failure (the "maintain" bit referring to altitude or flight plan ... which). I had thought that the terminology for altitude changes and assignments was standardized, as well as clearances. Also, clearance changes are usually presented in a standardized language.

I'd be grateful for explanation on that, in terms of variations in terminology.

Edited to fix silly spelling errors. :O

Richard_Brazil
1st Nov 2010, 16:30
Lonewolf suggests two possibilities:
1. We are either dealing with a translation issue, or this reporter has no idea what he is talking about, and hasn't talked to any pilots or controllers to understand the system.
The original is article is ttp://g1.globo.com/brasil/noticia/2010/05/brasileiro-que-viajava-no-legacy-conta-como-foi-acidente-com-boeing.html. I have rechecked the translation, it's accurate.

In fact, the reporter talked to a Roberto Peterka (whose name he then misspelled) or else read Peterka's report, a 70-page item which wanders back and forth across that line which separates the misleading from the flat-out false.

2. Why would one not turn on TCAS if one has it equipped?

Peterka's maintains that since the TCAS was off at the time of the collision, and can't be turned off by accident, it must have been off all the time. He also says that since the TCAS was never called up on the MFD before the collision, it was never turned on; and the Legacy not long after takeoof passed another plane without a Warning or Advisory being issued, so the TCAS must have been off then.

Peterka claims that it's impossible to turn off the Legacy's transponder unintentionally. Since the FAA database prior to the 2006 accident showed six cases in the of Legacy transponders inexplicably going off the air, and the tranponder goes (or at least used to) go into standby if the pilot took more than five seconds to change the transponder code, the ain't true. While the NTSB's contention that a pilot could do it by using the footrest requires a contortionist, it does again establish that two touches of a button are all it takes.

Peterka says that TCAS must be selected on the MFD in order for TA/RA to be selected, the transponder code to be changed, etc.

Pages 39-41 of the Peterka report state that the Legacy was held at FL310 from 6:05 to 6:10 to allow another plane to pass at FL320. Those levels are within 1000 feet of each other, and as no TA was issued, the TCAS was never turned on.

He avoids claiming the two planes passed the point where the paths crossed, at the same time. The copy I have of radar screen shots is too blurry to see the horizontal proximity.

Another of Peterka's arguments is that N600XL was carrying far more fuel than it needed, and that the only reason to do this would be that it was anticipated that the plane might be denied access to RVSM airspace, and have to fly lower where fuel consumption is higher, there being no other reason to carry extra fuel.

On page 47, he says Lepore did not have the minimum time in an EMB 135 to serve as PIC. Why? Because some of his hours were in SJC, aboard N600XL, only the FAA registration hadn’t been issues yet, and it had a temporary Brazilian registration of “PT SFN” so the hours don’t count for certification because they were not aboard an American-registered aircraft.

I am neither an air traffic controller or a pilot, but qualified people tell me that all these arguments are bunkum. Any reaction here?

fellman
1st Nov 2010, 16:53
Pages 39-41 of the Peterka report state that the Legacy was held at FL310 from 6:05 to 6:10 to allow another plane to pass at FL320. Those levels are within 1000 feet of each other, and as no TA was issued, the TCAS was never turned on.

For two aircraft flying straight and level at FL310 the TA vertical threshold is 850ft. So, if the two aircraft were 1,000ft apart, a TA would not be issued.

Lonewolf_50
1st Nov 2010, 17:40
Richard: thanks, I think I better understand what was being discussed in that regard.

Not a pilot anymore, but I preferred the boxes with switches and detents over the computer MFD + menus system for changing freqs and transponder codes. Call me a Luddite if you must ... :oh: I am also disappointed in noting that the "reply" light feature that I was so used to seeing isn't the norm ... or so I think I read earlier in the thread. Doubtless there is a good reason for that based on distraction or light pollution or ... but then, how the heck do you know your IFF isn't responding to interrogation? :confused:
Peterka claims that it's impossible to turn off the Legacy's transponder unintentionally. Since the FAA database prior to the 2006 accident showed six cases in the of Legacy transponders inexplicably going off the air, and the tranponder goes (or at least used to) go into standby if the pilot took more than five seconds to change the transponder code, the ain't true.
Thanks. What an odd design feature ... doubtless software driven for what seemed like a good reason at the time as they were considering human/machine interface and task elements.
While the NTSB's contention that a pilot could do it by using the footrest requires a contortionist, it does again establish that two touches of a button are all it takes.
Heh, nothing is sailor-proof, we used to say in the Navy, so it is probably true that nothing in a cockpit is pilot-proof. :ok:

There are a variety of things in cockpits that one discovers can be inadvertently be switched on or off, which I suppose gives the ergonomics and interface engineers no end of work to do.

What I get from this tragic accident is that neither small error, the clearance 370 / 360 hitch, nor the "it's in standby" by itself is a fatal error, but their being in combination had a non-linear outcome, in terms of severity ... as to many swiss cheese alignments.

As to the many radio calls with no reply, by both ATC and the aircraft ... haven't all of us run into that once or twice in our flying days? It can take a while to get sorted out.

ATC Watcher
1st Nov 2010, 17:45
but qualified people tell me that all these arguments are bunkum. Any reaction here?
Absolutely, 1st class BS.

The contra arguments to these wrong statements and asumptions are all in the final report , and in the NTSB annex.
For info , the TCAS was not off, the transponder was set on stand-by inadvertantly , and by consequence inhibited the TCAS. Whether setting the SSR on SBY was due to wrong manipulation by the crew, the corner of the laptop they were using or the foot rest , is the only question mark here.This combined to a stupid HMI showing TCAS "ON" but referring to the display and not the system did not help the crew realising the error. For me Honneywell has as much responsibility in this SSR/TCAS "failure" as the crew.
But the real and major causes of this collision were not with TCAS, they lay on the ground, in Brazil.

oscarisapc
2nd Nov 2010, 15:41
Earlier in this thread is a reference to an article in Vanity Fair written by William Langewiesche about this crash. It describes chillingly how multiple human factors lined the holes up in the cheese, and an accident equivalent to two arrows hitting each other in flight took place. Vanity Fair magazine is not readily accessible but the article is now reproduced in a new book by Langewiesche entitled Aloft which is published by Penguin. Folks may wish to read it.
PS I have no interest in either publishing or selling!

Richard_Brazil
2nd Nov 2010, 16:05
Take the Langewiesche article with a grain of salt, or perhaps a pillar of salt.

He did not bother to speak to Joe Sharkey, the NY Times columnist who was aboard the Legacy. Joe was pissed about the article, the Brazilian Air Force phoned me about it, also pissed.

He manages to misspell an extremely common Brazilian name, Perreira if I recall, and that's like misspelling "Smith".

He also places a solemn emphasis on the native wisdom of local Indian chief Megaron. I have neighbors who do cultural documentaries. They know Megaron - they've got his email, for example - and inform me when they first met him, fifteen years ago, he tried to steal their canoe.

Richard_Brazil
8th Nov 2010, 02:07
Someone managed to film the Legacy. The stabilizer has been fixed, the winglet is missing.
YouTube - legacy ,aviao assassino!!! (http://www.youtube.com/watch?v=gqY4qukK5QA)

The audio essentially identifies the plane, and says this is an historic moment.

The new registry, N965LL, is visible on the tail.

Richard_Brazil
21st Nov 2010, 11:07
An article in the Cleveland Plain Dealer provides photos and, as seems inevitable, misinformation.

The military base - not the airfield - had been secret because it contained a borehole for testing a Brazilian atomic bomb, a project abandoned over 20 years ago, the secrecy being lifted many years before the Gol 1907 crash. The base has served for support in other air accidents, such as Varig RG-254 that took a wrong turn and got 1,000 miles lost in 1989. See Ivan Sant'Anna's book "Caixa-Preta" for more details.

Embraer Legacy 600 jet makes journey to Cleveland, years after colliding with jetliner over Brazil | cleveland.com (http://www.cleveland.com/business/index.ssf/2010/11/embraer_legacy_600_jet_makes_j.html)
Embraer Legacy 600 jet makes journey to Cleveland, years after colliding with jetliner over Brazil Published: Friday, November 19, 2010, 4:23 PM Updated: Saturday, November 20, 2010, 4:45 AM

http://media.cleveland.com//avatars/userpic-4689-200x200.png (http://connect.cleveland.com/user/agrant/index.html) Alison Grant, The Plain Dealer (http://connect.cleveland.com/user/agrant/index.html)
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http://media.cleveland.com/business_impact/photo/9061442-large.jpgView full size (http://media.cleveland.com/business_impact/photo/constant-aviationjpg-cb928bf75d9af2fe.jpg)Joshua Gunter, The Plain DealerA corporate Embraer Legacy 600 comes to a stop Friday outside the hangar at Constant Aviation at Cleveland Hopkins International Airport. The jet languished for years at a remote airstrip in Brazil, where it made an emergency landing after clipping a Boeing 737 in the air. The 737 crashed, killing 154 people aboard. 18Share (http://www.facebook.com/sharer.php?u=http%3A%2F%2Fwww.cleveland.com%2Fbusiness%2Find ex.ssf%2F2010%2F11%2Fembraer_legacy_600_jet_makes_j.html%23m odg_smoref_face&t=Embraer%20Legacy%20600%20jet%20makes%20journey%20to%20Clev eland%2C%20years%20after%20colliding%20with%20jetliner%20ove r%20Brazil%20%7C%20cleveland.com&src=sp)

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The corporate jet was on its maiden flight, zooming 37,000 feet above dense Amazonian jungle, when the seven people on board felt a jolt and heard a loud bang, followed by silence.
The Embraer Legacy 600 had struck something, nobody knew what. And the collision had sheared off a 5-foot-tall winglet at the end of one of its wings.
"The leading edge of the wing was losing rivets and starting to peel back," travel writer Joe Sharkey later wrote about the near-death experience, which he called the most harrowing half hour of his life.
The pilot and co-pilot stayed calm, scanning the impenetrable rainforest for a place to land. But the Legacy was losing speed. The situation was quickly deteriorating.
Then one of the pilots spotted a runway through the dark canopy. The corporate jet came down hard on a landing strip of what turned out to be a secret military base. The passengers and crew stumbled off the aircraft . . . facing drawn guns.
That they were alive was a fact of almost insurmountable odds, Sharkey recalled in a column for The New York Times. "Maybe we are all actually dead," he remembered joking as gallows humor broke out in the barracks where military personnel had sent them to sleep.
A few hours later they learned the terrible news from the only one among them to speak Portuguese.
The commander at Cachimbo Air Base said that a Gol Airlines Boeing 737 with 154 people on board was reported missing right where the smaller plane felt the collision. No one survived on the jetliner. It was the deadliest accident in Brazilian aviation history.
The Embraer Legacy languished at the military base, ensnared in investigations and legal charges.
But at 11 a.m. Friday -- more than four years after the accident on Sept. 29, 2006 -- it landed at Cleveland Hopkins International Aiport and taxied up to the hangar of Constant Aviation.
A team of 10 engineers, mechanics and avionics specialists from Constant Aviation spent several weeks in October working on the aircraft at the Cachimbo base. The base had long since been declassified as a secret military outpost because of worldwide news of the crash.

http://media.cleveland.com/business_impact/photo/9061468-large.jpgView full size (http://media.cleveland.com/business_impact/photo/constant-aviationjpg-fb0d071123b97b34.jpg)Joshua Gunter, The Plain DealerThe storied corporate jet will remain in Cleveland for three months for repairs.
The Legacy had spent a year and a half outside in jungle dampness. All of its Honeywell avionics displays had to be replaced, Constant Aviation President Steve Maiden said, in addition to fixing the damaged left wing and a damaged tail part.
Constant Aviation -- the single largest U.S. repair company for the Embraer Legacy -- had contacted the company that insured the aircraft after the accident.
Constant Aviation does about 70 percent of Legacy scheduled maintenance on Legacys in the United States and 99 percent of 48-month inspections for U.S.-registered Legacys.
"That's our niche," Maiden said.
Constant Aviation also has a mobile recovery team that specializes in heavy structural repair of damaged planes. The company recently sent a team to Ottawa, Canada, to remove and replace the nose section of a plane.
The Legacy involved in Brazil had initially been purchased by charter/management firm ExcelAire of Ronkonkoma, N.Y., and was on its delivery flight from an Embraer factory when the accident happened.
The Legacy's insurer declared the plane a write-off and sold it to a new owner, whom Maiden did not identify. AINonline, an aviation news site, said FAA records listed the new owner as Cloudscape of Wilmington, Del.
The storied Legacy will be at Constant Aviation's repair facility at Hopkins for about three months, undergoing a detailed, 2,500-hour inspection and getting a new wing.
Dan Hubbard, spokesman for the National Business Aviation Association, said it's the only business jet he's heard of that collided with a jetliner, much less made it through the horrifying occurrence.
"You're talking inches, and something else could have happened," Maiden said. "If there was a 2-foot difference, they wouldn't have hit each other. Of if the 737 was 18 inches higher, the 737 would have made it."
The crash site of the jetliner was found after a day-long search using multiple planes and helicopters. Rescuers had difficulty reaching the site because of the dense forest. Some rappelled out of aircraft to reach the wreckage.
The cause of the accident is still in dispute, although there is no question that the planes were flying at the same altitude. The accident was investigated by both the Brazilian Air Force and the U.S. National Transportation and Safety Board.
Brazil concluded the collision resulted from a combination of errors from air traffic controllers and the Legacy's pilots. The NTSB said the pilots of both planes acted properly and pointed to a variety of air traffic control errors.

Mark_Space
30th Dec 2010, 12:55
From the Wikileaks release of 21 December is this account crash investigation from the US Embassy:

Cable Viewer (http://www.wikileaks.ch/cable/2007/06/07BRASILIA1006.html)

Richard_Brazil
31st Mar 2011, 12:22
Jan Paladino was heard yesterday by videoconference from Long Island, see NY Times article below. Joe Lepore will be heard today. Although the trial of the pilots and the controllers has been separated, the controllers were heard by the same judge Tuesday in Brasilia. The judge has promised a verdict by the end of April.


http://www.nytimes.com/2011/03/31/nyregion/31plane.html?_r=1
A Trial in Brazil, With Testimony on Long Island

By WILLIAM GLABERSON (http://topics.nytimes.com/top/reference/timestopics/people/g/william_glaberson/index.html?inline=nyt-per)

Published: March 30, 2011

CENTRAL ISLIP, N.Y. — It’s a small room in the federal courthouse here. Four men sit around a table, all business, looking up at two television screens. On one of the screens, another man in a business suit speaks in Portuguese. His words are then translated into English. He is asking questions about altitude, about transponders, about air-traffic control.

Enlarge This Image
http://graphics8.nytimes.com/images/2011/03/31/nyregion/Y-PLANE1/Y-PLANE1-articleInline.jpg
Robert Stolarik for The New York Times

Jan Paul Paladino, center, and his lawyers on Wednesday on Long Island, after he spoke in his defense against Brazilian charges.


Related



On the Road: Colliding With Death at 37,000 Feet, and Living (http://www.nytimes.com/2006/10/03/business/03road.html?ref=nyregion) (October 3, 2006)
Midair Collision Probably Led to Brazil Crash, Officials Say (http://www.nytimes.com/2006/10/02/world/americas/02crash.html?ref=nyregion) (October 2, 2006)
Brazil Lays Some Blame on U.S. Pilots in Collision (http://www.nytimes.com/2008/12/11/world/americas/11brazil.html?ref=nyregion) (December 11, 2008)
Brazilian Judge Detains Pilots in Midair Collision (http://www.nytimes.com/2006/10/04/world/americas/04crash.html?ref=nyregion) (October 4, 2006)


Robert Stolarik for The New York Times

Demonstrators outside the courthouse demanded that two American pilots be held accountable.


The hushed atmosphere in this little room on Long Island belies the catastrophic matters at stake, for this is a trial stemming from a 2006 air collision at 37,000 feet on a clear day in another hemisphere that left 154 people dead, their bodies scattered in the dense rain forest (http://topics.nytimes.com/top/news/science/topics/forests_and_forestry/rain_forests/index.html?inline=nyt-classifier) of Brazil (http://topics.nytimes.com/top/news/international/countriesandterritories/brazil/index.html?inline=nyt-geo).
Two planes collided that day, a jetliner and a new commuter jet that was being delivered to its buyer. The large jet crashed; the small one was brought to an emergency landing by its two pilots, both of them American, both from Long Island. The pilots, along with several air-traffic controllers, were criminally charged in Brazil with negligence for causing the crash, but the two Americans have declined to return to that country.
So the trial has come to them, and to Central Islip. On Wednesday one of them took the stand — or, at least, a virtual stand — in his own defense. The second is to testify on Thursday. They agreed to testify, saying they did nothing but fly professionally under dire circumstances; if convicted, they seem certain to fight extradition. A prison sentence could be as long as four years.
It is not unusual for witnesses to testify on video in the United States for a foreign case. But officials with the Justice Department and the State Department were hard pressed to cite another instance in which an American citizen on trial in a distant nation was given his or her day in court here, in the United States, through a little silver camera like the one that watched the pilot Jan Paul Paladino (http://travel.nytimes.com/travel/guides/central-and-south-america/brazil/rio-de-janeiro/50071/paladino/restaurant-detail.html?inline=nyt-classifier) motionlessly on Wednesday.
It was an almost surreal day of questions haltingly asked and answered. On the screen, a waiter with a tray and a bow tie could be seen serving small cups of coffee to those in a makeshift courtroom in the justice ministry headquarters in Brasília, where relatives of the dead have staged protests and demanded punishment for the two pilots. Technical problems plagued a session that lasted hours. The video connection broke down repeatedly, and the listeners on Long Island, including the pilots’ Brazilian lawyer, learned that Portuguese turns into an indecipherable rumble if the hook-up is not perfect.
“I can’t hear,” said Mr. Paladino, who is from Westhampton Beach. “I’m sorry, forgive me; the audio’s very difficult,” he grimaced, as a Brazilian judge, Murilo Mendes, pressed ahead with question after question about how two planes could have ended up in the same spot in a deserted sky.
Treaty provisions permit this proceeding, and procedures are in place. The Justice Department works as a coordinator of sorts to make the legal sessions possible. There were the familiar trappings: an American flag in the Long Island frame (on the right screen in Central Islip) and the Brazilian flag behind Judge Mendes (left screen).
The proceedings began with the judge’s statement that Mr. Paladino had the right to remain silent. The camera in Brasília panned the room once, showing an orderly crowd awaiting the latest in a trial that has proceeded in fits and starts since the fall of 2007. The testimony of Mr. Paladino and the other pilot on the Embraer (http://topics.nytimes.com/top/news/business/companies/embraer-empresa-brasileira-de-aeronautica-sa/index.html?inline=nyt-org) Legacy 600, Joseph Lepore, is to be the last at their trial. A decision from the judge is expected in April.
The nightmare collision, the unlikely survival of the passengers on the smaller plane and the devastating fate of the Gol Airlines (http://topics.nytimes.com/top/news/business/companies/gol-linhas-aereas-inteligentes-sa/index.html?inline=nyt-org) Boeing (http://topics.nytimes.com/top/news/business/companies/boeing_company/index.html?inline=nyt-org) 737 in the dense Amazon rain forest drew wide attention. A writer who contributes to The New York Times, Joe Sharkey, happened to be on board the Legacy writing an article for another publication. He detailed his harrowing experience (http://www.nytimes.com/2006/10/03/business/03road.html) on The Times’s front page, and was questioned by officials along with other surviving passengers in 2006. He is not involved in the criminal case.
In Brazil, the story of the death of children, a medical student, a captain of industry and others aboard the Boeing 737 has been something of a national obsession, tinged at times with rumor and anti-Americanism.
As in many trials, there were moments of high drama on Wednesday. The judge spoke firmly. A pause. The translator: “Your profession, please.”
Another pause. Mr. Paladino, a pale 38-year-old, sat up a little straighter. “Pilot,” he said.
The Brazilian prosecutors have accused the American pilots of committing an offense similar to criminally negligent homicide by flying when their radar might have been off, failing to follow their flight plan and flying at the wrong altitude. The pilots say they had no warning of any malfunction and followed the instructions of air-traffic controllers.
When those charges of carelessness came up, as they did repeatedly, Mr. Paladino spoke firmly as he described what it was like in the cockpit of the smaller plane, with seven aboard, as something rocked it in the air.
Still, it was not quite the confident voice pilots use over the public address system, as he spoke looking squarely at the big flat-screen television. “I wasn’t even sure if it even involved another aircraft,” he said as he described the growing emergency. With the equipment seeming to be working and the plane on course, he said, another plane out there over the Amazon seemed impossible.
“I could not believe,” he said, “that an aircraft would be involved given all the things I just mentioned, and we would still be alive.”
But if there were those moments that brought a stark reminder of what this proceeding was about, there were many more moments when the technology seemed to conspire against real emotion. Mr. Paladino gave an impassioned explanation to rebut the claim that the pilots might have turned off the transponder that sends a signal to keep track of planes.
Again, a pause. Then the translator: “O.K. There was a break-up in your answer.”
In the courthouse, Mr. Paladino repeated himself again as he described those events over a faraway rain forest.
Next to Mr. Paladino was his Brazilian lawyer, Theo Dias, and next to him was Joel R. Weiss, his Long Island lawyer. Mr. Paladino described the last moment before the crash. He had spoken routinely to an air-traffic controller. Then, he said, “I started to transmit again, and then the collision occurred.”
On the television in the small room, the translator was back from Brasília. “I’m sorry, repeat that, please,” he said.
Benjamin Weiser contributed reporting.




A version of this article appeared in print on March 31, 2011, on page A21 of the New York edition.

Richard_Brazil
17th May 2011, 00:40
From the Folha de S. Paulo, less than an hour ago:


http://www1.folha.uol.com.br/cotidiano/916685-pilotos-do-jato-legacy-sao-condenados-a-4-anos-de-prisao.shtml

16/05/2011 - 20h52 Legacy pilots are condemned to four years of prison

ANDRÉ MONTEIRO
From SÃO PAULO

American pilots Joseph Lepore and Jan Paul Paladino, who were on the Legacy jet that collided with a Gol plane, were condemned this Monday to for years and four months of prison, for putting aviation safety at risk.
The decision was issued by Federal judge Murilo Mendes, of the Federal court of Sinop (MT). The accident took place in 2006 and caused the deaths of the 154 occupants of the Gol plane. According to the decision, they should serve the sentence is the semi-open regime (in which the prisoner only sleeps in the jail).
Currently, Paladino works for American Airlines, and Lepore continues at the charter firm ExcelAire, owner of the Legacy. The two live in the United States.
The Folha did not manage to contact the lawyers who represent the pilots in Brazil.

[photo of teleconference interrogation]
At the end of last year, the trial on the accident was divided in two: one on the pilots and the other on the air traffic controllers - accused of errors which contributed to the collision of the aircraft.
Sentence (86 pages, in Portuguese) available on G1/Globo site in two parts:

http://estaticog1.globo.com/2011/05/Golpilotosparte2.pdf and http://estaticog1.globo.com/2011/05/Golpilotosparte1.pdf

Jet Jockey A4
17th May 2011, 00:51
What a crock of sh!t!

What else to expect from a third world country.

It seems to me there is a lot of a$$ covering going on in this story.

With all the corruption in the legal system in Brazil (and other institutions) I wouldn't believe a word from anyone associated on the Brazilian side.

Anyway I'm sure we have not heard the last of this story and it will be interesting to see what the American side as to say about the verdict and what they intend to do with both pilots involved in this accident.

broadreach
17th May 2011, 01:26
Thanks, Richard, hadn't seen that.

Thanks also JetJockeyA4, for your unbiased view. Yes, there will be more on this to agitate the legal gristmill but, for practical purposes, Mr Paladino and Mr Lepore will continue flying for airlines who presumably trust their professional qualifications. Good for them.

RatherBeFlying
17th May 2011, 01:49
Brazil is not the only country capable of producing perverse verdicts in a court of law. In fact in the good ol' USA and Canada too, we frequently see longstanding murder convictions overturned.

Here in Ontario, a long sequence of murder, manslaughter and criminal negligence convictions because of a rogue pathologist have been getting overturned one by one.

The pilots may overturn the verdict on appeal, but in the meantime, they would do well to avoid any country that has an extradition agreement with Brazil -- mind you, Brazil is not in the habit of making extradition agreements with other jurisdictions.

Richard_Brazil
17th May 2011, 01:53
The sentence is not enforceable until there is no further appeal possible - a situation likely to be years down the line.

I'm reading the sentence, the judge appears not to have been taken in by the "assistant to the prosecution" who as he says, frequently complained about delay in the press, but never once in court.

Eighty-six pages take time to read, though. As of now, no articles based on it have appeared.

Understated
17th May 2011, 06:01
http://www.nytimes.com/2011/05/17/world/americas/17brazil.html?_r=1&ref=todayspaper

Richard_Brazil
17th May 2011, 19:34
Some quotes from the 86-page verdict on Joe Sharkey's blog (http://joesharkeyat.********.com/2011/05/more-on-brazil-verdict-its-excessively.html).

If link doesn't work, it's JOESHARKEY.COM (http://www.joesharkey.com) www(dot)joesharkey(dot)com

Rob21
18th May 2011, 11:14
Jet Jockey A4, don't be so angry. The sentence (4 years and 4 months) was "modified" in the US and "transformed" in to community service for Brazilian Institutions in the US.
Not so bad, uh?

Now, both pilots know how the transponder/TCAS went from ON to STAND BY.

Both pilots know they should have followed the flight plan, changing their flight level even having "lost" contact with ATC (here in Brazil we only fly on the wrong level when ATC "begs" you to do so).

Both pilots know they could have avoided sendind down that 737 if they had done their homework.

They know, and I feel sorry for them.

Jet Jockey A4
18th May 2011, 12:40
Rob21…

“Jet Jockey A4, don't be so angry. The sentence (4 years and 4 months) was "modified" in the US and "transformed" in to community service for Brazilian Institutions in the US.
Not so bad, uh?

Now, both pilots know how the transponder/TCAS went from ON to STAND BY.

Both pilots know they should have followed the flight plan, changing their flight level even having "lost" contact with ATC (here in Brazil we only fly on the wrong level when ATC "begs" you to do so).

Both pilots know they could have avoided sendind down that 737 if they had done their homework.

They know, and I feel sorry for them.”

I sense the sarcasm loud and clear...

I will start by saying I'm sorry! I jumped the gun and I should not have insulted Brazil, its judicial system and especially the military controlled ATC system, right.

I’ll admit I don’t understand Portuguese, let alone read it so I and many others will have to rely on an English version of the verdict to make some sort of judgement in this affair. We also have to keep in mind that any translation from one language to another might be flawed with missing words, badly translated words that might make you miss the exact context of a word or phrase.

From you sarcastic reply I have to deduce that you believe the Yanks are guilty of something and that they should be going to jail preferably in Brazil for the murderous act they committed.

You must also believe that the big bad Americans flexed their muscles or paid off someone including the judge with some American green back to have the verdict watered down, modified and reduced to community work done in the USA for the two pilots.

However if I believe the translated verdict, the only thing the judge said the American pilots were guilty of was that their TCAS was turned “OFF”, whether it was intentional, unintentional or that it had failed we do not know. Assuming the pilots were low time on the aircraft and that this was their first ferry of such an aircraft it is very possible that at some point in the flight that they could have selected the TCAS to “OFF” without even knowing it.

If the transponder was “OFF” then why didn't Brazilian ATC tell them?

In the end unless you believe and you can prove to me and to many others and especially the judicial system in Brazil that the American pilots did turn “OFF” their TCAS on purpose with the sole intent of a preplanned collision with the 737 to cause destruction and death of all onboard you cannot justify a “guilty” verdict, especially one that carries a 4 years and 4 month sentence for what is an “accident”.

I will agree with you on one thing and no I will not be sarcastic like you in saying it...

“I feel sorry for them”... I do because they will have to live the rest of their life knowing full well they were part of a major aviation accident in which many lives were lost.


Finally I will terminate this chat with the definition of "accident" according to Webster...

a : an unforeseen and unplanned event or circumstance.

b : lack of intention or necessity : chance <met by accident rather than by design>.

I certainly don't think their actions were planned so to me it is an accident plain and simple.

Just my $0.02.

Rob21
18th May 2011, 23:21
Jet Jockey A4,

Please, don't get me wrong. I know the pilots had no intention to cause the accident.

Of course ATC had an enormous "contribution" to the accident, and one controller was convicted.

IMHO the pilots could (or should) be able to operate the avionics properly, could have studied the route carefully and even question the controllers about the level change.

At the moment of the accident, the only controller "proficient" in English was away from his station. Maybe that's why the junior controller did not question the Legacy about their transponder. He had the primary "target" on his scope (no altitude...) and thought that the Legacy pilots knew about the altitude change.

Of course the pilots did not turn off the transponder on purpouse.

But it was off (or STBY) at the moment of the accident.

No one had directly caused the accident, but the pilots and the controllers played a big part in it.

Regards

galaxy flyer
18th May 2011, 23:32
The status of the transponder is irrelevant, it might have prevented the accident, but it didn't cause the accident. Part of any criminal proceeding is intent; no one can possibly believe the pilots intended to cause this mid-air. If a pilot willfully violates the law, does something dangerous (low flyby, for example) fine, prosecute. In this cause, no.

GF

aterpster
18th May 2011, 23:35
GF:

You're applying American (U.S.) law to a Latin American country.

Jet Jockey A4
19th May 2011, 00:54
Rob21...

"Jet Jockey A4,

Please, don't get me wrong. I know the pilots had no intention to cause the accident.

Of course ATC had an enormous "contribution" to the accident, and one controller was convicted.

IMHO the pilots could (or should) be able to operate the avionics properly, could have studied the route carefully and even question the controllers about the level change.

At the moment of the accident, the only controller "proficient" in English was away from his station. Maybe that's why the junior controller did not question the Legacy about their transponder. He had the primary "target" on his scope (no altitude...) and thought that the Legacy pilots knew about the altitude change.

Of course the pilots did not turn off the transponder on purpouse.

But it was off (or STBY) at the moment of the accident.

No one had directly caused the accident, but the pilots and the controllers played a big part in it.

Regards"

As in most accidents it's the broken links usually 3 or more that will get you in trouble.

Obviously there are many such broken links in this accident.

Starting with the controllers and Brazil's ATC system letting a new or junior controller in charge.

Language seems to be another issue here but both the controllers and pilots should be more vigilant if they feel and instruction, clearance or a readback is somewhat confusing to either party.

Yes the pilots should know how to operate their avionics but I'm pretty sure the transponder was turned "OFF" or to "STBY" by mistake without either pilots noticing it, why or how I don't know.

How do we know that a passenger visiting the cockpit while at altitude did not turn off the transponder by mistake? After all it was a ferry flight with a reporter onboard and perhaps the crew was showing off the cockpit and avionics.

What if the transponder has simply failed?

In all the above hypothetical situations, ATC should have picked it up and advised the pilots right away that they were not getting a transponder return regardless who was behind the screen.

As for studying the route before the flight well you don't know for a fact that they didn't. Heck we sometimes get wrong way altitudes to help out ATC or fly a certain segment of an airway in the wrong direction again for ATC purposes. How were these pilots supposed to know this wasn't the case?

IMHO, most of the blame lies with the ATC in this accident. The one link in this accident that could have prevented the collision, the transponder/TCAS was unfortunately turned "OFF" or on "STBY" at the wrong time.

Finally if Brazilian law cannot differentiate between a planned action causing harm or death and one that was unplanned or done by a genuine mistake with no intent, then I have to say that Brazil as some pretty stupid laws on their books.

There is no way in Hell that logically these two pilots should be guilty and have to spend time in jail for what most think is a truly unfortunate "accident".

Agnostique75
20th May 2011, 11:40
Without commenting on this particular case, some honourable members of this thread seem to be under the false impression that criminal charges brought against an individual can only stem from “wilful”, “planned” or “intentional” actions.

This is not the case and is not a specific “Latin American” curiosity. In most countries on this planet –including the USA-, if your actions or the absence thereof, can be directly linked to the death of an individual, you will be held accountable, generally in front a criminal jurisdiction. If it is demonstrated that there was no intention to cause death, the charges will be qualified accordingly: “involuntary manslaughter”, “accidental homicide”, “homicide by imprudence”, “criminal negligence” etc…

The terms are plenty to describe this situation and will vary from country to country. The principle remains however intangible.

Best regards,

A.

Richard_Brazil
20th May 2011, 12:13
“What can be said is that it is only by luck that Jomarcelo did not commit other errors as serious as those imputed to him by the Federal Prosecutors' Office. It was only luck, because competence, he didn't have. Perhaps he even imagined that he had it, but he did not. ”

“[Jomarcelo] was there, alone, without an assistant, without a supervisor, he and his lack of knowledge, he and his inaptitude to exercise the function, he and his license in his pocket, conceeded irresponsibly, only because the system needed people to work.”

“Jomarcelo is now removed from the work of control. And not because of the criminal case (...) What was done was to fix a mistake after the accident. After the authorities of the aviation system put to work in air traffic control a person who didn't have the minimum qualifications to even come near a console."

“Jomarcelo complied with the duty to be informed. Who did not comply with the duty to inform was the school that trained air traffic controllers. And even if it had complied with the duty to teach, it did not comply wih the basis duty to fail a student unsuited to the job”

“One cannot, therefore, demand, of Jomarcelo, more than he did. By his notorious deficiencies, one can only give thanks that he did not err with more frequency. If, that is, he didn't in fact err.”

“They made Jomarcelo believe that he was a controller and he, certainly believing that he really was, sat down at the console and began to "work".

onetrack
20th May 2011, 12:20
The situation that Brazil and its aviation & law fraternity cannot seem to come to grips with... is that ATC, was originally, and still is, designed to prevent aircraft from colliding.
These two aircraft collided because of failings in the setup, structure and operation of Brazilian ATC. It really is that simple.

The fact that a simple error was made by the pilots, that compounded the ATC failings, is not something they need to, or should be, punished for.
I believe that every part of the Brazilian legal response is an attempt to shift the entire blame for the collision, on to pilots who do not deserve that total blame.
The blame was laid on the Legacy pilots by the Brazilians, within hours of the collision being known. They have tried to reinforce that belief with a judgement handed down in a Brazilian court.

When you have an ATC system totally run by the military, controlling civilian operations... and there are also holes in the coverage, training, and responsibility, of that ATC... there is always going to be a disaster in the offing.

ATC Watcher
20th May 2011, 22:06
This is quite an extraordinary judgement by all counts. If I read the verdict correctly ( someone can correct me if I am wrong ) the main controller in charge ( Jomarcelo) was not "qualified" by his peers ( he actually failed) but was nevertheless put in charge of a sector by its management (i.e. the Brazilian Air force ) and left alone on the position. The judge said that Jormarcelo Portuguese was already bad and his English worse, etc.. so he released him on the account that he was not responsible as he should not have been put into this position. Then he condemmend the other controller to 3 years for failure to select a fequency on his sector ( and did not hear the legacy calls later ), as well as the 2 Legacy pilots for : "failing to monitor their instruments and avionics", and for " not having noted that their transponder/TCAS was off for nearly one hour." ! Madness!

Now appeals are going to be filed, so this is not the end, but this judgement put the ball into the air force camp, as if the Jomarcelo judgement is confirmed, then they are responsible for the collision. Hopefully when that becomes clear, the remaining controller and the 2 pilots sentences can be overturned.Let's hope so at least.

Jet Jockey A4
20th May 2011, 22:56
onetrack...

"The situation that Brazil and its aviation & law fraternity cannot seem to come to grips with... is that ATC, was originally, and still is, designed to prevent aircraft from colliding.
These two aircraft collided because of failings in the setup, structure and operation of Brazilian ATC. It really is that simple.

The fact that a simple error was made by the pilots, that compounded the ATC failings, is not something they need to, or should be, punished for.
I believe that every part of the Brazilian legal response is an attempt to shift the entire blame for the collision, on to pilots who do not deserve that total blame.
The blame was laid on the Legacy pilots by the Brazilians, within hours of the collision being known. They have tried to reinforce that belief with a judgement handed down in a Brazilian court.

When you have an ATC system totally run by the military, controlling civilian operations... and there are also holes in the coverage, training, and responsibility, of that ATC... there is always going to be a disaster in the offing."

Very well said!

aterpster
21st May 2011, 01:21
onetrack:

When you have an ATC system totally run by the military, controlling civilian operations... and there are also holes in the coverage, training, and responsibility, of that ATC... there is always going to be a disaster in the offing.


Sadly, I think the ill-informed judge is using the principle of "the last clear chance to avoid the accident."

Thus, in his mind, the TCAS would have provided the last clear chance to avoid the mid-air had the Legacy crew had it turned on.

I suspect his judgment is more of the B.S. I propose as opposed to any attempt to protect Brazil's establishments.

If I am correct, the court is severly limited in Brazil.

Richard_Brazil
21st May 2011, 02:46
Sadly, I think the ill-informed judge is using the principle of "the last clear chance to avoid the accident."

No, not the case. The opinion is really quite corageous. To find the controller most at fault innocent, on the grounds that he was so incompetent he never should have been let near a console, and ask the Prosecutor-General to indict whoever put him there ...

It's not putting all the blame on the people at the "pointy end".

His understanding of air traffic evolved, he attemped to learn and did learn. Some of his decisions - like calling an experienced pilot as a "neutral" witness were unusual and caused complaint by the lawyers on all sides, but turned out to be really surprisingly good.

The decision on the pilots is 86 pages. on the controllers 39, and I won't be doing complete translations of both. My evaluation of the judge before the verdicts was that he is independent and intelligent; on reading the verdicts I revise that to more independent and intelligent than I had thought.

The Brazilian press, on the other hand, has failed to rise to its usual standard, already dismally low.

Jomarcelo) was not "qualified" by his peers ( he actually failed)
Failed four times, actually, according to testimony in a 2007 Congressional hearing.

The decision in not stupid, it is not "least resistance", it does not look for some obscure aspect of a statute in which the judge can avoid actually judging the facts in the case. It is not going to make him any friends in the Air Force, either.

In Brazil, both the prosecution and defense can appeal. The prosecution will have a very hard time overturning any of the five counts of innocent. The guilty verdict seems less robust.

Rob21
22nd May 2011, 11:25
Richard,

I did not read all 39 pages on the controllers prosecution (do you have a link for it?).

I am curious to know if the judge took in to consideration that Jomarcello was in the console not because he wanted, but because he was ordered to...

Richard_Brazil
22nd May 2011, 12:25
I am curious to know if the judge took in to consideration that Jomarcello was in the console not because he wanted, but because he was ordered to...

'But does it not configure concrete danger, by chance, when the aviation safety system put someone to work in the task of air traffic controller, when that person does not have the least qualification? He who approves people known to be incompetent for the task is not committing the crime of Article 261 of the Criminal Code? For me, it is clear that yes. I say more. I say that, at least, a person who approves someone who is not qualified can create in the person approved the illusion that he is, in fact, a professional. Even more so in the military area, where the principle of hierarchy rules. There one cannot contest a superior order, for better or worse. If the superior says, "go there and control, you are licensed, what should the subordinate say? "No, I won't go, your order is manifestly illegal!".'

The verdict on the controllers isn't posted anywhere I'm aware of. Send me your email, and I'll send you a copy.

There was a front-page article yesterday in the Folha de S.Paulo, Brazil's leading newspaper. Their reporter in Mato Grosso, Rodrigo Vargas, has followed the accident since the beginning, and understands. There was a major article in national magazine Época, titled "We're still on collision course", but alas I am in a small town where weekly magazines arrive three days later than in the Big City.

Rob21
22nd May 2011, 14:33
Very good article on the yesterday's Folha de São Paulo newspaper. I thought that Jomarcelo was convicted, but in reality it was Lucivando...

Obrigado!!!

Richard_Brazil
22nd May 2011, 23:20
Jet Jockey A4 posted some thoughts, to which I'll give the relevant parts of the verdict. Please note I am neither a pilot nor an air traffic controller, and I am giving the judge's words, not my own.

This will answer Jet Jockey's questions, but I think it will also answer another question. The opinion is neither lazy, not stupid, nor jingoistic, no ignorant. It's well considered and well reasoned. The opinion can be disagreed with and appealed (as it certainly will be) but reading it, I think the judge is a credit to the bench.

Language seems to be another issue hereThe controller barely speaks Portuguese, knows nothing of English and, worse yet, does not have mastery of the technical skills for the exercise of the job - "he was, for me, a controller who did not have the qualifications to be a controller", said the witness."but both the controllers and pilots should be more vigilant if they feel and instruction, clearance or a readback is somewhat confusing to either party.The information was excessively clear. The expression 'permission for Eduardo Gomes' leaves no doubt that the control tower was ordering the pilots to fly at level 370 to Manaus. It's a very categorical piece of information.

If the flight level came unequivocally, but without an indication of the final destination, it would be comprehensible to demand that the pilots question the authorization, that they seek additional clarification, that they ask if the level were to be used only to Manaus or if it serves for the whole route. But no. Mister João Batista made the affirmation stripped of any ambiguity. Mister João Batista, furthermore, responsible for this tremendously gross error, decisive for the outcome that was seen, was not even indicted by the Federal Prosecutors' Office. ]And, the pilots did readback and confirm the 37,000 foot clearance to Manaus.Yes the pilots should know how to operate their avionics but I'm pretty sure the transponder was turned "OFF" or to "STBY" by mistake without either pilots noticing it, why or how I don't know. Taking into consideration the affirmation that it is not possible, through the simple handling of the FMS, to disconnect the transponder, consistency is lost to the argument that all possible technical failures having been discarded, there remains only the possibility of unintentional human error. In fact, if it is true that unintentional human error, discarding technical failure, exists as a plausible possibility and cannot be discarded, then one cannot forget or discard the hypothesis under which, at the moment of turning off the transponder, the pilots operated the FMS, a device whose handling, however incorrect it might be, does not allow, according to the Criminalistic Insititute, the turning off of the transponder. The analysis of the proof made by the prosecution and by the assistant to the prosecution takes into account only the first point, making no mention of the second. But the fact is that the technical experts’ affirmations, at the point in which they analyze the context in which the turning off of the transponder occurred, place in check the general conclusion that it is only by human failure that it could have been turned off, because at that moment and in that specific situation, in which the pilots operated the FMS, even if error were to be admitted as a concrete hypothesis, its occurrence would not have the capacity to produce the result - as is attested to, in an unequivocal manner, by the expert report. How do we know that a passenger visiting the cockpit while at altitude did not turn off the transponder by mistake? After all it was a ferry flight with a reporter onboard and perhaps the crew was showing off the cockpit and avionics.The judge doesn't cover that, presumably having correctly determined that it's not worthy of a response. However, the transponder went off during a period of over a minute of silence on the CVR while Paladino and Lepore were doing fuel calculations, Paladino on a laptop and Lepore on the FMS. As to it being Joe Sharkey, he has written what happened, on the front page of the New York Times (http://www.nytimes.com/2006/10/03/business/03road.html?scp=1&sq=joe%20sharkey%20and%2037,000%20feet&st=cse) among other locations, and he wasn't in the cockpit. If you want to ask him, do so, I won't.

What if the transponder has simply failed?What calls attention is the intentional restraint in the use of language. The report does not make a categorical affirmation, of the type “there was no failure in the equipment”, for example, before referring to the nonexistence of “factual evidence to explain the interruption of the emission of the signal”. The most that can be extracted from this affirmation in the report is, at a stretch, the conclusion that, testing the equipment after the accident, with the adoption of practices which provoke even abnormal situations, it was verified that it (the device) in that situation and at that specific moment,did not present errors. But the report does not affirm that the shutdown did not happen because of an error of N600XL’s systems. To affirm that there is no evidence which explains the shutdown of the transponder is not the same as to affirm that it did not happen because of equipment failure. The limitation of the technical work is understood. If the Legacy aircraft had had a system of recording the transponder data, the possibility of the elucidation of this controversial fact would be more easily within the reach of the experts.
In all the above hypothetical situations, ATC should have picked it up and advised the pilots right away that they were not getting a transponder return regardless who was behind the screen.The pilots’ defense also sustains, based on the legislation in force (ICA 100-12), that primary responsibility for monitoring the transponder is the Air Traffic Control Center’s. That the Center has the obligation to control the functioning of the transponder no one any longer doubts. The legal provisions indicated in the briefs, moreover, leave no doubt in this regard. But that is not the point. In criminal law, the blame of one agent does not annul the blame of the other, if both contribute to the crime. As for studying the route before the flight well you don't know for a fact that they didn't. But, if the pilots were aware of the route, it is because they were, in some manner, familiar with the plan, and accepted, because that is how the tower authorized them, to fly at level 370, fulfilling furthermore, as to the route, the trajectory foreseen in the plan. If there were unaware of the information on the plan, it would not be possible to comprehend why they took that route and not another. If the followed the route correctly, it is because they knew it. And if they knew it, it can only be because they learned it after examining the flight plan. The circumstance, then that the pilots did not contest the route - which was not in the authorization - is a proof in their favor, and not against them. This is a circumstance which greatly reinforces the supposition that they accepted, consciously, the order to fly at F370.
Heck we sometimes get wrong way altitudes to help out ATC or fly a certain segment of an airway in the wrong direction again for ATC purposes. How were these pilots supposed to know this wasn't the case?Contrary to how it may appear, it is not prohibited to fly "the wrong way". As long as it is authorized by the Center, such trajectories are perfectly possible. [...] Today it's easy to understand why it's not forbidden to fly "the wrong way". During the instructional phase of the trial, it was easy to assimilate the idea that airspace is "dynamic", that the conditions existing at any moment can change quickly, and that it is in the Control Center's responsibility for changes in altitude that may become necessary. The climb and descent of airplanes is something more common than it appears. And if it were not so common, the indisputable fact is that it is perfectly possible, and of this no one any longer has doubt. IMHO, most of the blame lies with the ATC in this accident. The one link in this accident that could have prevented the collision, the transponder/TCAS was unfortunately turned "OFF" or on "STBY" at the wrong time.

Finally if Brazilian law cannot differentiate between a planned action causing harm or death and one that was unplanned or done by a genuine mistake with no intent, then I have to say that Brazil as some pretty stupid laws on their books.The judge does explain the legal difference in the decision, but as this is a pilots' technical board and not a lawyers' technical board, I'm not going to post that part.

There is no way in Hell that logically these two pilots should be guilty and have to spend time in jail for what most think is a truly unfortunate "accident".

bubbers44
23rd May 2011, 00:22
Flying over Cuba on a N/S course we would be routinely assigned altitudes that didn't comply with the hemispheric rules of odd/even because the corridor was being intercepted from different angles. We got familiar to it and didn't think of it. ATC has 100% responsibility for traffic separation and the pilot just needs to comply.

I have had controllers tell me several times they weren't receiving my transponder so switched to the other and it worked. I don't believe they shut it off, it may have been intermitent. New airplanes always have a lot of glitches. Even new airliners have most of their problems in the first weeks until all the brand new stuff gets stable. I hold Brazilian ATC 100% responsible. Leave our pilots that complied with all your
ATC instructions alone.

aterpster
23rd May 2011, 08:16
bubbers44:

I have had controllers tell me several times they weren't receiving my transponder so switched to the other and it worked. I don't believe they shut it off, it may have been intermitent. New airplanes always have a lot of glitches. Even new airliners have most of their problems in the first weeks until all the brand new stuff gets stable. I hold Brazilian ATC 100% responsible. Leave our pilots that complied with all your
ATC instructions alone.

I am inclinded to agree with you. Nonetheless, if my recollection is correct, the controller in this case couldn't observe whether the transponder was operating, because the crash occurred in an area without radar coverage. Thus, any discussion of the transponder for TCAS purposes couldn't include the controller as a monitor of transponder operations in the area in which the collision occurred.

Rob21
23rd May 2011, 11:56
Richard,

Do you know exactly which were the words used for the authorization at São José ?

In Brazil, the normally used phraseology for clearence is : "Liberado conforme", and in the U.S they use "Cleared as filed".

When a pilot taking off from an airport in the U.S., he hears something like this: "Cleared as filed, climb and maintan thirty seven thousand feet, call Control Center 122.22..."
This is typical clearance issued by DEPARTURE.

In Brazil is pretty much the same," Liberado (cleared) conforme (as filed), mantenha (climb and maintain) 37.000 pés (37.000 feet)...

Departure gives you exactly this. Instructions for your departure. If you should maintain same altitude to destination, this is not DEPARTURE "jurisdiction", instructions en route are given by Control Center.

No tower gives liberation (or clearance) on procedures to follow in route. This is up to Control Center, and this works for any part of the world, under ICAO regs.

So, if the Legacy pilots understood they were cleared all the way to Manaus at the same altitude, based on the clearance given by DEPARTURE at São José, this sounds very strange to me.

But I don't know if after take-off from São José, when they called Centro Brasília, if they got specific instructions to not to change FL entering the Airway to Manaus.

Richard_Brazil
23rd May 2011, 12:23
the controller in this case couldn't observe whether the transponder was operating, because the crash occurred in an area without radar coverage.
Two controllers were tried in Federal court. Jomarcelo had the Legacy on his screen, with the transponder, with 37.000 feet, for many minutes, and without the transponder, for many minutes more.

When Lucivando took over, the Legacy was already in a region which Brasilia controlled, but for which only Manaus could see the radar.
Do you know exactly which were the words used for the authorization at São José ?
It's on the thread somewhere, in the verdict only in Portuguese. But no "as filed". It was apparently the practice of Brazilian ATC to give clearances that didn't follow what the written procedures specify, so much so that controllers were acquitted in the Military Court trial because they were just doing what everybody else did.

The judge complains that the controller who gave the incorrect clearance was not even indicted. See Joe Sharkey's blog for text.

For him, Gol 1907 was the second notch on his console. Twenty years and ten days before, he had sent N219AS into a granite monolith with an incorrect clearance. In that case, the accident was blamed not on ATC errors, Brasilia failing to answer calls made on assigned frequencies, inadequate English in the SJC tower, or an AIS room which was unprepared to deal with foreign pilots flying in Brazil for the first time, all of which problems were identified.

No, in 1986 the blame was put on the American pilots. "Every accident has a known precursor", "causes that are not corrected will lead to another accident". QED, and RIP 154 souls.

MountainBear
23rd May 2011, 21:20
The controller barely speaks Portuguese, knows nothing of English

Offtopic:

Once upon a time, I had volunteer gig where I was a teacher of English as Second Language, primarily to Latin American immigrants. There was one particular student that was having no end of trouble learning English and I was at my wits end on how to handle the situation. I decided to talk with some of the other students in the group to see if they could give me any advice on how to get through to him. Their response: "Don't worry. He can't speak Spanish either."

Lesson learned: some people are just dumb.

On topic:

Based on what you have transcribed RB I too think the judge is a credit to the bench.

Richard_Brazil
28th May 2011, 15:42
Embraer Legacy 600 2006 Serial #: 14500965 - General Aviation Services (http://www.genav.com/AircraftForSale/Embraer/14500965.html)

As the ad says, "Price: Make Offer".

Swiss Cheese
10th Jun 2011, 08:05
We should not forget the Honeywell Transponder on the Legacy, and the suggestions/allegations that it has a tendency to go into uncommanded sleep mode...

As always in these tragic situations, it is a chain of causes. Had the transponder been functioning, then the TCAS systems would have worked as designed...

Anyone know more about the alleged Honeywell Transponder problem?

His dudeness
10th Jun 2011, 09:49
I don´t really do, but my airplane (Cessna C680) has Honeywell (EPIC) on it as well and it does a lot of weird things IMO. We do get a master caution since the last software update when the TXPR is stby when airborne. I never had a transponder switch to stby unintentionally, but that doesn´t mean much; as I said the system does weird things. For the time being we are forbidden to fly coupled ILS´es, since there has been incidents where the A/P went below G/S at low altitudes...

ATC Watcher
13th Jun 2011, 19:16
There were some incidents involving other Embraer types equipped with same avionics. One that come to my mind is an Air france between Italy/ Swiss and France which lost his transponder and went undected for half an hour , discovered when having an airprox with a BA near Lyon. Details must be in the BEA web site , about 6 months before teh GOL/Legacy collision.

Richard_Brazil
10th Oct 2012, 21:52
The TRF1 appeals court in Brasília is to hear the Legacy pilots' case this coming Monday, 15/10/2012.

The prosecutor is asking that the sentence be increased; the defense is asking that they be acquitted of the one accusation of which they were convicted (found innocent on the other five, not that you'd know it from the Brazilian press). The prosecution is not appealing the five acquittals, though prosecutors can do that here. There's also a "Victims' Association" representing a small percent of the victims' relatives, that's calling for a pair of crosses and some spikes.

The appeal seems to have gotten more coverage in the American press via AP, than in the Brazilian press.

I vouch for the translation, not for the accuracy of the original. For example, the conversation between the PIC and the Brasilia ATC commandant was by phone, not radio as the prosecutor would have it.

- Richard

Acidente da Gol: MPF quer pena maior para pilotos do jato Legacy &mdash; Procuradoria Regional da República - 1ª Região (http://www.prr1.mpf.gov.br/noticias/acidente-da-gol-mpf-quer-pena-maior-para-pilotos-do-jato-legacy-1)

Gol accident: MPF wants greater penalty for pilots of the Legacy jet
last modified 09/10/2012 15:08
Federal Court decision sentenced the defendants to 4 years and 4 months' imprisonment in halfway house. Jail term was commuted to community service.

The Federal Prosecutor's Office issued an opinion calling for increasing the penalty for pilots Jan Paul Paladino and Joseph Lepore, involved in the Gol crash that killed 154 people in 2007. Lepore and Paladino piloted the Legacy jet that collided in midair with a Gol Boeing, not detected by the jet, which was at the time of the accident with collision avoidance systems off. The case will be heard on October 15 by the 3rd Chamber of the Regional Federal Tribunal for the 1st Region (TRF1).

The Federal Judge of the 1st Court of the Judiciary Subsection of Sinop (MT) sentenced both pilots to the penalty of four years and four months in prison in a halfway house, which was commuted to service to the community and suspension of their pilots' licenses, to be served after the judgment becomes final, that is, when it can no longer be appealed.

Not satisfied with the decision, federal prosecutors appealed to the Federal Court of the 1st Region seeking an increase of the penalty and the impossibility of commutation. The MPF based his claim based on art. 121 of the Criminal Code. According to the article, the penalty is increased by one third if the crime results from failure to observance the technical regulations of a profession, art or craft.

In the opinion, the regional prosecutor's Republic Osnir Belize defends the thesis. "The penalty should be more severe because the defendants are professional pilots, however, kept the aircraft's anti-collision system shut down for nearly an hour, which caused the accident," he said.

Osnir Belice also emphasizes that the law only authorizes the commutation when the term of imprisonment is not more than four years and the circumstances are favorable to the defendants. "In the case of Gol Flight 1907, the negligence, carelessness, recklessness and carelessness [NT: Google's translation, but it's just a list of synonyms] of the convicted pilots aggravated omiss conduct, adding to the result produced, represented by the 154 deaths," he argues.

The indictment offered by the MPF / MT in 2007 accused the pilots did of not observing the flight plan, maintaining the collision avoidance equipment (TCAS and transponder) off for almost an hour and not triggering the communication failure code after 12 unsuccessful attempts to contact with the control tower. However, the Federal Court held that the defendants' only mistake was to not notice indication on the control panel that showed the TCAS was inoperative.

For federal prosecutors, the sentence must be modified. "The defendants flew 58 minutes without contact with the flight control, without triggering the transponder and without triggering the communication failure code, which contributed to the accident," explains Belize.

Federal police said in the inquiry initiated to investigate the causes of the accident that the defendants were not aware of the flight plan. Expert examinations found that the anti-collision equipment presented no technical fault and the Cindacta IV commander, in testimony to the PF, said that Joseph Lepore, after the accident, said by radio that the TCAS was off.

According to the Legacy pilots' defense, no device issued warning signs indicating the TCAS was shut down. They also argued that the monitoring of the transponder should have been done by the flight controller, who would be responsible for informing the commander of the aircraft when the equipment was inoperable.

The representative of the MPF refutes the argument. "The civil aviation rules impose on pilots the obligation to keep all aircraft equipment on, especially the collision avoidance system and to communicate to ATC any system malfunction during the flight," he concludes.

The case will be heard by the TRF1's 3rd chamber the 15th.

Case No 2009.36.03.002962-5

Richard_Brazil
9th Mar 2013, 12:37
For those who continue to follow the case, some updates:


Here (http://nationalairwayscorporation.********.com.br/2011/10/return-of-embraer-legacy-600-n965ll.html) is a detailed account of getting N600XL from Cachimbo to Cleveland.
A photo of the Legacy with the new wing, the old one visible behind leaning up against the hangar, is here (http://nationalairwayscorporation.********.com.br/2011/10/return-of-embraer-legacy-600-n965ll.html).
Planespotters.net (http://www.planespotters.net/Production_List/Embraer/ERJ-145/14500965,XA-MHA-Private.php) says N600XL, later N965LL, is now XA-MHA and registered to Mexican charter company Flymex since Jan 23, 2013.

There has been continued coverage of the legal saga of the Legacy pilots in ainonline.com which had a reporter at the Regional Federal Tribunal hearing in Brasília on October 15, 2012.

There was a five day course in Brasília at the end of November on "The Judicial Power and Aviation Safety", which was devoted less to the aftermath of accidents, than to explaining to judges how the law can, and why it should, take measures about open landfills near airports. That conference included the Federal Police's aviation accident investigators. Again, ainonline, and the January issue of AIN, will tell you more. There's additional news, in Portuguese, on the Superior Military Tribunal's site under Notícias - Centro de Estudos Judiciários da JMU (http://cejum.stm.jus.br/noticias).

There are honest people in Brazil concerned about safety. The general in charge of CENIPA, on going into the reserves, told a national newsweekly that safety investigations should be independent of the military. I have heard the same view, privately, from a Federal judge who's studied air accident cases.

The word from the military prosecutors' office (which reports to the prosecutor-general, not to the military) is that had the controller most responsible not been removed from ATC by the Air Force, a legal effort would have been made to insure he wasn't controlling air traffic.

A disturbing development is that Sérgio Salles, the Brazilian pilot who acted as an expert witness for the Legacy pilots, is being charged by prosecutors with false testimony. This is something that is frequently threatened and rarely done. The pilot won at the trial level, the prosecution appealed (they can do that in Brazil) and even if he again wins, a prosecution is in itself punitive, costly and worrying.

easa
9th Mar 2013, 18:48
The cvr picked up the captain asking " is the tcas on ? "
It was deliberately turned off.
I can't believe the pilots were received back in America with applause. 150+ people dead.

aa73
9th Mar 2013, 23:14
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.

aa73
16th Mar 2013, 15:07
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.

aterpster
16th Mar 2013, 15:26
aa73:

Never felt safe flying in Brazil ever since then. Sorry but that's just the way it is.

How about all the places down south?

aa73
16th Mar 2013, 17:28
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?)

YRP
16th Mar 2013, 21:12
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.

aa73
17th Mar 2013, 14:16
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.

DozyWannabe
17th Mar 2013, 16:54
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 :mad: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.

misd-agin
17th Mar 2013, 22:28
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.

Fact? Or opinion?

Austrian Simon
29th Jan 2017, 15:07
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 (http://avherald.com/h?article=4a424405)

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 ...

ATC Watcher
29th Jan 2017, 17:54
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.

Austrian Simon
30th Jan 2017, 14:29
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)

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 Brasilian and US investigators).

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

ATC Watcher
30th Jan 2017, 14:57
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 .

Richard_Brazil
1st Feb 2017, 18:50
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?

The allegation against the Legacy pilots in the Brazilian press was that they were inexperienced in the model and failed to notice the "TCAS OFF" message.

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.
There's a software upgrade, which wasn't applied (pp. 24); having EASA and ICAO request that operators apply the upgrade is among the safety recommendations (pp.27). Whether LOT pilots were told of the procedures in the Dec. 2007 Embraer Operational Bulletin, the commission couldn't determine; that LOT provide simulator training on the issue is another safety recommendation (pp. 27).

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).


The prosecutor claimed the pilots turned off the transponder "by using the equipment". In the trial verdict, the judge pointed out that the Brazilian Federal Police established that the transponder can be put into standby using the RMU, but not by using, correctly or incorrectly, the FMS, and the transcript shows the pilots were using the FMS at the time. So, innocent of turning off the transponder. On appeal at the Regional Federal Tribunal, the appeals court reversed that and found them guilty of turning it off, without giving any explanation for the reversal on that point. I attended the hearing and don't recall the matter being argued.

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.

ATC Watcher
2nd Feb 2017, 16:48
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 ..

GlueBall
4th Feb 2017, 06:41
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. :ooh: