GOL 737 and Legacy mid-air CVRs

[Junker-13]

There is couple lawsuits against both pilots but it appears to me unless they intentionally turned the transponder OFF they have no fault.

Initially both pilots were accused to intentionally turn off the transponder. After reviewing the CVRs a couple times I found it may not be the case. At least the First Officer seemed surprise to see it was OFF.

From the Legacy 2 hrs and 5 min tape:
About 1:26 min from the beginning
First Officer: “Dude! [Do] you have the TCAS on?”
Captain: “Yes, the TCAS is off.”

Any impute from the Brazilian community on this forum? How the whole case is viewed from the general public and/or the Brazilian aviation community. I just want to find out if most opinions changed over the past 2 years.

Obrigado,

Junker-13

[alemaobaiano]

Junker

The general public doesn't seem interested, there was little in-depth coverage of the accident report in the mainstream media and the flooding in Santa Catarina is more immediate and relevant to the majority.

From the professionals there is no real surprise, the report commented heavily on deficiencies in the ATC system, which isn't news to anyone here, although a number of foreign commentators seem quite surprised that CENIPA actually said it.

AB

[Willie Everlearn]

A rather short description of the event was recently published in an article in Flight International. Ergonomics and Human Factors seem to have played a huge part in this tragedy. Then there is to a certain degree, complacency on (both) flight decks. Cruise flight, middle of the night over a rather large dark and quiet area. Not much R/T to engage in. Safety and security of TCAS. Yawn! Midair could never happen. Not even in Switzerland.

The suggestion by Brasilian authorities that the Legacy pilots MUST be criminally responsible and therefore, charged is beyond ridiculous. The odds of their having survived the mid air at all, must be somewhere close to that of discovering life on Mars. But who knows what goes through the minds of Civil Servants motivated to satisfy a public outcry for blood rather than to use prima facia evidence.

What an incredible..... nearly impossible.... accident?

may God rest the souls of those who tragically lost their lives and give peace to those who struggle on.

[alemaobaiano]

What an incredible..... nearly impossible.... accident?

Not really. One of the points made in the report was that both aircraft were modern designs, equipped with the latest navigation technology and therefore capable of following a route very accurately. As such, if the aircraft are at the same level they are very likely to collide. Hence the suggested use of offsets as one of the recommendations (something I believe European carriers already do).

AB

[Willie Everlearn]

alemaobaiano

You raise an excellent point.
My belief/understanding is that the Embraer was to climb at a specific point subject to ATC clearance, which didn't come. It went downhill from there.

Human Factors - Humans did not question ATC/Humans did not provide the climb clearance in a timely manner to the Embraer Flight Crew.
Result - Two aircraft on the same airway at the same altitude in opposing directions.
RNP - The nav accuracy of both modern aircraft must have been spot on. In the old days, with INS, it is unlikely these aircraft would have been so close at their crossing point.

The odds of any collision even with this considered must be astronomical.

Compacency due to the reliability of TCAS? That 'tap on the shoulder' when TAs are quite common.

Ergonomics - A foot placed on a footrest switching the TCAS off. What are the odds?

[Junker-13]

Can someone explain the rules in Brasil in regard to altitudes in route?

In the US even if dispatch filed a climb altitude, sometimes over a VOR but many times just a fix. We don’t climb until ATC assigned a higher altitude. In some cases usually descents ATC give a clearance that may be the same or complete different from the file flight plan. For example descent/climb and cross the XYZ VOR at FL220, but if ATC don’t say something we just don’t climb or descent without ATC authorization. Just to be honest I am not sure if this procedure is ICAO standard or is just in the US.

I don’t know if I understand it correctly, but in Brasil if the file flight plan have climbs and descents along the route, even if ATC don’t say something we are suppose to comply with the altitudes on the file flight plan. Is this just in Brazil or is like that in the rest of the ICAO world?

Note: If there is Lost of Communication in instrument conditions the pilot is supposed to squawk 7600 and fly the highest:
- Minimum altitude on the chart
- Altitude ATC has advised may be expected in a further clearance
- The last altitude give by ATC

Obrigado

Junker-13

[Junker-13]

Sorry for VanityFair article, you don’t have to read, too much sensationalism. Just listen to the tapes. The last 50 seconds of the GOL 737 and the last 42 minutes of the ExcelAir N600XL.

William Langewiesche on the Amazon air crash: About Us: vanityfair.com (http://www.vanityfair.com/magazine/2009/01/air_crash200901)

[Junker-13]

Again about 1:26 from the beginning of the ExcelAire tape they talk about the transponder.

http://atcbrasil.*************/2008/12/estado-legacy-pilots-should-answer-for.html


http://atcbrasil.*************/2008/12/aviationweek-brazil-air-force-ntsb-spar.html

[Junker-13]

Excellent, there are a total of 5 videos.

YouTube - GOL FLIGHT 1907 Part 1 (http://www.youtube.com/watch?v=TbhwVLBZbYE)

[alemaobaiano]

Ergonomics - A foot placed on a footrest switching the TCAS off. What are the odds?

Willie

That possibility was considered extremely remote by the investigators due to the physical contortions required to hit the TCAS switch, twice within 20 seconds. The most likely answer given in the report was that the PIC switched the TCAS off inadvertently when he accessed the fuel page on the RMU due to his unfamiliarity with the aircraft. The RMU can be used as a back-up to the main screens, and has a number of auxiliary pages, including fuel. As their fuel state at Manaus was the main concern at that moment, according to the CVR, it seems the most plausible option.

AB

[Willie Everlearn]

alemaobaiano

Do you know if this aircraft is similar to the E190 with a CCD? I need to research more on the Legacy. Is it not an EMB145?

Having listened to the 'CVR' from an earlier post, I find my initial listen to the recording still has me wondering whether or not the TCAS was on or off. The crew seemed to be under the impression it was ON.

obrigado

[alemaobaiano]

Willie

The Legacy is based on the ERJ-135, which is in turn based on the ERJ-145, so data for the 145 would be applicable, subject to some minor functional differences, but as I'm now on holiday I don't have the Legacy AOM to hand.

The report (from DFDR data) identified the precise moment that the TCAS was switched off from RMU 1, which is the PICs side, so we know it was off, what we don't really know is how the crew remained unaware of the situation. There are at least four separate indications of TCAS OFF visible to the crew, but as this was a switched event it wouldn't be flagged as a caution, and so no chime/buzzer/bell indication. A TCAS failure would generate a chime and a caution, IIRC, but selecting TCAS to off doesn't.

Junker

Sorry, just saw your post. I asked a few commercial pilots today, and nobody could point out the exact regulation, but the general view was that you would not change level without ATC clearance, even if it was in your flight plan, or due to an airway restriction. I won't be able to clear that up 100% until I get back to work in January and dig out the regulations, so if anyone else has the definitive answer it would be much appreciated.

BTW, before anyone accuses me of blaming the pilots and ignoring the ATC failures, I'm not. I am trying to address some specific questions from other posters, not shift responsibility.

AB

[Junker-13]

Thanks AB,

Thank you for all the information you are providing.

Very interesting about comparing the FDR with the CVR and see what the pilots were saying at the time the TCAS went OFF. I believe you are correct, there is a very strong possibility they switched the TCAS off inadvertently when they accessed the fuel page. By any chance do you know the exactly time, how many minutes from the beginning of the CVR tape the TCAS went OFF? Like that I can check it myself.

I believe no one should be charge for, pilots or controllers. Unless they intentionally did something wrong they should not be charge. We are all humans, we all make mistakes. The correct thing would be to be able to report problems without fear, learning from it, preventing future problems. (he he, I know, nice in theory) It does work for some airlines but not all.

It is nice for you to have OFF until the end of the year. I will work until tomorrow and I will get back to work on the 26.

Feliz Natal!!!

Junker

[alemaobaiano]

From page 101 of the English version the TCAS went into Standby mode between 19:00:01.5 UTC and 19:01:44.3 UTC, during discussions about fuel states.

It's also interesting that CENIPA commented on the reluctance of the controllers to answer questions due to the ongoing criminal investigation, and that FSI refused to comment on the pilot training because of possible civil legal action. How is that going to create a climate where individuals can answer questions fully in the interest of safety?

Junker, thanks, I need to get away from Sao Paulo for a while so I'm off to the mountains for a few days.....peace, quiet, and German food :ok:

AB

[Willie Everlearn]

alemaobaiano

Thanks again for the info.
Nice to see you're in Sao Paulo. Nice this time of year.

Have a pleasant and very merry Christmas as I know the weather is perfect down there. We have a very white Christmas up here in Canada.

It's unfortunate in disasters like this that someone shoulders the blame but as with most accidents whether they involve cars, boats, planes or trains, someone, usually human, IS to blame. We expect the investigators will get it right.

I was intrigued to hear the Legacy crew only caught the first three numbers of their assigned ATC frequency and had to cycle through the comms to try and contact ATC. The unfamiliar crew usually has the harder time in strange airspace. Which probably falls under Risk Management to a certain degree.

Willie

[Junker-13]

Controllers forgot to assigned lower altitude and probably forgot the handover to the next controller. NTSB report says the controller tried to contact the Legacy, but probably was already out of reach. One thing that helps is the crew to monitor 121.5 frequently.

The one thing that strikes me was the fact that the crew did not even attempt to communicate with ATC for 58 minutes while they were in an altitude that was different from the file flight plan.
(From the 2:05 minutes Legacy CVR tape: From the beginning of the tape; last ATC communication was 00:17 min on the tape; first attempt to contact ATC at 1:15 on the tape; it equals to 58 min.)

I believe they did the correct thing staying at the last assigned altitude even though the flight plan called for a descent after Brasilia but how long do you go without asking ATC for a lower altitude. They never did. It is not the first and it will not be the last that a controller forgets to give lower altitude or forgets to give a handover but how long do you go when things get too quiet. They where chatting and pushing buttons for about 1 hour to then realize they were too long without talking with someone.

Junker-13

[dannyjet]

Not only an issue of risk management but also one of situational awareness.

As a pilot you are supposed to be familiar with your filed flight plan and even though a flight plan is only a proposal for a route of flight, or better said; a proposed route to obey a legal requirement, if we take into consideration that original flights almost always change from that shown in the flight plan, again, as a pilot; I would have a copy of it and would be AWARE of its changes. I want to know how the flight differs from the flight plan as I go along and this is imperative.

I think in this case the crew relaxed too much while cruising and they got even more distracted checking the aircraft's new systems.

What strikes me the most is the fact that the transponder was on standby just minutes before the collision and on ALT mode just minutes after the collision. How can this happen?

If we talk about blame, it is either ATC's or the Legacy's crew. And there is good evidence that the latter did several mistakes along the way towards the collision, such as not communicating with ATC, not being familiar with their aircraft and therefore letting this fact to make them lose situational awareness of the flight itself, turning off the transponder even though if it was inadvertently, and having a real mess with frequencies, when the copilot tried like a dozen of them not really sure of which one to use.

I am also not blaming either pilots or ATC... but if I had to, I think it is a more serious issue to fly an unfamiliar aircraft in unfamiliar airspace and not be aware of this fact by making sure you are at least flying the correct flight plan than to be a controller and forget to clear someone for a lower altittude. The pilot should know better than ATC in this case and should not be relying completely on ATC.

My two cents based on what I know about this interesting accident.

[Junker-13]

Verbatim from the NTSB report: About 16:02, when the airplane was about 30 nm north-northwest of BRS, the transponder return from the Legacy airplane was no longer observed on ATC radar and remained undetected by ATC radar until shortly after the collision. (http://www.ntsb.gov/recs/letters/2007/A07_35_37.pdf)

The collision occurred at 16:57. That’s 55 minutes with no transponder. I don’t know if it was OFF or on Standby.

[theobvious]

This is a wake-up call. Why are you all blind?

Suppose we shoot 2 bullets at each other. Then we have the bullets equipped with collision avoidance tech. Then we put people inside the bullets. Then the collision avoidance system fails. Tell me what is the cause of the "accident"?

ARE YOU ALL DAMNED FOOLS? This was no accident. It was by design. It was bound to happen.

These men and women and children died because of our crappy use of technology. We gain the tech to make highways in the skies. Our tech reduces the millions of highways we would have without it to only a few of them. We send bullets over them.

Air Traffic Control above the Amazon is a joke. A collision is impossible WITHOUT it.

The damned truth is we managed to do it! We did it!

We look like little kids when our intention blows up in our face. Then we say it was the others that didn't play according to the rules? I think we need to be spanked real good.

"You've been living in a dream-world, Neo"