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Mid-air collision over Brasil

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Old 9th Dec 2006, 06:35
  #961 (permalink)  
 
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Originally Posted by A310driver
The news that the pilots have been released is good ....very good.
The news that they have been charged criminally is bad ....very bad.
This should be a wake-up call to all pilots flying internationally especially those flying to/in Brazil.
Should we now expect that similar charges will be laid against the ATC folks on duty and the honchos who ran(or were supposed to run) the ATC organization, even at the very top??? I expect the answer is "no" because they are part of the military and exempt from civil prosecution(or something like that).
Good show Brasilia!
Indeed. Not a very good show recently, looking at severe delays out of Brazil and the recent ATC breakdown. Do I see a power struggle here?

Good the pilots are out of the country. Maybe it might be a good idea for those who don't really need to fly there to stay out...
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Old 9th Dec 2006, 08:50
  #962 (permalink)  
 
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http://abcnews.go.com/Travel/story?id=2707598&page=1
Criminalizing Aviation Accidents Only Assures Repeats

Dec. 7, 2006— On the clear, late afternoon of Sept. 29 , two sophisticated jets approached each other along an airway known as UZ6. Their combined speed was in excess of a 1,000 miles per hour. Both were at 37,000 feet over the Amazon jungle, and neither set of pilots were aware of the other.
No alarms went off. No air traffic control warnings were given. And no rules were broken because both crews had climbed to their assigned altitude.
In a micro-second, the left, upturned "winglet" of the brand-new Embraer Legacy 600 business jet sliced into the left wing of the Boeing 737. The Embraer's pilots knew only that an explosive force of some sort had rocked them, and that they now had a marginally controllable airplane.
For the pilots of the commercial airline flight known as Gol 1907, however, the situation was far worse. Their essentially new Boeing 737 was becoming uncontrollable. As the business jet they'd hit limped toward an emergency landing, the 737 impacted the dense forest below. All 137 people aboard died.
Within hours of the crippled business jet's safe landing at an airfield just north of the collision point, the Brazilian government began investigating the accident with a painfully obvious emphasis on finding someone to blame, rather than finding an explanation for the tragedy.
The passengers and owner of the damaged Embraer 600 — held and questioned for 36 hours — were eventually released.
But even as another arm of the Brazilian government began to suspect that the crash had been nothing more than a tragic accident and not a result of any purposeful or negligent act by either set of pilots, an overzealous prosecutor was asking a Brazilian court for authority to confiscate the U.S. passports of the two American pilots.
In the weeks afterward, Brazilian authorities confronted the truth — that their own air traffic controllers had made a massive human error by placing the two jets at the same altitude in opposite directions along the same airway.
Yet no effort was made to present that evidence to the court and release the crew. Instead, the two American pilots — both personally devastated over the loss of the 737 — found themselves threatened with prosecution for 137 counts of manslaughter.
Beyond the outrage that Brazilian officials have richly earned, Brazil's willingness to criminalize an aviation accident also dealt a serious blow to aviation safety worldwide. Why? Because most air accidents result from unintended human mistakes, and the only way we find out about such mistakes, and give ourselves the chance to change our human systems in order to prevent further incidents, is by asking surviving crew members to speak openly.
But, if telling the truth about your own errors may land you in prison and ruin your life, who in their right mind would rush to give a prosecutor information that could be used against you? The result is that the mere threat of criminal prosecution for mistakes made in the cockpit (or the maintenance hangar or the control tower) utterly shuts down the flow of vital safety information we need.
When a pilot flagrantly disregards rules or procedures or instructions and knowingly puts his or her passengers and the public below at risk, it's "pilot error."
When a pilot fails because he or she is human — failures such as starting a takeoff on a runway clearly too short to sustain flight (such as in Lexington, Ky., earlier this year) — the problem is "human error." The two are markedly different.
Human error problems account for more than 85 percent of all aviation accidents. Disasters often result from pilots being imperfect, making mistakes despite their best efforts. Blaming humans for being human is at once absurd and wholly ineffective in preventing accidents.
The best way to prevent the same human errors from happening in the future is to understand everything we can about how the system supported the error, and then change that system to safely absorb such errors.
Criminal prosecution of pilots for making human errors only shuts down the flow of information we need to get even safer; it does nothing to prevent recurrences.
This does not mean that a pilot who purposefully does something unsafe (such as drink and fly) should not be held criminally liable. Subjecting such fringe-element airmen to prosecution in no way worries the 99-plus percent who would never do such things.
But equating human mistake with crime, as some nations have tried to do too often over the years, is a trend that must be stopped cold.
As the internationally respected Flight Safety Foundation said just this week in a joint resolution issued in response to Brazil's outrageous behavior: "…criminal investigations and prosecutions in the wake of aviation accidents can interfere with the efficient and effective investigation of accidents and prevent the timely and accurate determination of probable cause and issuance of recommendations to prevent recurrence." (http://www.flightsafety.org/pdf/resolution_10_06.pdf)
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Old 9th Dec 2006, 10:12
  #963 (permalink)  
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Excellent article , except for one small part :

In the weeks afterward, Brazilian authorities confronted the truth — that their own air traffic controllers had made a massive human error by placing the two jets at the same altitude in opposite directions along the same airway.
Yet no effort was made to present that evidence to the court and release the crew.
Talking about " massive human error" made by their " own controllers" " placing" aircraft at same altitude, calling this " evidence" to be presented in court, etc.. does nothing to advance his point on decriminilisation of accidents . ( especially since I do not think anybody knowingly "placed" the Legacy at the same altitude as the 737 )

He also conviniently forget the failure of the Legacy transponder and the the fact this this remained unoticed by the crew.

Based on what I have read so far, I think people, both Controllers and Pilots have been put into a situation by sofware traps , both in the ground by an ATC system full of VHF and radar coverage holes and automatically changing things , and in the air by an avionic suite prone to failures and errors difficult to spot..

Focussing on the individual people involved ( the controllers and the pilots) is perhaps human, but the real issues are in the design of systems that leave individuals in a position to eventually make errors. Change the individuals, the chances are the same errors would have been made.

The FSF statements are far beter phrased, and we should all support this. criminalisation of accidents, and incidents reporting is a disgrace that will set things back decades if Political spheres do not stop it.
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Old 9th Dec 2006, 11:09
  #964 (permalink)  
 
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They are supposed to return for trial.
I think "supposed" is the operative word here. No way they are returning......
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Old 9th Dec 2006, 12:04
  #965 (permalink)  
 
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Outstanding!

Good news regarding Mr. Lepore's and Mr. Paladino's returning home.
I knew this day would come (oh ye of little faith.)

Flight Safety link to resolution on criminalization of aviation accidents here. ABC news link was incorrect.

I think "supposed" is the operative word here. No way they are returning......
Unless the US State department becomes directly involved (as in the back-channel efforts for their release), the pilots would be compelled to return in accordance with international agreements signed between the US and Brazil, should the Brazilian government request.
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Old 9th Dec 2006, 12:19
  #966 (permalink)  
 
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Originally Posted by ATC Watcher
Excellent article , except for one small part :
Talking about " massive human error" made by their " own controllers" " placing" aircraft at same altitude, calling this " evidence" to be presented in court, etc.. does nothing to advance his point on decriminilisation of accidents . ( especially since I do not think anybody knowingly "placed" the Legacy at the same altitude as the 737 )
He also conviniently forget the failure of the Legacy transponder and the the fact this this remained unoticed by the crew...

...but on 08 Oct, I said:
You'll forgive, perhaps, my insolance in asserting that "Air Traffic Control" is a misnomer. Obviously ATC has no mechanical or electronic control of an aircraft, but has the responsibility to provide a path clear of hazards to the aircraft's destination, and provide appropriate communication.

ATC also has alternate procedures for loss of contact with an aircraft. If a flight "goes dark" for whatever reason--intentional or not--it becomes a hazard to other aircraft, and ATC must follow those contingency procedures...
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Old 9th Dec 2006, 13:04
  #967 (permalink)  
 
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I spend several hours yesterday on the steps of the Federal Police superintendency in Sγo Paulo chatting with the reporters while the pilots were inside. I got a copy of the official press release, and was one of about twenty who attended the very brief press conference afterwards.

When the police accuse someone here, the word in Portuguese is "indiciar". That is almost invariably mistranslated to English as "indict", which is far more serious, a criminal charge made by a prosecutor or grand jury. I spoke with the correspondents for Reuters and AP to try to keep a mere mistranlation from elevating what Jan and Joe's friends and neighbors read, into something more serious than it is.

The charge may not have been correctly described in any of the papers. The article is "placing a vessel or aircraft in danger"; the official press release does refer to paragraph 3, which is specifically about causing damage to a vessel or aircraft. Formally, I think, they were charged with having damaged the Boeing.

Also, there have been references to judicial cooperation between Brazil and the United States, when something is a crime in both jurisdictions. I do not know if there is American law that criminalizes "placing a vessel or aircraft in danger", and I don't know if the charge was deliberately chosen based on that. I am not a lawyer.

Here's a link to video, showing the police chief, and even the cavalry - yes, the cavalry - keeping the press from the van with the pilots:

http://gmc.globo.com/GMC/1,,2465-p-M598792,00.html

A couple of peculiar things were not covered in the press. There was an extraordinary long delay in preparing the press release, a single page that says very little. The press conference was very formalized, done only on the condition that it would be a formal statement with no questions afterwards. And that indeed was how it was done. There were not even any declarations "off the record" afterwards; I followed the reports from the principal paper to the press secretary's office to check on that. The "off the record" declarations are usually the most dangerous.

The fact that no questions were allowed may be linked to no answers being possible. While the police chief did say that "negligence" rather than "imprudence" was the reason, nothing in the press release gives a clue as to what act or failure to act resulted in the charge.

There is a line in the press release about "other conducts may be identified as other causes of the accident", the oral statement made it clear that that refers to "other people". While previous newspaper reports have said that when the inquiry is finished (it will be extended for at least another month, and probably monthly thereafter until the Air Force accident report is finished) there may be additional charges against the pilots, that was not even mentioned, must less emphasized, in the press release.

The Federal Police moved the location of the depositions on Thursday at least three times, and newspaper reports laid that to concern about the pilots "physical safety". Then they moved it to Brazil's largest city, at 08:00 AM, and kept them there for six hours, after announcing the place and time the night before.

Protests? Picket lines? Bereaved relatives of accident victims calling for American blood? How many you ask, from the families of 154 dead, in a city of eleven millions. Let me check my notes here. Ah, there it is, a total of zero.

This of course did not make the papers.

The stampedes to get pictures of them leaving were rather amusing. There were several of these, some accidental, some set off on purpose by older photographers just to see the young ones panic.

One reporter volunteered that his paper was going to send him to New York on the same plane as the pilots, and several others concurred.

The reporters treated with the greatest respect by their colleagues were Kleber Tomaz of the Folha, and Marcello Godoy of O Estado.

Godoy quoted penalties for a number of articles from the Criminal Code from his head, including Article 261, under which the pilots were charged, and which is obscure. He also quoted by heart article and paragraph numbers from ICAU regulations, and said, "When you change heading, you change flight level".

If his coverage is unsympathetic, at least he got badly sunburnt during his hours on the steps.

The pilots flew back on a chartered flight, on another Legacy. That it was another Legacy did, in several online news sources and probably on broadcast news, push the "accused" from the subheadline, farther down into the coverage.

The police chief, the delegado, would certainly be carded if he tried to drink in New York. He is presiding over the inquiry while his superior is on vacation. But there were other policemen there, including some from the Federal Police department that deals with civil aviation. These must, by necessity, have many more years of experience than he does, and a deep knowledge of the subject under investigation, of which he can have only a layman's grasp, having been in charge of this since Monday. And he's from the countyside, suddenly in the big city, and on the other side was an ex-Minister of Justice, and the national press encamped en masse on the staircase. He can't have been having a great day.

I'm not sure if this in entirely appropriate for this pilots' rumour network - I'm not a pilot, and this is first-hand. But I appreciate what I have been able to learn on the accident from reading the many pages of posts from very knowledgable people here, and thought some might be interested in this.
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Old 9th Dec 2006, 15:02
  #968 (permalink)  

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Thumbs up

Thank you Richard_Brazil, our PPRuNe reporter at the scene. Your assistance and oblique perspective is greatly appreciated.
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Old 9th Dec 2006, 17:40
  #969 (permalink)  

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The primary function of ATC is to assure positive separaton of aircraft in a manner that makes safe and efficient use of the navigable airspace.

The Legacy was cleared to maintain FL 370.

Several minutes before crossing BRS it checked in with ATC reporting level at 370. ATC acknowledged and confirmed flight level and advised "radar identified/contact". At this point, all systems are apparently normal and there is no requirement from a regulatory or procedural standpoint for the Legacy to change level; in fact, quite the opposite, as at this time, the aircraft would only be permitted to change level on direction from ATC regardless of flight plan request.

ATC data indicates that approximately 11 minutes after this communications exchange, at point well beyond BRS, the secondary radar/beacon return from the aircraft ceased. The ATC system apparently inserted and displayed a bogus level of 360 presumed to have been derived from either flight plan data or interpolation of primary radar data. In any case, where was ATC for the next half-hour before an attempt was made to contact 600XL which had descended to FL 360 without a clearance (according to ATC displayed data)? The single attempt by ATC to contact the aircraft at this point with no contact should have set-off all kinds of alarms/proccedures if ATC then determined that the Legacy was in NORDO status, primary returns only.

With opposite direction traffic assigned the same level as last assigned to the Legacy and the latter now assumed to be NORDO as a primary target only, would not the proper procedure been an all out effort to advise the next sector and any known conflicting traffic of this situation? At a minimum, the GOL flight should have been advised that they had converging traffic last assigned 370, assumed to be at 360 but unconfirmed; more appropriately, the GOL flight should have been assigned a new level which would not conflict with either 360 or 370 and/or given a separation vector(it apparently was in radar contact).

Whether there were equipment issues aboard the aircraft and/or in the ATC facilities(for example,symbology alerting to loss of ModeA/C) or in communications coverage/performance is significant only in the context of their roles as contributing factors. The breakdown of basic, elementary ATC procedures and situational awareness are at the root. PROVIDE POSITIVE SEPARATION.

The earliest time that the pilots could be assumed to have been aware of a problem was literally moments before the collision; ATC had nearly an hour to recognize and do something...anything...about the problem and certainly, after the failed attempt to communicate 30 minutes before impact, abnormal situation procedures should have been set in motion.
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Old 9th Dec 2006, 18:41
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"...Dias called the police decision "biased" and "discriminatory," and said police were simply "looking for someone to blame for the crime." ..."
____________________________________________________________ _

Well, I guess that just about sums it up!

"...placing the aircraft in danger..." ? YGBSM?!
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Old 9th Dec 2006, 22:54
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New York today




Last edited by caos; 10th Dec 2006 at 00:01.
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Old 10th Dec 2006, 02:40
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Thank you for posting that long over due photo.
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Old 10th Dec 2006, 12:58
  #973 (permalink)  
 
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the video (in portuguese)

http://gmc.globo.com/GMC/1,,2465-p-M599306,00.html
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Old 10th Dec 2006, 16:33
  #974 (permalink)  
 
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Nothing new under the sky

Forgive me - for I am a lowly silent member. But for only my second post, can I add that on this thread, it's time some of you read Band of Brothers by Ernest Gann. Susbtitute one country for another and one military scenario for another, and much will be clearer. Sadly its how the non-system works in some places....

What surprises me ( as an ex Africa flyer) is how come this happened in Brazil before it happened in Africa. Fate is the hunter - to coin a phrase....
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Old 10th Dec 2006, 17:58
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Slats 1

you are quite right..."band of brothers" does come into play in this situation.

another book that also touches on the same subject is one called, "the crowded sky".
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Old 10th Dec 2006, 19:48
  #976 (permalink)  
 
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It will be no surprise to some ppruners that Gann's one of my favorite authors, and that Band of Brothers is a favorite work. Slats One has planted it right on the numbers.
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Old 11th Dec 2006, 09:39
  #977 (permalink)  
 
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Originally Posted by Halfnut
And the relevance of this is? Has there been the slightest hint of corruption in relation to this investigation? Incompetence, possibly. Unreasonable press releases, certainly. CYA attitudes, happens everywhere. Corruption?

Things may not have happened the way our US members wanted it to, but it happened according to Brazilian law and accident investigation procedures, however dumb that may be to some. Now that the two pilots are home perhaps this accident investigation can be concluded in peace and quiet and we can find out why this happened, and hopefully prevent a recurrence of another TCAS aided collision.
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Old 11th Dec 2006, 11:33
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TCAS aided collision?
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Old 11th Dec 2006, 12:59
  #979 (permalink)  
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Actually this wasn't a "TCAS Aided" collision. We have seen those where tcas moved aircraft towards each other. We have also seen where tcas wasn't followed correctly and THAT caused a collision (not the tcas itself).

But in this case tcas did nothing, and as such had no part in the collision. What happened in this case is that it appears at the flight levels Brazilian ATC cannot function on its own without a net...

TCAS shouldn't be necesary in the flight levels. IT is, and required of course... But in this case TCAS didn't cause the accident, or induce a change of plans on the controller. It just didn't correct someone else's error. BIG difference.

And the charging the crew with not assertaining whether the Transponder was working is assenine. Again, that is more of a controller's resposibility. In many cases there is NO WAY to verify in the cockpit, unless you want me calling ATC every 30 seconds and asking. "What altitude do you show us at?"

As to there effect on air safety. If I witnessed a crash in Brazil, or had knowledge of a cause I wouldn't say a word till I left the country, in light of what happened here. NOT something you want if you are trying to make your sky safer... It simply wouldn't be worth the risk that I might be locked up or forced to stay in the country.

Cheers
Wino
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Old 11th Dec 2006, 16:06
  #980 (permalink)  
 
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Wino says:
Actually this wasn't a "TCAS Aided" collision.
Perhaps a wordsmith could call it a "TCAS-abetted" collision.

Many would agree that the presumption of having working TCAS causes some actions to be taken and others not... i.e. different rules of practice when TCAS is in the game.

If the ATC had known TCAS could not / would not resolve a conflict between opposing aircraft on the airway, they might have been quicker to vector the in-contact Gol aircraft slightly so as to cut a wider swath from the airway centerline where the Embraer was expected to be.

And if the folks in the Legacy had realised they were more than ordinarily vulnerable to traffic conflicts, due to the inop TCAS and inop radar surveillance, they might have offset their own track a teensy bit to the right of airway center to allow for 'contingencies'.

Similarly, the GOL crew might have been more inclined to enquire about opposite direction traffic if they knew there was no TCAS umbrella and realised that the adjacent ATC regions did not share or forward opposing traffic information in a timely manner.
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