Mid-air collision over Brasil

[ATC4US]

As far as I know, nobody said that the crew didn’t read back and didn’t accept the clearance properly, and everybody said that they were indeed cleared to FL 370. As far as I know NTSB/CENIPA blames the crew (besides transponder issue) for “Before beginning a flight, the pilot-in-command of an aircraft shall familiarize himself with all available information appropriate to the intended operation.” and they didn’t. And “The Legacy crew failed to act with special caution, considering that the pilots had little knowledge, not only of the Legacy’s operation, but of Brazilian air space:
• when they did not question the authorization received, with level FL370 (37,000 feet) for the entire route, differently than in the original flight plan, which foresaw different levels than previously authorized;
• when they perceived, by the onboard documentation (and, if they did not perceive, they had the professional duty to have done so) that level FL370 (37,000 feet) on airway UZ6 provided for traffic in the direction opposite that in which the aircraft was proceeding.”

[PBL]

ATC4US,

has anyone attempted to show that these alleged failings of the Legacy crew were causal to the accident?

PBL

[mm_flynn]

Originally Posted by ATC4US

"4-4-1. Clearance
a. A clearance issued by ATC is predicated on known traffic and known physical airport conditions. An ATC clearance means an authorization by ATC, for the purpose of preventing collision .... IT IS NOT AUTHORIZATION FOR A PILOT TO DEVIATE FROM ANY RULE, REGULATION, OR MINIMUM ALTITUDE NOR TO CONDUCT UNSAFE OPERATION OF THE AIRCRAFT.
b. 14 CFR Section 91.3(a) states: "The pilot-in-command of an aircraft ...
(Federal Aviation Administration - Aeronautical Information Manual - Official Guide to Basic Flight Information and ATC Procedures)

While US regulations have little direct relevance to the proceedings in Brazil, it is worth reading on in 14 CFR where it says § 91.179 IFR cruising altitude or flight level.
Unless otherwise authorized by ATC, the following rules apply—

(a) In controlled airspace. Each person operating an aircraft under IFR in level cruising flight in controlled airspace shall maintain the altitude or flight level assigned that aircraft by ATC.

This clearly says - 'maintain the last level assigned by ATC' (as all of the pilots keep saying. It would be interesting to know what Brazil's regulations are for IFR altitudes in controlled airspace are (I had naively assumed all countries required compliance with your last ATC clearance - other than in an emergency)

The prosecutors almost seem to be arguing that Brazil's ATC is not competent to assign an altitude!!

[ATC4US]

has anyone attempted to show that these alleged failings of the Legacy crew were causal to the accident?

The news (Agestado, Folha, Globo) say that the official Air Force documents (I understand that is Military Police Inquiry and CENIPA/NTSB investigation) produced until now on the investigation leave no doubts: despite the controllers performance having been a "contributing" factor in the accident, the "determining" factor in the tragedy was really the two North American pilots Joseph Lepore and Jan Paul Paladino. The Military Police Inquiry (IPM, has no legal effects to pilots), indicted the controllers for "carelessness" and "lack of diligence" and that the pilots had "neglect conduct". They say that the responsibility for navigation is that of the pilot-in-command of the aircraft and crew had to follow the indications on the aeronautic chart (I understand as the RVSM issue), which is a required document in the command cabin. They say the clearance was wrong (didn’t mention the route) and incomplete (they should had said “as filed”). Controllers said on their testimony that they knew that there was 3 different levels, but this is the way they use to do. They don’t say “as filed”. The conclusion that is reached is that the pilots considered that the current flight plan was one, while the flight controllers considered that there was another, as is explained: (1) A flight plan, requested and cleared, from the radio clearance, to the Legacy’s crew, which provided level FL370 from São José dos Campos to Manaus; (2) a flight plan, submitted and approved to and by ACC-Brasilia, which foresaw three different flight levels, obeying the flight plan originally submitted: level FL370 from São José dos Campos to Brasilia; FL360 from Brasilia to waypoint TERES; and FL380 from waypoint TERES to Manaus. The most relevant neglect conduct of the North American pilots is in respect to radio communication. They say neither they nor any other pilot in any part of the world needs controllers to know at what frequencies they should position their communications apparatus (Is this true?). The navigation charts register the frequencies sector by sector. Lepore and Paladino knew that in Sector 9, between São José and Brasilia, the frequencies are 125.05MHz 133.10MHz and 121.50MHz. On entering Sector 7, in Brasilia to Manaus, the frequencies are 123.30MHz, 128.00MHz, 133.05MHz, 135 90MHz and 121.50MHz. The frequency 121.50MHz appears in all of the sectors because it is the universal emergency band.

[mumbo jumbo]

About time IFALPA got to grips with the ridiculous nature of this 'keystone cops' Brazilian excuse for an investigation. Just reading the excuses put forward by the authorities in Brazil and the defense of their interpretation of the rules in the post above, we should be demanding that Brazil be blacklisted.

Just as we have done over the years where the aviation authorities were too ignorant and ineffective to get their airspace organised and made safer by upgrading equipment such as with Greece in the recent past, Brazil should be shamed by being awarded Black Star status. Until they get their ATC system and their ridiculous interpretations of Air Law sorted out, the flying public should be made aware of the deficiencies in Brazil and we as airline pilots who have to operate within and through their airspace should be demanding boycotts and avoidance.

The Brazilians obviously are proud of their aviation heritage but the time has come after reading the above translations of their various government organisations or lawmakers, to show them up for the buffoons that they appear to be. Boycott Brazil and their third world aviation infrastructure!

[ATC4US]

"However, to get around this problem, without being bound to the Federal Police’s conclusions in its inquiry into the accident, we will take some informative elements from it, principally the “Report on the Facts by Investigation Specialists”, registered under number DCA06RA076A, of the National Transportation Safety Board (NTSB)"
(...)
"The task of transcribing the Legacy’s Black Box was conducted by a team composed of a chairman and three members:
- Albert G. Reitan, Transportation Safety Specialist (CVR), National Transportation Safety Board (chairman of the group);
- Steven M. Demko, Air Safety Investigator, National Transportation Safety Board;
- Tony James, Air Safety Investigator, Federal Aviation Administration (FAA) which is part of the United States Transportation Department; and
- Greg Brinkman, Chief Operating Officer, ExcelAire Service, Inc."

[PBL]

ATC4US,

I thank you for some informative posts on what the current state of the investigation is. I also thank you for answering my questions directly!

I don't necessarily like what I read, but that is not to do with you, of course. Please keep us informed.

PBL

[ATC4US]

PBL,

I thank you for some informative posts...

You are wellcome.

That is what I READ. It is not what I think.

Regards.

[aviadornovato]

The Brazilians obviously are proud of their aviation heritage but the time has come after reading the above translations of their various government organisations or lawmakers, to show them up for the buffoons that they appear to be. Boycott Brazil and their third world aviation infrastructure!

First:

Our aviation infrastructure really appears to be a s... We have to admit that

Second:

I wanna see you pilots not only in websites as anonymous users proposing boycotts.
Do it openly face to face with your airline bosses !!!
Let's see how "machos" you are

[marciovp]

Cenipa

I am a proud Brazilian and Ii know a little about aviation. Perhaps I am repetitive but, unfortunatelly:

CENIPA is a branch of the Air Force, and the Air Force is responsible for Air Traffic Control in Brazil.

ATCs in Brazil, for the most part, don't speak English to carry on a conversation beyond the niddy griddy.

Either the Legacv pilots understood it wrongly or the ATC in Sao Jose told them wrongly but they were flying 370 to Manaus passing thorugh Brasilia.

The software in Brasilia showed them flying 370:360 (360 being the software that did not require confirmation with the pilots). This hapened for 7 minutes. Then the Legacy transponder went off ( see FAA commmunication) and stayed of for about one hour. The radar in Brazilia showed 360Z360, the first 360 coming from an unreliable military radar and the seconf from he software. It also showed cleaely that no info was coming from the transponder. In no moment Brasilia tried to talk to the Legacy pilots about this anormality. When they did was just to tell them the frequency of Manaus.

The Brazilian government and the Air Force have manteined that the Air Traffic Control equipments and softwares are of last generation and have no problems. The ATCs disagree.

I am wainting from a statement from NTSB.

[ATC4US]

Dear fellowcountryman marciovp,

The conclusions you are waiting for:

(...)
3. The occurrence of problems or functional failures in the software installed in the Air Traffic Control System, was not characterized, at the time of the accident;
4. The flight rules for Brazilian Air Space are correct by international standards, as prescribed by the International Civil Aviation Organization (ICAO);
5. The Air Traffic Control radiocommunication system, from an exclusively technical aspect, did not present failures, because other aircraft that flew over the region of the accident, including some close to the Legacy N600XL, did not have any communication problems; that the Legacy did not manage to communicate with ACC-Brasilia is linked to the use of differing frequencies on the part of the pilots and of some foreseen frequencies not being programmed in the console that controlled the Sector in which the aircraft flew;
6. The communications problems between controllers and pilots that occurred when the Legacy aircraft was cleared for takeoff, at the São José dos Campos Aerodrome, were not due to the low technical quality of the transmission, nor to the incorrect or deficient use of the English language in communication with the pilots: it was, essentially, due to the incorrect form in which the content was transmitted, which does not signify that there should not be investment in improvement of the flight controllers’ conversational English;
7. There were no incorrect indications nor the appearance of unknown signals on the radar screens of the air traffic controllers’ consoles; this does not indicate, however, that there does not exist the possibility of improving the system, such as by the inclusion of audio alerts to indicate exceptional circumstances;

[Rob21]

It is rare that we see so many mistakes (IMHO) on a single flight.

1. The clearance given to the pilots was incomplete. And this led to a misunderstanding about the FL. Normally, when a controler gives you clearance (in Portuguese), he starts giving you the destination and then the "details". So when the pilots got the FL (370) information, right after the destination (Manaus) and no other word on changing FLs, they read back FL 370 to Manaus and were not corrected.
The other instructions were related to the departure procedure, and that was understood.

2. The pilots did not familiarise themselves enough with the route to question the incomplete clearance. IMO, the pilots should have questioned the non standard FL for that specific airway. Allow me a simple analogy: You are on an interstate hwy, I-40, going west. Between Flagstaff and Wiliams there was an accident and the the traffic had to be deviated to momentarily accommodate westbound traffic in the "wrong" side of the road, facing (controlled) eastbound traffic. If the highway patrol (controllers) authorise you to go all the way to Los Angeles on I-40 east, something must be wrong. I would not question if I didn't know that I-40 was not a 2-way road.

3- The controller in Brasilia did not "remind" the pilots to change FLs. He probably thought the pilots knew what to do, and the pilot expected the controller to tell him what to do.

4- The pilots were not familiar with the Legacy avionics. It is too much of a coincidence that the transponder went off (or stand by) when the pilots were changing radio frequencies, and it's clear (per CVR) that they both were confused about operating the avionics.

5- The controllers did not notice the transponder was off.

6- The pilots, facing communication problems (not radio problems), did not try to call other traffic to try a "bridge" with Brasilia (or Manaus). They only did that after the collision, whith success. At that point, the transponder started transmitting again.

I am against criminal prosecution for these pilots and controllers. Maybe loose their licences, IF it is proven "reckless flying" and "reckless controlling" was the cause for the midair collision. Note I said IF...

[CDN_ATC]

These guys were American pilots.


American/Canadian pilots, and every other pilot on the planet at some point will fly through "Structured" airspace. Which means certain normally reserved eastbound/westbound levels are switched to accomodate heavy traffic flows.

It's up to the Controller to enforce those rules.

Also in the two major non-radar areas I work around, and they are the busiest non-radar areas out there, there is no such thing as a "Wrong-Way level"

For example in Gander Oceanic, and NY Oceanic (Two of the biggest and busiest non-radar areas on the planet) airplanes routinely fly what would normally be considered "WestBound" levels, eastbound and vice versa.

It has to be that way because of the required extra separation required, in order to accomodate the ever growing traffic volume. When they enter radar airspace, we identify them, and put them to a "Right Way" level.


What I'm getting at here is that flying at FL370 westbound would not be as strange to these pilots as some on this board seem to think, in fact if they're in and out of radar airspace, to them it would be routine I've never had a pilot ask me "Hey Center should we really be at this level?"


Let me also add that everyday I get professional pilots, from all the biggest majors in the world asking for an inappropriate level for no reason other than performance, so being a biz-jet and being cleared at a certain flight level, it would never cross their minds, or the minds of most pilots to question the flight level.

My opinion of course, and based on the few facts we have on the subject.

[ATC4US]

More about final CENIPA/NTSB report:

"Cenipa investigators also suggested more rigorous requirements (inspection) of foreigner pilots that operate in the country, requiring needed familiarity with Brazilian air traffic system. In this case, concluded that Legacy’s pilot-in-command didn’t have complete familiarity with glass cockpit technology, by which instructions of flight and operation of aircraft are virtually displayed in cockpit windshield. This partially explain the not intervention in the transponder, although alerts showed that it was off. One recommendation in this case is to reinforce the training for this virtual environment."


CDN_ATC,
Do you know how far is Manaus from Brasilia and how intense is the traffic in this airway? It's equal to crossing all Europe on wrong level. There is a chance of 100% to face another aircraft.

[RatherBeFlying]

Once ATC gives a crew a clearance and the crew accepts it, the crew's responsibility is to comply with the clearance.

Upon receipt of a flight plan, it is ATC's responsibility to determine a clearance that will not conflict with other traffic.

ATC's responsibility is separation.

Aircrews' responsibility is to fly in compliance with clearance.

ATC does not fly the airplane.

Aircrews do not tell ATC how to do their job -- If you see a green traffic light, do you first check to see that the traffic lights for the intersecting street are red before proceeding?

[applevid]

a green traffic light means you can go into the intersection ...IF IT IS CLEAR.

green doesn't just mean blindly go.

and one should keep the big picture in mind...ATC can make a mistake too.

[GlueBall]

Irrespective of the filed flight plan [a "plan" is not a clearance] with intended en route cruise level changes: It is is impractical reality for any airplane anywhere to change its last assigned Flight Level without talking to somebody.

Take this example: One day last year we were en route SIN-DXB. We were "cleared as filed" and over the Arabian Sea our "filed" flight plan had directed us to climb from FL340 to FL360. But Mumbai HF radio was dead on all frequencies. No other airplane over the Arabian Sea was able to contact Mumbai Radio. Needless to say, we maintained our last assigned Flight Level [thankfully as did all the other airplanes] until we had established VHF contact with Muscat Center. Between waypoints SUGID [Mumbai FIR] and PARAR [Muscat FIR], the radio outage lasted approximately 1 hour. It would have been suicidal for us to have followed our flight plan and to have climbed on our own in this busy airspace.

[ATC4US]

It seems to me that you people are forgetting that "the pilots considered that the current flight plan was one, while the flight controllers considered that there was another" and "the Air Traffic Control radiocommunication system, from an exclusively technical aspect, did not present failures, because other aircraft that flew over the region of the accident, including some close to the Legacy N600XL, did not have any communication problems". Your examples are very diferent of what really happened. GlueBall, for instance, imagine that in your filed plan you were supposed to climb from FL340 to FL350 over Arabian Sea because all planes in the same direction as you goes odd levels and against you came even. What did you do? Would you keep FL 340? I'm not a pilot, but I would never do that without ATC give me a good reason

[mumbo jumbo]

Originally Posted by ATC4US

What did you do? Would you keep FL 340? I'm not a pilot, but I would never do that without ATC give me a good reason

Aha! And once again we have the ridiculous situation where we are forced, ad nauseum, to try and explain to these "non-pilots" what happens in the real world. Of course you "...would never do that without ATC give me a good reason..." because you are not a fcuking pilot and you don't understand the rules. Give us a break and go and get your licences and a job for a few years flying commercial airliners and then come back and tell us what you would and wouldn't do if ATC told you something.

CDN_ATC has explained, very succinctly and to the point, what and how we as pilots deal with clearances. It is also explained very clearly to the "non-pilots" the difference between a flight plan and an ATC clearance. I have yet to fly anywhere in the world where the differences are not understood by professional pilots. Yet here, we once again are going to have to explain to "non-pilots" the differences.

If these few examples of Brazilian "non-pilots" way of thinking and lack of understanding of the rules of the air are anything to go by, and I assume that most of the people conducting these investigations are "non-pilots", then it's a foregone conclusion what the result is going to be. No need to hold anyones breath because the pilots are going to be blamed for the fcuk up of the Brazilian ATC.

Will you please stop trying to persuade us with your stupid comparisons of highway driving or traffic lights. If you are not a pilot then you should at least save us from your stupidity by expecting us to change what we all already know about the differences between clearances and flight plans. Brazil has shown us that they are not competent enough to deserve first world status when it comes to their airspace infrastructure and the way their accidents are investigated. Blacklist them. I have already discussed this with our flight planning department and we already have special procedures in place for any flights that cross Brazilian airspace.

It has been explained many times already on this thread the difference between a flight plan and a clearance. It has also been explained many times how we deal with differences between a flight plan and level changes once en-route, whether in a radar or non-radar environment. For the "non-pilots" to keep trying to tell us that we should have changed flight level because the flight plan said so only goes to prove to us that we are dealing with "non-pilots" who have no idea how we actually operate and for them to try and quote the rules to us is as insulting as me calling them incompetents and buffoons because of their total lack of comprehension and understanding.

The above is not meant to insult those "non-pilots" who are experts in their fields of aviation incident and accident investigation and at least have an understanding of what is being explained about the differences between flight plans and clearances. Unfortunately, their cause is not helped by the "non-pilots" who are trying to persuade us that they somehow know better than us how to fly a clearance.

[lomapaseo]

The above is not meant to insult those "non-pilots" who are experts in their fields of aviation incident and accident investigation and at least have an understanding of what is being explained about the differences between flight plans and clearances. Unfortunately, their cause is not helped by the "non-pilots" who are trying to persuade us that they somehow know better than us how to fly a clearance

If we leave out the judicial aspects of this discussion, then the only thing that counts is the resulting recommendations to prevent future accidents with similar causal factors. This will require uniformity or better understanding within the aviation infrastructure. Driving on the road on the ground has nothing to do with this.