Mid-air collision over Brasil

[ATC Watcher]

Not going to continue on this silly discussion about "what the pilots should have done or not " waste of time . Everything has already been said by professionals here. Let's move on .

What I really find interesting , is those " leaks" in the CENIPA reports posted here ( if indeed they are leaks, this is Internet after all )

I especially like this one :

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 conjunction with that one :

4. The flight rules for Brazilian Air Space are correct by international standards, as prescribed by the International Civil Aviation Organization (ICAO)

An admission that Brazil ATS system is not what the rest of the world do, even if it is not in contradiction with ICAO SARPS ?

As to the Communications :

5. The Air Traffic Control radiocommunication system, from an exclusively technical aspect, did not present failures

Ah ! so it does has failures which are not exclusively technical ?
This is perhaps why they keep on transferring a/c to other sectors always giving an alternate frequency ?

[pilot-br]

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.

Who asked you to explain us anything? We, Brazilians, are just reporting you NTSB/CENIPA conclusions published by the newspaper, and it seems that they don’t agree with you. And, it seems that many of you, as PBL ("I don't necessarily like what I read, but that is not to do with you, of course. Please keep us informed."), like to know them in advance. You don't need to loose your time if you don't want.

Ah ! so it does has failures which are not exclusively technical ?

Yes, there is a lot of them, such as:

"

(...)
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."

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.

The point is how a real pilot here deals with an undoubtly wrong clearance, and not persuade you of anything. We apologyse, if this is what you are thinking.

[ATC Watcher]

Pilot br :
on communications :

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;

If I read this , and having seen the IFATCA report on the Brasilia centre VHF and radar coverage. I can deduct that the coverage of the VHF frequency they were last given was not for the whole part of their route through that sector , and that now, in the report the pilots are accused of not having selected an alternate/spare one .
Am I correct in this interpretation ?

If yes, then I want to add , that in " normal ATS procedures " (*) it is up to ATC to initiate transfer of communications and frequency changes. Unless , (like in Oceanic for instance ), ATC says , " make your next position report ( in 20 or 30 minutes ) on xxx,xx Mhz, if no contact, alternate is XXX,xx MhZ .etc..

I did not read any of this in the Brasilia R/T transcript published by the NTSB.
For me, they were on a given sector frequency, and the boundary of that sector was until close to the point they collided, and they had no reason to select another one.
------------------------------------------------------------------------

(*) " that is what the rest of the world I know , do.

Is there something specific to Brazil mentioned in the Bazilian AIP ?

[mumbo jumbo]

Originally Posted by pilot-br

...and it seems that they don’t agree with you.

Of course it doesn't agree with me or anyone else that flies professionally for a living for that matter. Based on the information we have received so far from all the leaked reports by the Brazilians tasked with investigating this collision we are now told that the pilots were responsible for not correcting a bad clearance or adhering to a flight plan.

This just stinks of a smear campaign to incriminate the pilots because of deficiencies in the Brazilian ATC system. We, the professional pilots are, according to the leaked information, expected to read back a clearance which is then accepted on read-back and then analyze it for inconsistencies AFTER it has been accepted. On top of that, the Brazilians expect us to then go fly and whilst en-route, in a supposedly radar environment, to change flight levels whether or not we can talk with ATC even though the clearance we read back and was accepted on read-back, stipulated no level change.

Please, spare us the anguish at being berated for just being the messengers of this daft information. It reeks to high heaven of a corrupt, inept and downright dangerous administration of a third world, tin-pot air traffic system. Banana republic attitudes to blaming the 'foreigner' for the ills of their own inherently dangerous failings in some belated attempt to deflect blame or scrutiny.

Just so as it has a remote chance of sinking in... we read back a clearance and unless the controller points out that our read back is wrong we then have to assume that it was given correctly in the first place In addition, if we are cleared to our destination and only given one flight level then we stay at flight level until ATC advise us otherwise. We do not start climbing willy nilly just because the flight plan said so. That's all it was... a flight plan. The clearance from ATC is the final instruction on what to do and if they fcuked it up and didnt catch it on the read-back from the pilots then it is ATC who are at fault.

No amount of argument, especially from "non-pilots" with absolutely no grounding in aviation law and the day to day operation of jet aircraft will convince anyone else on here who happens to make their living by flying aircraft professionally, to change their minds. Even those with ATC experience are pointing out the holes in the leaked reports which make it even more obvious that there is a corrupt attempt to cover up the deficiencies in the Brazilian ATC system and to lay blame elsewhere. Pathetic.

[pilot-br]

For me, they were on a given sector frequency, and the boundary of that sector was until close to the point they collided, and they had no reason to select another one.

The following affirmative was published by Folha (biggest Brazillian newspaper) and all Brazilian newspapers as an extract of NTSB/CENIPA final report (It's not my words, it's not my opinion. Don't kill the messenger!):

"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 . 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."

The collision occurred in Sector 7 shortly before entry into FIR Amazônica.

The clearance from ATC is the final instruction on what to do and if they fcuked it up and didnt catch it on the read-back from the pilots then it is ATC who are at fault.

This is not in dispute by anyone. That is why controllers were indicted and besides that, for "lack of diligence".

[pilot-br]

One more no-pilot stupid question: If they were cleared to Manaus why they deviated to Brasília instead of going by Goiania

[pilot-br]

This just stinks of a smear campaign to incriminate the pilots...

I think that there is no "sides" here. It's a factual debate.

[aviadornovato]

Banana republic attitudes to blaming the 'foreigner' for the ills of their own inherently dangerous failings in some belated attempt to deflect blame or scrutiny.

Hey Dude,

Try to keep your conversation on-topic. If you have any adiction to dick measurement contests this is not the place for you to be.


By the way:

What are the special measures your company adopted regarding Brazil. Do they include a boycott, Dude ?

[A310driver]

Glueball

Of course, you know that "cleared as filed" refers to route only and does not include altitude/level even if requested in flight plan. The only change that can be effected without an ATC clearance would be to comply with an MEA under lost-comm conditions where the previously cleared altitude is lower than the MEA and no EFC was issued for a higher altitude at the appropriate point.

[pilot-br]

Of course, you know that "cleared as filed" refers to route only and does not include altitude/level even if requested in flight plan.

Please also give your justification, with reference to ICAO procedures.

[pilot-br]

Not necessary, I've found:

"f. Cleared to (destination) airport as filed” does NOT include the en route altitude filed in a flight plan. An en route altitude will be stated in the clearance or the pilot will be advised to expect an assigned or filed altitude within a given time frame or at a certain point after departure. This may be done verbally in the departure instructions or stated in the DP."

[Rob21]

Lost comm procedures should not include changing the transponder code?

The argument that the Legacy didn't loose radios, that is why they didn't change the transponder code, does not make any sense to me. A radio that does not have a 2-way communication, is not a "functional" equipment. If you call, and have no answer, to me this is a non working radio. The fact that the Legacy' pilots could hear radio "chats", but could not establish a 2-way communication, for me is enough to change to "lost radio" transponder code.

[pilot-br]

Rob21,

If you call, and have no answer, to me this is a non working radio.

Legacy called ATC only a few minutes before accident, so radio was ok until that moment, but ATC called Legacy 30 minutes before collision and had no answer!!! This would be the moment, for ATC, to start lost-comm procedures, and they didn't. And, they should have called them before that, when transponder went off!!

[pilot-br]

It seems that Asia are facing same issues as us:

International Civil Aviation Organization
The Seventh Meeting of the Regional Airspace Safety Monitoring Advisory Group (RASMAG/7)
Bangkok, Thailand, 4 – 8 June 2007
(...)
Summary
This paper provides the definition of Large Height Deviation (LHD) and its causes for flight operations in the RVSM airspace.
(...)
1. Introduction
1.1 For the past meetings of the RVSM implementation in the Asia Region, the issue of LHD has been discussed in great details due to the significant number of occurrences, especially in the RVSM airspace of Western Pacific/South China Sea (WPAC/SCS).
(...)
2.2 The causes of LHD occurrence include:
• Operational errors (aircraft operating at a flight level other than the assigned flight level due to ATC/Pilot loop errors and incorrect clearance), which is categorized into three causes:
- Flight crew not following the correct ATC clearance
- ATC issuing an incorrect ATC clearance
- Receiving ATC unit unable to apply the separation standards during a transfer of control responsibility between two ATC units
• Aircraft contingency events occurring in situation where the pilot cannot initially follow normal contingency procedures and is forced to climb/descend through flight levels before diverting from track,
• Deviation due to the effect of high level meteorological condition, and
• Deviation due to Technical Collision Avoidance System (TCAS) advisories, which includes:
- Flight crew correctly following the TCAS Resolution Advisory (RA)*,
- Flight crew incorrectly following the TCAS RA, and
- Any vertical displacement not conforming to the resolution advisory.
2.3 It is important to note that the LHD resulting from actions complying with the TCAS RA would not reflect risk in the RVSM airspace since it is a proper remedial action of flight crew to prevent the possible mid-air collision between aircraft. Nonetheless, it is strongly recommended that all LHD occurrences related to TCAS advisory be reported to the responsible RMA for detailed airspace safety analyses.

[Rob21]

pilot-br,

Our government should be ashamed for allowing the airspace over Brazil get in to this mess.

I heard a rumor saying some international airline pilots are being instructed by their Ops to fly on the "shoulder" of the airways when over Brazil's airspace.

I imagine how nice is to have TCAS. But Gol 1907 had a nice and working TCAS and didn't save all those people...

[ATC Watcher]

pilot-Br. Caution not to mix things up !!

LHDs are monitored to verify the target level of safety of RVSM operations.This does not explain the problems Brazil ATS currently faces.

In your case the Legacy was flying exactly at the altitude it was set to fly : 37.000 ft, and so was the GOL 737 . Should one of them had an altitude deviation , not even a large one , as it is meant in this WP , they would have missed.
The Brazil collision has nothing to do with RVSM operations or LHDs.
The collision would have occurred the same below 290.

[pilot-br]

ATC Watcher,

Are you saying that we are not facing "ATC issuing an incorrect ATC clearance?". I thought we were

Just remembering:
"It is worth clarifying that the “UZ6” airway has traffic in both directions, as if it were a “two way street”, with levels distributed from FL290 to FL410. Aircraft that are traveling from north to south fly at odd levels (FL 290, FL 310, FL 330,... to FL 410), while those that are traveling from south to north normally fly at even levels (FL 300, FL 320, FL 340,... to FL 400). This vertical space from FL290 to FL410 is reserved for RVSM - Reduced Vertical Separation Minimum – flights, with separation between aircraft being 1,000 (one thousand) feet."

I thought that when we clear a aircraft to fly a few hours northwest at level FL370 is not correct, or at least it is not the best. It's very difficult to put way all traffic that are coming odds to southeast. It seems that a better clearance would be 360 or 380, don't you think? And it seems that it is even more incorrect when we want to clear only the first leg and we clear all route. We don't know even the correct phraseology

[Brian Abraham]

From AIN today

IFALPA to Brazil: Don’t Criminalize Midair Collision
The International Federation of Air Line Pilots’ Associations (IFALPA) late last week called on the Brazilian government “to return to agreed international standards and principles in the investigation” of the midair collision of a Gol Airlines Boeing 737-800 and an ExcelAire Embraer Legacy 600. The September 2006 accident, which killed all 154 aboard the airliner, focused attention on Brazil’s air transport system, as well as the Legacy’s American pilots–Joe Leopore and Jan Paladino. In the letter to Brazilian authorities, IFALPA said it has “serious concerns” about the government’s indictment and possible criminal prosecution of the Legacy pilots and air traffic controllers. The pilot group is also disturbed that the legislative inquiry and federal police investigation have been conducted before CENIPA, Brazil’s safety board, could publish its independent technical investigation. Accordingly, IFALPA wants the Brazilian government to suspend the legislative inquiry and the Justice Ministry to adjourn criminal proceedings. Instead, IFALPA said, Brazil should focus on applying “any lessons and recommendations made in the [forthcoming] CENIPA report that will improve air safety.”

[aviadornovato]

IFALPA wants the Brazilian government to suspend the legislative inquiry and the Justice Ministry to adjourn criminal proceedings.

IFALPA will keep "wanting" those things.

First because the legislative inquiries are both already over (Senate and Chamber of Deputies).

Second because Brazil is not a dictatorship anymore and thus only the legislative itself and the Judiciary could respectively stop the legislative inquiries and "adjourn" the criminal proceedings.

The Justice Ministry only controls the Federal Police, not the Federal Prosecutors, which are independent and cannot be dismissed by the Executive Branch.

IFALPA should learn more about the countries to which it issues its recommendations

[barit1]

ATC Watcher correctly notes:

... the Legacy was flying exactly at the altitude it was set to fly : 37.000 ft, and so was the GOL 737 . Should one of them had an altitude deviation , not even a large one , as it is meant in this WP , they would have missed.

A few decades ago, autopilot and navigation accuracy were "loose" enough that a significant (albeit imperfect) additional layer of separation redundancy existed. Two aircraft on the same route at the same altitude had only a small probability of occupying exactly the same space at the same time. History will never tell us how many near-GOL-1507's happened and went unrecognized.

Autoflight refinement, RVSM, GPS ad inf. have stolen this last slice of the cheese from the aviator's safety net. Two aircraft cleared on the same route at the same altitude have a much higher probability of exchanging paint.