Mid-air collision over Brasil

[Ace Rimmer]

But that is exactly my point, the indictments have been made, the hearings have started WITHOUT the CENIPA report.

[pilot-br]

But that is exactly my point, the indictments have been made, the hearings have started WITHOUT the CENIPA report.

But Ace Rimmer, this is the law and Constitution, everywhere. And CENIPA doesn't have justice power. If someone don't want to talk to CENIPA, they may, and justice may cite them, justice can even arrest them if someone deny to testify. CENIPA may not do that.

If this investigation finds evidence of wilful negligence by any party then procecute away...BUT this is NOT the case here

Don't you think that a transponder off and wrong clearance is not a strong suspicion of criminal negligency? One (pilots) is blaming the other (ATC) of criminal negligency. Pilots says they were cleared, ATC says they were not. It was the pilots that accusated ATC of criminal negligency. Someone in this history acted with criminal negligency. And remember, CENIPA won't blame anyone, as forseen in Anex 13. The facts emerged in CENIPA investigation will tell who is telling the truth, in the timely moment. The process can't stop until there. A process don't stop because the technical investigation is not ready. And it's not necessary that the negligence be "wilful".

PS: I'm being blocked to post in this forum. Why do you think they are doing that?

[lomapaseo]

The facts emerged in CENIPA investigation will tell who is telling the truth, in the timely moment.

I doubt that.

The interpretation of the truth will still be left to the eyes of the reader against their already made up mind.

Cenipa will simply cite causal factors (including some that are possible but not confirmed) and recommendations for prevention of these possible factors coming together again.

It would be a shame if we (in aviation) continue to polarize ourselves about who is right and wrong, rather than fixing the causal factor linkages.

The criminal part of this is a legal matter and while decried by many under Annex 13 it will not be solved outside of Brazil.

[pilot-br]

lomapaseo,

I doubt that.

We are entering in a wider debate about justice, and I totally agree with you that truth depends on the eyes of the judge, in EVERY judgment, and not only aircraft accident judgment. The accident was here; it was Brazilians who died, so Brazil has the right to judge it, the same as if the accident were in USA, the judge would be American. I’m always trying to concentrate in the facts, but this accident is different from others we are used to see. No equipment failure was proved until now, although a lot of people insisted on this theory. And that is why I insist in the facts, and the documents I’m dealing with are the same as Joe Sharkey in their blog, but we (Brazilians) have different interpretations. It's well known that we have radar and radio covertures holes, old equipments, our airspace is in a mess, but all of these facts, that is totally true, was not possible to be related to this accident. All the radar records show all the movements of all aircrafts flying in the region. All radio conversation was recorded by other aircrafts in same region, even the Boeing recorded the messages sent to Legacy. All that was proved, until now, and it is not necessary that CENIPA tell us, points to controllers and pilots procedures faults. It is enough their testimonials and independent technical expertise point of view to we make our mind. There was conflicting testimonials of pilots and controllers. It’s not necessary that CENIPA reveals CVR to we know it. Unfortunately, there were fatalities, and then, it’s not the professionals involved (pilots, controllers and their unions) that would be the judge. Professionals are heard thru their technical investigation, but then justice goes on. It’s the same with doctors, hospitals, engineers, attorneys, drivers and all professionals that have lives on their hands. Take the doctors as example, when there is a medical malpractice doctors are heard but are not them and their classes associations that will judge, and it is not their associations that will ask justice to stop the process until they have their findings. I’m not here to convince anyone. I’m here to tell you what Brazilians think, how our justice system is. I think that a lot of people here are willing to hear us, as I am willing to hear you.

[ATC Watcher]

Pilot-br :

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

From your alias here I initially thought you were a commercial pilot. Having seen your posts now, I began to realize that you are most probably a lawyer, or at least someone knowledgeable with the law rather than in Aircraft operations and ATC.

So , for the sake of closing our debate let me just say that in our case above , the Bangkok WP on RVSM you quoted refers to height deviations to measure RVSM compliance and target Level of safety(TLS) Using this WP to prove something in a Brazil accident is not very wise.

Your vision of this case is that of a justice person : someone must have made an error, so by looking for the individuals , and punishing them we will ensure peace.( and the good name of our Country )

In Aviation accident investigation we are interested in finding the causes, and issue recommendations for the accident not to happen again .
Legal procedures and fears of prosecution should not enter the equation. If they do people are not talking and we learn nothing.

In our case here, errors have been committed of course, as always . But why is far more interesting than by who.
Restoring radar coverage and VHF coverage on all frequencies in Brasilia for instance would be one of those things a proper investigation would be looking at recommending. ( read the Fohla on line article of last monday (15 Oct) on this issue, very, very interesting)

If you take a flight tomorrow with your family between Sao Paulo and Manaus, the implementation of proper technical investigation recommendations will be 1000 times more effective in ensuring your family safe flight than sending 4 controllers and 2 pilot in jail.

Incidentally, after the Tenerife crash in 1977, one of the additional recommendation in one of the 3 reports was to warn about the " fear of prosecution " inhibiting many actors to tell the truth to the investigators then.

Unfortunately nothing has changed 30 years later.

[pilot-br]

ATC Watcher,

You are arguing that airspace safety improvement and criminal liability are mutually exclusive, and they aren't. We want our skies safer, we fly here, so I am more interested than everyone in this forum. And I am not a lawyer, not an attorney, not a pilot, and it is not a MS flight simulator pilot that pretend to be a pilot that will give me lessons. I want to know why 154 of my friends died.

[lomapaseo]

And I am not a lawyer, not an attorney, not a pilot, and it is not a MS flight simulator pilot that pretend to be a pilot that will give me lessons. I want to know why 154 of my friends died.

We continue to hear the same plea from the survivors of TWA800 and the SA295 Helederbeg accident in post after post on their internet sites. Collectively there are just as many believers as there are non-believers in any theory or causal factor linkages in these accidents, including the published final report from the chief investigating agency. It's clear to me that neither a Final technical Report nor even a judicial finding will satisfy all that the truth has been found.

For the survivors with little aviation knowledge or understanding they may feel consoled by a jury of peers or a judge. For those of us interested in continued flying with our families we are consoled by the technical understanding, the lessons learned and the adoption of the recommendations that follow.

[pilot-br]

ATC Watch:

read the Fohla on line article of last monday (15 Oct) on this issue, very, very interesting

Folha:

Of four frequencys that Legacy’s pilots could have used, two were unavailable to controllers and one not operational.
(…)
Complete transcriptions of radio conversation between ATC and aircrafts in accident region, obtained and analyzed by Folha, also prove that Cindacta-1 received and ignored at least three calls of Legacy before collision .

This is not new and was mentioned by leaked report of CENIPA, as:
19:48:13s to 19:52:07s (three minutes before collision): the Legacy tried twelve times, always without success and always using different frequencies, to make contact with Sector 7 of ACC-Brasilia, according to the following list:
19:48:13 to 19:49:30: 3 attempts - Frequency: Unknown
19:50:09 to 19:50:27: 2 attempts - Frequency: 123.30 Mhz
19:50:45 to 19:51:21: 3 attempts - Frequency: Unknown
19:51:42 : 1 attempt - Frequency: 133.05 Mhz
19:52:07 to 19:52:56 - Frequency: Unknown
In the previous list, the frequencies, when determined, signify communications that were received by ACC-Brasilia, but were not heard by the controller responsible for Sector 7, since these frequencies were not programmed on his console. The information registered as unknowns were not received by ACC-Brasilia, having been collected from their appearance on the Legacy’s CVR.

Folha:

The frequencies that must be used, indicated in the aeronautical chart for that sector, are: 123.30 Mhz, 128.00 Mhz, 133.05 and 135.90. Each sector has its own list. Pilots should be informed by Cindacta which of them they should use (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 – Agestado), whereas controllers listen and transmit on until six simultaneous frequencies in their consoles (workstation). At September, 29 of 2006, however sector 7 controllers had only frequency 135,90 Mhz available. The other five were of sectors 8 and 9, that they were watching that day

Sorry, but what is the new here? Sectors 8 and 9 are much more crowded, so if controllers allocate just one frequency for sector 7, always will have just one frequency operational.

And Folha conclusion:

These revelations don’t exempt responsibility of controllers for proved failures raised in investigations: to clear a collision altitude for the jet, to neglect surveillance of Legacy and don’t put in action foresaw lost communication procedures that could avoid the accident. Not even remove the responsibilities of pilots Joseph Lepore and Jan Paladino for flying with transponder (equipment that feeds anti-collision system) turned off.

lomapaseo:

For those of us interested in continued flying with our families we are consoled by the technical understanding, the lessons learned and the adoption of the recommendations that follow.

I respect that.

I think that all of us, Brazilians and you, understood what happened. We are only worried about some facts, as the mess of our airspace, our safety issues, that are being published by blogs and forums, althought be true, but are not cause of this accident, but just intended to baffle us and you.

[pilot-br]

Just one more provocative reflection: That day, a dozen of aircrafts received clearances of the same format as Legacy received, and for years they are receiving this kind of clearance, as the controller Felipe S.R. said in his testimony. All of these pilots understood that this format of clearance is partial and presumed they were cleared only to the first sector. Legacy was the only one aircraft that followed the rule and kept same level until destiny. Could you imagine if all of those pilots had followed the rules? God bless them by disobeying the rules.

[bsieker]

Originally Posted by pilot-br

ATC Watcher,
You are arguing that airspace safety improvement and criminal liability are mutually exclusive, and they aren't. We want our skies safer, we fly here, so I am more interested than everyone in this forum. And I am not a lawyer, not an attorney, not a pilot, and it is not a MS flight simulator pilot that pretend to be a pilot that will give me lessons. I want to know why 154 of my friends died.

For a concise argument about why criminal prosecution and the conduct of an accident ninvestigation aimed at finding causes and improving safety are conflicting, I refer you to the Joint Resolution by various organisations involved in aviation safety.

To quote its key points:

[...]

Recognizing that information given voluntarily by persons interviewed during the course of safety investigations is valuable, and that such information, if used by criminal investigators or prosecutors for the purpose of assessing guilt and punishment, could discourage persons from providing accident information, thereby adversely affecting flight safety;

[...]

1. [...] By identifying the “what” and the “why” of an accident, aviation safety professionals will be better equipped to address accident prevention for the future. Criminal investigations can and do hinder the critical information gathering portions of an accident investigations, and subsequently interfere with successful prevention of future aviation industry accidents.

2. [...] The benefit of gaining accurate information to increase safety standards and reduce recurring accidents greatly outweighs the retributive satisfaction of a criminal prosecution, conviction, and punishment. Increasing safety in the aviation industry is a greater benefit to society than seeking criminal punishment for those “guilty” of human error or tragic mistakes.

[...]

Bernd

[Rob21]

flight plan activation

1- If it was possible to file a flight plan maintaining FL 370 all the way to Manaus, why they chose to file a more "complex" and less fuel efficient plan?

2- I believe all pilots know (in Brasil also) that what you get from the tower at the airport of origin is an initial clearance. And if it is a "small" airport, you normally activate your flight plan AFTER take-off. So normally what pilots get from tower is the clearance for the BEGINNING of the flight, like the TO procedure, speed liberation, altitude and route. Destination is included as per regulations, but this does not mean that you shall fly all the way to the destination following departure instructions.

3- So my question is: Did the Legacy activate their flight plan?.
4- After take-off, leaving ATZ, since they understood they were cleared all the way to Manaus, did they inform their intentions (fly 370 all the way) to the control center?

[ATC Watcher]

Pilot -Br , in quoting the Fohla you seem to have missed ( unintentionally I hope ) the crucial NEW information in the report ( in bold ) :

The complete transcriptions of the radio conversations between
control and the aircraft in the region of the accident, obtained and analyzed
by the Folha, also show that Cindacata-1 received and ignored at least
three calls from the Legacy before the collision.
The motive is linked to the equipment's limitations: of the four
options of frequencies that the American may have used, according to the
Brazilian aeronautic chart, two were unavailable for the controller and another wasn't even in operation.
In summary, there was only one possible frequency and the American pilots
never received instructions to tune to it, as has already been released.

Also do not forget that we have not yet seen the CENIPA report,as you seem to have. For me this information was new and explains quite a lot.

you said later :

No equipment failure was proved until now, although a lot of people insisted on this theory

Playing with the words again . I would argue for equipment design failures both in the ATC system ( e.g assigning automatically Flight plan altitude, replacing Mode C altitude with military height finders average height, etc.. . and in the Embraer aircraft avionic suite ( e.g ability to switch off transponder ( and TCAS) in a single key stroke without adequate warning to the crew ) .
I consider those TO BE major technical issues and failures.

I will not even go into the facts of assigning frequencies in areas with known coverage shortcomings, and applying radar procedures in known areas with no radar coverage, placing transfer of control/communications in those black out areas, and so on.
you said :

our airspace is in a mess, but all of these facts, that is totally true, was not possible to be related to this accident.

I agree with the mess, I disagree strongly with the fact that it is not related to this accident.

[marcosCR]

ALERT

TO PPRuNe members:
The administrators are deleting all messages of this thread, without saying a word. All of today posts where deleted. Shame on you.

[marcosCR]

ALERT

TO PPRuNe members:
The administrators are deleting all messages of this thread, without saying a word. All of today posts where deleted. Shame on you.

[Lost in Saigon]

"Legacy was the only one aircraft that followed the rule and kept same level until destiny. Could you imagine if all of those pilots had followed the rules? God bless them by disobeying the rules."

NO. You are wrong. Dead wrong. On that day, the Legacy was the only aircraft to have both a transponder failure and communication failure at a critical point in their flight. I am quite sure that most of the other aircraft flying that day could have fallen into the same trap.

As pilots we are very careful to maintain the last assigned altitude unless cleared by ATC. Even if radio contact is lost.

What if GOL had just been cleared to 36,000'? What if the Legacy pilots had taken the initiative to change altitude to 36,000' on their own because they had lost radio contact? Can you just imagine the outcry if they then collided at 36,000'.

The fault here is totally with Brazilian ATC...... They were unable to maintain separation in a very straightforward situation. Many parts of the world have no radar at all. Many parts of the world have gaps in radio coverage. It is not difficult to seaprate aircraft in these situations if you follow some very basic rules.

The way I see it, Brazilian ATC has very lax procedures, poorly designed equipment, and it was just a matter of time before an accident like this happened.

Just pray it won't happen again.

[marcosCR]

Lost in Saigon:

NO. You are wrong. Dead wrong.

NO. YOU are wrong. Dead wrong. Read controllers testimonials, they use to do that for years. It seems you are lost in the world, not only in Saigon.

[ATC Watcher]

marcosCR : (re?) joined today and already aggressive, again , and wrong in your assumptions, again.

What lost-in-saigon said makes a lot of sense to most of us here. .

What do you expect with this? You know something in Aviation that we don't ?

[marcosCR]

ATC Watcher,
It seems that Lost in Saigon missed the following. Copy before administrator delete.

It is well known, that an aviation accident is not the result of an isolated failure. It is always the result of a succession of inter-related factors, what we call, here, determining factors and contributing factors. In the collision between the two aircraft under consideration, indubitably, the determining factor is identified as the turning off of the transponder/TCAS system by the Legacy’s crew.
It should be perceived that, even if all the mechanisms of the Brazilian Air Space Control System had failed, or even, if neither radars of any other form of communication existed, the accident would not have happened if the transponder/TCAS system had been on.
As contributing factors, we point to all sorts of procedural failures on the part of the Legacy pilots and of some air traffic controllers.
For the pilots, the following procedural failures can be listed, besides that indicated as determining:
• the lack of proficiency in the handling of the Embraer Legacy aircraft, especially in the operation of its avionics, characterizing incompetence;
• not using the communications failure code on the transponder;
• not using the emergency frequency in due time when the communications failure was characterized;
• conducting the aircraft in an imprudent manner and being negligent of security rules; and
• the low situational awareness of the Legacy’s crew.
For the air traffic controllers, in an overall way, can be listed the following procedural failure of a contributing type:
• flight clearance solicited and granted in an incorrect form, indicating for the Legacy cruising level FL370 (37,000 feet) from São José dos Campos to Manaus;
• the existence of deactivated radio frequencies on the controller’s console;
• not adopting the prescribed measures as soon as it was detected that the Legacy’s transponder was not functioning;
• not adopting corrective measures as soon as it was detected that the Legacy aircraft was proceeding against traffic on Airway UZ6; and
• not adopting the prescribed measures when the failure of bilateral communication was characterized.
Of the responsibilities of the Legacy crew One of the crucial questions through which the whole investigative proceeding passes is that of what was the valid flight plan was for the Legacy N600XL’s trip, and 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 in detail below:
- a flight plan, requested and cleared, from the radio clearance, to the Legacy’s crew, which provided level FL370 (37,000 feet) from São José dos Campos (SP) to Eduardo Gomes Airport, in Manaus (AM); and
- 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 (37,000 feet) from São José dos Campos (SP) to Brasilia (DF); FL360 (36,000 feet) from Brasilia (DF) to waypoint TERES; and FL380 (38,000 feet) from waypoint TERES to Eduardo Gomes Airport, in Manaus (AM).
This fact, especially, has served as an argument for those who take up the defense of the North American pilots, as they understand that the current flight plan corresponds to the verbal authorization provided them on the departure from São José dos Campos, and in which, considering the procedural rules, they have reason on their side. However, in at least two moments related to this fact, 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 (sic);
• 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. Although there is documentary evidence the crew had marked the flight route on an aeronautic chart of Brazilian air space, according to the indictment presented by the Federal Prosecutors’ Office against the pilots, as far as everything has been seen, the probably is immense that the pilots did not even become aware of the originally presented flight plan, only coming to worry to about this after embarking on the aircraft, since there are no records of their presence in the AIS Room of the São José dos Campos Aerodrome.
The lack of greater caution in the conduct of the aircraft can be observed by reading the transcription of the conversation between the crew, as per several transcripts presented in previous chapters of this same report. In truth, one verifies, yes, an evident carelessness in their conduct, allied to a lack of proficiency in handling the aircraft which they crewed, proving that the qualification formally documented does not correspond to the qualification in fact required.
Here is appealed to, as corroboration, the opinion of Commandant GEORGE WILLIAM CÉSAR DE ARARIPE SUCUPIRA, President of the Association of Aircraft Pilots and Proprietors, who testified to this CPI:
“(...)
It is difficult and not recommended that you emit an opinion on an accident before analyzing all of the causes that led to it. But, in summary, the attitude of the airplane was so contrary to any kind of regulation that there’s nothing to say. That is to say, the primary blame is the airplane’s for being on an incorrect altitude, and the airplane not respecting the flight plan that was done.
(...)
and they only noticed that they had the TCAS turned off and the transponder in the stand by position, after the blow they took. And they didn’t know what it was (...)”

[lomapaseo]

Legacy was the only aircraft to have both a transponder failure and communication failure at a critical point in their flight. I am quite sure that most of the other aircraft flying that day could have fallen into the same trap.

I agree that both the loss of communications and the transponder failure are both layers of swiss cheese that were nibbled at or perhaps even devoured whole. I would like to understand just how important so I'm looking for some relavancy here.
I'm sure that there are some individual statistics on communication failures as well as transponder failures. Are these airways so crowded that if these two failure conditions combine together the flight is doomed?
Or do we have yet another ingedient or two that makes this accident stand out?
Else we had to have just a random roll of the dice where several ingedients had to combine together?

[rafaelMX]

PPRuNe,
You like to play games. Me too. Be prepared. People will know who you are and this will not contribute to your cause.