Mid-air collision over Brasil

[varigflier]

Marty,

Don't come and fly here. After living in the states for most of my life, all I wanted to do was to come back and fly for the airlines here. 2 years later, I am ready to get out of here and not come back for a long time. The country is great to visit on vacation but living here and flying here sucks. You would not believe the type of captains we fly with here. People who barely know the difference between left and right, yet they think they are GOD because they have the 4 stripes. FOs get no respect here at all. CRM is 0% and ATC.....well I don't think I need to say anything about that. Maintenance is ok, accidents happen because of human error, mostly captain error, as FOs aren't allowed to do much, let alone have an opinion on the flight.
Not too long ago, our chief pilot and another captain high up almost killed everybody in EZE as they almost ran out of fuel and to cover it up, they ripped the pages off the a/c log. These are the same people who demand knowledge and a high degree of technical skills from FOs, yet they can't even manage their fuel burn and hold times. I'll take the worse airline in the states anyday over these idiots.

[marty1468]

WOW! It is really THAT bad huh? Thanks for the tip. I'll show my wife. I love Brazil and the people there but it's probably not the best place to get a job flying. Thanks for the tip Varigflier

[varigflier]

No problem Marty. Unfortunately it is really bad. I wouldn't want people to make the same mistake I made. Had I gone somewhere else, I would've been better off today. For the first time in my life I dread going to my flying job and can't wait to get out of here. Things have gotten worse since the accidents and if people don't do something about it, another one will come, it's just a matter of time.

[DA7X]

Hey Varigflier, I've been flying in Brazil for the last 32 years. I've come up the ranks, from F/E to Captain, your view is a very biased one, there are jerks (Capt and F/O) anywhere you go in this world. As the old saying goes "the grass is always greener on the other side", so my advice to you is go, get out of here fast, you are "too good" for us mortal brazilians.

[Richard_Brazil]

Accident commission clarification on Legacy transponder

On November 11, 2007, the Gol 1907 accident investigation commission issued an official statement on the Legacy transponder. It hasn't been posted here, so here's a link and a translation.

The statement doesn't say what caused the transponder to be disconnected, instead it lists several possibilities that have been discarded.

I am not a pilot, but I did have the opportunity in December to sit in the left-hand pilot's seat of a Legacy. I tried using the footrest, as warned against by the FAA. I couldn't push the fourth button on the RMU that way, and don't see how anyone else could. It's my personal and unprofessional opinion that the accident commission and not the FAA is correct on this, it wasn't the footrest.

- Richard

http://www.fab.mil.br/imprensa/Noticias/2007/11_nov/2611_voo_1907_comissao.htm

Flight 1907 – Commission clarifies on transponder

Because of the release of information, on the part of organs of the domestic and international press, on the accidental interruption of transponder transmissions in the case of the Flight 1907 accident, which provoked the non-functioning of the anti-collision system, the Aeronautic Accident Commission of Investigation informs that:

1) Up to now, there are no indications that there occurred an intentional act on the part of the crew of aircraft prefix NX600L in the sense of interrupting the transponder's transmission (STAND BY mode) ;

2) Ergonometic studies, CVR (Cockpit Voice Recorder) data, and reconstructions demonstrate that:

- The interruption of transponder transmissions occurred during a period of silence in the cabin, lasting 1 minute and 43 seconds, while the pilots of aircraft NX600L performed flight planning calculations for the next stage of the trip, with the pilot on the right using a laptop;

- According to the report of the reenactment flight, there is no way that a laptop resting on the lap of the pilot on the right can touch the button on the RMU (Radio Management Unit) control screen twice, in less than 20 seconds, to put the transponder in STAND BY mode;

- There is no way to utilize the footrest during the flight with the seat in the normal piloting position. It would be necessary to move it back. The movements of the seat positions are registered on the CVR and there is no register of movement (cabin noise) during the period in which the transponder ceases operation;

- The footrests have a protection which impedes a shoe sole from directly contacting the panel;

- If this occurs by an action by the pilot on the left, flexing and contorting his right foot, the buttons reached would be the first two, from top to bottom and on the left side of the RMU control panel, which have as their function the changing of the radio frequencies, and not the fourth button, which would permit changing the transponder mode (if it were touched twice in succession, in an interval of less than 20 seconds);

- Only the pilot on the left can, observing the description in the previous item, place his foot on the left side of the RMU);

- On the CVR, there is a commentary by the pilot on the left recommending not putting feet up in the cabin during the flight.

From all the evidence presented, the Commission reiterates that the conclusions aired by some organizations and press organs, domestic and international, on the use of the laptop or of the "footrest" on the flight in question, do not have any technical support in the work of the Aeronautic Accident Commission of Investigation, which is responsible for the procedure aimed at prevention.

Source: Aeronautic Accident Commission of Investigation / CENIPA

[410]

How long has it been since this easily avoidable tragedy? If the primary cause had been something of a technical nature, we would have seen a technical instruction from the manufacturer or the regulator demanding the problem be fixed post haste before the aircraft type concerned was allowed to continue flying.

Yet, despite everyone who flys the line knowing with utter certainty that if even only one of the two aircraft involved in this tragedy had been flying offset, the whole sorry episode would have amounted to nothing more than a filed and forgotten Air Safety Report (if that!!!), almost nothing has been done (granted, NATS are now 'encouraging' pilots to use offset not just for wake avoidance and Chinese ATC are leading the way in sometimes telling aircraft to fly offset), and we contine to fly right down the centreline of airways with ultra accurate navigation equipment.

An outsider - or a litigation lawyer - might ask why in the world we and every regulatory authority worldwide haven't seen the light and made enroute offsetting mandatory everywhere.

[Blip]

Here here 410!!

We offset when we drive a car down a country road don't we? Makes perfect sense. Why should it be such a big deal when flying an aeroplane?

All that has to be done is to define an air route with a horizontal dimension, say 1 nm either side of the centreline, and allow aircraft to pick a random fraction of a mile offset right of centreline e.g. 0.2 nm, or 0.7 nm right ( rather than a set distance of 1.0 nm just incase some idiot in the opposite direction enters an offset 1.0 nm left of centreline.)

Here in Australia we have first class ATC but I still prefer to offset just 0.2 nm right of track when flying trans-continental and out of radar coverage for this very reason.

[Wiley]

Blip, what equipment to you fly that allows .1nm offset?

[Blip]

Hello Wiley.

B737 NG

I also wanted to mention that there are serious ATC shortages here in Australia at the moment, to the point where we are being forced to use TIBA procedures for hours at a time during normal business hours in airspace surrounding some of our main cities!

The pressure our poor ATCer's must be working under. I hope the issues can be solved soon!

PS I just noticed the thread started by 410 about making offsets standard procedure and am reading though it now.

[Richard_Brazil]

"The risk of aviation disaster has not diminished"

The cover story in the January 25 issue of Época magazine, the number two Brazilian newsweekly, is titled "WORRY" and claims that nothing has been done to fix the ATC system, citing several incidents.

This cannot be taken at face value. For example in one incident of close approach or near collision (June 12, 2007, 15:30, São Paulo Guarulhos airport, Alitalia Boeing 777 AZA677 and Beechcraft King Air F90 PT LYZ. ) Época has a drawing of the planes separated by only 30 meters of vertical distance, and that's what is says in the text. However, the planes were also 1.2 nautical miles apart. The Air Force said it clarified that. Época says well, the air force confirmed the 30 meters, and it just disregarded the 1.2 nautical miles as being another subject. Right.

Two other incidents related are in the same region as the Legacy/Gol 1907 collision. One, on June 3, 2007, at 02:30 (UTC) as Air Canada flight 091 from Guarulhos in São Paulo to Toronto neared Manaus airspace at 32,000 feet, it couldn't make contact with ATC, and began to circle until it could establish communications. However, radar was out and it couldn't be seen by ATC. Momentarily it appeared on the screen, and ATC diverted American Airlines Flight 950 from Guarulhos to JFK and Delta Flight 120 also from Guarulhos to JFK, which were coming close behind at the same altitude.

There's also a reference to radar screens giving incorrect data on flights, again in the Sinop/Cachimbo region where the Gol Boeing went down. That can best been seen in the diagram accompanying the text, available (in Portuguese) here:
http://epoca.globo.com/infograficos/506_aviacao.html

Below, a partial translation of the Época article.

- Richard

Unpublished Air Force documents reveal that the risk of aviation disaster has not diminished

25/01/2008 - 23:18 | Issue no. 506

Cover Story:
WORRY

Unpublished Air Force documents reveal situations with high accident risks in Brazilian air space. Weren't two tragedies enough?

Wálter Nunes with Matheus Leitão
On June 12 of last year, the Presidency of the Republic's Airbus 319, known as Aerolula, took off from Guarulhos International Airport at about 15:30. President Luiz Inácio Lula da Silva had participated in the 7th CUT National Congress of Metal Workers and was returning to Brasilia. Every time the Presidency of the Republic's airplane turns on its motors, air traffic control increases its alertness. The distances between airplanes are increased and the controller begins to treat as a priority the airplane which appears on the control screen with the tag FAB01, the principal plane of the Brazilian Air Force fleet.



On that day it was no different. Aerolula was the center of attention. Until a breakdown in the Guarulhos control room blacked out three of the four consoles, the devices that allow the visualization of aircraft. With only one of them working, the controller responsible for the security of the Presidential aircraft began to monitor another 13 airplanes. At that instant, an Alitalia Boeing 777, call sign AZA677, which was taking from Guarulhos on its way to Italy, was rapidly approaching a private bimotor, call sign PT LYZ. [It seems to be a Beechcraft King Air F90, belonging to Ícaro Taxi Aéreo.] There was a high risk of collision. The air traffic controllers, perceiving the possibility of an accident, altered the trajectory of the Italian plane. But, as the two aircrafts' routes foresaw a curve soon ahead, the alteration determined wound up throwing one plane into the other. Only 30 meters separated the belly of the Alitalia plane from the roof of the bimotor. It seems like a long distance. For airplanes at an average velocity of 550 mph, it's not. The minimum safety margin, determined by international standards, is 300 meters.



The FAB (Brazilian Air Force) internal report classified the incident as serious, with a critical collision risk. The the Air Force internal investigation's conclusion is a synthesis of the problems of Brazilian air traffic control: equipment fails, the controllers work in improper conditions and are overloaded. The controller, with 14 airplanes on the same screen, one of them being Aerolula, erred. And almost caused a tragedy.

It was not the only case of a near accident in recent months. Internal Air Force documents, to which ÉPOCA had access, show hundreds of records of air traffic control failures. They go from breakdowns in equipment and maintenance failures to the existence of locations in Brazilian air space that the radars don't manage to monitor. They are failures similar to those that contributed to the accident with the Gol Boeing in September of 2006. After the collision with the Legacy jet, the Gol airplane crashed, killing 154 people. During the investigations of this tragedy, the country was alerted to the problems of air traffic control personnel and equipment. And began to have doubts about the true safety conditions of Brazilian aviation.

A second large-scale accident reinforced the trauma. On trying to land on a rainy day, in July, a TAM airplane overshot the runway, collided with one of the airline's warehouses and exploded, killing 199 people. Seventeen months after the aviation crisis began, doubts remain. Is traveling by air in Brazil safe? For Air Major-Brigadier Ramon Borges Cardoso, director-general of the Department of Air Space Control (Decea), "In terms of safety, we continue very well." According to him, the country was always safe. It has one of the best controls of air traffic in the world. The opinion is the opposite of that of the Swiss president of the International Federation of Air Traffic Controllers (Ifacta), Marc Baumgartner. "A new aviation accident in Brazil is a question of time", he says.

Some of the documents that the Air Force keeps secret seem to support Baumgartner. There, there are reported cases in which disasters were narrowly averted (see table). There are critical incidents - when one aircraft comes closer than it should to another. There are serious equipment failures, such as a radar that informs incorrect position and velocity for an airplane. And there is a record of a trainee participating in the monitoring of aircraft on his first day on the job.

"The number of incidents in Brazilian air space is similar to Europe, where there are ten times more passengers"

[...]

On this point, it's important to clarify what sort of risk this is. In the two aviation disasters of recent months, 353 people died. Accidents on the country's roads and highways kill 36,000 people a year. Diseases linked to cigarettes, more than 200,000. It is much less dangerous to fly than to drive a car on a street. But, historically, society accepts fewer risks when dealing with flight.

One of the problems indicated by pilots and air traffic controllers is the recurring failure of radars (which allow seeing the flights' location and information) and of the communication frequencies by which airplane and tower stay in verbal contact. Internal Air Force reports show that errors can cause accidents. Such as that involving a Canadian airplane which was flying across Brazil on its way to Toronto, on June 3 of last year. An Air Canada Boeing 767-300 was leaving the region controlled by Cindacta 1, in Brasilia, to enter the area controlled by Cindacta 4, in Manaus. Without managing to make contact the the flight control centers, the Air Canada pilot began to circle in Brasilia air space, but did not appear on the controllers' screens. He was mute and invisible. Two North American aircraft, belonging to American Airlines and Delta Air Lines, flew in the direction of the Canadian airplane at the same altitude, 32,000 feet. Suddenly, the image of the Air Canada plane appeared on the screen of the Brasilia flight controller - and quickly vanished. Unable to contact the Canadian plane, the Brasilia controller detoured the two American planes and avoided a tragedy. In the Danger Report, a document the controller filled out soon after the incident, he affirmed that luck saved everyone from "a large difficulty". But warned: "Luck isn't always on our side".

Publicly, Air Force officers deny that the equipment problems are serious. Internally, the failures are recorded in detail. A report by aviator major Eduardo Yoshiaki Toda is an example. He investigated a breakdown in the information of of the radars that monitor the region between the city of Sinop and the Serra do Cachimbo mountain range, in Mato Grosso. On March 27, 2007, the radars showed mismatched information on the altitude, velocity and direction of flights TAM 3749 and GOL 1641. Until the anticollision alarm went off. The image on the monitor showed that the two aircraft were at the same altitude and position. The accident signal was a false alarm. The controller only knew that the airplanes hadn't crossed and that the information on the screen was wrong, after contacting both pilots by radio. According to aviator major Eduardo Toda's report, the controller was removed from work [NT: it's ambiguous as to temporarily or permanently] after panicking, thinking he had been part of a tragedy involving two large airliners. Toda's document emphasizes the "danger of the psychological factor" resulting from technical problems. If failures such as these are common, flight controllers may start to not believe important information coming from the radar and "one day be surprised by a real accident", said the report. It was in this same region that the Gol Boeing collided with a business jet, killing 154 people. Pilots and controllers dubbed the region "blind spot" or "black hole" because of the constant failures of radio frequencies and radar. The Air Force always denied that there are points in Brazilian air space not covered by radar.
[...]

[Richard_Brazil]

Legacy pilots speak to Brazilian investigators

http://www.fab.mil.br/imprensa/Notic...m_voo_1907.htm

BULLETIN ON FLIGHT 1907 ACCIDENT - FEB. 7, 2008

Seeking to inform public opinion on the progress of the investigation into the Flight 1907 accident, this Center releases the following information supplied by the Center for the Investigation and Prevention of Aeronautic Accidents (CENIPA):

1) The CENIPA investigation, in accordance with Annex 13 of the Chicago Convention, does not have the purpose of placing blame or leading to criminal or civil responsibility. The investigation has as its sole objective the identification of contributing factors, to issue safety recommendation that can help avoid new aeronautic accidents;

2) In December of last year, the Commission of Investigation was sought out by representatives of the pilots of aircraft prefix N600XL, when the work was in the last stage of producing the final report. In the face of the importance of this testimony, which had not been undertaken previously by the crew's own decision, a meeting was set with Brazilian representatives of CENIPA. It is important to observe that information in this type of investigation is supplied voluntarily;

3) Between the 29th and 31st of January, members of the Commission heard the two pilots, in individual interviews, at the headquarters of the NTSB (National Transportation Safety Board), in Washington, in the United States. Three representatives of that American investigative body participated in the depositions. Until then, the crew of aircraft call sign N600XL had supplied information through the NTSB, responding to questionnaires sent by the Commission;

4) The pilots heard the two hours of audio recording registered on aircraft N600XL's black box (CVR) and responded to a long questionnaire elaborated by the Commission of Investigation on the accident;

5) Accompanied by a lawyer, the pilots affirmed that they did not perform any intentional act to interrupt the functioning of the transponder, and consequently, of the aircraft's anticollision system, as well as also not perceiving or remembering having done something that could have caused the interruption, accidentally, of the cited pieces of equipment;

6) The information supplied is important for the clarification of relevant points in the investigation, by being cross-referenced with other data already found, and for the formulation of possible scenarios which could lead to the non-functioning of the transponder. Evaluations made by the Commission show that the equipment was in usable condition, however was not in operation at the moment of the collision;

7) The Commission of Investigation made a final effort to hear the controllers, but on the advise of the lawyer for the defense, they persist in the position of not participating in any interview with the goal of helping in the work of investigation. This fact is due to fear of the utilization of information from the technical investigation, contrary to what is recommended by Annex 13 of the Chicago Convention, in criminal trials that are underway; and

8) Finally, it should be informed that the investigation is in its final phase and the new information collected will be introduced in the final report.

AIR FORCE CENTER FOR SOCIAL COMMUNICATION

Source: CECOMSAER [Acronym for Air Force Center For Social Communication]

[HarryMann]

I have not read all 70 odd ages diligently, but a hell of a lot of the salient discussion here... may I add a couple of observations?

When ATC knows that 'two Americans' (better still, two strangers) are flying in their airspace, and might even know or suspect that they are 'one-time' visitors... wouldn't it be good manners, as well as good stewardship of airspace, to take a bit more care and diligence over guiding their flight safely through what may be unknown territory? A slightly more watchful eye than a regular national flight for instance.. ?

Ok shoot me... but that's another kind of human factor one would think might be factored into ATC thinking.

Offsetting... I've read the lot. And yes, as a non-pilot (in your terms at least), I'm still gobsmacked that airways haven't long since been segregated laterally and that no aircraft should be on the centreline for long... The implications of increasing traffic and the introduction of GPS systems should surely have been thought through years ago.

I hate to criticise but a lot of the 'What if' thinking I thought was embedded in every aspect of aviation appears to have gone missing.

And for that ATC radar set to revert to 360Z360 , some non-aviation thinking there, that doesn't quite tie up with last known good height

For the sake of all those lost souls, the stubborness of thinking and tendency to not take high account of unusual circumstances and human factors in some areas of aviation, must be shifted aside...

[Brian Abraham]

From Aviation International News today.

Trial Stalled for ExcelAire Pilots
The Brazilian criminal court case against the two U.S. pilots–Joseph Lepore and Jan Paladino–and four air traffic controllers involved in a fatal midair between an ExcelAire Legacy 600 and a Gol Airlines Boeing 737-800 above the Amazon jungle in September 2006 has stalled while a judge decides whether the case will be heard in a military court or a federal criminal court. The conflict about who should hear the case arises from the fact that the air traffic controllers are civilians who function within a military organization. Brazil’s Superior Tribunal of Justice, the highest court for non-constitutional issues, is expected to make that decision next month. Lepore and Paladino, who safely landed their damaged Legacy, face charges under the Brazilian criminal code that they unintentionally endangered an aircraft through negligence by somehow disengaging the transponder. Last month, they spoke to Cenipa investigators for some 20 hours over the course of three days at the NTSB offices in Washington, D.C. Cenipa, Brazil’s aviation accident investigation agency, said inspection of the equipment showed that the transponder was in working order but not operating at the time of the collision. Joel Weiss, the pilots’ lawyer in the U.S., says that they didn’t do anything to turn off the transponder.

[Richard_Brazil]

Trial delays in Sinop

There are two different issues at the STJ, Brazil's second highest court, holding up the judgment. One is, as described above, the jurisdiction on judging the controllers - civil or military?

The most recent news on that is a week old: http://www.sonoticias.com.br/mostra.php?id=62160 and they say "maybe February 27", which is tomorrow.

While the federal trial judge wrote 8-10 pages on the issue when accepting the indictments (out of a total of maybe 12 pages, if I recall correctly), for a non-lawyer it doesn't seem that complex. The military prosecutor-general said on the radio in December of 2006 that the controllers could be tried in common courts. In a recent newspaper interview, the president of the highest military court described how when both civilian and military criminal codes apply, the military are usually judged in civilian courts. Though he didn't refer specifically to Gol 1907.

The newspapers haven't noted that while the civil court indicted four controllers, the military inquiry brought charges against five. But people go into journalism because they can't count.

Pilots should keep a special eye on that fifth controller, though. If he hadn't been forcibly retired, he'd be working toward his third airliner. Cough.

Another problem there is that the military court sent the indictment back to the military prosecutors, claiming it was "inept". Not an entirely unreasonable contention, as one controller was charged with violating Air Force Regulation something-or-other, said regulation being the Aeronautic Code and three hundred pages long. The charge lacked specificity, to put it mildly.

There's a second issue, which is that the pilots are asking to be allowed to testify in the U.S., as they did for Cenipa. There's a habeas corpus pending on this, also in the STJ. The judge who will write the opinion has just been switched, this news from a day or two ago.

So both these issues may be decided in the next few days. May be. However, a judge in Brooklyn, Brian Cogan, will decide in early April whether or not the civil suits are more appropriately judged in Brazil than in the U.S. That makes a big, big difference in the value of verdicts or settlements, so the lawyers may be trying to keep anything from happening in Brazilian courts until that decision is made.

[CDN_ATC]

I get a kick out of all of this talk of off-setting on airways and how it's going to "save the day"

At least in my airspace it is far more common to have crossing track conflicts than opposite track conflicts, offsetting will never help the vast majority of near-misses.

Lets not forget two airplanes meeting crossing is going to be just as disasterous as opposite direction.

Yes a SLOP would eliminate that specific possibility of occuring on that specific airway, and I agree pilots should implement it, but be advised ATC should be advised if you're doing so.

[barit1]

...far more common to have crossing track conflicts than opposite track conflicts

An argument, I presume, for SVOP as well as SLOP.

[1xxxxx1]

DCN_ATC this is a thread about an accident were more than a hundred people died. And you write; “I get a kick out of all of this talk of off-setting on airways and how it's going to "save the day"

In this case it would have saved the day !

I can recall plenty of collisions that were head on with aircraft on the airway. But very few collisions from crossing traffic, these happen normally in a terminal aria. This is a different problem. Let’s solve one at a time.

Maybe it is against your work ethic that some pilots fly off set to be safer?
A safety that ATC is responsible for and sometimes not provides!

But my understanding is an airway should not be a line with zero margin. Today with GPS and RVSM it is. And how wide is an airway? Not 0NM
Anyhow I fly offset when enroute surely when in a non-radar environment and this without informing ATC. (we all would be very busy calling ATC every time)

And I lobby heavily for all pilots to do the same. I wrote it into our company SOP and train our pilots to do the same.
Finally my passengers and I are safer this way; it does not matter if by 1NM or 2 NM when the opposite traffic is doing the same or not.
You keep watching the crossing traffic but do not worry I will help as we have TCAS now. All this might save your day.

[barit1]

You keep watching the crossing traffic but do not worry I will help as we have TCAS now

Let me remind you that in the present case, TCAS did not (and could not) function.

[Wiley]

I get a kick out of all of this talk of off-setting on airways and how it's going to "save the day"

At least in my airspace it is far more common to have crossing track conflicts than opposite track conflicts, offsetting will never help the vast majority of near-misses.

Lets not forget two airplanes meeting crossing is going to be just as disasterous as opposite direction.

CDN ATC, it's not a dick measuring contest, OK? You seem to share the opinion of many ATCOs that somehow, flying offset is an insult to their professionalism. Your comment about crossing traffic conflicts may well be true, but for two aircraft in a crossing conflict to actually collide, they must BOTH reach that point of crossing at exactly the same time - a period of a few seconds, possibly a minute if the tracks cross at an angle that is not acute. An opposite direction conflict, (as in the tragic - and easily avoidable - Brazilian accident), and especially since the advent of ultra accurate GPS, can remain 'in place' - exactly - for many, many hours.

Taking that into account, most people would agree that the opposite direction problem far outweighs the crossing problem.

Unless, (it would appear from your comments), you are an ATCO.

[Tarq57]

Wiley, covered quite well, I thought. Very true. Somewhat analogous to the relative risk of shooting a red light at a quiet intersection, vs driving the wrong way down a quiet motorway, I think. The former may result in an unlucky meeting of metal, the latter almost certainly will.
Except for the last sentence, sorry.
I'm an ATCO, and think a fair bit about separation issues, how to mitigate against/recognize hazards etc. And although it is true that the consequences to myself are rather less dire than to the aircraft occupants, don't for a moment think that any ATCO is less likely to dwell on such matters than a pilot.
FWIW, in NZ we have approved lateral offsets promulgated, for oceanic airspace (not sure about domestic) and IIRC, no advice to ATC is required when doing same, up to a certain distance. I think the maximum is about 2nm.