Mid-air collision over Brasil
offset increases the risk of collision at intersections.
But OK lets say the risk of collisions at intersections is twice as likely, no lets say it is ten times more likely!, 10 x one in a million is still only one in one hundred thousand, yet by doing this, you reduce the risk of a collision such as the one in Brazil, from almost certainty (one in two) to one in one hundred thousand. (That is to say, two aircraft flying in opposite directions on the same air route, at the same altitude, navigating with the assistance of GPS which is capable of determining position to within a metre or so is going to mean they WILL end up at the same place at the same time, yet if the tracking of one of the aircraft is offset by 0.1 nm (180 metres) they are highly unlikely to collide. Even more so if they both offset (180 metres x 2 equals 360 metres).
I'd say that is a very good trade in risk!!
Of course I just made the numbers up but it illustrates the point I am trying to make.
I think in the end, common sense should prevail.
Redesigning the air routes so that they are all one way traffic may be the answer, but in the mean time while two way air routes still exist, I can think of no better technique to mitigate the current risks.
The simple fact is, if either one of these planes had offset 0.1 nm, this particular thread would not exist!
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I think in the end, common sense should prevail.
However I am not a mathematician ans was not a member of the ICAO Working Group that killed off the idea, but the fact is they won the issue.
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Well I've just spent the evening reading the whole report. I have been getting increasingly incensed at the consistent criticism of the American pilots' "airmanship".
They made a mistake; they failed to notice the mistake. ATC, on the other hand should have (a) advised them of the mistake and (b) if not corrected, kept other traffic at least 2,000' away from them.
Yes, the mistake was a contributing factor; yes the poor software was a contributing factor but the clear and single cause was a series of errors by ATC starting with an incomplete clearance, continuing with losing communication and failing to give increased vertical separation and culminating with effectively instructing two planes to fly into one another. Compared with that lack of competence and that criminal negligence, the crew's "lack of airmanship" is minute.
Of course, the really sad thing is that undoubtedly some poor, undertrained controllers will lose their jobs or even their liberty whilst their managers who permitted the atmosphere of negligence to exist go free.
Cliff.
They made a mistake; they failed to notice the mistake. ATC, on the other hand should have (a) advised them of the mistake and (b) if not corrected, kept other traffic at least 2,000' away from them.
Yes, the mistake was a contributing factor; yes the poor software was a contributing factor but the clear and single cause was a series of errors by ATC starting with an incomplete clearance, continuing with losing communication and failing to give increased vertical separation and culminating with effectively instructing two planes to fly into one another. Compared with that lack of competence and that criminal negligence, the crew's "lack of airmanship" is minute.
Of course, the really sad thing is that undoubtedly some poor, undertrained controllers will lose their jobs or even their liberty whilst their managers who permitted the atmosphere of negligence to exist go free.
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Re Decimal Offsets in ICAO
I attended a meeting of a Separation Assurance Sub panel meeting earlier this year with the express intention of getting small, micro, offsets back on the agenda. There was no opposition and considerable support, and a State Letter was promised in the near future. Since then things seem to have got stuck, so maybe another visit to Montreal will be needed soon.
The proposal is to permit random offsets of 0.5 NM or less right of track. This also covers the unidirectional airway case where otherwise everyone gets stacked neatly on top of each other, with obvious potential consequences (cf the A330/A340 near miss over the Atlantic in October 2000).
I am still baffled by the difference in the official response to the GOL accident compared to Uberlingen. The latter produced paroxysms of activity, not all of it very relevant; the latter has produced, er, nothing despite the obvious mitigation.
The proposal is to permit random offsets of 0.5 NM or less right of track. This also covers the unidirectional airway case where otherwise everyone gets stacked neatly on top of each other, with obvious potential consequences (cf the A330/A340 near miss over the Atlantic in October 2000).
I am still baffled by the difference in the official response to the GOL accident compared to Uberlingen. The latter produced paroxysms of activity, not all of it very relevant; the latter has produced, er, nothing despite the obvious mitigation.
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CVR audio released
There is controversy in the U.S. over an article in Vanity Fair magazine about the Brazil mid-air.
In it you will find a link to the actual audio on the CVR of both the Gol 737 and the ExcelAire Legacy aircraft.
A widely read blog Cranky Flier has posted comments by an airline pilot.
There seem to be two points of contention:
1) Should the CVR audio have been released; and
2) Were the actions by the Legacy crew appropriate.
Warning: The VF link is a long read, The audios are long download time MP3 files, the language spoken on Gol audio is Portuguese and the Legacy audio is in English but very long.
In it you will find a link to the actual audio on the CVR of both the Gol 737 and the ExcelAire Legacy aircraft.
A widely read blog Cranky Flier has posted comments by an airline pilot.
There seem to be two points of contention:
1) Should the CVR audio have been released; and
2) Were the actions by the Legacy crew appropriate.
Warning: The VF link is a long read, The audios are long download time MP3 files, the language spoken on Gol audio is Portuguese and the Legacy audio is in English but very long.
Last edited by kappa; 27th Dec 2008 at 19:41.
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How about implementing SLOP in that region too, just like over the North Atlantic and the Chinese RVSM ...
There is also a procedure I feel would be very important for ATC and pilots awareness: Common phraseology and language. English all times! I know that legislation allows you to speak the country's language and English, but for the sake of Safety, one should only use English as the aviation communication language.
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offset
I am puzzled by a discussion point in the NTSB report on page 8 :
However, I have not found any mentioning of OFFSET in capitals in the CENIPA report.
Have I overlooked something or am I misinterpreting?
There is no direct discussion of flight path offsets in the report or any discussion about the role that a lack of offset procedures played in the accident. Also, because the word “offset” is capitalized in the report, it would seem to need a definition somewhere.
Have I overlooked something or am I misinterpreting?
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From the last Aero Magazine (Brasil)
Translation in a hurry:
Flight 1907: The final report
After more than two years after the crash between the Boeing from GOL and the Legacy from Excelaire, the Cenipa (Center of investigation and prevention of Aviation Accidents) issued a final report of the factors that contribuited to the acciudent that killed 154 persons, in September 2006.According to the document , there were errors from the ATCs in Manaus, Brasilia and Sao Jose dos Campos and from the American pilots Joseph Lepore and Jan Paladino, that were commanding the Legacy of Excelaire. The Cenipa investigations were made in collaboration with the NTSB (National Transportation Safety Board), the American agency that also helped in report, following the recommendations of Oaci (International Organization of Civil |Aviation). But despite the collaboration, the conclusions of the two agencies give different weight to explain the same fact. For example, the NTSB emphasizes that the greater responsibility for the accident belongs to the problems in the structure of the Brazilian ATC, especially in Sao Jose dos Campos that authorized the flight plan for the American pilots. The aAmerican agency makes it relative the fact that the Legacy pilots did not complete the flight plan correctly - the airplane should fly to Brasilia at 370 and then descend to 360 and later climb to 380 and remaining there until Manaus. The pilots kept 370 for the whole flight until the collision. The NTSB also doesn´t mention that the transponder was switched to OFF during the flight even if this was unintentional.
My comment: If Sao Jose gave the pilots the new flight plan why should the follow the old? Makes no sense!
Flight 1907: The final report
After more than two years after the crash between the Boeing from GOL and the Legacy from Excelaire, the Cenipa (Center of investigation and prevention of Aviation Accidents) issued a final report of the factors that contribuited to the acciudent that killed 154 persons, in September 2006.According to the document , there were errors from the ATCs in Manaus, Brasilia and Sao Jose dos Campos and from the American pilots Joseph Lepore and Jan Paladino, that were commanding the Legacy of Excelaire. The Cenipa investigations were made in collaboration with the NTSB (National Transportation Safety Board), the American agency that also helped in report, following the recommendations of Oaci (International Organization of Civil |Aviation). But despite the collaboration, the conclusions of the two agencies give different weight to explain the same fact. For example, the NTSB emphasizes that the greater responsibility for the accident belongs to the problems in the structure of the Brazilian ATC, especially in Sao Jose dos Campos that authorized the flight plan for the American pilots. The aAmerican agency makes it relative the fact that the Legacy pilots did not complete the flight plan correctly - the airplane should fly to Brasilia at 370 and then descend to 360 and later climb to 380 and remaining there until Manaus. The pilots kept 370 for the whole flight until the collision. The NTSB also doesn´t mention that the transponder was switched to OFF during the flight even if this was unintentional.
My comment: If Sao Jose gave the pilots the new flight plan why should the follow the old? Makes no sense!
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William Langewiesche...
has written a recent article for Vanity Fair about this crash. He's a professional pilot and a professional writer and the article, while written for the layman, is worth a read, I think.
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The Vanity Fair article has already been referred to and linked in my post #1476 above.
But there is a very new comment by Joe Sharkey, one of the pax on the Legacy aircraft.
In it he cites
If you want to read the entire statement, go to IFATCA and look on the right for 'Position Statement - Brazil - A Missed Opportunity'. Click on it and a PDF file will appear or download.
But there is a very new comment by Joe Sharkey, one of the pax on the Legacy aircraft.
In it he cites
The International Federation of Air Traffic Control Associations (IFATCA), in a statement to be released today, expresses "disappointment" with the lengthy Brazilian report, compiled by an aviation investigations panel called CENIPA, which operates under the aegis of the Brazilian Air Force -- which runs that country's long-troubled commercial air-traffic control system.
Last edited by kappa; 15th Jan 2009 at 03:43.
Kudos to IFATCA
As a programmer of some decades, I am well aware of the tendency of software projects to add features without appropriate consultation with those at the coalface.
What often happens is management gets a bee in its bonnet and puts a feature in the specifications, but Joe Programmer never gets an opportunity to check out how the feature will affect those at the coalface.
Management tells the programmers what they want in the software without bothering to run it by the coalface workers -- asking coalface workers their opinion and acting upon it is something too many managements feel is beneath their station
Mind you, programmers are quite capable of dropping in a feature without bothering to inform either management or coalface workers
What often happens is management gets a bee in its bonnet and puts a feature in the specifications, but Joe Programmer never gets an opportunity to check out how the feature will affect those at the coalface.
Management tells the programmers what they want in the software without bothering to run it by the coalface workers -- asking coalface workers their opinion and acting upon it is something too many managements feel is beneath their station
Mind you, programmers are quite capable of dropping in a feature without bothering to inform either management or coalface workers
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IFATCA comunicado
12 January 2009
POSITION STATEMENT
BRAZIL: A MISSED OPPORTUNITY
The final accident report of the mid-air collision in Brazil involving flight GOL 1907 and
N600XL which occurred on September 29, 2006 at FL 370 was published on 10
December 2008 by the Brazilian aviation accident investigation bureau CENIPA (Centro
de Investigação e Prevenção de Acidentes Aeronáuticos.
IFATCA notes that whereas the inquiries in regards to the events in the cockpit of the
Legacy private jet seem to have received a lot of attention and were done with rather
detailed care by CENIPA, the same cannot be said for investigations on the ATC-side.
The Federation notes with disappointment that the well-evidenced failures and safety
problems of the Brazilian ATC-system, including its contributions to the fatal chain of
events of the accident, have not received the required attention and detailed scrutiny
from CENIPA. This is disappointing as in the aviation community there was hope that
the final accident report would shed a neutral light on the problems and shortcomings of
the Brazilian ATM-system, in particular on these elements that were part of the chain of
events leading to the mid-air collision of 2006.
The final accident report admittedly focuses on some events and problems on the ATCside,
but these items do not lead to clear conclusions. They also do not lead to the
issuance of safety recommendations as a logical consequence. Rather, the "Analysis of
the Surveillance" section, starting on page 253 of the report, ends on page 255 with the
following paragraph:
"The pieces of equipment involved in the scenario of the occurrence did not
present design failures, since they functioned within their specifications on the
day of the accident, removing the possibility of a contribution of the
Communication and Surveillance Systems and Equipment."
IFATCA's Human Factor Specialist, Bert Ruitenberg, co-author with Dr. Anne Isaac of
the book that was cited several times in the final accident report of CENIPA, says
"However the mere fact that equipment 'functions within its specifications' doesn't mean
the specifications were well-designed! In order to identify design failures, the content of
the specifications needs to be looked at - not how a system functions relative to its
specifications"
INTERNATIONAL FEDERATION OF
AIR TRAFFIC CONTROLLERS’ ASSOCIATIONS
1255 University Street, Suite 408, Montreal (Quebec) H3B 3B6 CANADA
Tel: +1 514 866 7040, Fax: +1 514 866 7612, Email: [email protected]
Page 2 of 4
On 24 November 2006, two months after the accident occurred, IFATCA included the
following statements in our press release:
"IFATCA has been very much surprised by what was seen when visiting the
ACC [Area Control Centre] in Brasilia after the accident in early October
2006. The cleared flight level ("nivel autorizado") on the aircraft label, as it
appeared on the radar screen, was not only fed by controllers into the system
(once the clearance was transmitted by radio to the aircraft, and the aircraft
had correctly read back the clearance), but there were occasions when this
was done automatically by the system itself without any direct input from the
controllers. This automatic change did not show prominently on the aircraft
label as it should (both the fonts and the colours of the label remained the
same as before). The "explanation" given by the [Brazilian] authorities was
that this FL was actually the Flight Plan Level of the flight and so it was
"normal" to change it automatically when an aircraft passes over a fix (or
[navigation]-aid) where a change of flight level is requested by the flight plan."
"In many ACCs of the world, this crucial information of the cleared flight level
("nivel autorizado") is fed by the controllers into the system once the
clearance is transmitted by radio to the aircraft (and this has been correctly
repeated by the pilot = read-back). This "feeding of the system" is sometimes
done by hand-writing on paper strips, while other systems work electronically
whereby the input is done directly onto the label of the flight that appears on
the radar screen at the CWP (Controller Working Position). What is very
important, even crucial, is that the ground ATC system and the aircraft cockpit
always dispose of the same information."
"IFATCA believes that operators in the air (the pilots), and on ground (the
controllers), fell victim to unacceptable systems traps brought on by 'non-error
tolerant', and 'bad system design' of air traffic control and flight equipment in
use. We are confident that our statements concerning this equipment are
accurate, and said equipment is responsible for starting the fatal chain of
events of September 29, 2006, and therefore, contributed to the mid-air
collision."
The automatic level changes by the ATC software are mentioned, investigated and
explained to a certain degree in the report, and the CENIPA considerations clearly hint
to several safety issues related to this tool, yet CENIPA does not issue any safety
recommendation for this controversial feature. This is surprising, as it is a known fact
that the United States' National Transportation Safety Board (NTSB) had already in
2006 issued a safety recommendation related to this same system and in particular the
automatic level changes.
In accordance with international standards, the NTSB in 2008 was given the opportunity
to comment on the final report by CENIPA before its publication, and the comment is
included in the report as Appendix 2. The NTSB inter alia states the following:
Page 3 of 4
"[…] the use of the automatic "cleared altitude" field change has the potential
to mislead controllers, is a poor human factors design, and is a clear finding
of risk. In fact, this event was one of the first that is directly tied to the
accident scenario. This feature has the undesirable effect of making the ATC
automation "lead" the actual clearance issued to the flight crew. A basic tenet
of ATC is to have a double check of clearances. The automatic change takes
away a method for the [controller] to reinforce the proper clearance in his
mind. If the controller makes the entry, the action of keying in the numbers
helps to confirm that he has issued the correct altitude and that the pilot has
read back the clearance correctly. Therefore, the automatic change of the
datablock field from "cleared altitude" to "requested altitude" without any
indication to, or action by, the [controllers] led to the misunderstanding by the
sector 7 controller about what altitude clearance was issued to N600XL.
[Conclusion]"
"We recommend modifying the software to make it clear to controllers
whether this field of the datablock is displaying a requested altitude or a
cleared altitude. At the least, a "reminder" feature should be distinguishable
from a display that reflects the actual clearance status of the aircraft. This
feature has been discussed in worldwide ATC publications, and the report
must address the issue completely. A detailed assessment of this feature
should be conducted, and, if the feature is not changed, the assessment
should completely demonstrate why retaining the
feature is desirable. Such an assessment must specifically show training and
procedures that fit with the feature and support correct issuance of clearances
in accordance with ICAO document 4444. [Recommendation]"
These and other statements from the NTSB 2008 comment in the CENIPA report
confirm the statements made by IFATCA in our November 2006 Press Release. What is
more, they say with so many words that "poor human factors design" is applicable to a
key aspect of the ATC system in Brazil, i.e. the display of flight information to controllers
in the data label on their radar screens. "[...] A design in which two distinctly different
pieces of information (that is,
requested altitude and cleared altitude) appear identical on the display is clearly a latent
error", according to the NTSB comment.
IFATCA notes that in late 2008 CENIPA have issued a new Safety Recommendation
that requires the installation of the CLAM-tool (Cleared Level Adherence Monitoring tool)
for all en-route control centres of Brazil. Whilst IFATCA supports the installation of a
CLAM tool, it must be noted that CLAM is a "safety net" to alert controllers of a possible
problem. It is not a solution for the inherent design flaw of the operating system that
allows the displayed level to be changed without knowledge and input from the
controllers.
In conclusion, IFATCA thinks the identified shortcomings in the CENIPA report are a
missed opportunity for the Brazilian aviation authorities to restore trust and safety in the
Page 4 of 4
national aviation system. This final accident report could have served as the starting
point for an extensive and desperately needed healing process, the trigger event to
reorganize and restructure the national ATC-system that received a lot of criticism and of
which the safety is openly questioned. This has unfortunately not occurred, as CENIPA
(an integral part of the same Brazilian Air Force that is responsible for the provision of air
traffic control) has chosen to put the main responsibility for the mid-air collision of 2006
on the frontline operators only. This CENIPA decision appears driven by a reluctance to
expose staff and departments situated in its own organization.
IFATCA has noted with satisfaction the dissenting opinion expressed by the NSTB. The
Federation notes that the NTSB comes to very similar conclusions in regards to the
Brazilian ATC-system, and the points and features that have played a role in the mid-air
collision of September 2006. IFATCA agrees with the NTSB that these problems and
issues still continue to exist, and that they mostly likely will not be addressed and fixed
by the clean-up process initiated by the Brazilian authorities,. Even after the CENIPA
accident report the deeply rooted structural and organizational problems and - issues of
the Brazilian ATM-system continue to exist. Indeed a missed opportunity, yet hopefully
not a lost opportunity: after all, safety improvements can also be made without the
guidance of a CENIPA recommendation!
www.IFATCA is the worldwide organization reipfartecas.eonrgt ing more than fifty thousand air traffic
controllers in over 130 countries. Amongst its goals are the promotion of safety,
efficiency and regularity in international air navigation and the protection and
safeguarding of the interests of the air traffic control profession.
International Federation of Air Traffic Controllers' Associations
POSITION STATEMENT
BRAZIL: A MISSED OPPORTUNITY
The final accident report of the mid-air collision in Brazil involving flight GOL 1907 and
N600XL which occurred on September 29, 2006 at FL 370 was published on 10
December 2008 by the Brazilian aviation accident investigation bureau CENIPA (Centro
de Investigação e Prevenção de Acidentes Aeronáuticos.
IFATCA notes that whereas the inquiries in regards to the events in the cockpit of the
Legacy private jet seem to have received a lot of attention and were done with rather
detailed care by CENIPA, the same cannot be said for investigations on the ATC-side.
The Federation notes with disappointment that the well-evidenced failures and safety
problems of the Brazilian ATC-system, including its contributions to the fatal chain of
events of the accident, have not received the required attention and detailed scrutiny
from CENIPA. This is disappointing as in the aviation community there was hope that
the final accident report would shed a neutral light on the problems and shortcomings of
the Brazilian ATM-system, in particular on these elements that were part of the chain of
events leading to the mid-air collision of 2006.
The final accident report admittedly focuses on some events and problems on the ATCside,
but these items do not lead to clear conclusions. They also do not lead to the
issuance of safety recommendations as a logical consequence. Rather, the "Analysis of
the Surveillance" section, starting on page 253 of the report, ends on page 255 with the
following paragraph:
"The pieces of equipment involved in the scenario of the occurrence did not
present design failures, since they functioned within their specifications on the
day of the accident, removing the possibility of a contribution of the
Communication and Surveillance Systems and Equipment."
IFATCA's Human Factor Specialist, Bert Ruitenberg, co-author with Dr. Anne Isaac of
the book that was cited several times in the final accident report of CENIPA, says
"However the mere fact that equipment 'functions within its specifications' doesn't mean
the specifications were well-designed! In order to identify design failures, the content of
the specifications needs to be looked at - not how a system functions relative to its
specifications"
INTERNATIONAL FEDERATION OF
AIR TRAFFIC CONTROLLERS’ ASSOCIATIONS
1255 University Street, Suite 408, Montreal (Quebec) H3B 3B6 CANADA
Tel: +1 514 866 7040, Fax: +1 514 866 7612, Email: [email protected]
Page 2 of 4
On 24 November 2006, two months after the accident occurred, IFATCA included the
following statements in our press release:
"IFATCA has been very much surprised by what was seen when visiting the
ACC [Area Control Centre] in Brasilia after the accident in early October
2006. The cleared flight level ("nivel autorizado") on the aircraft label, as it
appeared on the radar screen, was not only fed by controllers into the system
(once the clearance was transmitted by radio to the aircraft, and the aircraft
had correctly read back the clearance), but there were occasions when this
was done automatically by the system itself without any direct input from the
controllers. This automatic change did not show prominently on the aircraft
label as it should (both the fonts and the colours of the label remained the
same as before). The "explanation" given by the [Brazilian] authorities was
that this FL was actually the Flight Plan Level of the flight and so it was
"normal" to change it automatically when an aircraft passes over a fix (or
[navigation]-aid) where a change of flight level is requested by the flight plan."
"In many ACCs of the world, this crucial information of the cleared flight level
("nivel autorizado") is fed by the controllers into the system once the
clearance is transmitted by radio to the aircraft (and this has been correctly
repeated by the pilot = read-back). This "feeding of the system" is sometimes
done by hand-writing on paper strips, while other systems work electronically
whereby the input is done directly onto the label of the flight that appears on
the radar screen at the CWP (Controller Working Position). What is very
important, even crucial, is that the ground ATC system and the aircraft cockpit
always dispose of the same information."
"IFATCA believes that operators in the air (the pilots), and on ground (the
controllers), fell victim to unacceptable systems traps brought on by 'non-error
tolerant', and 'bad system design' of air traffic control and flight equipment in
use. We are confident that our statements concerning this equipment are
accurate, and said equipment is responsible for starting the fatal chain of
events of September 29, 2006, and therefore, contributed to the mid-air
collision."
The automatic level changes by the ATC software are mentioned, investigated and
explained to a certain degree in the report, and the CENIPA considerations clearly hint
to several safety issues related to this tool, yet CENIPA does not issue any safety
recommendation for this controversial feature. This is surprising, as it is a known fact
that the United States' National Transportation Safety Board (NTSB) had already in
2006 issued a safety recommendation related to this same system and in particular the
automatic level changes.
In accordance with international standards, the NTSB in 2008 was given the opportunity
to comment on the final report by CENIPA before its publication, and the comment is
included in the report as Appendix 2. The NTSB inter alia states the following:
Page 3 of 4
"[…] the use of the automatic "cleared altitude" field change has the potential
to mislead controllers, is a poor human factors design, and is a clear finding
of risk. In fact, this event was one of the first that is directly tied to the
accident scenario. This feature has the undesirable effect of making the ATC
automation "lead" the actual clearance issued to the flight crew. A basic tenet
of ATC is to have a double check of clearances. The automatic change takes
away a method for the [controller] to reinforce the proper clearance in his
mind. If the controller makes the entry, the action of keying in the numbers
helps to confirm that he has issued the correct altitude and that the pilot has
read back the clearance correctly. Therefore, the automatic change of the
datablock field from "cleared altitude" to "requested altitude" without any
indication to, or action by, the [controllers] led to the misunderstanding by the
sector 7 controller about what altitude clearance was issued to N600XL.
[Conclusion]"
"We recommend modifying the software to make it clear to controllers
whether this field of the datablock is displaying a requested altitude or a
cleared altitude. At the least, a "reminder" feature should be distinguishable
from a display that reflects the actual clearance status of the aircraft. This
feature has been discussed in worldwide ATC publications, and the report
must address the issue completely. A detailed assessment of this feature
should be conducted, and, if the feature is not changed, the assessment
should completely demonstrate why retaining the
feature is desirable. Such an assessment must specifically show training and
procedures that fit with the feature and support correct issuance of clearances
in accordance with ICAO document 4444. [Recommendation]"
These and other statements from the NTSB 2008 comment in the CENIPA report
confirm the statements made by IFATCA in our November 2006 Press Release. What is
more, they say with so many words that "poor human factors design" is applicable to a
key aspect of the ATC system in Brazil, i.e. the display of flight information to controllers
in the data label on their radar screens. "[...] A design in which two distinctly different
pieces of information (that is,
requested altitude and cleared altitude) appear identical on the display is clearly a latent
error", according to the NTSB comment.
IFATCA notes that in late 2008 CENIPA have issued a new Safety Recommendation
that requires the installation of the CLAM-tool (Cleared Level Adherence Monitoring tool)
for all en-route control centres of Brazil. Whilst IFATCA supports the installation of a
CLAM tool, it must be noted that CLAM is a "safety net" to alert controllers of a possible
problem. It is not a solution for the inherent design flaw of the operating system that
allows the displayed level to be changed without knowledge and input from the
controllers.
In conclusion, IFATCA thinks the identified shortcomings in the CENIPA report are a
missed opportunity for the Brazilian aviation authorities to restore trust and safety in the
Page 4 of 4
national aviation system. This final accident report could have served as the starting
point for an extensive and desperately needed healing process, the trigger event to
reorganize and restructure the national ATC-system that received a lot of criticism and of
which the safety is openly questioned. This has unfortunately not occurred, as CENIPA
(an integral part of the same Brazilian Air Force that is responsible for the provision of air
traffic control) has chosen to put the main responsibility for the mid-air collision of 2006
on the frontline operators only. This CENIPA decision appears driven by a reluctance to
expose staff and departments situated in its own organization.
IFATCA has noted with satisfaction the dissenting opinion expressed by the NSTB. The
Federation notes that the NTSB comes to very similar conclusions in regards to the
Brazilian ATC-system, and the points and features that have played a role in the mid-air
collision of September 2006. IFATCA agrees with the NTSB that these problems and
issues still continue to exist, and that they mostly likely will not be addressed and fixed
by the clean-up process initiated by the Brazilian authorities,. Even after the CENIPA
accident report the deeply rooted structural and organizational problems and - issues of
the Brazilian ATM-system continue to exist. Indeed a missed opportunity, yet hopefully
not a lost opportunity: after all, safety improvements can also be made without the
guidance of a CENIPA recommendation!
www.IFATCA is the worldwide organization reipfartecas.eonrgt ing more than fifty thousand air traffic
controllers in over 130 countries. Amongst its goals are the promotion of safety,
efficiency and regularity in international air navigation and the protection and
safeguarding of the interests of the air traffic control profession.
International Federation of Air Traffic Controllers' Associations
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Response to IFATCA by Air Force
The most comprehensive article in the Brazilian press was by Leila Suwwan, in O Globo. When she was at the Folha de S. Paulo, Leila did a lot of coverage of the aviation sector, and even went to an IFATCA conference in Istambul.
I haven't translated her article, as Joe Sharkey covered the IFATCA statement and everyone here can read the full original. And due to other demands on my time (another American pilot falsely jailed in Brazil was finally released yesterday night, after more than a year in prison.) Here's what the Air Force had to say in response to Leila's article.
RESPONSE TO THE NEWSPAPER O GLOBO, ON JANUARY 15, 2009
In relation to the O GLOBO newspaper article, on January 15, 2008, titled “Controllers criticize Brazilian conclusion on Gol Flight 1907 accident”, the Air Force Center for Social Communication (CECOMSAER) would like to clarify some points that, apparently, passed unnoticed in the journalistic investigation by this distinguished communication vehicle.
The Brazilian air traffic control system does not present a “clear risk” directly linked to that collision (flight 1907). It is worth remembering that the features of the X-4000 software which were at the center of the controversy, have been in use in the country since the 1980s, deriving from the French system that had served Brazil. Air traffic controllers are not only trained to use X-4000, but have also participated directly in the modernization of the software, seeing as they are the product’s end users.
The Federal Court of Audit itself, which evaluated the features of the X-4000 program, clarified in a decision, “there is no way to affirm that the system is unsafe for supplying air traffic control services”. In fact, the Final Report concluded that the air traffic control system in itself was not a contributing factor in the accident’s occurrence.
In parallel, on consulting the Table of Contributing Factors in Civil Aviation Accidents from 1998 to 2007 (source: :: CENIPA - Centro de Investigação e Prevenção de Acidentes Aeronáuticos :: , link PPAA), it can be verified that. of the more than 20 factors that contributed to accidents in the country, air traffic control stands out by being the factor that least appears, with only 0.8% (it is the lowest index!).
It is worth pointing out that in Montreal (Canada), during the 36th Session of the ICAO General Assembly, which was held from September 18-28, 2007, specialists from several countries ratified Brazil in the elite group of countries with the best capacity to administer their air traffic.
As it relates to the Final Report on the GOL accident, it is worth emphasizing further that the main product of the technical investigation is not this document, but rather the safety recommendations (RSVs) it contains. What does this mean? A Flight Safety Recommendation is the establishment of an action or group of actions that could be directed to the public in general, to specific groups of users or to a determined public or private organization, referring to a specific circumstance that demands attention, looking to the elimination or control of a risk condition. In sum, it is the final result of the countless actions that are taken for the prevention of aviation accidents and, in this sense, the principal tool used to improve the level of operational safety.
Among the 60 Flight Safety Recommendations formulated because of this accident, all available in the Final Report, half were addressed to the Department of Air Space Control (DECEA).
Therefore, the Air Force Command understands that the investigation of this accident was opportune for presenting recommendations to the Department of Air Space Control (DECEA), exactly with the view of improving the Brazilian Air Traffic Control System.
I haven't translated her article, as Joe Sharkey covered the IFATCA statement and everyone here can read the full original. And due to other demands on my time (another American pilot falsely jailed in Brazil was finally released yesterday night, after more than a year in prison.) Here's what the Air Force had to say in response to Leila's article.
RESPONSE TO THE NEWSPAPER O GLOBO, ON JANUARY 15, 2009
In relation to the O GLOBO newspaper article, on January 15, 2008, titled “Controllers criticize Brazilian conclusion on Gol Flight 1907 accident”, the Air Force Center for Social Communication (CECOMSAER) would like to clarify some points that, apparently, passed unnoticed in the journalistic investigation by this distinguished communication vehicle.
The Brazilian air traffic control system does not present a “clear risk” directly linked to that collision (flight 1907). It is worth remembering that the features of the X-4000 software which were at the center of the controversy, have been in use in the country since the 1980s, deriving from the French system that had served Brazil. Air traffic controllers are not only trained to use X-4000, but have also participated directly in the modernization of the software, seeing as they are the product’s end users.
The Federal Court of Audit itself, which evaluated the features of the X-4000 program, clarified in a decision, “there is no way to affirm that the system is unsafe for supplying air traffic control services”. In fact, the Final Report concluded that the air traffic control system in itself was not a contributing factor in the accident’s occurrence.
In parallel, on consulting the Table of Contributing Factors in Civil Aviation Accidents from 1998 to 2007 (source: :: CENIPA - Centro de Investigação e Prevenção de Acidentes Aeronáuticos :: , link PPAA), it can be verified that. of the more than 20 factors that contributed to accidents in the country, air traffic control stands out by being the factor that least appears, with only 0.8% (it is the lowest index!).
It is worth pointing out that in Montreal (Canada), during the 36th Session of the ICAO General Assembly, which was held from September 18-28, 2007, specialists from several countries ratified Brazil in the elite group of countries with the best capacity to administer their air traffic.
As it relates to the Final Report on the GOL accident, it is worth emphasizing further that the main product of the technical investigation is not this document, but rather the safety recommendations (RSVs) it contains. What does this mean? A Flight Safety Recommendation is the establishment of an action or group of actions that could be directed to the public in general, to specific groups of users or to a determined public or private organization, referring to a specific circumstance that demands attention, looking to the elimination or control of a risk condition. In sum, it is the final result of the countless actions that are taken for the prevention of aviation accidents and, in this sense, the principal tool used to improve the level of operational safety.
Among the 60 Flight Safety Recommendations formulated because of this accident, all available in the Final Report, half were addressed to the Department of Air Space Control (DECEA).
Therefore, the Air Force Command understands that the investigation of this accident was opportune for presenting recommendations to the Department of Air Space Control (DECEA), exactly with the view of improving the Brazilian Air Traffic Control System.
Air Brigadier Antonio Carlos Moretti Bermudez
Head of the AIR FORCE CENTER FOR SOCIAL COMMUNICATION
Head of the AIR FORCE CENTER FOR SOCIAL COMMUNICATION
A Perfect Example of Upper Management - Coalface Worker Disconnect
Re: RESPONSE TO THE NEWSPAPER O GLOBO, ON JANUARY 15, 2009
Thank you, Air Brigadier Antonio Carlos Moretti Bermudez
Head of the AIR FORCE CENTER FOR SOCIAL COMMUNICATION for this excellent example.
Thank you, Air Brigadier Antonio Carlos Moretti Bermudez
Head of the AIR FORCE CENTER FOR SOCIAL COMMUNICATION for this excellent example.
I am having some difficulty in deciphering the weasel words in the Airforce statement. For this I look to others for help
Are they saying that the software is fine and that since there were no direct recommendations by the commision against the use of this software by the controllers that everything is fine on their end?
Are they saying that the software is fine and that since there were no direct recommendations by the commision against the use of this software by the controllers that everything is fine on their end?
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Lomapaseo asked for clarification of the Air Force's statement.
Brigadeir Kersul of Cenipa, Brigadier Bermudez of the press office, and Brigadier Ramon of DECEA, all report to the Air Force High Command. This is a simple statement of fact, and any conclusions you may draw are your own.
The X-4000 ATC software normally shows on the radar screen an aircraft's exact height from the transponder via the secondary radar, an equal sign, and then the cleared altitude. If the transponder or the secondary radar fails, a "feature" of the software switches the number on the left to the altitude given by the primary radar, inexact and not approved for civil air traffic control, and the number on the right is changed to the altitude in the filed flight plan, which may not be the same as the current clearance given by ATC.
That explanation is based on the NTSB report. The NTSB further explains that the software changes not only the source of each number, but its meaning, calling this bad user interface design.
The TCU (Tribunal de Contas da União) is sort of like the U.S. Congressional Budget Office, but specialized in post-mortems. One of its roles is to supply expert advice on technical issues to the government. The TCU report was discussed about halfway through this article: Brazil Midair Marks Second Anniversary with Open Questions: AINonline and some aspects of the TCU report might cause some to question what the Air Force's priorities are on this issue.
I am neither a pilot nor an air traffic controller. I am, however, a computer programmer, which gives me a rare chance to emit technical opinions here. I endorse RatherBeFlying's comment, but will speculate in more detail.
My own view is that a programmer, facing the question of what to do when one of his data sources disappeared, came up with the clever idea of using another. He probably repeatedly tested the notion, and confirmed that what his test radar screen showed, matched what his test flight plan database recorded. His idea kept everything in synch.
He forgot that the map is not the territory; that what is important is that where the controller thinks the pilot is, and where the pilot thinks he ought to be, must be the same.
He automatically changed the altitude, skipping the controller's instruction to the pilot. He switched the data souce from one that was accurate to one that wouldn't show that there was a problem: it was neither clearly wrong nor clearly missing, it provided only the illusion of information.
Regarding marciovp's contention that
my understanding from reading the various reports is that there is a difference between FAA and ICAO in rules for communications failures. Under FAA rules you stay at the last assigned altitude; under ICAO rules you revert to the filed flight plan.
Here again, the programmer may have run a simulation, where automated models of "pilots" always realized immediately that they had lost communications, and where they were correctly programmed with ICAO rules. Pilots, however, are not computers, and loss of communications is not an instant, black-and-white event. That may be obvious to people who work in cockpits, but it is not clear to people who work in cubicles. RatherBeFlying explained about that.
Regarding the Vanity Fair article, there are major errors on critical issues, but I'll confine myself to two trivial examples based on the local knowledge I do have, rather than the aviation knowedge I don't. Langewiesche misspelled the very common Brazilian name "Pereira", which is like getting "Smith" wrong. Second, he takes at face value Indian chief Megaron's contention that Air Force soldiers stole watches and such. I've never met Megaron, but I have neighbors who have (they do anthropological documentaries), and they say the first time they met him, he tried to steal their canoe.
Brigadeir Kersul of Cenipa, Brigadier Bermudez of the press office, and Brigadier Ramon of DECEA, all report to the Air Force High Command. This is a simple statement of fact, and any conclusions you may draw are your own.
The X-4000 ATC software normally shows on the radar screen an aircraft's exact height from the transponder via the secondary radar, an equal sign, and then the cleared altitude. If the transponder or the secondary radar fails, a "feature" of the software switches the number on the left to the altitude given by the primary radar, inexact and not approved for civil air traffic control, and the number on the right is changed to the altitude in the filed flight plan, which may not be the same as the current clearance given by ATC.
That explanation is based on the NTSB report. The NTSB further explains that the software changes not only the source of each number, but its meaning, calling this bad user interface design.
The TCU (Tribunal de Contas da União) is sort of like the U.S. Congressional Budget Office, but specialized in post-mortems. One of its roles is to supply expert advice on technical issues to the government. The TCU report was discussed about halfway through this article: Brazil Midair Marks Second Anniversary with Open Questions: AINonline and some aspects of the TCU report might cause some to question what the Air Force's priorities are on this issue.
I am neither a pilot nor an air traffic controller. I am, however, a computer programmer, which gives me a rare chance to emit technical opinions here. I endorse RatherBeFlying's comment, but will speculate in more detail.
My own view is that a programmer, facing the question of what to do when one of his data sources disappeared, came up with the clever idea of using another. He probably repeatedly tested the notion, and confirmed that what his test radar screen showed, matched what his test flight plan database recorded. His idea kept everything in synch.
He forgot that the map is not the territory; that what is important is that where the controller thinks the pilot is, and where the pilot thinks he ought to be, must be the same.
He automatically changed the altitude, skipping the controller's instruction to the pilot. He switched the data souce from one that was accurate to one that wouldn't show that there was a problem: it was neither clearly wrong nor clearly missing, it provided only the illusion of information.
Regarding marciovp's contention that
My comment: If Sao Jose gave the pilots the new flight plan why should the follow the old? Makes no sense!
Here again, the programmer may have run a simulation, where automated models of "pilots" always realized immediately that they had lost communications, and where they were correctly programmed with ICAO rules. Pilots, however, are not computers, and loss of communications is not an instant, black-and-white event. That may be obvious to people who work in cockpits, but it is not clear to people who work in cubicles. RatherBeFlying explained about that.
Regarding the Vanity Fair article, there are major errors on critical issues, but I'll confine myself to two trivial examples based on the local knowledge I do have, rather than the aviation knowedge I don't. Langewiesche misspelled the very common Brazilian name "Pereira", which is like getting "Smith" wrong. Second, he takes at face value Indian chief Megaron's contention that Air Force soldiers stole watches and such. I've never met Megaron, but I have neighbors who have (they do anthropological documentaries), and they say the first time they met him, he tried to steal their canoe.
Richard_Brazil's scenario is a reasonable programming / system design possibility.
A conscientious programmer or designer will give careful consideration to cases where the data source disappears and, quite naturally, solicit substitutes. The low level guy generally kicks such use cases (quite possibly with a proposed solution) upstairs to the lead designers who will run them by the client.
Note that the Brazilian side reports that the software performs to specification; so, we can be sure that this element of the spec was accepted by the client, the Brazilian Air Force.
That would not be by any means the first time that a stupid specification was accepted by a client - think millions
A conscientious programmer or designer will give careful consideration to cases where the data source disappears and, quite naturally, solicit substitutes. The low level guy generally kicks such use cases (quite possibly with a proposed solution) upstairs to the lead designers who will run them by the client.
Note that the Brazilian side reports that the software performs to specification; so, we can be sure that this element of the spec was accepted by the client, the Brazilian Air Force.
That would not be by any means the first time that a stupid specification was accepted by a client - think millions
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From Aviation International News today
Brazilian Prosecutors Appeal Dismissed Pilot Charges
Prosecutors in Brazil are appealing the dropping of some accusations in the 2006 midair collision between a Gol Airlines Boeing 737-800 and an ExcelAire Embraer Legacy 600. The airliner crashed into the Amazon forest, killing all 154 aboard, while the business jet made an emergency landing at an Air Force base. Judge Murilo Mendes recently dismissed accusations that the American Legacy pilots, Joe Lepore and Jan Paladino, were negligent in not taking emergency steps for communications loss, ruling that nothing suggested an emergency situation. He also dropped charges against two of the air traffic controllers involved, accepting as normal the fact that they weren’t alarmed by another failure of an ATC system “characterized…by poor functioning, by repeated defects.” The judge’s downgrading of charges against another controller was not appealed, leaving no defendant facing a penalty greater than four years. Additionally, last week the Supreme Court in Brazil ruled that defendants can’t be jailed until all appeals are exhausted, a process that can take more than six years. Even if convicted, there is now little chance any of those accused in the accident will serve time.
Brazilian Prosecutors Appeal Dismissed Pilot Charges
Prosecutors in Brazil are appealing the dropping of some accusations in the 2006 midair collision between a Gol Airlines Boeing 737-800 and an ExcelAire Embraer Legacy 600. The airliner crashed into the Amazon forest, killing all 154 aboard, while the business jet made an emergency landing at an Air Force base. Judge Murilo Mendes recently dismissed accusations that the American Legacy pilots, Joe Lepore and Jan Paladino, were negligent in not taking emergency steps for communications loss, ruling that nothing suggested an emergency situation. He also dropped charges against two of the air traffic controllers involved, accepting as normal the fact that they weren’t alarmed by another failure of an ATC system “characterized…by poor functioning, by repeated defects.” The judge’s downgrading of charges against another controller was not appealed, leaving no defendant facing a penalty greater than four years. Additionally, last week the Supreme Court in Brazil ruled that defendants can’t be jailed until all appeals are exhausted, a process that can take more than six years. Even if convicted, there is now little chance any of those accused in the accident will serve time.
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This is a very long post(actually two posts). But I believe it to be very important to write this.
I have finally completed reading this accident report and was very disappointed. In my opinion, the Brazilian Aeronautical Accident Investigation and Prevention Center(CENIPA) is not impartial and has gone out of their way to put as much blame as possible on the Legacy pilots well beyond what blame should have been apportioned to them.
Over and over they come up with all kinds of nitpicking stuff that is normal everyday airline type activity and used these examples in an unfair attempt to portray the pilots as having poor airmanship. I have many examples but there are more that I have not commented on. I have also posted my own comments on the many examples that make this a very poor accident investigation report.
CENIPA says “The crew was operationally unprepared to fly the equipment.
Such operational unpreparedness refers to the fact that they had not flown together before the trip to Brazil; that they had studied the new aircraft together, but not deeply enough (in detail”)(pg 193) This is because the captain was new on the aircraft and the F/O had been a captain on very similar Regional Jet version but was newly hired and trained on the Legacy version. Yet it is not out of the ordinary for a crew to have never flown together before or both pilots to be new on an aircraft. We see this with the first arrival of new A-380 at various airlines for international flights.
CENIPA states “Considering that the item “Flight Plans” of the “Air Carrier Operations Manual” mentions that it is the responsibility of the PIC the opening and closing of an FPL through the nearest Flight Service Station (FSS) or Aeronautical Information Service (AIS) facility, it can be observed that the PIC did not comply with this determination, as he transferred this responsibility for the FPL to the SIC.” (pg 94) and “…the PIC allowed the crew to separate at one of the crucial moments of the mission: the elaboration of the FPL (including the planning of the flight), and at the conduction of the pre-flight of the airplane, during the phase that preceded the departure.”(pg 94) It would appear the investigators they never heard of delegation before. That is a sign of a good piloting technique and CRM. Delegating the SIC to open or close a flight plan does not mean the PIC is any less responsible for it. A good example in the aviation industry is the PIC normally delegates a walkaround to another crewmember. The fact that they were not together for the “Elaboration of the FPL” is irrelevant as the crew followed all ATC clearances.
CENIPA states “The PIC decided to stay in the cockpit of the N600XL airplane, to continue with the flight preparation phase (pre-flight execution) and data insertion into the FMS, while the SIC was in the Embraer Delivery Management sector dealing with the planning and studying the weight and balance calculation software. By then, the pilots should have inserted the navigation into the FMS of the aircraft together. They were about to start a long duration flight, and for the first time without the assistance of an Embraer pilot (Safety Pilot)”.(pg 94) How many pilots out there have entered a flight plan into the FMS’(s) while the other pilot is busy with other activities? This is normal occurrence. There is nothing to suggest that the route in the FMS was not confirmed before departure. It is just more nitpicking of a real world scenario where some issues have been delegated by the PIC and is extremely unlikely to have had any effect on whether they would have noticed later on that ATC had not cleared them to the filed flight level.
Under reasons for a lack of preparation CENIPA says:
“Even the mentioned delay in delivering the flight plan and other data of the planning on the part of Embraer, alleged by the pilots, does not excuse them from their responsibility to forecast and manage possible delays in the preparation of the flight, especially for being in a place and under circumstances they had never experienced before”.(pg 191) So even the fact that of the late delivery of the “flight plan and data of the planning” from Embraer is now the pilot’s fault. Notice how they say “alleged by the pilots, a term typically used in criminal cases and a term used more than once by CENIPA on the pilots statements including the reason for being in the washroom by the captain.
CENIPA makes the statement of “The crew was OPERATIONALLY UNPREPARED to fly the equipment” on page 193 with reasons given below:
“Such operational unpreparedness refers to the fact that they had not flown together before the trip to Brazil; that they had studied the new aircraft together, but not deeply enough (in detail); and that they were not aware that the repositioning of the new aircraft, which the PIC had never flown before, would not be a routine flight..”
“The coordination of the cockpit preflight procedures contributed to the pilots not acquiring a perfect situational awareness, relative to the flight plan which had been submitted to the airspace control units.”
“They got to the moment of departure with doubts and expectations relative to the functioning of the system of fuel transfer from the extra tanks of the aircraft, a feature that was not present in the simulator used in their training”.
“At the moment of departure, they had not duly evaluated the consequences of the weight and balance on account of the reduction of the runway length available at the destination airport, informed by a NOTAM, something which was highly distracting to them during the flight, in detriment of the monitoring of the aircraft systems with which they were not well familiarized.”
“These factors made the pilots focus their attention on the fuel system, since it was a long distance flight, a considerable part of which over the Amazon rainforest. Consequently, they decided to configure the fuel system on the MFD screens of both sides.” With the exception of the NOTAM oversight, I believe CENIPA is making up excuses to blame the pilots. Never having flown together before is an everyday reality in the aviation industry. The pilots knew their flight plan and flew it as filed and amended by ATC. Concern about the fuel system(which was different from their training) was to be expected. There is nothing to indicate that they did not operate the fuel system properly and it showed good airmanship to be concerned about it.(keep in mind that it suspected that the transponder ceased operation during fuel system inputs of the Radio Management Unit RMU box of the integrated avionics system)
CENIPA goes on about this saying on page 192 “…It is not common for pilots who intend to fly an aircraft with which they are not accustomed, to be trying to solve doubts up to the last moment before departure, to the detriment of the time necessary to study the planning for the conduction of the flight to be initiated.” Actually it is quite common for a flight crew to be trying to solve doubts up to the last moment of departure and seeing as the crew filed and flew their flight plan as cleared by ATC this shows once again blame being put on a crew for an aspect of flight done properly.
Another example of unjustly accusing the pilots of poor airmanship is when the crew passed over the BRS VOR, the aircraft changed heading as it joined a new airway. This is when the aircraft started flying an airway at a wrong way altitude for direction of flight, though it was the altitude they had been cleared to maintain by ATC. Keep in mind that one of the pilots was using a laptop at this time for performance calculations at destination as it was discovered in flight that a NOTAM indicated a runway length reduction. The report notes that there was no verbal mention of the heading change over the VOR and “No dialog between the crewmembers was recorded in the CVR that could indicate that the flight was being monitored by any of them”(pg 80).
And
“As observed from the transcripts of the CVR, during this period of time, when the recordings indicate the use of the laptop, the crew focused on the calculation of the performance, without any conversation or comments that might suggest that the pilot in command was checking the information of the flight instruments at intervals. These circumstances denote a poor situational awareness on the part of the pilots.”(pg102)
On page 209 the report calls this poor airmanship. I would like to ask how many of you out there verbally note whenever a heading change is made by the autopilot while enroute? Since when does a lack of conversation indicate a lack of monitoring or poor situational awareness or airmanship? Assumptions like these destroy the credibility of CENIPA and make me wonder if they had any investigators with piloting experience.
At some point after passing the BRS VOR and flying out of range of ATC, the transponder stopped operating without the pilot’s knowledge. It is mentioned on page 229 about the “conspicuous” STANDBY indications on the aircraft as if it would just jump out at a crewmember if only time was taken to look in that direction. I’m sure it was to the investigators when they knew to look for such an indication. However it ignores the obvious reality that these standby indications won’t be obvious someone when they are unaware that it is there and buried in among a lot of other information. In fact, it took me a significant amount of time to find the TCAS FAIL annunciator in Fig. 31 on page 92 even when specifically looking for it.
The attacks on the pilots in the report become ridiculous when it criticizes a crewmember for not adhering to the standard English phraseology when he said “six souls on board” in response to a question from ATC about the number of persons on board.
Here some more quotes from the report.
“It is not good practice to be involved, while flying, in any type of task that demands too much attention that, otherwise, would be paid to the adequate operation of the aircraft systems or to the navigation being conducted.”(pg199) This is real world stuff. Crew members do actually perform other tasks in flight whether it is consulting an MEL, looking at performance charts and many other tasks including sleeping if approved. There is no evidence that the flight crew was not keeping a general overview on the flight deck during this period. It is just CENIPA using any excuse it can to blame the pilots.
“As was confirmed in an interview given by the pilots a year after the accident, more attention was paid to the lateral navigation than to the vertical navigation (levels). As already commented, this is common in the programming of the FMS for long routes. However, the lack of pre-established procedures on the part of the company for this type of operation contributed to the pilots’ diminished attention to this aspect.”(pg 199)
And
“When one considers the different versions about the moments and preparations prior to the flight, one gets to the conclusion that the pilots did not work methodically enough, did no to prepare themselves for tasks they had to do by themselves, and transferred the responsibility for those tasks to other people. Contributed to this the fact that the operator did not have standard procedures established to cover all the nuances that involved the receipt of a new aircraft, mainly in the case of executive flights, in which the scenarios are varied.” (pg 191). Does CENIPA really believe that an SOP can be written to cover as the report says “all the nuances involved in the receipt of a new aircraft”? How is an operator going to do that with a type not even in their fleet yet? Perhaps by hiring a person experienced on similar type to be a crewmember as Excelaire did with a complete initial course on type including international operations.
Under Organizational influences, it is stated:
“It was also observed that the company had two contracts with training centers for the execution of annual trainings of the CRM, as well as refreshers, and that the training for the operation of the N600XL was provided to the crew by EMBRAER, at the FSI. The difficulties presented by the crew at the pre-flight and at the ferry flight indicate that the mechanisms developed by the company to supervise the efficiency of the training taken up by the pilots were inefficient regarding the prevention of the performance deficiencies shown by the crew of the N600XL.”
“The validation of a training program takes place as the knowledge acquired by the pilots proves sufficient for the execution of all the functions necessary for the accomplishment of the mission, as well as makes it possible to detect any problems with the necessary anticipation for the implementation of corrective actions.”(pg 168)
Does CENIPA really believe that a training provided for an aircraft will prepare pilots for “any problems with the necessary anticipation for the implementation of corrective actions”. Have any pilots out there ever gone onto a new plane with complete and total knowledge of their aircraft and navigation systems and how to properly deal with any and every scenario they faced with “with the necessary anticipation for the implementation of corrective actions” and could have done so on their first flight. This is a ridiculously high expectation of perfection and a complete disregard of the reality that we learn a lot of stuff once we start flying the aircraft.
An example of the efforts by CENIPA over and over to paint the crew as not properly paying attention properly based on nothingness are given here on page 197. “Two minutes later, the ground controller made two calls to the aircraft, which was
taxiing, but there was no reply.”
This leads CENIPA to conclude that
“While they were taxiing, a low situational awareness could be observed on the part of the pilots, possibly due to their paying attention to other tasks in the cockpit, without being attentive to the radiotelephony.” This is something that has nothing to do with the accident, something that happens every day to many flights, and something that fails to take into reality that there is more going on in the flight deck than just listening out to ATC.
Concerning the long period of time that the crew did not talk to ATC before making repeated attempts to do so just prior to the collision leads to this conclusion
“The little concern with the lack of communication, mainly if one considers that it was a flight in a foreign country, denotes a low level of airmanship, professionalism and concern with the situational awareness on the part of the crew. However, it is worth pointing out that the fact that they were under radar surveillance and could hear the radio transmissions between the other aircraft contributed to their unconcern.”(228)
CENIPA says the pilots are unprofessional, lacking in airmanship and have a low situational awareness because of their lack of communication with ATC. In reality, you can see that they admit that they could hear radio transmissions and guess what? They are in Portuguese so it is that much more difficult to realize that you are out of range of ATC when you are in reality, tuning out these foreign language transmissions. How many of us have gone out of range of ATC on a flight? Were you unprofessional because of it? Another unrealistic expectation of perfection. These things happen very frequently.
There are of course many other small pointed remarks attempting to paint the whole mission by the pilots and Exelaire as unprofessional woven throughout the report.
I have finally completed reading this accident report and was very disappointed. In my opinion, the Brazilian Aeronautical Accident Investigation and Prevention Center(CENIPA) is not impartial and has gone out of their way to put as much blame as possible on the Legacy pilots well beyond what blame should have been apportioned to them.
Over and over they come up with all kinds of nitpicking stuff that is normal everyday airline type activity and used these examples in an unfair attempt to portray the pilots as having poor airmanship. I have many examples but there are more that I have not commented on. I have also posted my own comments on the many examples that make this a very poor accident investigation report.
CENIPA says “The crew was operationally unprepared to fly the equipment.
Such operational unpreparedness refers to the fact that they had not flown together before the trip to Brazil; that they had studied the new aircraft together, but not deeply enough (in detail”)(pg 193) This is because the captain was new on the aircraft and the F/O had been a captain on very similar Regional Jet version but was newly hired and trained on the Legacy version. Yet it is not out of the ordinary for a crew to have never flown together before or both pilots to be new on an aircraft. We see this with the first arrival of new A-380 at various airlines for international flights.
CENIPA states “Considering that the item “Flight Plans” of the “Air Carrier Operations Manual” mentions that it is the responsibility of the PIC the opening and closing of an FPL through the nearest Flight Service Station (FSS) or Aeronautical Information Service (AIS) facility, it can be observed that the PIC did not comply with this determination, as he transferred this responsibility for the FPL to the SIC.” (pg 94) and “…the PIC allowed the crew to separate at one of the crucial moments of the mission: the elaboration of the FPL (including the planning of the flight), and at the conduction of the pre-flight of the airplane, during the phase that preceded the departure.”(pg 94) It would appear the investigators they never heard of delegation before. That is a sign of a good piloting technique and CRM. Delegating the SIC to open or close a flight plan does not mean the PIC is any less responsible for it. A good example in the aviation industry is the PIC normally delegates a walkaround to another crewmember. The fact that they were not together for the “Elaboration of the FPL” is irrelevant as the crew followed all ATC clearances.
CENIPA states “The PIC decided to stay in the cockpit of the N600XL airplane, to continue with the flight preparation phase (pre-flight execution) and data insertion into the FMS, while the SIC was in the Embraer Delivery Management sector dealing with the planning and studying the weight and balance calculation software. By then, the pilots should have inserted the navigation into the FMS of the aircraft together. They were about to start a long duration flight, and for the first time without the assistance of an Embraer pilot (Safety Pilot)”.(pg 94) How many pilots out there have entered a flight plan into the FMS’(s) while the other pilot is busy with other activities? This is normal occurrence. There is nothing to suggest that the route in the FMS was not confirmed before departure. It is just more nitpicking of a real world scenario where some issues have been delegated by the PIC and is extremely unlikely to have had any effect on whether they would have noticed later on that ATC had not cleared them to the filed flight level.
Under reasons for a lack of preparation CENIPA says:
“Even the mentioned delay in delivering the flight plan and other data of the planning on the part of Embraer, alleged by the pilots, does not excuse them from their responsibility to forecast and manage possible delays in the preparation of the flight, especially for being in a place and under circumstances they had never experienced before”.(pg 191) So even the fact that of the late delivery of the “flight plan and data of the planning” from Embraer is now the pilot’s fault. Notice how they say “alleged by the pilots, a term typically used in criminal cases and a term used more than once by CENIPA on the pilots statements including the reason for being in the washroom by the captain.
CENIPA makes the statement of “The crew was OPERATIONALLY UNPREPARED to fly the equipment” on page 193 with reasons given below:
“Such operational unpreparedness refers to the fact that they had not flown together before the trip to Brazil; that they had studied the new aircraft together, but not deeply enough (in detail); and that they were not aware that the repositioning of the new aircraft, which the PIC had never flown before, would not be a routine flight..”
“The coordination of the cockpit preflight procedures contributed to the pilots not acquiring a perfect situational awareness, relative to the flight plan which had been submitted to the airspace control units.”
“They got to the moment of departure with doubts and expectations relative to the functioning of the system of fuel transfer from the extra tanks of the aircraft, a feature that was not present in the simulator used in their training”.
“At the moment of departure, they had not duly evaluated the consequences of the weight and balance on account of the reduction of the runway length available at the destination airport, informed by a NOTAM, something which was highly distracting to them during the flight, in detriment of the monitoring of the aircraft systems with which they were not well familiarized.”
“These factors made the pilots focus their attention on the fuel system, since it was a long distance flight, a considerable part of which over the Amazon rainforest. Consequently, they decided to configure the fuel system on the MFD screens of both sides.” With the exception of the NOTAM oversight, I believe CENIPA is making up excuses to blame the pilots. Never having flown together before is an everyday reality in the aviation industry. The pilots knew their flight plan and flew it as filed and amended by ATC. Concern about the fuel system(which was different from their training) was to be expected. There is nothing to indicate that they did not operate the fuel system properly and it showed good airmanship to be concerned about it.(keep in mind that it suspected that the transponder ceased operation during fuel system inputs of the Radio Management Unit RMU box of the integrated avionics system)
CENIPA goes on about this saying on page 192 “…It is not common for pilots who intend to fly an aircraft with which they are not accustomed, to be trying to solve doubts up to the last moment before departure, to the detriment of the time necessary to study the planning for the conduction of the flight to be initiated.” Actually it is quite common for a flight crew to be trying to solve doubts up to the last moment of departure and seeing as the crew filed and flew their flight plan as cleared by ATC this shows once again blame being put on a crew for an aspect of flight done properly.
Another example of unjustly accusing the pilots of poor airmanship is when the crew passed over the BRS VOR, the aircraft changed heading as it joined a new airway. This is when the aircraft started flying an airway at a wrong way altitude for direction of flight, though it was the altitude they had been cleared to maintain by ATC. Keep in mind that one of the pilots was using a laptop at this time for performance calculations at destination as it was discovered in flight that a NOTAM indicated a runway length reduction. The report notes that there was no verbal mention of the heading change over the VOR and “No dialog between the crewmembers was recorded in the CVR that could indicate that the flight was being monitored by any of them”(pg 80).
And
“As observed from the transcripts of the CVR, during this period of time, when the recordings indicate the use of the laptop, the crew focused on the calculation of the performance, without any conversation or comments that might suggest that the pilot in command was checking the information of the flight instruments at intervals. These circumstances denote a poor situational awareness on the part of the pilots.”(pg102)
On page 209 the report calls this poor airmanship. I would like to ask how many of you out there verbally note whenever a heading change is made by the autopilot while enroute? Since when does a lack of conversation indicate a lack of monitoring or poor situational awareness or airmanship? Assumptions like these destroy the credibility of CENIPA and make me wonder if they had any investigators with piloting experience.
At some point after passing the BRS VOR and flying out of range of ATC, the transponder stopped operating without the pilot’s knowledge. It is mentioned on page 229 about the “conspicuous” STANDBY indications on the aircraft as if it would just jump out at a crewmember if only time was taken to look in that direction. I’m sure it was to the investigators when they knew to look for such an indication. However it ignores the obvious reality that these standby indications won’t be obvious someone when they are unaware that it is there and buried in among a lot of other information. In fact, it took me a significant amount of time to find the TCAS FAIL annunciator in Fig. 31 on page 92 even when specifically looking for it.
The attacks on the pilots in the report become ridiculous when it criticizes a crewmember for not adhering to the standard English phraseology when he said “six souls on board” in response to a question from ATC about the number of persons on board.
Here some more quotes from the report.
“It is not good practice to be involved, while flying, in any type of task that demands too much attention that, otherwise, would be paid to the adequate operation of the aircraft systems or to the navigation being conducted.”(pg199) This is real world stuff. Crew members do actually perform other tasks in flight whether it is consulting an MEL, looking at performance charts and many other tasks including sleeping if approved. There is no evidence that the flight crew was not keeping a general overview on the flight deck during this period. It is just CENIPA using any excuse it can to blame the pilots.
“As was confirmed in an interview given by the pilots a year after the accident, more attention was paid to the lateral navigation than to the vertical navigation (levels). As already commented, this is common in the programming of the FMS for long routes. However, the lack of pre-established procedures on the part of the company for this type of operation contributed to the pilots’ diminished attention to this aspect.”(pg 199)
And
“When one considers the different versions about the moments and preparations prior to the flight, one gets to the conclusion that the pilots did not work methodically enough, did no to prepare themselves for tasks they had to do by themselves, and transferred the responsibility for those tasks to other people. Contributed to this the fact that the operator did not have standard procedures established to cover all the nuances that involved the receipt of a new aircraft, mainly in the case of executive flights, in which the scenarios are varied.” (pg 191). Does CENIPA really believe that an SOP can be written to cover as the report says “all the nuances involved in the receipt of a new aircraft”? How is an operator going to do that with a type not even in their fleet yet? Perhaps by hiring a person experienced on similar type to be a crewmember as Excelaire did with a complete initial course on type including international operations.
Under Organizational influences, it is stated:
“It was also observed that the company had two contracts with training centers for the execution of annual trainings of the CRM, as well as refreshers, and that the training for the operation of the N600XL was provided to the crew by EMBRAER, at the FSI. The difficulties presented by the crew at the pre-flight and at the ferry flight indicate that the mechanisms developed by the company to supervise the efficiency of the training taken up by the pilots were inefficient regarding the prevention of the performance deficiencies shown by the crew of the N600XL.”
“The validation of a training program takes place as the knowledge acquired by the pilots proves sufficient for the execution of all the functions necessary for the accomplishment of the mission, as well as makes it possible to detect any problems with the necessary anticipation for the implementation of corrective actions.”(pg 168)
Does CENIPA really believe that a training provided for an aircraft will prepare pilots for “any problems with the necessary anticipation for the implementation of corrective actions”. Have any pilots out there ever gone onto a new plane with complete and total knowledge of their aircraft and navigation systems and how to properly deal with any and every scenario they faced with “with the necessary anticipation for the implementation of corrective actions” and could have done so on their first flight. This is a ridiculously high expectation of perfection and a complete disregard of the reality that we learn a lot of stuff once we start flying the aircraft.
An example of the efforts by CENIPA over and over to paint the crew as not properly paying attention properly based on nothingness are given here on page 197. “Two minutes later, the ground controller made two calls to the aircraft, which was
taxiing, but there was no reply.”
This leads CENIPA to conclude that
“While they were taxiing, a low situational awareness could be observed on the part of the pilots, possibly due to their paying attention to other tasks in the cockpit, without being attentive to the radiotelephony.” This is something that has nothing to do with the accident, something that happens every day to many flights, and something that fails to take into reality that there is more going on in the flight deck than just listening out to ATC.
Concerning the long period of time that the crew did not talk to ATC before making repeated attempts to do so just prior to the collision leads to this conclusion
“The little concern with the lack of communication, mainly if one considers that it was a flight in a foreign country, denotes a low level of airmanship, professionalism and concern with the situational awareness on the part of the crew. However, it is worth pointing out that the fact that they were under radar surveillance and could hear the radio transmissions between the other aircraft contributed to their unconcern.”(228)
CENIPA says the pilots are unprofessional, lacking in airmanship and have a low situational awareness because of their lack of communication with ATC. In reality, you can see that they admit that they could hear radio transmissions and guess what? They are in Portuguese so it is that much more difficult to realize that you are out of range of ATC when you are in reality, tuning out these foreign language transmissions. How many of us have gone out of range of ATC on a flight? Were you unprofessional because of it? Another unrealistic expectation of perfection. These things happen very frequently.
There are of course many other small pointed remarks attempting to paint the whole mission by the pilots and Exelaire as unprofessional woven throughout the report.
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Here is the clearance to destination as given by ATC(Eduardo Gomes is the destination airport):
“NOVEMBER SIX ZERO ZERO X-RAY LIMA, ATC CLEARENCE TO EDUARDO GOMES, FLIGHT LEVEL THREE SEVEN ZERO DIRECT POÇOS DE CALDAS, SQUAWK TRANSPONDER CODE FOUR FIVE SEVEN FOUR. AFTER TAKE-OFF PERFORM OREN DEPARTURE.”
It is quite obvious that aside from any other restrictions from ATC that they are cleared to maintain FL370 all the way to destination, yet CENIPA tries to fault the crew saying on page 198 “A clearance delivered in an incomplete manner, and pilots that did not have enough time to analyze the flight plan filed, on account of a lack of proper anticipation of the procedures concerning the preparation for the flight, the N600XL ended up departing with situational awareness incongruent with the plan activated by ACC BS.” In fact they questioned ATC about the initial altitude to maintain and flew exactly as cleared by ATC. CENIPA complains that the pilots are basically incompetent based on every little thing it seems, yet after years of evaluation cannot figure out what the definition of a clearance limit is.
The NTSB has a 14 page report at the end of the Brazilian final report which criticizes CENIPA’s investigation. Among many things, the NTSB critique states the following:
“At numerous points in the report, there is discussion and analysis of the initial ATC clearance issued by São José ground control and the pilot’s understanding of portions of the clearance. Specifically, the terms “clearance limit” and “cleared as filed” appear to be misunderstood. “Clearance limit” is defined in ICAO document 4444 as “the point to which an aircraft is granted an air traffic control clearance” and in the FAA Pilot/Controller Glossary (P/CG, part of FAA Order 7110.65 and the Aeronautical Information Manual) as “the fix, point, or location to which an aircraft is cleared when issued an air traffic clearance.” However, numerous times this phrase is associated with the altitude portions of a clearance. The report correctly notes that the initial clearance issued to N600XL before departure from São José dos Campos did not follow the correct format for an initial clearance. However, we believe that the ground controller’s statement “clearance to Eduardo Gomes,” could not realistically be interpreted as anything other than the “clearance limit” item of the clearance. Furthermore, numerous statements in the report imply that issuance of a clearance limit, whether for the intended destination or an intermediate navigational fix, correlates with the assigned altitude. Section 4.5.7.1 of ICAO document 4444 describes the relevant application of a clearance limit, which in no way affects the assigned altitude of the airplane. The report cites section 11.4.2.5.1 of ICAO document 4444, which reads as follows:
Clearances shall contain the following in the order listed:
(a) aircraft identification;
(b) clearance limit;
(c) route of flight;
(d) level(s) of flight for the entire route or part thereof and changes of
levels if required;
Note. If the clearance for the levels covers only part of the route, it is important for the air traffic control unit to specify a point to which the part of the clearance regarding levels applies whenever necessary to ensure compliance with 3.6.5.2.2 a) of Annex 2.
(e) any necessary instructions or information on other matters such as SSR
transponder operation, approach or departure maneuvers, communications
and the time of expiry of the clearance.
This section is quite clear that the note referring to en route level changes applies to the “altitude” (levels) portion of the clearance. A common application of this procedure would be the issuance of a crossing restriction, as in the example in ICAO 4444 11.4.2.5.2.2b. Therefore, we submit that, although the initial departure clearance was incomplete and in a nonstandard format, the issuance of a clearance limit did not contribute to any misunderstanding. It is possible that, if the initial departure clearance had been stated as discussed above, it may have served as a reminder to the flight crew; however, any intervening altitude assignment by the en route controllers would be in force unless amended.
These instances include, but are not limited to, pages 39, 40, 54, 97, 197, 198, 201, 217, 250, 252, and 256.”
ON page 253 the CENIPA says “When the pilots noticed that they were having difficulties contacting the control units, they did not either attempt any calls on HF frequencies or follow the international rule concerning the use of the code 7600 in case of communications failure” Since when is being out of range of ATC a com failure justifying a squawk of 7600? How many pilot’s reading this have squawked 7600 as they were using their properly operating radios to find a new ATC frequency? In fact they even did receive a transmission from ATC shortly before the collision. Their comms did not fail.
No doubt CENIPA looked desperately for any regulatory infraction that the pilots may have made. Yet all they could find was that when the captain went to the washroom, the copilot did not have his oxygen mask on. A complete non-issue in this accident and something that is done all the time. Yet the Gol pilots get no criticism and are treated as shining stars. But oddly, hidden away in the final report recommendations on page 18 is this statement directed at Gol Airlines: “To reevaluate the SOP, “General Index of Chapters” / 1- General Procedures / 1.8 – Conversation in the Cockpit (Sterile Cockpit), and set up a protocol for cell phone utilization by crew members, when they are in the command cockpit of the aircraft.” If the Excelaire pilots had done the same as this recommendation hints happened in the Gol cockpit, it would have been just another example seized upon by CENIPA as incompetent.
As well, important issues have not been covered properly if at all:
One of these issues is the ATC radar display format played a significant role in misleading the controllers as to the actual altitude of the Legacy aircraft. There are no recommendations on changes to this. Fortunately the NTSB recognized this obvious danger and recommended changes.
Another is the fact that the report is unable to fully investigate or publish all the available information available because as is repeatedly stated, many involved parties refused to cooperate with the investigation. “On account of the legal processes in progress in Brazil, the Excelaire attorneys instructed all the company’s employees(which would include the pilots) to not give any interviews directly to the Brazilian investigation commission, and only give clarifications to the NTSB, which would then pass the interviews to the CIAA”(pg 78).
and
“The company that trained the Legacy pilots, Flight Safety International refused to receive the visit of the CIAA at the unit of Houston-Texas and brought considerable difficulties for the investigation of the instruction given to the pilots in the simulator”(pg 262).
and
“The fact that the controllers of Brasilia ACC involved in the accident refused to take part in the interviews hindered the precise identification of the individual aspects which contributed to the occurrence of active failures (attention, memory, motivation, expectations, attitude, knowledge, etc.). As a result, those aspects remain in the field of hypotheses”(pg 171).
And most importantly
“The authorities responsible for the judicial processes aiming at the verification of the criminal liabilities requested all the material gathered by this commission until then, when two months had elapsed after the accident. For this reason, the attorneys representing the controllers instructed their clients not to give any declarations, even after it was exhaustively explained that the purpose was to prevent the occurrence of further accidents”(pg 240).
Yet despite all this hinderance to the investigation, an obvious safety hazard, there are no recommendations to the Brazilian government to not criminalize aircraft accidents.
This whole criminalization procedure brings us to an issue central to the investigation. The non-operation of the transponder. The transponder stopped operating over 50 minutes before the collision probably due to being inadvertently disabled. Less than three minutes after the collision there is discussion about the TCAS. While nothing is specifically said about doing something to turn on the transponder, tests on the equipment revealed no faults so it would seem that the transponder was accidentally shut off and then turned back on after the collision. This unintentional error by the crew would be a contributing factor to the accident.
Yet the pilots denied having reactivated the transponder. Why would they do this when aside from the astronomical odds of the transponder having done all this by itself, it seems to be the only logical explanation?
This is why:
After the accident there was a public outcry to put the pilots in jail along with many false accusations based on limited information. They were accused of intentionally turning off the transponder and flying at different altitudes. The pilot’s claimed that they were at the altitude cleared by ATC(now a known fact). Yet Brazil’s Defense Minister called that “ a frivolous statement ... It was irresponsible” and in the same interview denied ATC responsibility. Given the above statement in the report of “The authorities responsible for the judicial processes aiming at the verification of the criminal liabilities requested all the material gathered by this commission until then, when two months had elapsed after the accident.”, who is going to tell the honest truth about an error made, especially when you look at page 266 and see two signatures authorizing the final report. They are the Chief of General staff of Aeronautics and the Chief of CENIPA. Both are Brigadier Generals. The Air Force run accident investigation board was investigating an accident with the Air Force run ATC involving a highly emotional event in Brazil. And all the statements are being taken for the judicial process where the pilots are facing many years in jail.
My opinion is that in the end, the military knew they couldn’t escape criticism of obvious ATC fault but made sure that as much blame as possible was put on the pilots in an attempt to escape much of the blame.
I highly recommend that anyone reading about this accident confine themselves to the NTSB section of the report. Here are some highlights.
“we believe that the ground controller’s statement “clearance to Eduardo Gomes,” could not realistically be interpreted as anything other than the “clearance limit” item of the clearance.”
“Hemispherical altitudes such as those shown on the index of an IFR chart or in the Aeronautical Information Manual, although used as conventions by ATC, are only a requirement when operating in uncontrolled airspace. The implication that a crew should somehow observe hemispherical altitudes while being positively controlled by an ATC facility is incorrect.”
“We do not agree that the analysis is sufficient to support any deficiency in the conduct of the flight, which can be related to planning. The crew flew the route precisely as cleared and complied with all ATC instructions. The crew’s awareness of their current altitude and its relation to the hemispheric convention applicable to the course of flight north of Brasilia is entirely independent of the requested level in the flight plan. The implication that a crew should somehow observe hemispherical altitudes while being positively controlled by an ATC facility is incorrect”.
“ATC did not issue an amended clearance; therefore, the crew had no reason to
change altitudes and could not unilaterally do so.”
“N600XL proceeded for an inordinately long time without two-way communication”
“they did have a long term opportunity to note a nonstandard situation and request clarification or confirmation from ATC”.
“Contributing to this accident was the undetected loss of functionality of the airborne collision avoidance system technology as a result of the inadvertent inactivation of the transponder on board N600XL”.
”Further contributing to the accident was inadequate communication between ATC and the N600XL flight crew.”
“NOVEMBER SIX ZERO ZERO X-RAY LIMA, ATC CLEARENCE TO EDUARDO GOMES, FLIGHT LEVEL THREE SEVEN ZERO DIRECT POÇOS DE CALDAS, SQUAWK TRANSPONDER CODE FOUR FIVE SEVEN FOUR. AFTER TAKE-OFF PERFORM OREN DEPARTURE.”
It is quite obvious that aside from any other restrictions from ATC that they are cleared to maintain FL370 all the way to destination, yet CENIPA tries to fault the crew saying on page 198 “A clearance delivered in an incomplete manner, and pilots that did not have enough time to analyze the flight plan filed, on account of a lack of proper anticipation of the procedures concerning the preparation for the flight, the N600XL ended up departing with situational awareness incongruent with the plan activated by ACC BS.” In fact they questioned ATC about the initial altitude to maintain and flew exactly as cleared by ATC. CENIPA complains that the pilots are basically incompetent based on every little thing it seems, yet after years of evaluation cannot figure out what the definition of a clearance limit is.
The NTSB has a 14 page report at the end of the Brazilian final report which criticizes CENIPA’s investigation. Among many things, the NTSB critique states the following:
“At numerous points in the report, there is discussion and analysis of the initial ATC clearance issued by São José ground control and the pilot’s understanding of portions of the clearance. Specifically, the terms “clearance limit” and “cleared as filed” appear to be misunderstood. “Clearance limit” is defined in ICAO document 4444 as “the point to which an aircraft is granted an air traffic control clearance” and in the FAA Pilot/Controller Glossary (P/CG, part of FAA Order 7110.65 and the Aeronautical Information Manual) as “the fix, point, or location to which an aircraft is cleared when issued an air traffic clearance.” However, numerous times this phrase is associated with the altitude portions of a clearance. The report correctly notes that the initial clearance issued to N600XL before departure from São José dos Campos did not follow the correct format for an initial clearance. However, we believe that the ground controller’s statement “clearance to Eduardo Gomes,” could not realistically be interpreted as anything other than the “clearance limit” item of the clearance. Furthermore, numerous statements in the report imply that issuance of a clearance limit, whether for the intended destination or an intermediate navigational fix, correlates with the assigned altitude. Section 4.5.7.1 of ICAO document 4444 describes the relevant application of a clearance limit, which in no way affects the assigned altitude of the airplane. The report cites section 11.4.2.5.1 of ICAO document 4444, which reads as follows:
Clearances shall contain the following in the order listed:
(a) aircraft identification;
(b) clearance limit;
(c) route of flight;
(d) level(s) of flight for the entire route or part thereof and changes of
levels if required;
Note. If the clearance for the levels covers only part of the route, it is important for the air traffic control unit to specify a point to which the part of the clearance regarding levels applies whenever necessary to ensure compliance with 3.6.5.2.2 a) of Annex 2.
(e) any necessary instructions or information on other matters such as SSR
transponder operation, approach or departure maneuvers, communications
and the time of expiry of the clearance.
This section is quite clear that the note referring to en route level changes applies to the “altitude” (levels) portion of the clearance. A common application of this procedure would be the issuance of a crossing restriction, as in the example in ICAO 4444 11.4.2.5.2.2b. Therefore, we submit that, although the initial departure clearance was incomplete and in a nonstandard format, the issuance of a clearance limit did not contribute to any misunderstanding. It is possible that, if the initial departure clearance had been stated as discussed above, it may have served as a reminder to the flight crew; however, any intervening altitude assignment by the en route controllers would be in force unless amended.
These instances include, but are not limited to, pages 39, 40, 54, 97, 197, 198, 201, 217, 250, 252, and 256.”
ON page 253 the CENIPA says “When the pilots noticed that they were having difficulties contacting the control units, they did not either attempt any calls on HF frequencies or follow the international rule concerning the use of the code 7600 in case of communications failure” Since when is being out of range of ATC a com failure justifying a squawk of 7600? How many pilot’s reading this have squawked 7600 as they were using their properly operating radios to find a new ATC frequency? In fact they even did receive a transmission from ATC shortly before the collision. Their comms did not fail.
No doubt CENIPA looked desperately for any regulatory infraction that the pilots may have made. Yet all they could find was that when the captain went to the washroom, the copilot did not have his oxygen mask on. A complete non-issue in this accident and something that is done all the time. Yet the Gol pilots get no criticism and are treated as shining stars. But oddly, hidden away in the final report recommendations on page 18 is this statement directed at Gol Airlines: “To reevaluate the SOP, “General Index of Chapters” / 1- General Procedures / 1.8 – Conversation in the Cockpit (Sterile Cockpit), and set up a protocol for cell phone utilization by crew members, when they are in the command cockpit of the aircraft.” If the Excelaire pilots had done the same as this recommendation hints happened in the Gol cockpit, it would have been just another example seized upon by CENIPA as incompetent.
As well, important issues have not been covered properly if at all:
One of these issues is the ATC radar display format played a significant role in misleading the controllers as to the actual altitude of the Legacy aircraft. There are no recommendations on changes to this. Fortunately the NTSB recognized this obvious danger and recommended changes.
Another is the fact that the report is unable to fully investigate or publish all the available information available because as is repeatedly stated, many involved parties refused to cooperate with the investigation. “On account of the legal processes in progress in Brazil, the Excelaire attorneys instructed all the company’s employees(which would include the pilots) to not give any interviews directly to the Brazilian investigation commission, and only give clarifications to the NTSB, which would then pass the interviews to the CIAA”(pg 78).
and
“The company that trained the Legacy pilots, Flight Safety International refused to receive the visit of the CIAA at the unit of Houston-Texas and brought considerable difficulties for the investigation of the instruction given to the pilots in the simulator”(pg 262).
and
“The fact that the controllers of Brasilia ACC involved in the accident refused to take part in the interviews hindered the precise identification of the individual aspects which contributed to the occurrence of active failures (attention, memory, motivation, expectations, attitude, knowledge, etc.). As a result, those aspects remain in the field of hypotheses”(pg 171).
And most importantly
“The authorities responsible for the judicial processes aiming at the verification of the criminal liabilities requested all the material gathered by this commission until then, when two months had elapsed after the accident. For this reason, the attorneys representing the controllers instructed their clients not to give any declarations, even after it was exhaustively explained that the purpose was to prevent the occurrence of further accidents”(pg 240).
Yet despite all this hinderance to the investigation, an obvious safety hazard, there are no recommendations to the Brazilian government to not criminalize aircraft accidents.
This whole criminalization procedure brings us to an issue central to the investigation. The non-operation of the transponder. The transponder stopped operating over 50 minutes before the collision probably due to being inadvertently disabled. Less than three minutes after the collision there is discussion about the TCAS. While nothing is specifically said about doing something to turn on the transponder, tests on the equipment revealed no faults so it would seem that the transponder was accidentally shut off and then turned back on after the collision. This unintentional error by the crew would be a contributing factor to the accident.
Yet the pilots denied having reactivated the transponder. Why would they do this when aside from the astronomical odds of the transponder having done all this by itself, it seems to be the only logical explanation?
This is why:
After the accident there was a public outcry to put the pilots in jail along with many false accusations based on limited information. They were accused of intentionally turning off the transponder and flying at different altitudes. The pilot’s claimed that they were at the altitude cleared by ATC(now a known fact). Yet Brazil’s Defense Minister called that “ a frivolous statement ... It was irresponsible” and in the same interview denied ATC responsibility. Given the above statement in the report of “The authorities responsible for the judicial processes aiming at the verification of the criminal liabilities requested all the material gathered by this commission until then, when two months had elapsed after the accident.”, who is going to tell the honest truth about an error made, especially when you look at page 266 and see two signatures authorizing the final report. They are the Chief of General staff of Aeronautics and the Chief of CENIPA. Both are Brigadier Generals. The Air Force run accident investigation board was investigating an accident with the Air Force run ATC involving a highly emotional event in Brazil. And all the statements are being taken for the judicial process where the pilots are facing many years in jail.
My opinion is that in the end, the military knew they couldn’t escape criticism of obvious ATC fault but made sure that as much blame as possible was put on the pilots in an attempt to escape much of the blame.
I highly recommend that anyone reading about this accident confine themselves to the NTSB section of the report. Here are some highlights.
“we believe that the ground controller’s statement “clearance to Eduardo Gomes,” could not realistically be interpreted as anything other than the “clearance limit” item of the clearance.”
“Hemispherical altitudes such as those shown on the index of an IFR chart or in the Aeronautical Information Manual, although used as conventions by ATC, are only a requirement when operating in uncontrolled airspace. The implication that a crew should somehow observe hemispherical altitudes while being positively controlled by an ATC facility is incorrect.”
“We do not agree that the analysis is sufficient to support any deficiency in the conduct of the flight, which can be related to planning. The crew flew the route precisely as cleared and complied with all ATC instructions. The crew’s awareness of their current altitude and its relation to the hemispheric convention applicable to the course of flight north of Brasilia is entirely independent of the requested level in the flight plan. The implication that a crew should somehow observe hemispherical altitudes while being positively controlled by an ATC facility is incorrect”.
“ATC did not issue an amended clearance; therefore, the crew had no reason to
change altitudes and could not unilaterally do so.”
“N600XL proceeded for an inordinately long time without two-way communication”
“they did have a long term opportunity to note a nonstandard situation and request clarification or confirmation from ATC”.
“Contributing to this accident was the undetected loss of functionality of the airborne collision avoidance system technology as a result of the inadvertent inactivation of the transponder on board N600XL”.
”Further contributing to the accident was inadequate communication between ATC and the N600XL flight crew.”
Last edited by punkalouver; 1st Apr 2009 at 02:09.