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Mid-air collision over Brasil

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Old 30th Mar 2009, 20:53
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I found it quite interesting to discover the parallels between the Brazilian midair and another midair between large jets back in 1993 detailed below.

German Air Force TU-154 and USAF C-141 on Sep 13, 1997:

Synopsis: The mission was returning from a UN support mission to Namibia . Shortly after level off, the aircraft collided with a German Air Force Tu-154. The nine crew members aboard the C-141 and 24 crew and passengers aboard the Tu-154 were killed.

The C-141 had flown from Ascension Island to deliver UN humanitarian supplies to Windhoek Namibia , in southwestern Africa . They were scheduled to return that evening.

The German Air Force Tu-154 had departed Cologne for Capetown South Africa, with stops in Niamey Niger and Windhoek Namibia . The Tu-154 crew had filed a flight plan, in Niamey , requesting an initial cruise altitude of FL350 with a subsequent enroute climb to FL390. They received a small reroute while transiting the airspace of Gabon . The crew never requested the enroute climb and remained at FL350 for the duration of the flight. Passing western Africa , the course of the Tu-154 changed from westerly to easterly, requiring a change in flight level to comply with international air traffic control procedures. Neither the Tu-154 aircrew nor African air traffic control agencies requested a change in altitude.

The C-141 crew departed on the return leg for Ascension Island at 1611 local time (1411 GMT). Shortly after level off, at FL350, the C-141 collided with the Tu-154, approximately 80NM off the coast of Namibia . Cockpit voice recordings, from the Tu-154, indicated that someone in the German airplane spotted the Starlifter just moments before the collision, but not in time to maneuver away. The Tu-154 struck the C-141 in the lower fuselage.

A French Air Force aircraft, in the vicinity, heard a single "mayday" distress call. A US reconnaissance satellite reported a bright flash at position 18.8° South, 11.3° East at 1510 GMT, approximately one hour after the C-141 departed.

At 1600 GMT (2 hours after the scheduled takeoff), when they did not receive a departure message for the C-141, ATC personnel at Ascension attempted to verify the aircraft’s departure. For the next 15 hours they made 50 phone calls attempting to contact Namibian authorities. At 1055 GMT, they finally notified AMC TACC that the aircraft was overdue. AMC declared the aircraft missing at 1100 GMT, nearly 20 hours after the collision.

The Namibian Air Traffic Control Agency reported that they were controlling the C-141. They also claimed that they had not received a flight plan for the German aircraft. They were unaware that it was in their airspace. The German aircraft had just entered the Namibian FIR but had not yet made radio contact with the Namibian ATC, at the time of the collision. Investigation revealed that the Aeronautical Fixed Telecommunications Network (AFTN) was inoperative. Luanda ( Angola ) ATC had not contacted Windhoek , as required by ICAO procedures. The South Africa Air Line Pilots Association had labeled the Angolan airspace as "critically deficient". SAALPA had recorded 77 near-midair collisions over Africa , in 1996.

Reports indicate that at the time of the mishap weather conditions were VMC. The sun was low in the northwestern horizon (within 30 degrees of the horizon) and, within 30 degrees of the C-141 flight path, making visual clearing for traffic difficult. Local sunset occurred approximately one hour after the Starlifter’s departure from Windhoek . Neither the C-141 nor the TU-154 was equipped with TCAS (Traffic Collision Alert System). At a press conference on September 16, Brig. Gen. Duncan McNabb was questioned on why only VIP aircraft of the 89th AS were equipped with TCAS; he replied that Air Force pilots are trained "to always be looking outside". The Air Force subsequently equipped a small number of C-141s with TCAS.

Also: ASN Aircraft accident Lockheed C-141B Starlifter 65-9405 Namibia
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Old 30th Mar 2009, 21:50
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punkalouver : Caution . It is a bit more complicated than what this short report says . The way the Flight planning of the Tu154, was done, the single plan with 2 legs ( non ICAO standard) and the subsequent non-rerouting of the 2nd leg of the PLN by Niamey due faulty AFTN were critical to the accident. They also apparently ( suggested in the German AF verbal briefing in March 1998) decided , because they could not contact Luanda, to change their route to avoid Angola airspace , and go over the sea to re-join Windhoek. Luanda and Windhoek did not had their Flight Plan.
Flying (way) off route, at the wrong altitude not talking to anyone and expecting to see and avoid at 450 Kts was streching the odds a bit too far.
Totally different from the Gol/legacy collision.
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Old 31st Mar 2009, 02:52
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I'm sure there were significant differences. It just seemed in many ways to be similar. Have never seen a report on the accident.
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Old 31st Mar 2009, 07:24
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The written report was never made public ( to my knowledge at least , but it is over 10 years now, if someone knows of it I would be for one very interested to read it )
Both aircraft were military, so the investigation do not fall under ICAO , and Annex 13 recommendations do not apply here .
There only was a joint satement by USAF and GAF end of March 1998,and a verbal briefing done in Bonn by the GAF for the Press end March or early April 98.
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Old 31st Mar 2009, 11:13
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@punkalouver

I highly recommend that anyone reading about this accident confine themselves to the NTSB section of the report.
I think I would prefer to read the whole report and make up my own mind.

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 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.
Hmm. I suspect the pilots realised they were at least to some degree resonsible for the inop transponder. That is the obvious conclusion from the reported discussions with ATC. I doubt they had in mind the organisational structure of CENIPA at that 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.
Puhlease! You're clutching at straws. There is no indication that the GOL pilots were anything but completely blameless. You accuse CENIPA of "nitpicking" but make a vague slur against the GOL crew in the same post. A double standard methinks.

I suspect you're quite right that the report is not - impartial - but neither is your defence of the Embraer crew. My impression was that they were underprepared and that their professionalism, in a number of areas, was some distance away from "irreproachable".
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Old 1st Apr 2009, 01:52
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Thanks for taking the time to read my critique. It took a long time to prepare.

Originally Posted by GXER




I think I would prefer to read the whole report and make up my own mind.
Understandable. My statement should be directed at people unfamiliar with aviation but looking for answers such as the Brazilian public.

Originally Posted by GXER
Hmm. I suspect the pilots realised they were at least to some degree resonsible for the inop transponder. That is the obvious conclusion from the reported discussions with ATC. I doubt they had in mind the organisational structure of CENIPA at that time.
Going from memory, the pilots were interviewed about a year later by Cenipa after having made initial statements through the NTSB no doubt after being briefed in detail by lawyers about the investigative process in Brazil. I would guess they were well aware of the structure of Cenipa(ie the Air Force investigating itself)
Originally Posted by GXER

Puhlease! You're clutching at straws. There is no indication that the GOL pilots were anything but completely blameless. You accuse CENIPA of "nitpicking" but make a vague slur against the GOL crew in the same post. A double standard methinks.

I suspect you're quite right that the report is not - impartial - but neither is your defence of the Embraer crew. My impression was that they were underprepared and that their professionalism, in a number of areas, was some distance away from "irreproachable".
I believe that the Gol pilots were blameless. However I suspect based on this recommendation to Gol about cellphone use in the cockpit(of which there is no detail in the report) that this happened on that flight. My point is as stated earlier ie. a suspicion that if the Embraer pilots had done this, Cenipa would have crucified them over it instead of not detailing it at all in the report.

I'm not sure where you feel that I am impartial or where the Embraer pilots were unprofessional. Please detail.

It is obvious that they made some errors such as accidentally turning off the transponder and not noticing a NOTAM about runway length at destination and therefore trying to confirm that the could meet performance limitations after departure. Making an error is not unprofessional.

In my view their transponder mistake was a contributing cause to the accident but ATC error was the primary cause.
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Old 1st May 2009, 16:44
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Interview with Legacy passenger

David Rimmer, an ExcelAire executive who was aboard the Legacy, spoke to an Aviation Week reporter at an aviation safety conference in April:

Bus Av Now Blog Article

He speaks of "disappointment" at the inaction of the Consulate, and "disappointment" at the Cenipa report. Some interesting analogies to the treatment of the TAM crash. Also, he thinks Brazil finds survivors/witnesses inconvenient.

He emphasizes the role of the media in the case.

Aviation International News has an interview by Robert P. Mark with Roger Cox of the NTSB:
Brazil Midair Underscores Value of Thorough Research: AINonline
Brazil Midair Underscores Value of Thorough ResearchBy Robert P. Mark
May 1, 2009
Accidents
Operational threat identification and risk mitigation remain a primary concern for those who operate internationally. NTSB senior air safety inspector Roger Cox, the lead investigator on the Gol Airlines/ExcelAire Legacy midair, used the accident as an example of why international operators should take the time to fully understand what may be asked of them in less than normal situations in another country.
[more at site]
The ATC errors seem to have resulted from a combination of flawed systems, understaffing, and poorly trained and inexperienced controllers.

The flaws in the software were pointed out not only by the NTSB (as in the article above) but by Brazil's own TCU, a sort of equivalent to the Congressional Budget Office.

The officers of the air traffic controllers' association (not a union, most of the ATCO's are military, and can't unionize, though they can associate) are among the most experienced controllers. One, who was on duty (though not involved) the night Gol 1907 went missing, immediately reviewed the control center tapes and knew there had been a collision. Last I heard, he was out of the control tower and at a desk in the Air Force Ministry. Another controller with over 20 years' experience now reports every day to an Air Force base, where he is given nothing to do all day long, and studies books on breeding dairy cattle.

Many other experienced controllers have retired, discontent with the current situation.

Meanwhile, training has been abbreviated, allowing new controllers to be put in front of radar screens more quickly. Formerly only five sergeants (the military controllers are mostly sergeants) were promoted to officer every year, but know it's fifty. On the surface that's good, because it finally puts them close to a living wage. However, the goal may be maintaining control over the workers. In a casual conversation, there's a feeling that those being promoted to officer are not the best qualified, but those fastest to salute. "If you don't trust him as a controller, will you trust him as a supervisor?" was one comment.

While in much of the world the recession has brought a drop in air travel and bought time, in Brazil the airlines expect "only single-digit growth" for commercial traffic this year. That's not a breathing space, merely a reduction in the pressure.

I hear that grave incidents continue to be frequent, 125 in Brasilia in January.

The lawyer for the Brazilian Air Traffic Controllers' association, Roberto Sobral, spoke at the IFATCA convention in Croatia in April. I have not yet obtained a copy of his speech.

- Richard
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Old 2nd May 2009, 06:49
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The lawyer for the Brazilian Air Traffic Controllers' association, Roberto Sobral, spoke at the IFATCA convention in Croatia in April. I have not yet obtained a copy of his speech.
He basically confirmed what you say above. He said many experienced controllers have left, new mainly very young shortly trained with basic English levels are in.
Even more worrying he said serious incidents are now filtered out as controllers are prevented to file Occurrence reports.
He also announced that FEBRATCA ( the federation of Controllers Associations in Brazil) has decided to prosecute individually every chief of the Brazilian airforce, and a court case on that is expected before the end of the year.
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Old 2nd May 2009, 19:48
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For any sane operator in Brazilian airspace, SLOP must be STRONGLY considered. You wouldn't drive down the centerline of a two-lane road.
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Old 10th May 2009, 16:03
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whatsoever

Am I that naive to assume that if there were no traffic control at all, flying down the "middle of the road" would not result in a collision IF both aircraft had TCAS on?
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Old 10th May 2009, 21:14
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This isn’t entirely off-thread; please bear with me for a few minutes.

The Gol/Legacy accident – and later the TAM tragedy, gradually revealed some of the worst things about Brazilian politics, e.g. the way in which parastatal organisations like Infraero, the airports authority, are carved up to serve political parties in exchange for congressional support. They also helped shed some light on how the military have to share bedding with politicians to get the funding they require – or think they do.

Infraero went through several audits in 2007-8. Unsurprisingly, it was found to be riddled with corruption and the staff bloated with political appointees. The entire board was replaced – with new political appointees, new names to the same chairs.

Nelson Jobim took over as Defense Minister in 2007, a week after the TAM Congonhas accident. Since then my own impression is that he’s been mainly occupied with damage control, i.e. keeping the military off the front pages, and in working out arms deals.

Recently, though, something seems to have changed. Over the last few weeks the political appointees, all (or perhaps most – I haven’t checked the political affiliations) of them members of Jobim’s own PMDB party, have been dismissed and there’s a general management cleanup in process.

I’m not sure how to read this – it may be the air force reaction to the threat of airport privatization, “just get the politicians out of our hair and at least give us a chance to run the thing properly”. Whatever the reason, it shakes the system up and makes it a little more transparent, neither of which can be bad. Richard_Brasil will surely have a better view on what’s happening.
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Old 10th May 2009, 23:30
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Am I that naive to assume that if there were no traffic control at all, flying down the "middle of the road" would not result in a collision IF both aircraft had TCAS on?
If TCAS were "prime reliable", never failed, then you might come to that conclusion.

But competent ATC plus TCAS gives an additional layer of Swiss cheese, less likely the holes will line up.

SLOP adds yet another layer, permitting the system to tolerate some degradation in one of the first two. I fail to see why ALL layers are not utilized.
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Old 11th May 2009, 00:29
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Have you been flying in Brazil lately? Infrastructure is bad, from ground to air, no complete radar surveillance and bad radios added to lack of parking positions, bad runways, etc... do you believe safety is improved by pilots flying where they want instead of where they should?
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Old 11th May 2009, 01:49
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Let's use this thread as an example. According to the GOL/Legacy case, both aircraft were "where they should" be - that is, where ATC assigned them. How did that work out?

Safety is improved by pilots using all the separation tools available to them.
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Old 26th Sep 2009, 15:34
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The widow of one of the GOL victims is now suing the Legacy passenger Joe Sharkey for allegedly insulting the honour of Brazil The plaintiff seeks (at least) a public apology from him, to be published in the New York Times as well as on air by some TV & radio stations which interviewed him...

the suit is based on a Brazilian law that allows any citizen to claim damages for an alleged insult to the dignity or honor of Brazil in any case involving a crime.
Freelance US journalist sued for defamation in Brazil | AlterNet
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Old 26th Sep 2009, 19:18
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She wants to shoot the messenger...
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Old 26th Sep 2009, 21:47
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Cool World Peace

How about uniting the people of the world by getting rid of lawyers?
I believe Shakespeare promoted this concept in one of his works
years ago!
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Old 26th Sep 2009, 22:24
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In the country of the black hole

http://oglobo.globo.com/pais/noblat/...egro-44738.asp


Articles
Sent by Demóstenes Torres -


Dec 5, 2006 03:15 AM


In the country of the black hole


The New York Times journalist Joe Sharkey is a survivor of Brazil's worst aviation disaster. He was one of the passengers on the Legacy that collided with the Gol aircraft. Sharkey was the first reporter to denounce the pantomime of the Brazilian authorities in the management and safeguarding of the country's air space. At first he injured our patriotic spirits with the arrogant and ethnocentric tone of a Caucasian from the metropolis predisposed to disdain this third-world cane field. However, each new article published by the Brazilian media on the deficiencies of the air traffic control system has shown the North American to be right.


Joe Sharkey feeds his blog almost daily with caustic articles on the Brazilian tragedy. It's clear that he has taken on the mission of freeing the two pilots of the Legacy, after all, they saved his life. Until the investigations are concluded no one can be blamed, but the pilots showed extraordinary airmanship in landing the Embraer jet after the collision. That's because the pilot of a cargo aircraft, who spoke fluent English, oriented them on the position of the Air Force base in the Amazon jungle, since they were unable to communicate with the Brazilian controllers.


The journalist considers that the pilots are being maintained in a condition analogous to hostages, when they should be treated as heroes and sent home in first class, which seems inevitable considering the follies of the Brazilian government. The collision of the two aircraft was caused by a set of human and equipment failures, but wound up as a tragedy foretold because the government did not react promptly. Evasions and denials will not resolve the crisis of confidence in a public service that Brazilians were sure was one of the best in the world, especially after the billions invested in Sivam.


If it's true that the radars didn't work, that aircraft disappear in black holes and that there there's a shortage of air traffic controllers it's needful to admit that flying in Brazil is almost asking to die. Brazilian air space is equivalent to the country's precarious roads and what does the government do? Deny the evidence of the aviation blackout and promise that everything will be improved with a pothole-filling operation that will be done by summer. As Sharkey calls him, the Minister of Defense, Wonderful Waldir, lives with his head in another orbit: now he says that he wasn't informed of a certain problem, now he simply denies that there is a black hole, obsolete radar or impounded resources. As José Simão says the only things that's flying in Brazil is the Minister of Defense.


The problem, Minister, is that in this uniformly blue sky, not even passenger airliners are any longer seen. And what disrespect to the families of the dead of the Flight 1907 accident! The Air Force, Infraero, and ANAC knew that there were no survivors, but waited 48 hours to give the news. So it's a function of the State to create expectations so that suffering is less painful? I wrote in this blog that the delays would be assimilated by Brazilians and become normal. That's what's happened, to the surprise of a Dutchman who put up with a three-hour delay to make a connection at Congonhas Airport. What most intrigued the citizen accustomed to European composure was the cheer that the passengers in the chaotic departure concourse sent up for each flight confirmed. A full platter and more to reinforce Joe Sharkey's arguments.




Demóstenes Torres is a prosecutor and senator (PFL-GO)
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Old 27th Sep 2009, 10:51
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Richard Brazil

The Minister of Defence is no longer Waldir Pires, and that article is from almost three years ago, so the comments of the good senator might be a little out of date. The comments of Joe Sharkey may well be accurate (or not) but when delivered in a tone of inherent superiority they will not be well received. He is, in the eyes of many Brazilians, a typical loud mouthed, opinionated gringo. IMHO many of his points ARE valid, but nobody will listen because of the delivery. I don't agree with suing him, but there are many who feel very strongly about him, and their views are not positive.

There has been time for change, but this being Brazil the following will probably have happened, much like the TAM accident at Congonhas (in which I was involved in the immediate aftermath).

1. Accident happens.

2. Public outcry about infrastructure failures.

3. Politicians promise to fix everything, if only we give them more money.

4. Time passes.

5. More time passes.

6. Public forgets, another accident happens for example.

7. Nothing is done.

8. Same accident happens again.

9. Go back to step 1.

Bem vindo ao Brasil
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Old 27th Sep 2009, 12:02
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Originally Posted by alemaobaiano
He is, in the eyes of many Brazilians, a typical loud mouthed, opinionated gringo. IMHO many of his points ARE valid, but nobody will listen because of the delivery. I don't agree with suing him, but there are many who feel very strongly about him, and their views are not positive.

There has been time for change, but this being Brazil the following will probably have happened, much like the TAM accident at Congonhas (in which I was involved in the immediate aftermath).

1. Accident happens.

2. Public outcry about infrastructure failures.

3. Politicians promise to fix everything, if only we give them more money.

4. Time passes.

5. More time passes.

6. Public forgets, another accident happens for example.

7. Nothing is done.

8. Same accident happens again.

9. Go back to step 1.

Bem vindo ao Brasil
Which explains the delivery from Sharkey. I suspect people being unwilling to listen has more to do with him being a terrble Gringo than anything else. There is a massive problem, if more people over there are upset at the truth being told by Sharkey in a direct, no holds barred approach as opposed than what is posted above. Pride overcomes lives once again and I have no time for aviation safety once again compromised by stupidity.
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