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Mid-air collision over Brasil

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Old 20th May 2011, 22:06
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This is quite an extraordinary judgement by all counts. If I read the verdict correctly ( someone can correct me if I am wrong ) the main controller in charge ( Jomarcelo) was not "qualified" by his peers ( he actually failed) but was nevertheless put in charge of a sector by its management (i.e. the Brazilian Air force ) and left alone on the position. The judge said that Jormarcelo Portuguese was already bad and his English worse, etc.. so he released him on the account that he was not responsible as he should not have been put into this position. Then he condemmend the other controller to 3 years for failure to select a fequency on his sector ( and did not hear the legacy calls later ), as well as the 2 Legacy pilots for : "failing to monitor their instruments and avionics", and for " not having noted that their transponder/TCAS was off for nearly one hour." ! Madness!

Now appeals are going to be filed, so this is not the end, but this judgement put the ball into the air force camp, as if the Jomarcelo judgement is confirmed, then they are responsible for the collision. Hopefully when that becomes clear, the remaining controller and the 2 pilots sentences can be overturned.Let's hope so at least.
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Old 20th May 2011, 22:56
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onetrack...

"The situation that Brazil and its aviation & law fraternity cannot seem to come to grips with... is that ATC, was originally, and still is, designed to prevent aircraft from colliding.
These two aircraft collided because of failings in the setup, structure and operation of Brazilian ATC. It really is that simple.

The fact that a simple error was made by the pilots, that compounded the ATC failings, is not something they need to, or should be, punished for.
I believe that every part of the Brazilian legal response is an attempt to shift the entire blame for the collision, on to pilots who do not deserve that total blame.
The blame was laid on the Legacy pilots by the Brazilians, within hours of the collision being known. They have tried to reinforce that belief with a judgement handed down in a Brazilian court.

When you have an ATC system totally run by the military, controlling civilian operations... and there are also holes in the coverage, training, and responsibility, of that ATC... there is always going to be a disaster in the offing."

Very well said!
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Old 21st May 2011, 01:21
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onetrack:

When you have an ATC system totally run by the military, controlling civilian operations... and there are also holes in the coverage, training, and responsibility, of that ATC... there is always going to be a disaster in the offing.
Sadly, I think the ill-informed judge is using the principle of "the last clear chance to avoid the accident."

Thus, in his mind, the TCAS would have provided the last clear chance to avoid the mid-air had the Legacy crew had it turned on.

I suspect his judgment is more of the B.S. I propose as opposed to any attempt to protect Brazil's establishments.

If I am correct, the court is severly limited in Brazil.
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Old 21st May 2011, 02:46
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Sadly, I think the ill-informed judge is using the principle of "the last clear chance to avoid the accident."
No, not the case. The opinion is really quite corageous. To find the controller most at fault innocent, on the grounds that he was so incompetent he never should have been let near a console, and ask the Prosecutor-General to indict whoever put him there ...

It's not putting all the blame on the people at the "pointy end".

His understanding of air traffic evolved, he attemped to learn and did learn. Some of his decisions - like calling an experienced pilot as a "neutral" witness were unusual and caused complaint by the lawyers on all sides, but turned out to be really surprisingly good.

The decision on the pilots is 86 pages. on the controllers 39, and I won't be doing complete translations of both. My evaluation of the judge before the verdicts was that he is independent and intelligent; on reading the verdicts I revise that to more independent and intelligent than I had thought.

The Brazilian press, on the other hand, has failed to rise to its usual standard, already dismally low.

Jomarcelo) was not "qualified" by his peers ( he actually failed)
Failed four times, actually, according to testimony in a 2007 Congressional hearing.

The decision in not stupid, it is not "least resistance", it does not look for some obscure aspect of a statute in which the judge can avoid actually judging the facts in the case. It is not going to make him any friends in the Air Force, either.

In Brazil, both the prosecution and defense can appeal. The prosecution will have a very hard time overturning any of the five counts of innocent. The guilty verdict seems less robust.
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Old 22nd May 2011, 11:25
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Richard,

I did not read all 39 pages on the controllers prosecution (do you have a link for it?).

I am curious to know if the judge took in to consideration that Jomarcello was in the console not because he wanted, but because he was ordered to...
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Old 22nd May 2011, 12:25
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I am curious to know if the judge took in to consideration that Jomarcello was in the console not because he wanted, but because he was ordered to...
'But does it not configure concrete danger, by chance, when the aviation safety system put someone to work in the task of air traffic controller, when that person does not have the least qualification? He who approves people known to be incompetent for the task is not committing the crime of Article 261 of the Criminal Code? For me, it is clear that yes. I say more. I say that, at least, a person who approves someone who is not qualified can create in the person approved the illusion that he is, in fact, a professional. Even more so in the military area, where the principle of hierarchy rules. There one cannot contest a superior order, for better or worse. If the superior says, "go there and control, you are licensed, what should the subordinate say? "No, I won't go, your order is manifestly illegal!".'

The verdict on the controllers isn't posted anywhere I'm aware of. Send me your email, and I'll send you a copy.

There was a front-page article yesterday in the Folha de S.Paulo, Brazil's leading newspaper. Their reporter in Mato Grosso, Rodrigo Vargas, has followed the accident since the beginning, and understands. There was a major article in national magazine Época, titled "We're still on collision course", but alas I am in a small town where weekly magazines arrive three days later than in the Big City.

Last edited by Jetdriver; 10th Oct 2012 at 23:31.
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Old 22nd May 2011, 14:33
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Very good article on the yesterday's Folha de São Paulo newspaper. I thought that Jomarcelo was convicted, but in reality it was Lucivando...

Obrigado!!!

Last edited by Jetdriver; 10th Oct 2012 at 23:31.
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Old 22nd May 2011, 23:20
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Jet Jockey A4's thoughts, judge's responses

Jet Jockey A4 posted some thoughts, to which I'll give the relevant parts of the verdict. Please note I am neither a pilot nor an air traffic controller, and I am giving the judge's words, not my own.

This will answer Jet Jockey's questions, but I think it will also answer another question. The opinion is neither lazy, not stupid, nor jingoistic, no ignorant. It's well considered and well reasoned. The opinion can be disagreed with and appealed (as it certainly will be) but reading it, I think the judge is a credit to the bench.

Language seems to be another issue here
The controller barely speaks Portuguese, knows nothing of English and, worse yet, does not have mastery of the technical skills for the exercise of the job - "he was, for me, a controller who did not have the qualifications to be a controller", said the witness.
"but both the controllers and pilots should be more vigilant if they feel and instruction, clearance or a readback is somewhat confusing to either party.
The information was excessively clear. The expression 'permission for Eduardo Gomes' leaves no doubt that the control tower was ordering the pilots to fly at level 370 to Manaus. It's a very categorical piece of information.

If the flight level came unequivocally, but without an indication of the final destination, it would be comprehensible to demand that the pilots question the authorization, that they seek additional clarification, that they ask if the level were to be used only to Manaus or if it serves for the whole route. But no. Mister João Batista made the affirmation stripped of any ambiguity. Mister João Batista, furthermore, responsible for this tremendously gross error, decisive for the outcome that was seen, was not even indicted by the Federal Prosecutors' Office. ]And, the pilots did readback and confirm the 37,000 foot clearance to Manaus.
Yes the pilots should know how to operate their avionics but I'm pretty sure the transponder was turned "OFF" or to "STBY" by mistake without either pilots noticing it, why or how I don't know.
Taking into consideration the affirmation that it is not possible, through the simple handling of the FMS, to disconnect the transponder, consistency is lost to the argument that all possible technical failures having been discarded, there remains only the possibility of unintentional human error. In fact, if it is true that unintentional human error, discarding technical failure, exists as a plausible possibility and cannot be discarded, then one cannot forget or discard the hypothesis under which, at the moment of turning off the transponder, the pilots operated the FMS, a device whose handling, however incorrect it might be, does not allow, according to the Criminalistic Insititute, the turning off of the transponder. The analysis of the proof made by the prosecution and by the assistant to the prosecution takes into account only the first point, making no mention of the second. But the fact is that the technical experts’ affirmations, at the point in which they analyze the context in which the turning off of the transponder occurred, place in check the general conclusion that it is only by human failure that it could have been turned off, because at that moment and in that specific situation, in which the pilots operated the FMS, even if error were to be admitted as a concrete hypothesis, its occurrence would not have the capacity to produce the result - as is attested to, in an unequivocal manner, by the expert report.
How do we know that a passenger visiting the cockpit while at altitude did not turn off the transponder by mistake? After all it was a ferry flight with a reporter onboard and perhaps the crew was showing off the cockpit and avionics.
The judge doesn't cover that, presumably having correctly determined that it's not worthy of a response. However, the transponder went off during a period of over a minute of silence on the CVR while Paladino and Lepore were doing fuel calculations, Paladino on a laptop and Lepore on the FMS. As to it being Joe Sharkey, he has written what happened, on the front page of the New York Times among other locations, and he wasn't in the cockpit. If you want to ask him, do so, I won't.
What if the transponder has simply failed?
What calls attention is the intentional restraint in the use of language. The report does not make a categorical affirmation, of the type “there was no failure in the equipment”, for example, before referring to the nonexistence of “factual evidence to explain the interruption of the emission of the signal”. The most that can be extracted from this affirmation in the report is, at a stretch, the conclusion that, testing the equipment after the accident, with the adoption of practices which provoke even abnormal situations, it was verified that it (the device) in that situation and at that specific moment,did not present errors. But the report does not affirm that the shutdown did not happen because of an error of N600XL’s systems. To affirm that there is no evidence which explains the shutdown of the transponder is not the same as to affirm that it did not happen because of equipment failure. The limitation of the technical work is understood. If the Legacy aircraft had had a system of recording the transponder data, the possibility of the elucidation of this controversial fact would be more easily within the reach of the experts.
In all the above hypothetical situations, ATC should have picked it up and advised the pilots right away that they were not getting a transponder return regardless who was behind the screen.
The pilots’ defense also sustains, based on the legislation in force (ICA 100-12), that primary responsibility for monitoring the transponder is the Air Traffic Control Center’s. That the Center has the obligation to control the functioning of the transponder no one any longer doubts. The legal provisions indicated in the briefs, moreover, leave no doubt in this regard. But that is not the point. In criminal law, the blame of one agent does not annul the blame of the other, if both contribute to the crime.
As for studying the route before the flight well you don't know for a fact that they didn't.
But, if the pilots were aware of the route, it is because they were, in some manner, familiar with the plan, and accepted, because that is how the tower authorized them, to fly at level 370, fulfilling furthermore, as to the route, the trajectory foreseen in the plan. If there were unaware of the information on the plan, it would not be possible to comprehend why they took that route and not another. If the followed the route correctly, it is because they knew it. And if they knew it, it can only be because they learned it after examining the flight plan. The circumstance, then that the pilots did not contest the route - which was not in the authorization - is a proof in their favor, and not against them. This is a circumstance which greatly reinforces the supposition that they accepted, consciously, the order to fly at F370.
Heck we sometimes get wrong way altitudes to help out ATC or fly a certain segment of an airway in the wrong direction again for ATC purposes. How were these pilots supposed to know this wasn't the case?
Contrary to how it may appear, it is not prohibited to fly "the wrong way". As long as it is authorized by the Center, such trajectories are perfectly possible. [...] Today it's easy to understand why it's not forbidden to fly "the wrong way". During the instructional phase of the trial, it was easy to assimilate the idea that airspace is "dynamic", that the conditions existing at any moment can change quickly, and that it is in the Control Center's responsibility for changes in altitude that may become necessary. The climb and descent of airplanes is something more common than it appears. And if it were not so common, the indisputable fact is that it is perfectly possible, and of this no one any longer has doubt.
IMHO, most of the blame lies with the ATC in this accident. The one link in this accident that could have prevented the collision, the transponder/TCAS was unfortunately turned "OFF" or on "STBY" at the wrong time.

Finally if Brazilian law cannot differentiate between a planned action causing harm or death and one that was unplanned or done by a genuine mistake with no intent, then I have to say that Brazil as some pretty stupid laws on their books.
The judge does explain the legal difference in the decision, but as this is a pilots' technical board and not a lawyers' technical board, I'm not going to post that part.

There is no way in Hell that logically these two pilots should be guilty and have to spend time in jail for what most think is a truly unfortunate "accident".
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Old 23rd May 2011, 00:22
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Flying over Cuba on a N/S course we would be routinely assigned altitudes that didn't comply with the hemispheric rules of odd/even because the corridor was being intercepted from different angles. We got familiar to it and didn't think of it. ATC has 100% responsibility for traffic separation and the pilot just needs to comply.

I have had controllers tell me several times they weren't receiving my transponder so switched to the other and it worked. I don't believe they shut it off, it may have been intermitent. New airplanes always have a lot of glitches. Even new airliners have most of their problems in the first weeks until all the brand new stuff gets stable. I hold Brazilian ATC 100% responsible. Leave our pilots that complied with all your
ATC instructions alone.
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Old 23rd May 2011, 08:16
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bubbers44:

I have had controllers tell me several times they weren't receiving my transponder so switched to the other and it worked. I don't believe they shut it off, it may have been intermitent. New airplanes always have a lot of glitches. Even new airliners have most of their problems in the first weeks until all the brand new stuff gets stable. I hold Brazilian ATC 100% responsible. Leave our pilots that complied with all your
ATC instructions alone.
I am inclinded to agree with you. Nonetheless, if my recollection is correct, the controller in this case couldn't observe whether the transponder was operating, because the crash occurred in an area without radar coverage. Thus, any discussion of the transponder for TCAS purposes couldn't include the controller as a monitor of transponder operations in the area in which the collision occurred.
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Old 23rd May 2011, 11:56
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Richard,

Do you know exactly which were the words used for the authorization at São José ?

In Brazil, the normally used phraseology for clearence is : "Liberado conforme", and in the U.S they use "Cleared as filed".

When a pilot taking off from an airport in the U.S., he hears something like this: "Cleared as filed, climb and maintan thirty seven thousand feet, call Control Center 122.22..."
This is typical clearance issued by DEPARTURE.

In Brazil is pretty much the same," Liberado (cleared) conforme (as filed), mantenha (climb and maintain) 37.000 pés (37.000 feet)...

Departure gives you exactly this. Instructions for your departure. If you should maintain same altitude to destination, this is not DEPARTURE "jurisdiction", instructions en route are given by Control Center.

No tower gives liberation (or clearance) on procedures to follow in route. This is up to Control Center, and this works for any part of the world, under ICAO regs.

So, if the Legacy pilots understood they were cleared all the way to Manaus at the same altitude, based on the clearance given by DEPARTURE at São José, this sounds very strange to me.

But I don't know if after take-off from São José, when they called Centro Brasília, if they got specific instructions to not to change FL entering the Airway to Manaus.
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Old 23rd May 2011, 12:23
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the controller in this case couldn't observe whether the transponder was operating, because the crash occurred in an area without radar coverage.
Two controllers were tried in Federal court. Jomarcelo had the Legacy on his screen, with the transponder, with 37.000 feet, for many minutes, and without the transponder, for many minutes more.

When Lucivando took over, the Legacy was already in a region which Brasilia controlled, but for which only Manaus could see the radar.
Do you know exactly which were the words used for the authorization at São José ?
It's on the thread somewhere, in the verdict only in Portuguese. But no "as filed". It was apparently the practice of Brazilian ATC to give clearances that didn't follow what the written procedures specify, so much so that controllers were acquitted in the Military Court trial because they were just doing what everybody else did.

The judge complains that the controller who gave the incorrect clearance was not even indicted. See Joe Sharkey's blog for text.

For him, Gol 1907 was the second notch on his console. Twenty years and ten days before, he had sent N219AS into a granite monolith with an incorrect clearance. In that case, the accident was blamed not on ATC errors, Brasilia failing to answer calls made on assigned frequencies, inadequate English in the SJC tower, or an AIS room which was unprepared to deal with foreign pilots flying in Brazil for the first time, all of which problems were identified.

No, in 1986 the blame was put on the American pilots. "Every accident has a known precursor", "causes that are not corrected will lead to another accident". QED, and RIP 154 souls.
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Old 23rd May 2011, 21:20
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The controller barely speaks Portuguese, knows nothing of English
Offtopic:

Once upon a time, I had volunteer gig where I was a teacher of English as Second Language, primarily to Latin American immigrants. There was one particular student that was having no end of trouble learning English and I was at my wits end on how to handle the situation. I decided to talk with some of the other students in the group to see if they could give me any advice on how to get through to him. Their response: "Don't worry. He can't speak Spanish either."

Lesson learned: some people are just dumb.

On topic:

Based on what you have transcribed RB I too think the judge is a credit to the bench.
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Old 28th May 2011, 15:42
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Legacy 600 for sale, 36 flight hours, one midair collision

Embraer Legacy 600 2006 Serial #: 14500965 - General Aviation Services

As the ad says, "Price: Make Offer".
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Old 10th Jun 2011, 08:05
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Chain of causes

We should not forget the Honeywell Transponder on the Legacy, and the suggestions/allegations that it has a tendency to go into uncommanded sleep mode...

As always in these tragic situations, it is a chain of causes. Had the transponder been functioning, then the TCAS systems would have worked as designed...

Anyone know more about the alleged Honeywell Transponder problem?
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Old 10th Jun 2011, 09:49
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I don´t really do, but my airplane (Cessna C680) has Honeywell (EPIC) on it as well and it does a lot of weird things IMO. We do get a master caution since the last software update when the TXPR is stby when airborne. I never had a transponder switch to stby unintentionally, but that doesn´t mean much; as I said the system does weird things. For the time being we are forbidden to fly coupled ILS´es, since there has been incidents where the A/P went below G/S at low altitudes...
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Old 13th Jun 2011, 19:16
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There were some incidents involving other Embraer types equipped with same avionics. One that come to my mind is an Air france between Italy/ Swiss and France which lost his transponder and went undected for half an hour , discovered when having an airprox with a BA near Lyon. Details must be in the BEA web site , about 6 months before teh GOL/Legacy collision.
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Old 10th Oct 2012, 21:52
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Legacy pilots' appeal to be heard Monday in Brasília

The TRF1 appeals court in Brasília is to hear the Legacy pilots' case this coming Monday, 15/10/2012.

The prosecutor is asking that the sentence be increased; the defense is asking that they be acquitted of the one accusation of which they were convicted (found innocent on the other five, not that you'd know it from the Brazilian press). The prosecution is not appealing the five acquittals, though prosecutors can do that here. There's also a "Victims' Association" representing a small percent of the victims' relatives, that's calling for a pair of crosses and some spikes.

The appeal seems to have gotten more coverage in the American press via AP, than in the Brazilian press.

I vouch for the translation, not for the accuracy of the original. For example, the conversation between the PIC and the Brasilia ATC commandant was by phone, not radio as the prosecutor would have it.

- Richard

Acidente da Gol: MPF quer pena maior para pilotos do jato Legacy — Procuradoria Regional da República - 1ª Região

Gol accident: MPF wants greater penalty for pilots of the Legacy jet
last modified 09/10/2012 15:08
Federal Court decision sentenced the defendants to 4 years and 4 months' imprisonment in halfway house. Jail term was commuted to community service.

The Federal Prosecutor's Office issued an opinion calling for increasing the penalty for pilots Jan Paul Paladino and Joseph Lepore, involved in the Gol crash that killed 154 people in 2007. Lepore and Paladino piloted the Legacy jet that collided in midair with a Gol Boeing, not detected by the jet, which was at the time of the accident with collision avoidance systems off. The case will be heard on October 15 by the 3rd Chamber of the Regional Federal Tribunal for the 1st Region (TRF1).

The Federal Judge of the 1st Court of the Judiciary Subsection of Sinop (MT) sentenced both pilots to the penalty of four years and four months in prison in a halfway house, which was commuted to service to the community and suspension of their pilots' licenses, to be served after the judgment becomes final, that is, when it can no longer be appealed.

Not satisfied with the decision, federal prosecutors appealed to the Federal Court of the 1st Region seeking an increase of the penalty and the impossibility of commutation. The MPF based his claim based on art. 121 of the Criminal Code. According to the article, the penalty is increased by one third if the crime results from failure to observance the technical regulations of a profession, art or craft.

In the opinion, the regional prosecutor's Republic Osnir Belize defends the thesis. "The penalty should be more severe because the defendants are professional pilots, however, kept the aircraft's anti-collision system shut down for nearly an hour, which caused the accident," he said.

Osnir Belice also emphasizes that the law only authorizes the commutation when the term of imprisonment is not more than four years and the circumstances are favorable to the defendants. "In the case of Gol Flight 1907, the negligence, carelessness, recklessness and carelessness [NT: Google's translation, but it's just a list of synonyms] of the convicted pilots aggravated omiss conduct, adding to the result produced, represented by the 154 deaths," he argues.

The indictment offered by the MPF / MT in 2007 accused the pilots did of not observing the flight plan, maintaining the collision avoidance equipment (TCAS and transponder) off for almost an hour and not triggering the communication failure code after 12 unsuccessful attempts to contact with the control tower. However, the Federal Court held that the defendants' only mistake was to not notice indication on the control panel that showed the TCAS was inoperative.

For federal prosecutors, the sentence must be modified. "The defendants flew 58 minutes without contact with the flight control, without triggering the transponder and without triggering the communication failure code, which contributed to the accident," explains Belize.

Federal police said in the inquiry initiated to investigate the causes of the accident that the defendants were not aware of the flight plan. Expert examinations found that the anti-collision equipment presented no technical fault and the Cindacta IV commander, in testimony to the PF, said that Joseph Lepore, after the accident, said by radio that the TCAS was off.

According to the Legacy pilots' defense, no device issued warning signs indicating the TCAS was shut down. They also argued that the monitoring of the transponder should have been done by the flight controller, who would be responsible for informing the commander of the aircraft when the equipment was inoperable.

The representative of the MPF refutes the argument. "The civil aviation rules impose on pilots the obligation to keep all aircraft equipment on, especially the collision avoidance system and to communicate to ATC any system malfunction during the flight," he concludes.

The case will be heard by the TRF1's 3rd chamber the 15th.

Case No 2009.36.03.002962-5
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Old 9th Mar 2013, 12:37
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Updates on the case and the Legacy

For those who continue to follow the case, some updates:
  • Here is a detailed account of getting N600XL from Cachimbo to Cleveland.
  • A photo of the Legacy with the new wing, the old one visible behind leaning up against the hangar, is here.
  • Planespotters.net says N600XL, later N965LL, is now XA-MHA and registered to Mexican charter company Flymex since Jan 23, 2013.
There has been continued coverage of the legal saga of the Legacy pilots in ainonline.com which had a reporter at the Regional Federal Tribunal hearing in Brasília on October 15, 2012.

There was a five day course in Brasília at the end of November on "The Judicial Power and Aviation Safety", which was devoted less to the aftermath of accidents, than to explaining to judges how the law can, and why it should, take measures about open landfills near airports. That conference included the Federal Police's aviation accident investigators. Again, ainonline, and the January issue of AIN, will tell you more. There's additional news, in Portuguese, on the Superior Military Tribunal's site under Notícias - Centro de Estudos Judiciários da JMU.

There are honest people in Brazil concerned about safety. The general in charge of CENIPA, on going into the reserves, told a national newsweekly that safety investigations should be independent of the military. I have heard the same view, privately, from a Federal judge who's studied air accident cases.

The word from the military prosecutors' office (which reports to the prosecutor-general, not to the military) is that had the controller most responsible not been removed from ATC by the Air Force, a legal effort would have been made to insure he wasn't controlling air traffic.

A disturbing development is that Sérgio Salles, the Brazilian pilot who acted as an expert witness for the Legacy pilots, is being charged by prosecutors with false testimony. This is something that is frequently threatened and rarely done. The pilot won at the trial level, the prosecution appealed (they can do that in Brazil) and even if he again wins, a prosecution is in itself punitive, costly and worrying.
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Old 9th Mar 2013, 18:48
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The cvr picked up the captain asking " is the tcas on ? "
It was deliberately turned off.
I can't believe the pilots were received back in America with applause. 150+ people dead.

Last edited by easa; 9th Mar 2013 at 19:01.
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