Mid-air collision over Brasil
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And please answer my questions about the transponder without bypassing the subject.
I am not familiar with the Legacy aircraft but most aircraft are the same.
If the transpnder fails, you will get a warning, but it is VERY easily missed.
If you turn off the transponder, then there will be no warning.
There is speculation that the crew accidently turned off the transponder.
This is not the cause of the accident. Aircraft experience transponder malfunctions every day. Some of these malfunctions are simple "finger problems".
I am not familiar with the Legacy aircraft but most aircraft are the same.
If the transpnder fails, you will get a warning, but it is VERY easily missed.
If you turn off the transponder, then there will be no warning.
There is speculation that the crew accidently turned off the transponder.
This is not the cause of the accident. Aircraft experience transponder malfunctions every day. Some of these malfunctions are simple "finger problems".
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There is speculation that the crew accidently turned off the transponder.
This is not the cause of the accident. Aircraft experience transponder malfunctions every day. Some of these malfunctions are simple "finger problems".
This is not the cause of the accident. Aircraft experience transponder malfunctions every day. Some of these malfunctions are simple "finger problems".
But anyway, shouldn't the crew monitor the a/c instruments, moreover when they are related to navigational information ?
What I am just trying to say is that this accident was caused by a series of mistakes from both the legacy crew and the Brazilian ATC. However I disagree with ATC4US when he says that the legacy crew should be responsible for not having changed its FL.
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No, flight crews do not continually monitor transponder operation. It is not a navigation instrument.
If it fails or is turned off, usually ATC will be the first to notice and ask the aircraft to confirm it is on.
If it fails or is turned off, usually ATC will be the first to notice and ask the aircraft to confirm it is on.
I support PPRuNe
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And as far as I know...
No, flight crews do not continually monitor transponder operation. It is not a navigation instrument.
If it fails or is turned off, usually ATC will be the first to notice and ask the aircraft to confirm it is on.
If it fails or is turned off, usually ATC will be the first to notice and ask the aircraft to confirm it is on.
Insofar as the Legacy pilots, in hindsight (pay attention...hindsight...) they could have done two things that could prevent the disaster: question the change in the flight plan to 370 to Manaus and see in their flight data screen the small yellow letters saying that the transponder was off. I said..in hindsight...knowing what happened...
We can´t make a statement that any ATC in every country will need the ATCs of planes to prevent air collisions... The system should be able to avoid collisions without ATCs...
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Many years ago I used to fly in uncontrolled airspace in northern Canada. All pilots gave position reports and provided their own separation. It worked very well.
Today the responsibility of separation lies solely with Air Traffic Controllers on the ground.
It is not the responsibility of the pilots to question an assigned altitude. Altitudes are assigned by ATC after giving consideration to all the traffic in the area. Often aircraft are temporarily assigned "wrong way" altitudes in order expedite the flow of traffic.
Aircraft warning systems are designed to give different levels of warnings to the pilots. Some warnings are very important and other warnings are not so important. The "transponder off" warning is a very un-important or non-critical warning. As a result it is very easy to miss.
These pilots were busy trying to establish radio contact and it is easy for me to understand why they missed a non-critical warning.
It is non critical because a transponder does not affect the ability of the aircraft to stay in the air. The aircraft will fly all day long without a transponder. The transponder does not separate traffic. It is only a tool that makes the job of an Air Traffic Controller a little easier to separate traffic. Again, it is the Air Traffic Controller's job to separate traffic and no one else.
These pilots did nothing wrong and it makes angry to see people with very little practical knowledge of Aviation and Air Traffic Control try to speculate on what should have been done, or what could have been done by these pilots.
Today the responsibility of separation lies solely with Air Traffic Controllers on the ground.
It is not the responsibility of the pilots to question an assigned altitude. Altitudes are assigned by ATC after giving consideration to all the traffic in the area. Often aircraft are temporarily assigned "wrong way" altitudes in order expedite the flow of traffic.
Aircraft warning systems are designed to give different levels of warnings to the pilots. Some warnings are very important and other warnings are not so important. The "transponder off" warning is a very un-important or non-critical warning. As a result it is very easy to miss.
These pilots were busy trying to establish radio contact and it is easy for me to understand why they missed a non-critical warning.
It is non critical because a transponder does not affect the ability of the aircraft to stay in the air. The aircraft will fly all day long without a transponder. The transponder does not separate traffic. It is only a tool that makes the job of an Air Traffic Controller a little easier to separate traffic. Again, it is the Air Traffic Controller's job to separate traffic and no one else.
These pilots did nothing wrong and it makes angry to see people with very little practical knowledge of Aviation and Air Traffic Control try to speculate on what should have been done, or what could have been done by these pilots.
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These pilots did nothing wrong and it makes angry to see people with very little practical knowledge of Aviation and Air Traffic Control try to speculate on what should have been done, or what could have been done by these pilots.
You can be angry at your will. We are very sorry but we just want to clear all doubts on why 154 of our fellow citizens died that day.
I am sure the same would happen if those 154 were, say, Canadian or US citizens.
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aviadornovato, the reason 154 died is perfectly clear:
1) the two aircraft were assigned the same altitude, which is a normal and temporary occurrance when the two are hundreds of miles apart;
2) as they became closer, ATC should have reassigned one or the other to a clear altitude;
3) ATC could not contact one of the aircraft, and then failed to reassign the other.
The pros in this forum understand this sequence very well. There are a dozen other side issues (why the radio & transponder failures, etc.), but when ATC fails to act to assure clearance, the negligence is obvious.
1) the two aircraft were assigned the same altitude, which is a normal and temporary occurrance when the two are hundreds of miles apart;
2) as they became closer, ATC should have reassigned one or the other to a clear altitude;
3) ATC could not contact one of the aircraft, and then failed to reassign the other.
The pros in this forum understand this sequence very well. There are a dozen other side issues (why the radio & transponder failures, etc.), but when ATC fails to act to assure clearance, the negligence is obvious.
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barit1,
I agree that pilots understand very well the sequence you've posted.
I also assume pilots understand a couple of other simple things:
1- ATC can make mistakes. Be sure you master the operation of your aircraft and the environment you are flying (terrain, weather, routes, etc...).
2- Other pilots can make mistakes, so if you don't understand the "chat" on the radio (foreign language), double check with ATC if you are doing OK.
We all know cases of controllers saving pilot's a##es and also cases of pilots questioning a controller instruction. And I believe this happens a lot.
IMHO, we don't see more midair collisions because of good controllers catching pilot's mistakes and good pilots catching controllers mistakes. When none of this works, we have TCAS. Now, when we have ATC mistakes, poor aircraft operation and poor environment awarness all together, then luck comes in. Good luck, and you are home thinking how close that one was. Bad luck, if you are home thinking that all those people maybe wouldn't have died if you had "read" the book or learned that "international sh#t"...
I agree that pilots understand very well the sequence you've posted.
I also assume pilots understand a couple of other simple things:
1- ATC can make mistakes. Be sure you master the operation of your aircraft and the environment you are flying (terrain, weather, routes, etc...).
2- Other pilots can make mistakes, so if you don't understand the "chat" on the radio (foreign language), double check with ATC if you are doing OK.
We all know cases of controllers saving pilot's a##es and also cases of pilots questioning a controller instruction. And I believe this happens a lot.
IMHO, we don't see more midair collisions because of good controllers catching pilot's mistakes and good pilots catching controllers mistakes. When none of this works, we have TCAS. Now, when we have ATC mistakes, poor aircraft operation and poor environment awarness all together, then luck comes in. Good luck, and you are home thinking how close that one was. Bad luck, if you are home thinking that all those people maybe wouldn't have died if you had "read" the book or learned that "international sh#t"...
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As one who will be interfacing up close and personal with ATC tomorrow I see it completely as a failure in the Brazilian ATC system. Now the big question is what will the people of Brazil demand next; a cover up or to use this tragedy to drag their country into the twenty-first system with a modern ATC system with well paid professional controllers. Along with this comes a modern judicial system that doesn’t go out on witch hunts looking for scapegoats but a judicial system that realizes the only way to fix problems like this that do occur is to encourage people to come forward to tell their side of the story without punishment.
It is now up to the people of Brazil to fix their ATC system.
It is now up to the people of Brazil to fix their ATC system.
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Along with this comes a modern judicial system that doesn’t go out on witch hunts looking for scapegoats but a judicial system that realizes the only way to fix problems like this that do occur is to encourage people to come forward to tell their side of the story without punishment.
Probably both controllers and pilots should not be prosecuted in the GOL/Legacy collision case but pushing for a generic immunity in any circumstance is very irresponsible IMHO and doesn't happen anywhere in this world.
As to the rest of your statement you are completely right: We should not cover up the problems with our ATC.
Nor should americans cover up the problem of pilots unfamiliar to a given A/C flying without sufficient training and putting the lives not only of Brazilians but of US citizens in danger too, no matter the eventual lack of correlation with the accident itself.
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aviadornovado ( and others ):
If you have a few minutes check this, It is not long:
http://www.atwonline.com/channels/sa...articleID=1815
If you are still there after reading it , then check this : ( a little bit longer, but not that much. )
http://www.lusa.lu.se/upload/Trafikf...humanerror.pdf
Then come back and debate with us.
If you have a few minutes check this, It is not long:
http://www.atwonline.com/channels/sa...articleID=1815
If you are still there after reading it , then check this : ( a little bit longer, but not that much. )
http://www.lusa.lu.se/upload/Trafikf...humanerror.pdf
Then come back and debate with us.
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A couple of questions for the pros here.
1- Is it possible to obtain a clearance to fly direct to your destination, in a route with no direct airway, above FL 240?
2- If 1 is affirmative, it seems to me that the Legacy was cleared direct to Manaus, not passing trough Brasilia. The only waypoint mentioned on the clearance was Poços de Caldas. So why the Legacy pilots understood they should go through Brasilia, if the clearance didn't mention that?
1- Is it possible to obtain a clearance to fly direct to your destination, in a route with no direct airway, above FL 240?
2- If 1 is affirmative, it seems to me that the Legacy was cleared direct to Manaus, not passing trough Brasilia. The only waypoint mentioned on the clearance was Poços de Caldas. So why the Legacy pilots understood they should go through Brasilia, if the clearance didn't mention that?
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I am glad to see that the moderators are taking an interest in the thread and deleting pure rubbish. Let me say that I hope they leave it open (as opposed to the peremptory manner in which they closed the Congonhas thread).
My take is as follows. Our Brazilian colleagues on this thread (as, before it was closed, on the Congonhas thread) are seriously trying to figure their way through two horrendous accidents that have occurred in the last year. I have today downloaded the 713-page final report of the parliamentary committee (CPI) of the Chamber of Deputies concerning what they officially term the "Crisis in the Air Traffic System". The report of the Senate committee is yet to come. The information was given to me by someone who has been "banned" from discussing these events in this forum, although I judge he has resurfaced under another name.
I am gratified to find my slight contributions to this debate (through one of the newspapers, Folha) considered on p210. I haven't read the complete document (it was enough for me to print it out today!)
This is a serious discussion, with two sides that are having a very hard time understanding each other. It is very noticeable that our Brazilian professional pilot colleagues are saying absolutely nothing. There is a reason for this.
We are debating with Brazilian lawyers and concerned others. It is very worrying to me that what are (by us) regarded as international air traffic control standards were apparently not followed, and that the consequences of that event are being drawn differently by Brazilians that by non-Brazilians. This indicates to me a significant cultural discrepancy that needs to be bridged.
The clearest statement of the non-Brazilian view has to my mind been given by [email protected]:11.56. I must say I agree with this view completely.
I appreciate the citation by ATC Watcher of work by Sidney Dekker. Sidney is one of the most persuasive purveyors of the view that when competent operators screw up, one should look for the faults inside the system design rather than in the operators' mental states (which, as he and I would argue, should be accounted for in any system which requires human operators essentially). Another advocate of this view is Don Norman. Don does not deal much with airplanes (he is more into door handles, tea kettles and coffee machines) but he is very readable and his insights translate.
PBL
My take is as follows. Our Brazilian colleagues on this thread (as, before it was closed, on the Congonhas thread) are seriously trying to figure their way through two horrendous accidents that have occurred in the last year. I have today downloaded the 713-page final report of the parliamentary committee (CPI) of the Chamber of Deputies concerning what they officially term the "Crisis in the Air Traffic System". The report of the Senate committee is yet to come. The information was given to me by someone who has been "banned" from discussing these events in this forum, although I judge he has resurfaced under another name.
I am gratified to find my slight contributions to this debate (through one of the newspapers, Folha) considered on p210. I haven't read the complete document (it was enough for me to print it out today!)
This is a serious discussion, with two sides that are having a very hard time understanding each other. It is very noticeable that our Brazilian professional pilot colleagues are saying absolutely nothing. There is a reason for this.
We are debating with Brazilian lawyers and concerned others. It is very worrying to me that what are (by us) regarded as international air traffic control standards were apparently not followed, and that the consequences of that event are being drawn differently by Brazilians that by non-Brazilians. This indicates to me a significant cultural discrepancy that needs to be bridged.
The clearest statement of the non-Brazilian view has to my mind been given by [email protected]:11.56. I must say I agree with this view completely.
I appreciate the citation by ATC Watcher of work by Sidney Dekker. Sidney is one of the most persuasive purveyors of the view that when competent operators screw up, one should look for the faults inside the system design rather than in the operators' mental states (which, as he and I would argue, should be accounted for in any system which requires human operators essentially). Another advocate of this view is Don Norman. Don does not deal much with airplanes (he is more into door handles, tea kettles and coffee machines) but he is very readable and his insights translate.
PBL
Last edited by PBL; 24th Oct 2007 at 20:08. Reason: SSppelling
PBL
You and many others have been extremely generous of your time on this thread. ATC Watcher!
In an anecdotal vein, some of the responses from the Brazilian end remind me of when I was stopped by a policeman while driving the wrong way up a one-way street where the traffic sign had been knocked down. “Sorry, officer, it’s not signposted”. “But everyone knows this is a one-way street, your fault for not knowing”.
You’ve mentioned the need to bridge a cultural discrepancy regarding the way Brazilians and non-Brazilians see the consequences of not following international ATC standards. I think your interpretation has a lot to do with the absence of contributions by Brazilian pilots and other professionals on here, which you’ve also mentioned. Had there been such contributions, I suspect they would echo those of the international community very closely.
The real discrepancy is more related to Brazil’s Portuguese legal and cultural baggage, which tends to surface in situations where it’s easier to apportion blame and decapitate the offender than to absorb the tragedy and apply whatever lessons might be learned from it to avoiding similar ones in future.
That, alongside a military ATC system where most of the professionals are long-serving subalterns and the “managers” are heirarchically superior but less experienced.
Were Brazilian commercial pilots and controllers to post here I do think the views expressed would be much closer to Barit1’s posting of 22 Oct.
As to why they haven’t come forward, I’d venture a few guesses, the main one being that they can be fairly easily identified. For all the size of Brazil’s air transport network, it’s still a small community. There are hundreds if not thousands of pilots wanting flying jobs and it’s not an economy where, if you’re not flying you can easily get a well-paying job doing something else. Speaking out can damage one’s career prospects. For the controllers, there’s military discipline and, usually, a linguistic challenge.
As to what happens now, post CPI, whew, I wonder. The air force seem to have been successful in rebuffing attempts to take ATC away but it would be inconceivable to presume they’d not absorbed some of the lessons. The CENIPA report will throw some light on that and I expect it will be at least moderately self-critical. After publication there will be a response from the air force and corresponding signals from the executive, and we might see some gradual changes.
For now, part of the CPI report is scathing toward Infraero, the airports authority, recommending the indictment of over twenty managers and directors on grounds of corruption. The executive response, apparently not related but in reality very much so, via the president’s chief-of-staff, has been “we’d like to see airports privatised.” Piano, piano...
For anyone else who might like to download the CPI final report, the 12.5mb pdf file (in Portuguese) can be found at:
http://www2.camara.gov.br/internet/c..._REVFinal1.pdf
You and many others have been extremely generous of your time on this thread. ATC Watcher!
In an anecdotal vein, some of the responses from the Brazilian end remind me of when I was stopped by a policeman while driving the wrong way up a one-way street where the traffic sign had been knocked down. “Sorry, officer, it’s not signposted”. “But everyone knows this is a one-way street, your fault for not knowing”.
You’ve mentioned the need to bridge a cultural discrepancy regarding the way Brazilians and non-Brazilians see the consequences of not following international ATC standards. I think your interpretation has a lot to do with the absence of contributions by Brazilian pilots and other professionals on here, which you’ve also mentioned. Had there been such contributions, I suspect they would echo those of the international community very closely.
The real discrepancy is more related to Brazil’s Portuguese legal and cultural baggage, which tends to surface in situations where it’s easier to apportion blame and decapitate the offender than to absorb the tragedy and apply whatever lessons might be learned from it to avoiding similar ones in future.
That, alongside a military ATC system where most of the professionals are long-serving subalterns and the “managers” are heirarchically superior but less experienced.
Were Brazilian commercial pilots and controllers to post here I do think the views expressed would be much closer to Barit1’s posting of 22 Oct.
As to why they haven’t come forward, I’d venture a few guesses, the main one being that they can be fairly easily identified. For all the size of Brazil’s air transport network, it’s still a small community. There are hundreds if not thousands of pilots wanting flying jobs and it’s not an economy where, if you’re not flying you can easily get a well-paying job doing something else. Speaking out can damage one’s career prospects. For the controllers, there’s military discipline and, usually, a linguistic challenge.
As to what happens now, post CPI, whew, I wonder. The air force seem to have been successful in rebuffing attempts to take ATC away but it would be inconceivable to presume they’d not absorbed some of the lessons. The CENIPA report will throw some light on that and I expect it will be at least moderately self-critical. After publication there will be a response from the air force and corresponding signals from the executive, and we might see some gradual changes.
For now, part of the CPI report is scathing toward Infraero, the airports authority, recommending the indictment of over twenty managers and directors on grounds of corruption. The executive response, apparently not related but in reality very much so, via the president’s chief-of-staff, has been “we’d like to see airports privatised.” Piano, piano...
For anyone else who might like to download the CPI final report, the 12.5mb pdf file (in Portuguese) can be found at:
http://www2.camara.gov.br/internet/c..._REVFinal1.pdf
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And for the ones who did not have the chance to read the Legacy's CVR trancription (in English) and maybe after reading this will see that the pilots were not confortable in that cockpit.
http://www1.folha.uol.com.br/folha/e...2-legacy-2.pdf
http://www1.folha.uol.com.br/folha/e...2-legacy-2.pdf
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GlueBall,
Info I had here (via press only) from the Gol Boeing 737-800's CVR was:
1- The crew had no problems with radio communications.
2- No voice sounds were recorded after impact. No screams, indicating the crew and passengers went unconscious as a result of the high rate of roll.
3- CVR stopped recording at 6.000 ft.
Sorry if I can't get you more info. I heard that the families of the victims are "demanding" access to the recordings, just like the families of the TAM accident had.
Info I had here (via press only) from the Gol Boeing 737-800's CVR was:
1- The crew had no problems with radio communications.
2- No voice sounds were recorded after impact. No screams, indicating the crew and passengers went unconscious as a result of the high rate of roll.
3- CVR stopped recording at 6.000 ft.
Sorry if I can't get you more info. I heard that the families of the victims are "demanding" access to the recordings, just like the families of the TAM accident had.
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aviadornovado ( and others ):
If you have a few minutes check this, It is not long:
http://www.atwonline.com/channels/sa...articleID=1815
If you are still there after reading it , then check this : ( a little bit longer, but not that much. )
http://www.lusa.lu.se/upload/Trafikf...humanerror.pdf
Then come back and debate with us.
If you have a few minutes check this, It is not long:
http://www.atwonline.com/channels/sa...articleID=1815
If you are still there after reading it , then check this : ( a little bit longer, but not that much. )
http://www.lusa.lu.se/upload/Trafikf...humanerror.pdf
Then come back and debate with us.
I read both texts and again I think that the approach is too generic.
What do those guys want, after all ? If they think that a given action or omission that causes an accident is not a consequence of gross negligence or any other criminal behaviour they just have to provide the correspondent reasoning IN THAT SPECIFIC CASE.
Why such generic and imprecise statements against criminal persecution in aviation ? Wouldn't a specific approach like saying "it was just an error not negligence in this case" or "he wasn't expected to do that much in that specific situation" work better ?
It is important to point out the contradictions:
In the first article one can read as follows
"At the same time, FSF points out that even an organization that promotes a "no blame" culture cannot tolerate irresponsible or careless acts, such as those involving a number of pilots being caught on the flightdeck under the influence of alcohol."
So the discussion should rest only on what could be seen as irresponsible and careless acts or not, shouldn't it ? The issue is wrongly addressed...
BTW, all the cases cited in the first article where icons of the wrong application of criminal law.
In the Linate accident, for instance, there was an obvious gross negligence from the directors of the airport.
A ground radar should be FULLY installed a long time before the accident but it wasn't. The guidance signs didn't follow the rules and were misleading.
But instead of convicting who was really to blame for the tragedy (yes, to blame: it was gross negligence) the Italian Judiciary at the end of the day put the blame on the only guy that should be spared: The ground controller Paolo Zacchetti.
This specific event is a typical case of Judiciary error. The wrong person is paying the price for the really guilty ones.
But this fact should not support a "no-blame" culture in aviation: It should only be a reminder that if there are any careless acts that cause an accident then the real perpetrators of such acts (or omissions) are the ones to be convicted and not to be spared in place of a scapegoat. Just so.
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Originally Posted by aviador novato
I read both texts and again I think that the approach is too generic.
Originally Posted by aviador novato
Why such generic and imprecise statements against criminal persecution in aviation ?
The first is that pursuing accidents with criminal proceedings ensures that accident participants, who could otherwise contribute to safety prophylaxis by sharing their knowledge of what went on, will first concentrate on their defence (or avoiding prosecution in the first place) and not share that otherwise invaluable knowledge.
This is not conjecture. This is fact. It is a phenomenon not only in aviation, but also, say, in rail travel. My colleagues at IfEV in Braunschweig, who are involved in many proceedings concerning rail accidents in Germany, say it is a pervasive problem and have specific examples to show it.
And this hinders learning from accidents. There is a very specific example from the Brühl railway accident in my talk at the Bieleschweig 9 Workshop in Hamburg in May 2007 (see http://www.rvs.uni-bielefeld.de
-> Bieleschweig Workshops -> 9th Workshop, Hamburg, May 2007
for the slides).
The second is that if criminal proceedings in the wake of accidents persistently and pervasively miss the mark, as we know they do from many other cases besides Linate, then there is a case for a general moratorium on criminal proceedings until there is some means of ensuring that the "wrong" people do not get blamed. This is why, for example, the Governor of Illinois, while a death-penalty supporter, instituted a moratorium on executions until the courts can be sure that no mistakes are made.
Originally Posted by aviador novato
It is important to point out the contradictions:
Originally Posted by aviador novato
So the discussion should rest only on what could be seen as irresponsible and careless acts or not, shouldn't it ? The issue is wrongly addressed...
Were the U.K. model to be applied to the GOL/Legacy midair, then the Air Force top command would be busy preparing their defence.
So I don't think one can legitimately claim that the issue is wrongly addressed, rather that the issue is differently addressed in different jurisdictions and the question is who has got it right. And if there is no way of settling the matter who has got it right (and it does seem to me to depend to some extent on different views of the polity), then it can be argued that a moratorium is an appropriate response.
PBL