Gol Transportes Aéreos Flight 1907

Gol Transportes Aéreos Flight 1907

A computer-generated rendering of two aircraft flying in opposite directions, slightly offset from each other, clipping each other's wings

Computer-generated image of Flight 1907 and N600XL about to collide. The Legacy's left winglet sliced off nearly half of the Boeing's left wing.[1][2]
Accident summary
Date 29 September 2006
Summary Mid-air collision, ATC error and TCAS on Legacy jet turned off
Site 200 km (120 mi) east
of Peixoto de Azevedo
Mato Grosso, Brazil
10°29′S 53°15′W / 10.483°S 53.250°W / -10.483; -53.250
Total fatalities 154 (all on the Boeing 737)
Total survivors 7 (all on the Embraer Legacy 600)
First aircraft
Type Boeing 737-8EH
Operator Gol Transportes Aéreos
Registration PR-GTD[3]
Flight origin Eduardo Gomes Int'l Airport
Manaus, Brazil
Stopover Brasília International Airport
Destination Galeão Int'l Airport
Rio de Janeiro, Brazil
Passengers 148
Crew 6
Fatalities 154 (all)
Survivors 0
Second aircraft
Type Embraer Legacy 600
Operator ExcelAire (delivery flight)
Registration N600XL[4]
Flight origin São José dos Campos
Regional Airport
Destination Eduardo Gomes International Airport
Passengers 5
Crew 2
Fatalities 0
Survivors 7 (all)

Gol Transportes Aéreos Flight 1907 (ICAO: GLO 1907) was a Boeing 737-8EH, registration PR-GTD, on a scheduled domestic passenger flight from Manaus, Brazil, to Rio de Janeiro. On 29 September 2006, local time 16:48 BRT, it collided in midair with an Embraer Legacy 600 business jet over the Brazilian state of Mato Grosso. All 154 passengers and crew aboard the Boeing 737 died when the aircraft broke up in midair and crashed into an area of dense jungle, while the Embraer Legacy, despite sustaining serious damage to its left wing and tail, landed safely with its seven occupants uninjured.[1][5][6]

The accident, which triggered a crisis in Brazilian civil aviation, was the deadliest in that country's aviation history at the time, surpassing VASP Flight 168, which crashed in 1982 with 137 fatalities near Fortaleza.[7] It was subsequently surpassed by TAM Airlines Flight 3054, which crashed on 17 July 2007 with 199 fatalities.[8] It was also the first crash of a Boeing 737-800, and the deadliest aviation accident involving a Boeing 737 (all series) aircraft at that time, eventually surpassed by Air India Express Flight 812, which crashed at Mangalore, India, on 22 May 2010 with 158 fatalities.[9]

The accident was investigated by both the Brazilian Air Force's Aeronautical Accidents Investigation and Prevention Center (Portuguese: Centro de Investigação e Prevenção de Acidentes Aeronáuticos (CENIPA)) and the U.S. National Transportation Safety Board (NTSB), with a final report issued on 10 December 2008. CENIPA concluded that the accident was caused by errors committed both by air traffic controllers and by the American pilots on the delivery flight of the Embraer Legacy, while the NTSB determined that all pilots acted properly and were placed on a collision course by a variety of "individual and institutional" air traffic control errors.[1][5][10][11]

Boeing aircraft and crew

Mid-sized twin-engine passenger jet with red-and-white GOL logo, whose wings end in 2-meter upturned winglets, on an airport taxiway. A lineman is crouching next to the nose gear.
PR-GTL, a similar model as PR-GTD
Final tally of passenger nationalities
NationalityPassengersCrewTotal
 Argentina10010
 United States606
 Mexico505
 France404
 Venezuela404
 Australia303
 Canada303
 Colombia303
 Portugal202
 South Africa202
 Japan101
 Brazil1056111
Total1486154

The Gol Transportes Aéreos twin turbofan Boeing 737-8EH aircraft, was a new Short Field Performance variant.[12] It had made its first flight on August 22, 2006 and been delivered to Gol on 12 September 2006, less than 3 weeks before the accident, with 186 seats (36 Economy Plus and 150 Economy seats).[13] Gol Flight 1907 (ICAO code "GLO 1907") departed Eduardo Gomes International Airport in Manaus on 29 September 2006, at 15:35 Brazil Standard Time (BST) (18:35 UTC),[note 1] en route to Rio de Janeiro–Galeão International Airport, with a planned intermediate stop at Brasília International Airport.[1]

There were 148 passengers and six crew members on board the Boeing airliner.[14] The crew consisted of Captain Decio Chaves Jr., 44, First Officer Thiago Jordão Cruso, 29, and four flight attendants. The captain, who had also been serving as a Boeing 737 flight instructor for Gol, had 15,498 total flight hours, with 13,521 in Boeing 737 aircraft. The first officer had 3,981 total flight hours, with 3,081 in Boeing 737 aircraft.[1]

There were 10 Argentine, 6 American, 5 Mexican, 4 French, 4 Venezuelan, 3 Australian, 3 Canadian, 3 Colombian, 2 Portuguese, 2 South African and 1 Japanese passengers on board. The remaining 111 occupants, including the 6 crew members, were Brazilian.

Embraer aircraft and crew

The twin turbofan Embraer Legacy 600 business jet, serial number 965 and registration N600XL, newly built by Embraer and purchased by ExcelAire Service Inc. of Ronkonkoma, New York, was on a delivery flight by ExcelAire from the Embraer factory to the U.S. It departed from São José dos Campos-Professor Urbano Ernesto Stumpf Airport (SJK), near São Paulo, at 14:51 BST, and was on its way to Eduardo Gomes International Airport (MAO) in Manaus as a planned en route stop.[1]

The ExcelAire flight crew consisted of Captain Joseph Lepore, 42, and First Officer Jan Paul Paladino, 34, both U.S. citizens.[15][16] Lepore had been a commercial pilot for more than 20 years and had logged 9,388 total flight hours, with 5.5 hours in the Legacy 600. Paladino had been a commercial pilot for a decade and had accumulated more than 6,400 flight hours, including 317 hours flying as captain of Embraer ERJ-145 and ERJ-135 jet aircraft for American Eagle Airlines. (The ERJ-145 and ERJ-135 aircraft are regional jets of the same family as the Legacy.) Paladino had also served as first officer for American Airlines, flying MD-82, MD-83 and Boeing 737-800 aircraft between the U.S. and Canada. Both pilots were legally qualified to fly the Embraer Legacy as captain.[1]

The five passengers consisted of two Embraer employees, two ExcelAire executives, and The New York Times business travel columnist Joe Sharkey, who was writing a special report for Business Jet Traveler.[17][18][19]

Collision

A map of Brazil with the approximate flight paths plotted on it in as red and green lines. The paths meet at the collision point, about halfway between Brasilia and Manaus.
Approximate flight paths from flight origins to crash site[20]
  Boeing southeast bound
  Embraer northwest bound

Just before 17:00 BST, the Boeing airliner and the Embraer business jet collided almost head-on at 37,000 feet (11,000 m), approximately midway between Brasília and Manaus, near the town of Matupá, 750 kilometers (470 mi) southeast of Manaus.[21][22][23] The left winglet of the Embraer cut off about half of the Gol plane's left wing. This caused the Boeing to nosedive and enter an uncontrollable spin, which quickly led to an in-flight breakup and crash into an area of dense rainforest, 200 kilometres (120 mi) east of the municipality of Peixoto de Azevedo.[24] All 154 passengers and crew on board died and the aircraft was destroyed, with the wreckage scattered in pieces around the crash site.[1]

Wreckage of the Gol aircraft

The Embraer jet, despite serious damage to the left horizontal stabilizer and left winglet, was able to continue flying, though its autopilot disengaged and it required an unusual amount of force on the yoke to keep the wings level.[1][25][note 2]

With radio relay assistance from Polar Air Cargo Flight 71, a Boeing 747 cargo aircraft flying in the area at the time, the Embraer's crew successfully landed the crippled jet at Cachimbo Airport, part of Campo de Provas Brigadeiro Velloso, a large military complex of the Brazilian Air Force at about 160 kilometers (100 mi) from the collision point.[1][25]

Passenger and journalist Joe Sharkey described his experience aboard the Embraer in an article for The New York Times, titled "Colliding With Death at 37,000 Feet, and Living", filed on 1 October 2006:[15]

And it had been a nice ride. Minutes before we were hit, I had wandered up to the cockpit to chat with the pilots, who said the plane was flying beautifully. I saw the readout that showed our altitude: 37,000 feet. I returned to my seat. Minutes later came the strike (it sheared off part of the plane's tail, too, we later learned).

Detention and charging of Embraer crew

Left wing of jet aircraft N600XL, with its upturned vertical winglet broken off
Damage to the Legacy's left side
Right wing of same aircraft, with the upturned vertical winglet intact
The undamaged right side of the Legacy, for comparison

Immediately after the Embraer's emergency landing at the Cachimbo Airport, BAF and Agência Nacional de Aviação Civil (ANAC) officials detained and interviewed its flight crew.[18] The officials also removed the two "black boxes"—Cockpit Voice Recorder (CVR) and Flight Data Recorder (FDR)—from the Embraer, and sent them to São José dos Campos, São Paulo, and from there to Ottawa, Canada, for analysis.[1][18]

In an initial deposition, the Embraer flight crew testified that they were cleared to flight level 370, approximately 37,000 feet (11,000 m) above mean sea level, by Brasilia ATC, and were level at that assigned altitude when the collision occurred. They also asserted that at the time of the collision they had lost contact with Brasilia ATC, and their anti-collision system did not alert them to any oncoming traffic.[26]

On 2 October 2006, the Embraer's captain and first officer were ordered by the Mato Grosso Justice Tribunal to surrender their passports pending further investigation. The request, made by the Peixoto de Azevedo prosecutor,[27] was granted by judge Tiago Sousa Nogueira e Abreu, who stated that the possibility of pilot error on the part of the Embraer crew could not be ruled out.[28] The Embraer crew were forced to remain in Brazil until their passports were released to them on 5 December 2006, more than two months after the accident, after federal judge Candido Ribeiro ruled there were no legal grounds for "restricting the freedom of motion of the foreigners."[29][30]

Prior to their scheduled departure to the United States, the crew were formally charged by Brazilian Federal Police with "endangering an aircraft", which carries a penalty of up to twelve years in prison. The pilots had to explain why they did not turn on the transponder.[31] The two pilots were allowed to leave the country after signing a document promising to return to Brazil for their trial or when required by Brazilian authorities. They picked up their passports and flew back to the United States.[32][33]

Search and recovery operation

Three men, one of whom is holding a partially mangled red metal box
The Boeing's flight data recorder

The Brazilian Air Force sent five fixed-wing aircraft and three helicopters to the region for an extensive search and rescue (SAR) operation. As many as 200 personnel were reported to be involved in the operation, among them a group of Kayapo people familiar with the forest.[34] The crash site of Gol Flight 1907 was spotted on 30 September by the BAF, at coordinates 10°29′S 53°15′W / 10.483°S 53.250°W / -10.483; -53.250Coordinates: 10°29′S 53°15′W / 10.483°S 53.250°W / -10.483; -53.250,[35] 200 km (120 mi) east of Peixoto de Azevedo, near Fazenda Jarinã, a cattle ranch.[17][36] It was reported that rescue personnel had difficulty reaching the crash site due to the dense forest.[37] The Brazilian airport administrator Infraero at first indicated the possibility of five survivors, but a later statement from the Brazilian Air Force, based on data collected by BAF personnel who rappelled (abseiled) to the crash site and local police who assisted in the SAR effort, confirmed that there were no survivors.[38] Brazilian President Luiz Inácio Lula da Silva declared three days of national mourning.[39]

A red palm-sized cylindrical metal container, lying in a shallow freshly dug hole in the ground, is labeled "ENREGISTREUR DE VOL / NE PAS OUVRIR".
The Boeing's CVR memory module was found embedded in the soil, after four weeks of intensive searching by 200 Army troops.[40][note 3]

The flight data recorder and a non-data part of the cockpit voice recorder from the Boeing 737 were found on 2 October 2006 and handed over to the investigators, who sent them to the Transportation Safety Board of Canada (TSB) in Gatineau, Quebec, Canada, for analysis.[note 4][41][42] On 25 October 2006, after nearly four weeks of intensive searching in the jungle by about 200 Brazilian Army troops equipped with metal detectors, the memory module of the Boeing's cockpit voice recorder was found.[1] The module was discovered intact, separated from other wreckage pieces, embedded in about 20 centimetres (8 in) of soil, and was also sent for analysis by the TSB in Canada.[40][43]

On 4 October, the recovery crews began moving the bodies to the temporary base established at the nearby Jarinã ranch. The BAF deployed a C-115 Buffalo aircraft to transport the bodies to Brasília for identification.[44]

The recovery teams worked intensively for nearly seven weeks in a dense jungle environment, searching for and identifying the victims' remains. The final victim was recovered and identified by DNA testing by 22 November 2006.[45]

Investigation

An aviation instrument-flying chart, showing, among many others, lines representing the airways flown by the Legacy jet.
IFR high altitude en route chart section of Brasilia area, depicting UW2, UZ6 airways

The accident was investigated by the Brazilian Air Force Aeronautical Accidents Investigation and Prevention Center (CENIPA) and the U.S. National Transportation Safety Board (NTSB). The NTSB, in accordance with the provisions of ICAO Annex 13, participated in the investigation representing the state of manufacture of the Boeing, state of registry and operator of the Embraer, and state of manufacture of the Honeywell avionics equipment installed in both planes.[5]

Once the black boxes and communication transcripts were obtained, the investigators interviewed the ExcelAire's flight crew and the air traffic controllers, trying to piece together the scenario which allowed two modern jet aircraft, equipped with the latest anti-collision gear, to collide with each other while on instrument flights in positive control airspace.

The Embraer's flight plan consisted of flying at FL370 up to Brasilia,[note 5] on airway UW2, followed by a planned descent at Brasilia to FL360, proceeding outbound from Brasilia northwest-bound along airway UZ6 to the Teres fix,[note 6] an aeronautical waypoint located 282 nmi (324 mi, 522 km) northwest of Brasilia, where a climb to FL380 was planned. According to the filed flight plan, the Embraer was scheduled to have been level at FL380, proceeding towards Manaus, while passing the eventual collision point, which was about 307 kilometres (191 mi) northwest of Teres.

The ExcelAire's crew asserted in their depositions and subsequent interviews that they were cleared by air traffic control (ATC) to FL370 for the entire trip, all the way to Manaus.[1] The actual transcript of the clearance given to the Embraer's crew prior to takeoff at São José dos Campos at 14:41:57 BST, as later released by CENIPA, was:[1]

November Six Zero Zero X-ray Lima, ATC clearance 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.

The Embraer's crew's altitude clearance to FL370 was further confirmed after their handoff to Brasilia, during which they had the following radio exchange with ATC at 15:51 BST:[1][46]

N600XL:Brasilia, November six hundred X-ray Lima, level... flight level three seven zero, good afternoon.
ATC:November six zero zero X-ray Lima, squawk ident, radar surveillance.[note 7]
N600XL:Roger.

This was the last two-way radio communication between the Embraer's crew and ATC prior to the collision.

Embraer flight and communication sequence

A standing middle-aged man wearing a suit, points to a screen showing a diagram of the two aircraft colliding by clipping each other's wings.
Investigation committee president Col. Rufino Antônio da Silva Ferreira presents the preliminary findings on 16 November 2006.[2]

The Embraer took off from São José dos Campos at 14:51, reaching FL370 at 15:33, 42 minutes later, where it remained until the collision.[1]

ATC maintained normal two-way radio contact with the Embraer up until 15:51, when the last successful radio exchange with the Embraer was made on VHF frequency 125.05 MHz with Brasilia Center.[note 8] At that point the Embraer was just approaching the Brasilia VOR.[note 9] The Embraer overflew the Brasilia VOR at 15:55, four minutes later, and proceeded northwest-bound along UZ6. At 16:02, seven minutes after crossing the Brasilia VOR, secondary radar contact was lost with the Embraer, thus stopping the display of the Embraer's reported altitude (Mode C) on the controller's radar screen.[note 10]

No attempt was made by either the Embraer or Brasilia Center to contact each other from 15:51 until 16:26 when, 24 minutes after the loss of secondary radar contact,[note 11] Brasilia Center called the Embraer and received no reply.

Brasilia Center then unsuccessfully attempted to contact the Embraer six more times, between 16:30 and 16:34. At 16:30 the Embraer's primary radar target became intermittent, and disappeared completely from the radar screen by 16:38, eight minutes later. Brasilia Center unsuccessfully attempted to effect a handoff of the Embraer to Amazonic Center at 16:53, by calling the Embraer in the blind.[note 12]

Aviation instrument-flying chart showing numerous lines representing airways and intersections, including the location of where the collision occurred, northwest of Brasilia.
IFR high altitude en route chart section of Teres fix area, depicting UZ6 airway and Cachimbo airbase; crash site is between Nabol and Istar fixes on UZ6

The Embraer, on the other hand, started calling Brasilia Center,[note 13] also unsuccessfully, from 16:48 and continued with twelve more unsuccessful attempts until 16:53. Some limited contact was made at that point, but the Embraer was unable to copy the Amazonic Center frequencies.[note 14] The Embraer then continued its attempts to reach Brasilia Center, seven more times until the collision.

The collision occurred at 16:56:54 BST at FL370,[1][25] and it was confirmed that neither Traffic Collision Avoidance System (TCAS) system had activated or alerted its respective crew, nor did any crew see the oncoming traffic visually or initiate any evasive action prior to the collision. While both planes were equipped with TCAS, it was later determined that the Embraer's transponder had ceased operating almost an hour earlier, at 16:02, rendering both planes unable to automatically detect each other.[1]

At 16:59:50, about three minutes after the collision, Amazonic Center started to receive the Embraer's secondary radar reply, with its correct altitude and last assigned code.[note 15] At 17:00:30 Amazonic Center unsuccessfully attempted to contact the Embraer by radio.

A white four-engine jumbo jet with a blue Polar logo, rolling out on an airport runway.
Polar 71, Registration N453PA, a Boeing 747 cargo aircraft similar to the one depicted, provided radio relay and translation assistance to the crippled Embraer jet.[1][25]

The Embraer started calling on the emergency frequency, 121.5 MHz, immediately after the collision, but as it was later determined in the CENIPA report, the emergency transceivers in the area were not operational and thus the crew was unable to reach ATC on that frequency.[1][25]

At 17:01:06 the Embraer established contact on the emergency frequency with a Boeing 747 cargo aircraft, Polar 71, which attempted to relay to ATC their request for an emergency landing, and continued to provide relay and translation assistance to the Embraer until its eventual landing.[1][25]

At 17:18:03 the Embraer contacted the Cachimbo Airport (SBCC) tower directly to coordinate its emergency landing there, and landed safely at Cachimbo at 17:23:00.

Gol 1907 flight and communication sequence

Gol 1907 took off from Manaus at 15:35, flying southeast-bound along UZ6 and reaching FL370 at 15:58, 23 minutes later, where it remained until the collision. There were no radio or radar contact problems with the flight until its handoff to Brasilia Center. There were no known attempts by ATC to warn Flight 1907 of the conflicting traffic.[1]

NTSB Safety Recommendation

Diagram of impact. 1. Impact, 2. Hydraulic lines, 3. Control surfaces.[2]

On 2 May 2007, the National Transportation Safety Board (NTSB) issued a Safety Recommendation document that included an interim summary of the investigation to date, as well as some immediate safety recommendations that the NTSB believes should be implemented by the U.S. Federal Aviation Administration (FAA) to enhance flight safety.[48] The NTSB reported that the Embraer apparently experienced a Traffic Collision Avoidance System (TCAS) outage, unknown to its flight crew prior to the collision, according to the Cockpit Voice Recorder (CVR):

Preliminary findings in the ongoing investigation indicate that, for reasons yet to be determined, the collision avoidance system in the Legacy airplane was not functioning at the time of the accident, thereby disabling the system's ability to detect and be detected by conflicting traffic. In addition, CVR data indicate that the flight crew was unaware that the collision avoidance system was not functioning until after the accident.

The NTSB added that the design of the Embraer's avionics is such that the non-functioning of the TCAS that apparently occurred is shown by a small static white text message, which may not be noticeable by the flight crew. The NTSB noted:

Using only static text messages to indicate a loss of collision avoidance system functionality is not a reliable means to capture pilots' attention because these visual warnings can be easily overlooked if their attention is directed elsewhere in the flight environment.

Based on its observations, the NTSB recommended to the FAA that design changes be implemented to improve the noticeability of TCAS annunciation, and that the FAA advise pilots of all aircraft to become more familiar with the details of this accident, potential loss of transponder and/or TCAS function, and how to recognize them.[5]

Final reports

CENIPA

A distraught woman talks into a microphone with her eyes closed, surrounded by reporters. On the front of the woman's white T-shirt there is a printed color portrait of a smiling man. Next to her stands a younger woman with her head down.
Relatives of Gol 1907 victims react to presentation of CENIPA's final report in Brasilia.

On 10 December 2008, more than two years after the accident, the Aeronautical Accidents Investigation and Prevention Center (CENIPA) issued its final report, describing its investigation, findings, conclusions and recommendations.[1] The CENIPA report includes a "Conclusions" section that summarizes the known facts and lists a variety of contributing factors relating to both air traffic controllers and the ExcelAire's flight crew.[49][50] According to CENIPA, the air traffic controllers contributed to the accident by originally issuing an improper clearance to the Embraer, and not catching or correcting the mistake during the subsequent handoff to Brasilia Center or later on. CENIPA also found errors in the way the controllers handled the loss of radar and radio contact with the Embraer.[1][50]

CENIPA concluded that the ExcelAire pilots also contributed to the accident with, among others, their failure to recognize that their transponder was inadvertently switched off, thereby disabling the collision avoidance system on both aircraft, as well as their overall insufficient training and preparation.[1][50][51]

NTSB

The U.S. NTSB issued its own report on the accident, which was also appended to the CENIPA report with the following Probable Cause statement:[5]

The evidence collected during this investigation strongly supports the conclusion that this accident was caused by N600XL and GOL1907 following ATC clearances which directed them to operate in opposite directions on the same airway at the same altitude resulting in a midair collision. The loss of effective air traffic control was not the result of a single error, but of a combination of numerous individual and institutional ATC factors, which reflected systemic shortcomings in emphasis on positive air traffic control concepts.

The NTSB further added the following contributing factors:

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.

Conflicting CENIPA and NTSB conclusions

While agreeing on most basic facts and findings, CENIPA and NTSB, which collaborated in the accident investigation, arrived at disagreeing interpretations and conclusions. The CENIPA report concludes the accident was caused by mistakes made both by air traffic controllers and by the ExcelAire pilots, whereas the NTSB focuses on the controllers and the ATC system, concluding that both flight crews acted properly but were placed on a collision course by the air traffic controllers.[5][10][11][52][53][54][55]

According to Aviation Week, "the U.S. National Transportation Safety Board (NTSB) strongly disagreed with the Brazilian conclusions regarding the Legacy pilots' actions as a causal factor, noting, 'The crew flew the route precisely as cleared and complied with all ATC instructions,' as did the GOL airlines crew."[10] Aviation Week adds that "the Brazilian military operates that country's air traffic control system, conducted the investigation and authored the report."[10]

Aftermath

Aviation crisis

Busy interior of an airport terminal, with people crowding around a ticket counter, where a woman ticket agent is seated, listening patiently to an animated customer waving her hand.
Passengers at Brasília International Airport inquiring about delayed flights.

The crash of Flight 1907 precipitated a major crisis in Brazil's civil aviation system, which included massive flight delays and cancellations, air traffic controller work-to-rule slowdowns and strikes, and public safety concerns about Brazil's airport and air traffic infrastructure.[56]

Historically, Brazil was ruled by its armed forces from 1964 until 1985.[57] Since then, a civilian government has taken over, but the country's airways (as of 2009) continued to be controlled and operated by the Brazilian Air Force (BAF) and run by generals, overseen by a civilian defense minister. Most of Brazil's air traffic controllers are military non-commissioned officers, and all Area Control Centers are run by the BAF.[58]

A silvery-haired balding man in his 80s, wearing a suit and tie.
Brazilian Defense Minister Waldir Pires was fired after being criticized for mismanaging the country's air traffic system.

In October 2006, as details surrounding the crash of Flight 1907 began to emerge, the investigation seemed to be at least partly focused on possible air traffic control errors. This led to increasing resentment by the controllers and exacerbated their already poor labor relations with their military superiors.[59] The controllers complained about being overworked, underpaid, overstressed, and forced to work with outdated equipment. Many have poor English skills, limiting their ability to communicate with foreign pilots, which played a role in crash of Flight 1907.[1] In addition, the military's complete control of the country's aviation was criticized for its lack of public accountability.[60][61]

Amid rising tensions, the air traffic controllers began staging a series of work actions, including slowdowns, walkouts, and even a hunger strike. This led to chaos in Brazil's aviation industry: major delays and disruptions in domestic and international air service, stranded passengers, canceled flights, and public demonstrations. Those who blamed various civilian and military officials for the growing crisis called for their resignation.[60]

On 26 July 2007, after an even deadlier crash in Brazil (TAM Airlines Flight 3054 on 17 July 2007) claimed the lives of 199 people, President Luiz Inácio Lula da Silva fired his defense minister, Waldir Pires, who had been in charge of the country's aviation infrastructure and safety since March 2006, and was widely criticized for their failures.[62] On the same day, Lula appointed former Supreme Court president Nelson Jobim to replace Pires, and vowed to improve Brazil's air traffic control system.[63]

Civil litigation

On 6 November 2006, the families of ten of the deceased filed a lawsuit for negligence against ExcelAire and Honeywell, alleging that the ExcelAire pilots were flying at an "incorrect altitude" and that the Honeywell transponder was not functioning at the time of the collision.[64] Other suits were subsequently filed on behalf of other victims, with similar allegations against ExcelAire and Honeywell.[65] The victims' families also filed suits against other U.S. based defendants, including the two Embraer pilots, as well as Raytheon, Lockheed Martin and Amazon Tech (manufacturers of Brazil's air traffic control equipment), and ACSS (manufacturer of the Embraer's TCAS).[66]

The attorney representing the Embraer crew, Miami-based Robert Torricella, responded to the allegation that the crew was flying at an "incorrect altitude" by stating that according to international regulations, clearances and directives issued by ATC supersede a previously filed flight plan, and in this case:[67]

... the flight plan cleared by air traffic control at the time of departure required the Embraer to fly all the way to Manaus at 37,000 feet and, absent contrary directives from air traffic control, the Embraer was obligated to follow its cleared flight plan. As the findings of the investigation are made public, we are confident that ExcelAire's pilots will be exonerated.

A Honeywell spokesperson stated that "Honeywell is not aware of any evidence that indicates that its transponder on the Embraer Legacy was not functioning as designed or that Honeywell was responsible for the accident."[68]

On 2 July 2008, U.S. District Court judge Brian Cogan of the Eastern District of New York dismissed the families' suits against all the U.S. based defendants under the premise of forum non-conveniens. Without ruling on the merits of the cases, and while allowing discovery to continue, Cogan recommended the Brazilian court system as a more appropriate jurisdiction for the dispute.[66][69]

Criminal proceedings

On 1 June 2007, Murilo Mendes, a Brazilian federal judge in the small city of Sinop, Mato Grosso, near the crash site of the Boeing, indicted the two Embraer pilots and four Brasilia-based air traffic controllers for "exposing an aircraft to danger."[70] On 8 December 2008, he dismissed charges of negligence against the pilots, but left in place a charge of "imprudence". He also dismissed all charges against two of the four Brasilia-based controllers and reduced the charges against the other two, but supported bringing new charges against a fifth controller, based in São José dos Campos, the Embraer's departure point.[71][72][73] On 12 January 2010, his ruling was overturned by Judge Candido Ribeiro in a federal court in Brasilia, reinstating the negligence charges against the pilots.[74][75]

On 26 October 2010, a military court convicted air traffic controller Sgt. Jomarcelo Fernandes dos Santos, sentencing him to 14 months in jail for failing to take action when he saw that the Embraer's anti-collision system had been turned off. Santos will remain free pending the outcome of the appeal process. Four other controllers were acquitted for lack of proof.[76] On 17 May 2011, Judge Mendes sentenced air traffic controller Lucivando Tiburcio de Alencar to a term of up to three years and four months but ruled he is eligible to do community service in Brazil instead and acquitted Santos on charges of harming Brazil's air transport safety.[77]

On 16 May 2011, Judge Mendes sentenced the two pilots to four years and four months of prison in a "semi-open" facility for their role in the collision, but he commuted the sentences to community service to be served in the United States. Brazilian authorities accused the pilots of turning off the Legacy's transponder moments before the accident and turning it on again only after the crash, but it was denied by the crew in a deposition via videoconference. Mendes said in his sentence that pilots had failed to verify the functioning of equipment for more than an hour, a length of time he called "an eternity" in aviation.[78] On 9 October 2012, Brazilian federal prosecutors announced that they had successfully appealed the sentence of the pilots, asking to increase their sentences by 17 months (a total of 5 years and 9 months).[79] The new trial was scheduled for 15 October, with the pilots again facing trial in absentia.[80] On that date, the court upheld the prior convictions, but modified the sentences to 37 months for each, requiring that the pilots "report regularly to authorities and stay home at night."[81]

Survivor aircraft

N600XL remained impounded at Cachimbo for almost three years, but in mid-2009 American company General Aviation Services agreed to buy the aircraft. The company partnered with Gantt Aviation and Constant Aviation to check and prepare it for its ferry to the US. Constant completed the work and finally on 19 November 2010 (more than 4 years after the accident) the aircraft, now with the new registration of N965LL, arrived at Cleveland International Airport to be refurbished and put up for sale.[82]

The plane was reported to be on sale in March 2011, even though repairs to the left wingtip and stabilizer were still being completed in August 2011. The plane was then sold to a private owner in 2013 registered XA-MHA.[83][84]

Dramatization

In 2007 Discovery Channel Brazil aired A Tragédia do Vôo 1907 ("The Tragedy of Flight 1907"), a documentary about the disaster.[85] The Association Family and Friends of Victims in Flight 1907 stated that the documentary exhibited bias on behalf of the Legacy pilots.[86]

The crash was the subject of a Season 5 episode of Mayday (also known as Air Crash Investigation) entitled Phantom Strike (also titled Death Over the Amazon and Radio Silence).

The Smithsonian Channel's "Air Disasters" documentary series, featured this accident in the second season's eighth episode titled "System Breakdown", released in 2011. Available on Netflix as of Oct. 2015.

See also

Notes

  1. ↑ All times mentioned in this article are Brazil Standard Time, UTC-3, unless otherwise noted.
  2. ↑ From CENIPA final report, under section 2.2.1 (Damage to airplanes): "The N600XL airplane sustained serious damages in the left wing and in the left stabilizer/elevator assembly".[1]
  3. ↑ The French text reads "FLIGHT RECORDER DO NOT OPEN."
  4. ↑ Canada was selected by CENIPA as a "neutral site" for the FDR/CVR analysis, due to the sensitive political aspects of this investigation.[41]
  5. ↑ FL370 is Flight Level 370, which is an altitude of approximately 37,000 feet Above Mean Sea Level (AMSL)
  6. ↑ The Teres fix is located on airway UZ6 at coordinates 12°28.5'S, 51°22.1'W, see: High Altitude Enroute chart
  7. ↑ Pressing the transponder's "ident" button in the aircraft ("squawking ident") allows the ATC controller to positively identify its target on the radar screen, verifying its position and altitude.
  8. ↑ Brasilia Area Control Center is designated as ACC BS.
  9. ↑ The VHF omnidirectional range (VOR) transmitter installation is a defined waypoint, underlying the airway.
  10. ↑
    • As it was later revealed in CENIPA's final report, the military controller's screen automatically reverted to displaying an unreliable altitude, normally used for air defense, derived from the primary radar detected range and the target's angle above the horizon.
    • CENIPA hypothesizes in its final report that at this point the Embraer's captain inadvertently deactivated the transponder. The captain has denied this in depositions and interviews.[1]
  11. ↑ Loss of secondary radar indicates to a controller that the aircraft's transponder signal is not being received by ATC.
  12. ↑
    • A handoff in aviation parlance refers to the transfer of responsibility for an aircraft under radar control from one controller to the next
    • "Calling in the blind" refers to making radio transmissions without receiving any acknowledgment.
    • Amazonic Area Control Center is designated as ACC AZ.
  13. ↑ According to CENIPA, the last transmission from ATC that was recorded on the Embraer's CVR was at 16:23:29 BST, approx. 25 minutes before the Embraer's first officer tried to call ATC. According to the published CVR, however, there were other radio transmissions (in Portuguese) audible on the frequency until approx. 2.5 minutes before the first officer began calling Brasilia.[47]
  14. ↑ To copy in aviation parlance means to understand a received radio transmission.
  15. ↑ CENIPA hypothesizes in its final report that at this point, based on CVR and FDR evidence, the first officer, having just discovered the transponder had been inadvertently switched off, reactivated it. The Embraer's crew have steadfastly denied switching the transponder on or off in depositions and interviews.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 "Final Report" (PDF). CENIPA. 8 December 2008. Archived from the original (PDF) on 4 June 2011. Retrieved 11 June 2009.
  2. 1 2 3 MELO FILHO, S. (2 October 2006). "Gol 737-800 x Legacy 600 Hypothetical Collision Configuration". Associação dos Engenheiros do ITA – WikITA. Retrieved 18 August 2013.
  3. ↑ "Registro Aeronáutico Brasileiro". Agência Nacional de Aviação Civil.
  4. ↑ "FAA Registry". Federal Aviation Administration.
  5. 1 2 3 4 5 6 "NTSB interim and final report links". NTSB. Archived from the original on 4 June 2011. Retrieved 11 June 2009.
  6. ↑ "Gol 1907 accident record". ASN. Retrieved 11 June 2009.
  7. ↑ "VASP 168 accident record". ASN. Retrieved 11 June 2009.
  8. ↑ "TAM 3054 accident record". ASN. Retrieved 11 June 2009.
  9. ↑ "Air India Express Flight 812 record". ASN. Retrieved 22 May 2010.
  10. 1 2 3 4 "Brazil Air Force, NTSB Spar on Midair Causes". Aviation Week. 11 December 2008.
  11. 1 2 Downie, Andrew; Wald, Matthew L. (10 December 2008). "Brazil Lays Some Blame on U.S. Pilots in Collision". The New York Times. Retrieved 31 March 2010.
  12. ↑ "Boeing 737 Design Enhancements Earn FAA Certification". Boeing. 27 July 2006. Archived from the original on 2006-11-10. Retrieved 30 September 2006.
  13. ↑ "200 Air Force Men at Boeing Crash Site in Brazilian Jungle". brazzilmag. 1 October 2006. Archived from the original on 2006-11-17.
  14. ↑ "Gol divulga lista de passageiros do vôo 1907" [Gol releases flight 1907 passenger list]. Brasil em Folhas (in Portuguese). 30 September 2006.
  15. 1 2 Sharkey, Joe (1 October 2006). "Colliding With Death at 37,000 Feet, and Living". The New York Times. Retrieved 31 March 2010.
  16. ↑ "Ocupantes do Legacy dizem ter sentido impacto" [Legacy occupants say they felt impact]. O Globo (in Portuguese). 1 October 2006.
  17. 1 2 Langewiesche, William (January 2009). "The Devil at 37,000 Feet". Vanity Fair. Retrieved 17 December 2008.
  18. 1 2 3 "Caixas-pretas do Legacy chegam a São José dos Campos para perícia" [Legacy's black boxes arrive in São Jose Dos Campos for analysis]. O Globo (in Portuguese). 1 October 2006.
  19. ↑ "Brazilian Authorities Suspect No Survivors From Jet That Crashed Carrying 155 People". Fox News Channel. 30 September 2006. Retrieved 30 September 2006.
  20. ↑ "Quadro mostra as hipóteses sobre a colisão dos aviões" [Diagram showing collision hypothesis]. Brasil em Folhas (in Portuguese). 3 October 2006.
  21. ↑ "Matupá, Brazil". Maps. Google. Retrieved 30 September 2006.
  22. ↑ "Avião da Gol desaparece na região de Matupá, em Mato Grosso" [Gol plane disappears near Matupá, Mato Grosso]. O Globo (in Portuguese). Globo G1. 29 September 2006.
  23. ↑ "Embraer divulga nota sobre acidente que envolveu uma da suas aeronaves" [Embraer releases statement on accident involving one of its planes]. O Globo (in Portuguese). Globo. 30 September 2006. Archived from the original on 2007-05-28.
  24. ↑ "Preliminary Synopsis". NTSB. Archived from the original on 22 June 2013. Retrieved 27 September 2014.
  25. 1 2 3 4 5 6 "Embraer's CVR Audio". Vanity Fair. Archived from the original on 14 June 2011. Retrieved 11 June 2009. (collision at 1:23:50 on MP3 clip)
  26. ↑ "Legacy estava sem contato com a torre de controle" [Legacy was without contact with air traffic controllers]. Brasil em Folhas (in Portuguese). 3 October 2006.
  27. ↑ "Pilotos do Legacy estão proibidos de deixar o Brasil" [Legacy pilots forced to remain in Brazil] (in Portuguese). Ministério Público do Estado de Mato Grosso. 2 October 2006. Archived from the original on 18 April 2008. Retrieved 2 October 2006.
  28. ↑ "Justiça manda apreender passaportes de pilotos do Legacy" [Court orders Legacy pilots to surrender passports]. Brasil em Folhas (in Portuguese). 2 October 2006.
  29. ↑ Prada, Paulo (6 December 2006). "Brazil Court Gives Police 3 Days to Free U.S. Pilots in Crash Inquiry". The New York Times. Retrieved 3 May 2010.
  30. ↑ "Pilots in Brazil crash leave for U.S.". thefreelibrary.com. Associated Press. 8 December 2006.
  31. ↑ "U.S. pilots charged in Brazilian plane crash". The New York Times. 8 December 2006.
  32. ↑ "Criminalizing Aviation Accidents Only Assures Repeats". ABC News. 7 December 2006.
  33. ↑ "Pilots in Brazil crash return to U.S.". USA Today. Associated Press. 9 December 2006.
  34. ↑ "Índios ajudam a resgatar vítimas de acidente com avião, o pior ocorrido no Brasil" [Natives assist in victim search; worst occurrence in Brazil's history]. Brasil em Folhas (in Portuguese). 1 October 2006.
  35. ↑ "Não há sobreviventes em acidente com o avião da Gol, diz Aeronáutica" [Aviation officials: there are no survivors in Gol plane accident]. Brasil em Folhas (in Portuguese). 30 September 2006.
  36. ↑ "Destroços de avião da Gol indicam queda vertical" [Gol plane wreckage indicates vertical dive]. Brasil em Folhas (in Portuguese). 30 September 2006.
  37. ↑ "Phantom Strike," Mayday
  38. ↑ "FAB diz que não há sobreviventes [BAF says there are no survivors]". O Globo (in Portuguese). 30 September 2006.
  39. ↑ "Lula declara luto nacional" [Lula declares national mourning]. O Globo (in Portuguese). 30 September 2006.
  40. 1 2 "Gravador de Voz – Vôo 1907". ANAC. Archived from the original on 11 November 2007. Retrieved 25 April 2007.
  41. 1 2 Bleyer, Bill (12 October 2006). "Recordings key to fate of LI pilots: Cockpit voices in collision sent to Canada for analysis; Brazil ready to blame fliers.". Newsday. Melville, NY.
  42. ↑ "Aeronáutica encontra caixas-pretas do Boeing da Gol" [Air Force recovers black boxes from Gol Boeing]. O Globo (in Portuguese). 2 October 2006.
  43. ↑ "Últimas informações sobre as caixas pretas e o trabalho da comissão de investigação" [Latest update on the black boxes and investigation commission work] (in Portuguese). ANAC. 3 October 2006. Archived from the original on 11 November 2007. Retrieved 15 June 2009.
  44. ↑ "Brazilian Air Force press release" (in Portuguese). Força Aérea Brasileira (Brazilian Air Force). 4 October 2006. Archived from the original on 22 October 2006. Retrieved 25 June 2009.
  45. ↑ "IML confirma identificação da última vítima da queda do Boeing da Gol" [IML confirms identification of last Gol Boeing victim]. Brasil em Folhas (in Portuguese). 22 November 2006.
  46. ↑ "Embraer's CVR Audio". Vanity Fair. Archived from the original on 14 June 2011. Retrieved 11 June 2009. (last ATC two-way comm at 17:55 on MP3 clip)
  47. ↑ "Embraer's CVR Audio". Vanity Fair. Archived from the original on 14 June 2011. Retrieved 11 June 2009. last radio transmission heard by Embraer at 1:12:30 on MP3 clip)
  48. ↑ "NTSB Safety Recommendation" (PDF). NTSB. 2 May 2007. Archived from the original (PDF) on 2008-10-30. Retrieved 18 December 2008.
  49. ↑ "Falhas de pilotos e controladores de vôo resultaram em acidente da Gol" [Gol accident caused by pilot and controller errors] (in Portuguese). Agencia Brasil. 10 December 2008. Retrieved 11 June 2009.
  50. 1 2 3 "Pilots and controllers blamed for Brazil crash". AP on Fox News. 10 December 2008.
  51. ↑ "Cenipa apresenta relatório final do acidente aéreo da Gol; leia o relatório" [CENIPA presents final report of the Gol aviation accident; read the report]. Brasil em Folhas (in Portuguese). 10 December 2008.
  52. ↑ "NTSB, Cenipa at Odds over Midair Accident Report". AIN Online. 11 December 2008.
  53. ↑ "NTSB, Brazilian Officials Differ on Blame For 2006 Midair". Aero-News. 11 December 2008.
  54. ↑ "NTSB: Loss of 'effective air traffic control' at root of 2006 Legacy 600, Gol 737 collision". Flight International (on Flightglobal). 8 November 2008.
  55. ↑ Lacagnina, Mark (February 2009). "Midair over the Amazon" (PDF). AeroSafety World: 11.
  56. ↑ "Are U.S. Pilots Being Made Scapegoats in Brazil?". Time. 21 December 2006.
  57. ↑ "Timeline: Brazil – A chronology of key events". BBC. 20 November 2009. Retrieved 24 June 2009.
  58. ↑ "Brazilian Aviation Crisis – Governmental Failure?". Scoop Online. 22 August 2007.
  59. ↑ "Brazilian aviation in chaos". Financial Times. 4 April 2007.
  60. 1 2 Downie, Andrew (3 April 2007). "The Chaos in Brazil's Blue Skies". Time.
  61. ↑ "FACTBOX-Brazil's deepening aviation crisis". Reuters. 18 July 2007.
  62. ↑ See for example:
  63. ↑ "Lula vows to fix aviation system". AP on NDTV. 26 July 2007.
  64. ↑ "US firms sued over Brazil crash". BBC. 6 November 2006. Retrieved 4 January 2010.
  65. ↑ "New Lawsuit Alleges Design Defect, Negligence in Brazil Crash". AP on law.com. 13 November 2006.
  66. 1 2 "Memorandum Decision and Order" (PDF). U.S. District Court Eastern District of New York. 2 July 2008. Retrieved 17 October 2012.
  67. ↑ "ExcelAire: Lawsuits Regarding Gol Jet Accident Premature". aero-news.net. 9 November 2006.
  68. ↑ "Lawsuit Blames Device Manufacturer, Airline for Brazil Crash". AP on law.com. 7 November 2006.
  69. ↑ "Brazilian air crash case dismissed by U.S. District Court for the Eastern District of New York". Rochester Daily Record on allbusiness.com. 16 July 2008.
  70. ↑ See for example:
  71. ↑ "Investigation Turns Criminal" (PDF). AeroSafety World: 16. February 2009.
  72. ↑ "Brazilian Judge Clears American Pilots of Carelessness". AIN Online. 11 December 2008.
  73. ↑ "Some charges out against US pilots in Amazon crash". Associated Press on International Business Times. 9 December 2008.
  74. ↑ "US Pilots Face Negligence Charges in Brazil Crash". Associated Press on ABC News. 12 January 2010.
  75. ↑ "Brazilian court overturns acquittal of U.S. pilots in 2006 air disaster". Xinhua News Agency. 12 January 2010.
  76. ↑ Lehman, Stan (27 October 2010). "Brazil air controller convicted over 2006 crash". Boston Globe.
  77. ↑ "Brazil air controller sentenced in 2006 crash case". Reuters. 20 May 2011.
  78. ↑ "Pilots Avoid Jail in Brazil Crash". The New York Times. 16 May 2011. Retrieved 22 May 2011.
  79. ↑ Lehman, Stan (9 October 2012). "US pilots to be retried for Brazil airline crash". Huffington Post. Associated Press.
  80. ↑ "US pilots to be retried for Brazil airline crash". Big Story, Associated Press. 9 October 2012.
  81. ↑ "Brazil upholds U.S. pilots' convictions in 2006 air disaster". Reuters. 15 October 2012.
  82. ↑ "National Airways Corporation: The return of Embraer Legacy 600 N965LL". Nationalairwayscorporation.blogspot.com. 16 October 2011. Retrieved 28 July 2013.
  83. ↑ "For sale: Legacy that escaped Brazilian mid-air smash | Flight International". Flightglobal. 1 April 2011. Retrieved 28 July 2013.
  84. ↑ Chuck Slusarczyk Jr and Mark Plumley (14 August 2011). "Photo: GOL collision Legacy repairs near completion » OPShots.net – Cyberhub to Cleveland Aviation and the World!". OPShots.net. Retrieved 28 July 2013.
  85. ↑ "A Tragédia do Vôo 1907" [The Tragedy of Flight 1907]. Archived from the original on 2011-10-03. Retrieved 2008-12-11.
  86. ↑ "Discovery Channel's documentary is not approved by the families of Flight 1907's victims". Retrieved 6 April 2015.
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