Brazil blames human error for 2006 midair airliner collision

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Saturday, December 6, 2008

This computer-generated image shows the two jets a split second prior to collision
The damage to the Legacy's wing. Notice that the winglet has been sheared completely off.

It has been revealed that the final report into a midair collision that killed 154 people in 2006 will blame a string of human error for the disaster. Gol Transportes Aéreos Flight 1907, a Boeing 737, crashed into the ground after an Embraer Legacy 600 executive jet's wing clipped it. The Legacy, owned by ExcelAire, performed an emergency landing at a nearby airbase.

The report says the Legacy's transponder was "inadvertently turned off by the hand of one of the pilots," and says this was the "central point in a chain of errors" leading to the collision. Crucially, the transponder failure - which the US pilots have denied causing - prevented the Traffic Collision Avoidance System (TCAS) from functioning.

A chunk of wreckage from the Gol airliner.

The investigation, which was conducted by the Brazilian Air Force, criticised air traffic control (ATC) on a number of points; the Legacy was not properly advised on the altitude at which it should be cruising, when one controller changed shift there was a miscommunication between them about the Legacy's altitude and there was a failure of communication between the Legacy and ATC.

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Was the crash report fair?

The ExcelAire pilots, Joseph Lepore and Jan Paladino, were only allowed to return home after promising they would return to Brazil if summoned by the courts. The pair, along with four air traffic controllers, have been indicted over the crash and all six face up to three years in prison each.

Collision detail

The purpose of this investigation, however, was not to acertain blame but to determine the root causes and suggest measures by which a reccurence can be avoided. Some moves have already been made in the aftermath; the accident was the deadliest in Brazil until TAM Airlines Flight 3054 crashed the following year and both were responsible for the 2006-2007 Brazilian aviation crisis. In response, a major overhaul of the nation's military ATC system is underway.

ExcelAire's executive vice president David Rimmer was critical of the report. "The transponder issue is a distraction from the true cause of the accident, which is an air traffic control system that put two airplanes on a collision course for about an hour," he said. He complained that ATC did not "recognize the transponder failure and to provide increased separation between the two jets, as required by international aviation regulations."

He was also concerned by the Air Force's methodology and the conclusions drawn from it. "We have no proof of how the transponder was turned off and no evidence to suggest it was inadvertently turned off by the pilots," he said. "[The Air Force] relied on theories rather than conducting in-depth testing of the equipment."

The report's official release is next week, however it has already been seen by Brazilian newspapers, hence making its findings public today.


Sources

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