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Gol Transportes Aéreos Flight 1907

Coordinates: 10°29′S 53°15′W / 10.483°S 53.250°W / -10.483; -53.250
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Gol Transportes Aéreos Flight 1907
Flight 1907's wreckage in the Amazon jungle
Accident
DateSeptember 29, 2006
SummaryMid-air collision
Site200 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 fatalities154
Total survivors7
First aircraft
TypeBoeing 737-8EH SFP
OperatorGol Transportes Aéreos
RegistrationPR-GTD
Flight originEduardo Gomes Int'l Airport
Manaus, Brazil
StopoverBrasília International Airport
DestinationGaleão Int'l Airport
Rio de Janeiro, Brazil
Passengers148
Crew6
Fatalities154 (all)
Second aircraft
TypeEmbraer Legacy 600
OperatorExcelAire (delivery flight)
RegistrationN600XL
Flight originSão José dos Campos
Regional Airport
DestinationEduardo Gomes International Airport
Passengers5
Crew2
Survivors7 (all)

Gol Transportes Aéreos Flight 1907 (ICAO: GLO 1907, IATA: G3 1907) was a Boeing 737-8EH SFP, registration PR-GTD, on a scheduled passenger flight from Manaus, Brazil to Rio de Janeiro, which collided in mid-air with an Embraer Legacy business jet on September 29, 2006 over the Brazilian state of Mato Grosso. All 154 passengers and crew aboard the Boeing 737 were killed as the aircraft crashed into an area of dense rainforest, while the Embraer Legacy, despite sustaining serious damage to its left wing and tail, landed safely with its seven occupants uninjured.[1][2][3]

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.[4] It was subsequently surpassed by TAM Airlines Flight 3054, which crashed on July 17, 2007 with 199 fatalities.[5]

The accident was investigated by both the Brazilian Air Force Centro de Investigação e Prevenção de Acidentes Aeronáuticos (CENIPA) and the U.S. National Transportation Safety Board (NTSB), with a final report issued on December 10, 2008. CENIPA concluded that the accident was caused by errors committed by both air traffic controllers as well as the Embraer's pilots, 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][2][6][7]

Boeing aircraft and crew

A similar model of the Gol aircraft

The Gol Transportes Aéreos twin turbofan Boeing 737-8EH aircraft, a new Short Field Performance variant,[8][9] had been delivered to Gol on September 12, 2006, seventeen days and 234 hours of operation prior to the accident flight.[10] Gol Flight 1907 (ICAO code "GLO 1907") departed Eduardo Gomes International Airport in Manaus on September 29, 2006, at 15:35 BST (Brazil Standard Time),[note 1] with a planned intermediate stop at Brasília International Airport, en route to Rio de Janeiro-Galeão International Airport.[1]

There were 148 passengers and six crew members on board the Boeing airliner.[11] 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]

Embraer aircraft and crew

File:DamagedLegacyInvolvedinGol1907.jpg
The Embraer Legacy at Cachimbo Air Base

The newly built twin turbofan Embraer Legacy 600 business jet, serial number 965 and registration N600XL,[12][13] owned and operated by ExcelAire Service Inc., a Ronkonkoma, Town of Islip, New York-based company,[14] was on a delivery flight from the Embraer factory to the U.S. It departed from São José dos Campos Regional 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 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, but only 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.[note 2] Paladino had also served as first officer for American Airlines, flying MD-82 and MD-83 jet 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, a magazine specializing in corporate jets.[17][18][19]

Collision

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 in mid-air at 37,000 feet (12.3 km), approximately midway between Brasilia and Manaus, near the town of Matupá, 750 kilometres (470 mi) south of Manaus.[21][22][23]

The Boeing suffered major structural damage, losing nearly half of its left wing, which quickly led to an in-flight breakup and crash into dense rainforest, 200 kilometres (120 mi) east of the municipality of Peixoto de Azevedo.[24] All 154 passengers and crew on board were killed—the highest death toll of any aviation accident involving a Boeing 737.[25] The wreckage of the aircraft was scattered in pieces around the crash site.[1]

The Embraer jet, despite sustaining serious damage to the left horizontal stabilizer and left winglet, was able to continue flying, though its autopilot disengaged and the required manual control inputs were high, especially at slower speeds.[1][note 3][26]

The Legacy's left winglet sliced off nearly half of the Boeing's left wing.[note 4][1]

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 the Brigadeiro Velloso Brazilian Air Force (BAF) Cachimbo air base, about 160 kilometres (100 mi) from the collision point.[1][26]

Passenger/journalist Joe Sharkey described his experience aboard the Embraer in a The New York Times article titled "Colliding With Death at 37,000 Feet, and Living", filed on October 1, 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

Damage to the Legacy's left side
The undamaged right side of the Legacy, for comparison

Immediately after the Embraer's emergency landing at the Cachimbo air base, 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 eventually 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 (11.2 km) 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.[27]

On October 2, 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,[28] 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.[29]

The Embraer crew were forced to remain in Brazil until their passports were released to them on December 5, 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."[30][31][32]

Prior to their scheduled departure to the United States, the crew were formally charged by Brazilian Federal Police with "endangering an aircraft", a charge that carries a penalty of up to twelve years in prison. Former Justice Minister Jose Carlos Dias, who was acting as a lawyer for the Embraer's crew, criticized the charges against them as being "biased" and "discriminatory".[33]

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.[34][35]

Search and recovery operation

The Boeing's flight data recorder

The Brazilian Air Force (BAF) sent five fixed-wing aircraft and three helicopters to the region, one of which equipped with a magnetic anomaly detector, for an extensive search and rescue 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.[36] The crash site of Gol Flight 1907 was spotted on September 30 by the BAF, at coordinates 10°29′S 53°15′W / 10.483°S 53.250°W / -10.483; -53.250,[37] 200 km (120 mi) east of Peixoto de Azevedo, near Fazenda Jarinã, a cattle ranch.[17][38] It was reported that rescue personnel had difficulty reaching the crash site due to the dense forest. 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.[39] Brazilian President Luiz Inácio Lula da Silva declared three days of national mourning.[40]

The Boeing's CVR memory module was found embedded in the soil, after four weeks of intensive searching.[41][note 5]

The flight data recorder and a non-data part of the cockpit voice recorder from the Boeing 737 were found on October 2, 2006 and handed over to the investigators, who sent them to the Transportation Safety Board of Canada (TSB) in Ottawa, Canada for analysis.[note 6][42][43] On October 25, 2006, after almost four weeks of intensive searching under harsh conditions in the jungle by numerous personnel equipped with metal detectors, the memory module of the Boeing's cockpit voice recorder was finally found. 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.[41][44]

On October 4, 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.[45]

The recovery teams spent nearly seven weeks, working intensively in an extremely harsh jungle environment, searching for and identifying the victims' remains. The final victim was recovered and identified by DNA testing by November 22, 2006.[46]

Investigation

File:H4-BRS.jpg
IFR high altitude en route chart section of Brasilia area, depicting UW2, UZ6 airways

The accident was investigated by the Brazilian Air Force CENIPA and the U.S. 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.[2]

Once the black boxes and communication transcripts were obtained, the investigators interviewed the Embraer'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 7] 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 8] an aeronautical waypoint located 282 nm (324 mi, 522 km) northwest of Brasilia, where a climb to FL380 was planned. According to the filed flight plan, the Embraer was 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 Embraer'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][47]

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 9]
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

Investigation committee president Col. Rufino Antônio da Silva Ferreira presents the preliminary findings on November 16, 2006.

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 10] At that point the Embraer was just approaching the Brasilia VOR.[note 11] 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 12]

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 13] 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 14]

File:H4-Teres.jpg
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 15] 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 16] 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][26] 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 17] At 17:00:30 Amazonic Center unsuccessfully attempted to contact the Embraer by radio.

Polar 71, a Boeing 747 cargo aircraft similar to the one depicted, provided radio relay and translation assistance to the crippled Embraer jet[1][26]

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][26]

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][26]

At 17:18:03 the Embraer contacted the Cachimbo air base (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

On May 2, 2007 the 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. FAA to enhance flight safety.[49]

The NTSB reported that the Embraer apparently experienced a TCAS outage, unbeknownst 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 annunciated 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 pilots’ 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.[2]

Final reports

CENIPA final report

Relatives of Gol 1907 victims react to presentation of CENIPA's final report in Brasilia.

On December 10, 2008, more than two years after the accident, 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 Embraer's flight crew.[50][51]

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][51]

CENIPA concluded that the Embraer pilots also contributed to the accident, among others, by not being sufficiently trained and prepared for their flight, and by not recognizing that their transponder was inadvertently switched off, thereby disabling the collision avoidance system on both aircraft.[1][51]

NTSB final report

The U.S. NTSB participated in the investigation and issued its own report on the accident, which was also appended to the CENIPA report, with the following Probable Cause statement:[2]

The evidence collected during this investigation strongly supports the conclusion that this accident was caused by N600XL and GLO1907 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, disagreed in their interpretations and conclusions. The CENIPA report concludes the accident was caused by mistakes made by both air traffic controllers and the Embraer 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.[2][6][7][52][53][54]

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."[6] Aviation Week adds that "the Brazilian military operates that country's air traffic control system, conducted the investigation and authored the report."[6]

Aftermath

Aviation crisis

Passengers at Brasília International Airport inquiring about delayed flights.
Main article: 2006–2007 Brazilian aviation crisis

The crash of Flight 1907 precipitated a major crisis of Brazil's civil aviation system, which included massive flight delays and cancellations, air traffic controller work-to-rule slow downs and strikes, and public safety concerns about Brazil's airport and air traffic infrastructure.[55]

Historically, Brazil was ruled by its armed forces from 1964 until 1985.[56] Since then, a civilian government has taken over, but the country's airways are still (as of 2009) controlled and operated by the Brazilian Air Force (BAF) and run by generals, overseen by a civilian defense minister. Most of the Brazil's air traffic controllers are military non-commissioned officers, and all Area Control Centers are run by the BAF.[57]

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, exacerbating their already poor labor relations with their military superiors.[58] 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.[59][60]

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 skies: major delays and disruptions in domestic and international air service, stranded passengers, canceled flights and public demonstrations, with calls for the resignation of various civilian and military officials blamed for the growing crisis.[59]

Brazilian Defense Minister Waldir Pires was sacked after being criticized for mismanaging the country's air traffic system.

On July 26, 2007, after an even deadlier crash in Brazil — TAM Airlines Flight 3054 — claimed the lives of 199 people, President Luiz Inácio Lula da Silva sacked 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.[61] On the same day, Lula appointed former Supreme Court president Nelson Azevedo Jobim to replace Pires, and has vowed to improve Brazil's air traffic control system.[62]

Legal action

On November 6, 2006, the families of ten of the deceased filed a lawsuit for negligence against ExcelAire and Honeywell, alleging that the Embraer pilots were flying at an "incorrect altitude" and that the Honeywell transponder was not functioning at the time of the collision.[63] Other suits were subsequently filed on behalf of other victims, with similar allegations against ExcelAire and Honeywell.[64]

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:[65]

... 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."[66]

Dramatization

Discovery Channel Brazil aired A Tragédia do Vôo 1907 ("The Tragedy of Flight 1907"), a documentary about the disaster.[67] In 2007 some family members of the Gol 1907 victims stated that they believed the documentary exhibited bias.[68]

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).

Passenger and crew list

Gol 1907 victim list[69]

Adão Adair de Melo Rodrigues, 41
Alexandre José Barbosa Santos, 35
Ana Cláudia Teixeira de Brito, 31
Ana Maria Caminha Maciel Silva, 50
André Luis Carneiro Da Fontoura Pereira, 31
Andreas Friendrick Kowalski, 42
Ângela Maria Conte Leite, 54
Antônia Carlos de Oliveira, 18
Antônio Carlos de Mattos, 63
Antônio Gregório Da Costa Pessoa, 58
Átila Antônio Assad Rezende, ?
Ausgusto Cândito da Silva Mendes, 44
Carlos Antônio de Souza Júnior, 28
Carlos Cruz, 26
Charlie Hudson Rangel de Oliveira, 27
Claudemir Cardoso Rosa, 48
Cláudio Avanci Da Rocha, 41
Cláudio Murilo Gonçalves Cardoso, 53
Daniel de Abreu Lleras, 5
Daniel de Oliveira Silva, 25
Divino Martins da Silva, 45
Décio Chaves Júnior, 44
Dornélio Lemos do Prado, 51
Douglas Scott Hancock, 35
Eduardo Ribeiro de Souza, 42
Elcio Luis Gonçalves Anchieta, ?
Eleta Cordero Pivotto, 51
Elizabeth Barbosa Da Costa, 22
Emanuelle Márcia Dos Santos, 22
Ênio De Oliveira, 39
Erther Viani Bortolozo Nunes, 38
Esdras Loureiro Lucas, 40
Etelvino Lins, 56
Eugênio Carlos Lequeves, 58
Fabiana Honorato Grangeiro Calandrini, 32
Felipe Carvalho da Silva, 24
Francielle Ferreira Mendes De Rezende, 22
Francisco Alves de Oliveira, 49
Francisco Anderson Geraldi De Farias, 55
Francisco Augusto Marques Garcia Júnior, 34
Francisco Carlos Nart, 48
Francisco das Chagas Moura Loiola, ?
Francisco de Oliveira Cavalcante, 59
Frederick André Anthony Michel, 36
Gilcley Silva Da Costa, 27
Gilson Iglesias de Azevedo, 46
Glécio Rodrigues Morais, 24
Gustavo André Pereira Cabrerizo, 42
Hamilton Vianna De Almeida Júnior, 47
Helen Cristina Corrêa Garcia, 35
Hélio Antônio Godoy, 50
Henrique Dias Barbosa, 39
Huenderfidel de Souza Viana, 45
Hugo Otto Beyer, 50
Inêz Rebouças de Lima Marques, 45
Ismar De Rezende, 58
Ivan Copat, 38
Izélia Monteiro De Melo, 59
Jakes Matias Ack, 37
Janine Abucater Padilha, 30
Joana Batalha Ignácio, 28
João Ariano Granjeiro Calandrini, 1.5
João Eloi Ramos, 49
João Francisco Garcia Leal, 55
Joseane da Silva Falcão, 29
Josenilda Ferreira da Costa, 30
José Humberto Barato, 52
José Inácio Ferreira Trindade, ?
Júlio César do Nascimento Mendes, 34
Júlio César Guidi, 40
Juvêncio Gomes da Silva, 45
José Luis Coelho, 43
Karla Rejane Almeida Neres, 29
Keila Bressan, 31
Kelison Castello Branco Rocha, 45
Lavosier De Souza Maia, 29
Lázaro Gonçalves Sobrinho, 59
Leonardo Ramalis Rodrigues Alves, 44
Lourdes Balbinotte Panizzi, 53
Luana Rangel Freixo, 24
Lucas Silva Lemos, 33
Luis Antonio Pereira de Carvalho, 55
Luiz Albano Vieira Custódio, ?
Luiz Fabiano Bonaroski, 33
Luiz Felipe Raphael Dos Santos, 47
Luiz Rogério Lobato Benedito, 51
Marcelo Artur Madureira Azevedo, 45
Marcelo Eduardo Fontes Lopes, 35
Marcelo Lopes, 25
Marcelo Machado Ferreira, 51
Marcelo Rigueira Torres, 50
Márcio Aquino De Oliveira, 57
Maria Auxiliadora Cardoso Macena, 60
Maria Das Dores Machado De Rezende, 58
Maria José De Oliveira Rodrigues, 35
Maria Valéria Pires da Cruz, 45
Maria Zilda Maia Moura, 41
Marilene Leão Alves Bovi, 58
Marina Padilha Da Motta Mendes, 24
Mário André Leite Lleras, 25
Mario Alves Malafaia, 69
Mário Braule Pinto da Silva, 48
Marlon Antonio Machado, 44
Mauro Romano, 50
Michel Guimarães Rondini, 25
Mozart Sant'ana júnior, 57
Nelson Colognese, 37
Nerisvan Dackson da Silva, 28
Nilo Duarte Dória, 47
Olga Macedo, 76
Oscar de Jesus de Oliveira, 33
Osman De Oliveira Melo, 50
Otto Bernard de Witt de Azevedo, 33
Patrícia de Souza Moreira, 27
Paulo César Felippe, 35
Paulo Gustavo Rodrigues Santos, 49
Pedro Henrique Braule Pinto Garcia, 3
Pedro Magalhães Peixoto, 3
Plínio Luiz De Siqueira Júnior, 38
Rayssa Geovana Costa Naranjo, 2
Regina Lygia Storino Gomes, 79
Renata Souza Fernandes, 31
Ricardo Leandro de Souza, 33
Ricardo Luis Bastos Tarifa, 44
Ricardo Mafra Radesca, 49
Rodrigo De Paula Lima, 24
Rogério Barboza Da Silva, 32
Rolf Ferdinando Gutjahr, 51
Ronaldo Noé, 49
Ronivon Alves Miranda, 29
Rosana Karine Campos Magalhães, 27
Ruth de Jesus, 65
Salustiano Januário dos Santos Rocha, 46
Samantha Xavier Reis, 31
Terezinha Eboli Botelho Benjamin, 63
Thalita Maria Malheiros de Araújo Lima, 22
Tiago dos Santos Eustáquio, 31
Tiago Jordão Cruso, 29
Valdinei Roberto Barbero, 43
Valter de Souza Pimentel, 52
Vandemir Ferreira de Oliveira, 52

Viviane Rossetti Carvalho, 22

See also

Notes

  1. ^ All times mentioned in this article are Brazil Standard Time, UTC-3, unless otherwise noted.
  2. ^ The ERJ-145 and ERJ-135 aircraft are regional jets of the same family as the Legacy.
  3. ^ 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]
  4. ^ Computer illustration of aircraft prior to collision.
  5. ^ The French text reads "FLIGHT RECORDER DO NOT OPEN."
  6. ^ Canada was selected by CENIPA as a "neutral site" for the FDR/CVR analysis, due to the sensitive political aspects of this investigation.[42]
  7. ^ FL370 is Flight Level 370, which is an altitude of approximately 37,000 feet Above Mean Sea Level (AMSL)
  8. ^ The Teres fix is located on airway UZ6 at coordinates 12°28.5'S, 51°22.1'W, see: High Altitude Enroute chart
  9. ^ Pressing the transponder's "ident" button in the aircraft ("squawk identing") allows the ATC controller to positively identify its target on the radar screen, verifying its position and altitude.
  10. ^ Brasilia Area Control Center is designated as ACC BS.
  11. ^ The VHF omnidirectional range (VOR) transmitter installation is a defined waypoint, underlying the airway.
  12. ^
    • 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]
  13. ^ Loss of secondary radar indicates to a controller that the aircraft's transponder signal is not being received by ATC.
  14. ^
    • 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.
  15. ^ 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.[48]
  16. ^ To copy in aviation parlance means to understand a received radio transmission.
  17. ^ 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. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa "Final Report" (PDF). CENIPA. December 8, 2008. Retrieved 2009-06-11.
  2. ^ a b c d e f "NTSB interim and final report links". NTSB. Retrieved 2009-06-11.
  3. ^ "Gol 1907 accident record". ASN. Retrieved 2009-06-11.
  4. ^ "VASP 168 accident record". ASN. Retrieved 2009-06-11.
  5. ^ "TAM 3054 accident record". ASN. Retrieved 2009-06-11.
  6. ^ a b c d "Brazil Air Force, NTSB Spar on Midair Causes". Aviation Week. December 11, 2008.
  7. ^ a b "Brazil Lays Some Blame on U.S. Pilots in Collision". The New York Times. December 10, 2008.
  8. ^ "Boeing 737 Design Enhancements Earn FAA Certification". Boeing. 2006-07-27. Retrieved 2006-09-30.
  9. ^ "Airliners.net Photos: Gol Transportes Aereos Boeing 737-8EH". Airliners.net. 2006-09-16. Retrieved 2006-09-30.
  10. ^ "200 Air Force Men at Boeing Crash Site in Brazilian Jungle". brazzilmag. 2006-10-01. Retrieved 2007-04-25.
  11. ^ "Gol divulga lista de passageiros do vôo 1907". Folha Online (in Portuguese). 2006-09-30. Retrieved 2006-09-30. {{cite news}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  12. ^ "Pictures of damaged Embraer Legacy aircraft". ANAC. 2006-10-01. Retrieved 2006-10-01.
  13. ^ "Embraer confirms it believes Legacy was involved in Gol Boeing 737 collision". Flight International. 2006-09-30. Retrieved 2006-09-30.
  14. ^ "Contact Us." Excelaire. Retrieved on November 16, 2008.
  15. ^ a b "Colliding With Death at 37,000 Feet, and Living". The New York Times. October 1, 2006.
  16. ^ "Ocupantes do Legacy dizem ter sentido impacto". O Globo (in Portuguese). 2006-10-01. Retrieved 2006-10-01. {{cite news}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  17. ^ a b Langewiesche, William (January 2009). "The Devil at 37,000 Feet". Vanity Fair. Retrieved 2008-12-17.
  18. ^ a b c "Caixas-pretas do Legacy chegam a São José dos Campos para perícia". O Globo (in Portuguese). 2006-10-01. Retrieved 2006-10-01. {{cite news}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  19. ^ "Brazilian Authorities Suspect No Survivors From Jet That Crashed Carrying 155 People". Fox News. 2006-09-30. Retrieved 2006-09-30.
  20. ^ "Quadro mostra as hipóteses sobre a colisão dos aviões". Folha Online (in Portuguese). October 3, 2006. {{cite news}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  21. ^ "Matupá, Brazil - Google Maps". Google Maps. Retrieved 2006-09-30.
  22. ^ "Avião da Gol Desaparece na Região de Matupá, em Mato Grosso". O Globo (in Portuguese). 2006-09-29. Retrieved 2006-09-30. {{cite news}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  23. ^ "Embraer divulga nota sobre acidente que envolveu uma da suas aeronaves". O Globo (in Portuguese). 2006-09-30. Retrieved 2006-09-30. {{cite news}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  24. ^ "NTSB Preliminary Synopsis". NTSB. Retrieved 2006-10-05.
  25. ^ "ASN database record for Boeing-737 accidents". ASN. Retrieved 2009-06-11.
  26. ^ a b c d e f "Embraer's CVR Audio". Vanity Fair. Retrieved 2009-06-11. (collision at 1:23:50 on MP3 clip)
  27. ^ "Legacy estava sem contato com a torre de controle". Folha Online (in Portuguese). October 3, 2006. {{cite news}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  28. ^ "Pilotos do Legacy estão proibidos de deixar o Brasil" (in Portuguese). Ministério Público do Estado de Mato Grosso. 2006-10-02. Retrieved 2006-10-02. {{cite news}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  29. ^ "Justiça manda apreender passaportes de pilotos do Legacy". Folha Online (in Portuguese). 2006-10-02. Retrieved 2006-10-02. {{cite news}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  30. ^ "Brazil releases passports of LI pilots". Newsday. December 5, 2006.
  31. ^ "Brazil Releases Passports of Long Island Pilots". AP on ABC News. December 5, 2006. {{cite news}}: Italic or bold markup not allowed in: |publisher= (help)
  32. ^ "Brazil returns passports of US pilots". Airline Industry Information. December 6, 2006.
  33. ^ "U.S. pilots charged in Brazilian plane crash". AP. December 8, 2006.
  34. ^ "Criminalizing Aviation Accidents Only Assures Repeats". ABC News. December 7, 2006.
  35. ^ "Pilots in Brazil crash return to U.S." AP. December 9, 2006.
  36. ^ "Índios ajudam a resgatar vítimas de acidente com avião, o pior ocorrido no Brasil". Folha Online (in Portuguese). 2006-10-01. Retrieved 2006-10-01. {{cite news}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  37. ^ "Não há sobreviventes em acidente com o avião da Gol, diz Aeronáutica". Folha Online (in Portuguese). 2006-09-30. Retrieved 2006-09-30. {{cite news}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  38. ^ "Destroços de avião da Gol indicam queda vertical". Folha Online (in Portuguese). 2006-09-30. Retrieved 2006-09-30. {{cite news}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  39. ^ "FAB diz que não há sobreviventes [BAF says there are no survivors]". O Globo (in Portuguese). 2006-09-30. Retrieved 2006-09-30.
  40. ^ "Lula declara luto nacional". O Globo (in Portuguese). 2006-09-30. Retrieved 2006-09-30. {{cite news}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  41. ^ a b "Gravador de Voz - Vôo 1907". ANAC. Retrieved 2007-04-25.
  42. ^ a b "Recordings key to fate of LI pilots: Cockpit voices in collision sent to Canada for analysis; Brazil ready to blame fliers". Newsday. Melville, NY. October 12, 2006.
  43. ^ "Aeronáutica encontra caixas-pretas do Boeing da Gol". O Globo (in Portuguese). 2006-10-02. Retrieved 2006-10-02. {{cite news}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  44. ^ "Últimas informações sobre as caixas pretas e o trabalho da comissão de investigação" (in Portuguese). ANAC. 2006-10-03. Retrieved 2009-06-15. {{cite web}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  45. ^ "Brazilian Air Force press release" (in Portuguese). Força Aérea Brasileira (Brazilian Air Force). 2006-10-04. Retrieved 2009-06-25.
  46. ^ "IML confirma identificação da última vítima da queda do Boeing da Gol". Folha Online (in Portuguese). November 22, 2006. Retrieved 2006-11-22. {{cite news}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  47. ^ "Embraer's CVR Audio". Vanity Fair. Retrieved 2009-06-11. (last ATC two-way comm at 17:55 on MP3 clip)
  48. ^ "Embraer's CVR Audio". Vanity Fair. Retrieved 2009-06-11. (last radio transmission heard by Embraer at 1:12:30 on MP3 clip)
  49. ^ "NTSB Safety Recommendation" (PDF). NTSB. May 2, 2007. Retrieved December 18, 2008.
  50. ^ "Falhas de pilotos e controladores de vôo resultaram em acidente da Gol" (in Portuguese). Agencia Brasil. December 10, 2008. Retrieved 2009-06-11. {{cite web}}: Unknown parameter |trans_title= ignored (|trans-title= suggested) (help)
  51. ^ a b c "Pilots and controllers blamed for Brazil crash". AP on Fox News. December 10, 2008. {{cite news}}: Italic or bold markup not allowed in: |publisher= (help)
  52. ^ "NTSB, Cenipa at Odds over Midair Accident Report". AIN Online. December 11, 2008.
  53. ^ "NTSB, Brazilian Officials Differ On Blame For 2006 Midair". Aero-News. December 11, 2008.
  54. ^ "Turned-off warning device tied to 2006 U.S.-Brazil air disaster". The New York Times on The Seattle Times. December 11, 2008. {{cite news}}: Italic or bold markup not allowed in: |publisher= (help)
  55. ^ "Are U.S. Pilots Being Made Scapegoats in Brazil?". Time. December 21, 2006.
  56. ^ "Timeline: Brazil - A chronology of key events". BBC. Retrieved 2009-06-24.
  57. ^ "Brazilian Aviation Crisis – Governmental Failure?". Scoop Online. August 22, 2007.
  58. ^ "Brazilian aviation in chaos". Financial Times. Apr 4, 2007.
  59. ^ a b "The Chaos in Brazil's Blue Skies". Time. April 3, 2007.
  60. ^ "FACTBOX-Brazil's deepening aviation crisis". Reuters. Jul 18, 2007.
  61. ^ See for example:
  62. ^ "Lula vows to fix aviation system". AP on NDTV. July 26, 2007. {{cite news}}: Italic or bold markup not allowed in: |publisher= (help)
  63. ^ "US firms sued over Brazil crash". BBC. November 6, 2006.
  64. ^ "New Lawsuit Alleges Design Defect, Negligence in Brazil Crash". AP on law.com. November 13, 2006. {{cite news}}: Italic or bold markup not allowed in: |publisher= (help)
  65. ^ "ExcelAire: Lawsuits Regarding Gol Jet Accident Premature". aero-news.net. November 9, 2006.
  66. ^ "Lawsuit Blames Device Manufacturer, Airline for Brazil Crash". AP on law.com. November 7, 2006. {{cite news}}: Italic or bold markup not allowed in: |publisher= (help)
  67. ^ "A Tragédia do Vôo 1907." Discovery Channel Brazil. Retrieved on December 11, 2008.
  68. ^ "The Association of Relatives and Friends of Gol's Flight 1907 Victims Announces That the Discovery Channel's Documentary is Not Approved by the Families of Flight 1907's Victims." Business Wire. June 21, 2007. Retrieved on March 10, 2009.
  69. ^ "Gol 1907 victim list" (in Portuguese). noticias.terra.com. Retrieved 2009-06-19.

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