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Brazil Blames US Pilots for Boeing Crash. Congressman Wants to Sue Them

Joe Lepore, Jan Paladino The final report of the Brazilian Air Force (FAB) on the crash between a Legacy executive jet and a Boeing over the Brazilian Amazon, in 2006, concluded that the accident that killed 154 people was the fault of the American pilots of the small jet and the air traffic controllers in BrasÀ­lia, Brazil's capital city.

The document found the collision between the planes could have been prevented if the US pilots from the Legacy had not, inadvertently, put the executive jet's transponder in stand-by position, in fact, turning off the vital equipment.

The instrument would have activated a system anti-collision that would have averted any solid object on its way. The tragedy, on September 29, 2006, became at the time Brazil's worst  air accident. In 2007 Brazil suffered an even worse air calamity, when an Airbus crashed on landing leaving 199 dead.

The new report mentions a series of mistakes by the American pilots and the air traffic controllers. The document tried to meticulously reenact what happened in the air in the minutes and hours before the crash, using among other elements both aircraft's black boxes and radar data.
 
The Air Force Social Communication Center, informed Saturday, December 6, the final report would be shown first to the relatives of the accident's victims this coming Wednesday, December 10, in Brasí­lia, at the Cenipa (Center for Investigation and Prevention of Aviation Accidents). The results of the inquiry, however, were leaked to daily Folha de S. Paulo, which has published its conclusion.

The Air Force is not denying the veracity of the Folha's report, but isn't confirming it either. And it is saying that it didn't find any errors of project or integration in the communication instruments (transponder and TCAS – the anticollision device) aboard the N600XL (the Legacy).

According to the Brazilian air authorities, the two American pilots, Joseph Lepore and Jan Paladino were interviewed, individually, at the NTSB (National Transportation Safety Board) headquarters in Washington, between January 29 and 31.

In their testimony, they told the Brazilian team that they did not take any intentional action that would turn off the transponder and the anticollision system of the aircraft. They also said that they didn't notice and don't remember having done anything that could have caused the interruption, accidentally, of the mentioned equipment.

On the other hand, the report determined that there is no reason to believe that the crash was caused by any deficiency in radar coverage, one factor that was mentioned in the weeks following the disaster, since there has been much criticism of the radar system implanted in Brazil, especially in the Amazon region.
 
The transponder, according to the official account, was incorrectly handled by Lepore and Paladin. The mistake consisted in turning off the equipment seven minutes after the Legacy overflew Brasí­lia. The device was turned on again only three minutes after the fatal collision, when the US pilots noticed that the transponder was in the stand-by mode.

The probe shows that the transponder remained inoperative, i.e., it didn't send any information to the Brasí­lia's air traffic tower for 58 minutes.

The Brazilian air authority sees a succession of mistakes leading to the crash. The first error was made by the Brazilian air traffic controller in São José dos Campos, the city from where the brand new plane was making its maiden flight to the company that bought it, ExcelAire from New Jersey. That flight operator didn't give precise instructions to the US pilots and told them they should fly at 37,000 feet all the way to the Manaus Airport.

The air controllers in Brasí­lia were also mistaken when they were unable to notice that the Legacy was not following the flight plan and had the wrong altitude. Besides, the military controller on duty also did not realize when the transponder was turned off.

Still another mistake took place when a new operator took control. The new controller was told by the colleague, who was leaving, that the Legacy was flying at 36,000 feet when in reality the executive jet was in a collision course with the Boeing, at 37,000 feet.

And once again nobody noticed that the transponder was disconnected. For 50 minutes there was no communication between the small plane and Brasí­lia's control tower. When the Manaus control tower took over, the wrong information on the altitude was again passed along.

According to the FAB, the American pilots weren't trained enough to pilot the Legacy and also were not aware of the flight rules in Brazil. The Brazilian norms adopt the standard from the ICAO (International Civil Aviation Organization). These rules specify that the flight plan must be rigorously obeyed.

The Americans, however, used FAA's (Federal Aviation Administration) procedures, which are the ones current in the United States. These rules establish that a flight plan should be maintained until orders to the contrary from the air traffic controlling tower.

There is also information that when the pilots attempted communication with Cindacta-1, the Brasí­lia tower,  they were not heard because another aircraft in the area interfered with the connection.

The inquiry concludes that it's not its intention to point fingers and assign blame, but to establish what factors contributed to the crash in order to avoid similar tragedies in the future.

As a result of the investigations new guidelines are being suggested to the different organs linked to the civil aviation, in Brazil and abroad, to improve flight safety.

One of them proposes that the transponder be improved since it was noted that's possible to confuse data from the airplane's radio with those from the transponder itself.  Moreover, the equipment can go into stand-by due to the pilot's negligence. Other recommendation is that a sound alarm be devised for airplanes and air control center that would go off when a transponder stop operating.

The reporter of a congressional inquiry about the air traffic crisis in Brazil, representative Marco Maia, from the ruling Workers Party (PT) commented that the Air Force's report conclusion once again stresses the need that Lepore and Paladino be brought to justice. Maia defends the idea that the American pilots should be held responsible criminally for the accident.

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  • Show Comments (10)

  • Airwtch

    Nothing justify…
    Even had ATC made serious mistakes (although they have done minor mistakes), nothing justifies a crew flying in a RSVM (Reduced Vertical Seperation Minima) in an inappropriate level by 2200 miles. Or is airspace ignorance or is a suicide attempt.

  • Marcelo

    I think that this report was writen by one of the lawyers trying to make some money out of this tragedy. At least its headline, that is 100% misleading.
    First – The air force report will be released Wed. Dec. 10th, 2008. Nobody out of the air force knows the full content of the report.
    2nd – Cenipa will not name anyone guilty of anything. They will try to show the many links in a chain of events that lead to the crash.
    3rd – The judge in charge of this case already dismissed the accusation of neglectful conduct for the pilots. The other accusation is still pending. However, the judgeÀ‚´s decision clearly states that there was no intention of turning the transponder and the the many attempts to call Brasilia BEFORE the crash are a proof that the US pilots tried to make contact and report their position to the Air traffic control.
    A much better article:
    http://www.vanityfair.com/magazine/2009/01/air_crash200901

  • bo

    How in the world….
    can the report state that there are no “dead zones” in Brazil’s radar coverage? How many pilots and ATC’s had we heard testify and make statements about losing contact with ATC and vice-versa after these accidents?

    What a joke.

  • Ric

    Not Guilty
    The Cenipa said there was culpability. But Federal Judge Murilo Mendes said that the neither the controllers nor the pilots of the Legacy were guilty of any negligence in the accident.

    Not guilty. Brazilian federal judge said, Not Guilty. It’s finally over. It was an ACCIDENT.

  • oz

    She’ll be right mate…
    Brazil take the Aussie “She’ll be right mate” mentality to another extreme….

  • ch.c.

    DOES ANY ONE REMEMBER ?
    And what about the big crater in SP metro construction ?
    In his resignation letter, the director wrote….”in view of the allocated budget and the quality of materials provided….it was an accident just waiting to happen”

    What’s new since then ? Was the crater filled with sand, or just filled with rains so that a diving school could be created ?
    Or did it happen during a secret exercise of your National Nuclear Center….because the hole was REAL BIG !!!!!

    ENJOY THE VIEWING OF THE QUALITY INFRASTRUCTURE YOU WANT TO BUILD IN THE OPEC NATIONS !
    And guess why BRAZIL got Nooooo major contracts :

    http://www.youtube.com/watch?v=p98eAqYxwy0

    And funny—so far Nooooo one has lost his job, was fired or sued ! The investigation report was probably so clear…that it was lost, destroyed or put in the 7th drawer of the judge !

    😀 😉 😀 😉 😉 😀 😉 😀 😉 😀 😉 😀 😉

  • C

    Brazil ATC’s Fault
    While the Traffic Collision Avoidance System (TCAS) would have been a back-up to probably avoid a collision, this is primarily the fault of air traffic control. Lax procedures and discipline on the part of ATC allowed both aircraft to be at the same altitude on reciprocal courses, regardless of RADAR coverage or TCAS.

  • forrest allen brown

    DOES ANY ONE REMBER
    the drilling rig brasil put into the water and it sank .

    it was reported by brasil that the maker of the platform made
    a erorr when they built it ,
    but yet it sets in to deep of water for any one to look at .
    and the oil company never paid for the rig
    and the ones that were killed familys tryed to sue the builder .
    as the brasilian navy said it was there fault .

    now brasil is building there own platforms who will they place the
    blame on when it goes down or kills someone

  • ch.c.

    So right Forrester !
    “the fault of the American pilots of the small jet and the air traffic controllers in BrasÀƒ­lia, Brazil’s capital city.”

    And guess….. WHO THEY ONLY WANT TO SUE ????

    CRIMINALS ALWAYS WANT TO SMOOTH DOWN THEIR OWN CRIMES.
    SO DO CHEATERS, LIARS AND HIDERS !

    Typical of Brazilian mentality.

    Also no doubt, that this tragedy comes back to the surface…to hide much darker reality elsewhere…such as in the economy, currency losses or whatever !!!!

    Robin the Crook gang is telling you once more…… look there….not where you should !

    A classic trick.

  • forrest allen brown

    again go for the money
    as of yet none of the ACT have been asked to give any formal tistmony ( they are still to sick )
    and have told the US courts they would n ot be coming to the US if there is a trail as it would be to
    much of a strain on them .

    why did not the 737 have a warning buzzer go off as to avoid the crash .

    the ACT could not here its system telling him of a close flight.

    like most things in brasil cover up to protect the countries short commings

    and place the blame on someone whom cant defend there selves in a brazilian court.

    and whose fault was the plane going off the runway in the rain the plans fault .

    not nthe brasilian airport .

    joao fatima will be comming here

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