Brazil’s Boeing Accident Report Concludes Nothing and Blames No One

The just-released preliminary report on the September 29 Boeing 737 accident in the Brazilian Amazon jungle, which left 154 dead, draws no conclusions and points no fingers at possible culprits for Brazil’s worst air accident ever.

We won’t have final conclusions in less than 10 months. The document whose content had already leaked to the press earlier this week was released today by the Brazilian Air Force, which is responsible for air control in the country as well as for this investigation.

In announcing the results of the probe so far, colonel Rufino Antônio Ferreira, who heads the investigations, commented: "I know there is a lot of expectation but any conclusion would be premature."

Ferreira made it clear that the Air Force doesn’t intend to point out any culprit or bring charges against anyone: "Responsibility is not the focus of our investigation. All we are going to do is to present what can be done to prevent accidents."

The report says that between 3:51 pm and 4:26 pm of September 29, the Legacy executive jet, piloted by Americans Joe Lepore and Jan Paladino, didn’t try even once to contact the Brasí­lia’s air control tower (Cindacta 1).

Brasí­lia then tried to contact the small jet seven times until 4:53 pm, when finally the Legacy pilots answered informing they couldn’t understand the information Cindacta 1 had sent them. According to the report, there was no problem of communication with the pilots of the Boeing.

The Air Force also confirmed that the Legacy was flying at 37,000 feet when the accident occurred. While the flight plan called for the executive jet to descend to 36,000 feet in Brasí­lia and then to ascend to 38,000 between Brasí­lia and Manaus, there have been reports that the American pilots were told by a flight controller to keep their altitude at 37,000 all the way through.

There is no record of the Legacy requesting to change its flight plan. But also there is no indication that air control instructed the plane to change its altitude.

The Legacy took off at 2:15 pm from São José dos Campos, in the interior of São Paulo, where the plane was bought from Brazilian manufacturer Embraer, and reached 37,000 feet at 3:33 pm. The plane kept this same altitude until 4:56:54 pm when the collision with the Gol’s Boeing 737 occurred. 

The shock probably happened between the Legacy’s left wing and the Boeing’s left wing. After the crash the Boeing became uncontrollable diving in the Mato Grosso jungle.

The anti-collision systems of both planes didn’t emit any traffic alert or instruction for an evasive action that would have prevented the accident.

Long Way to Go

The investigation will go through five phases and  the report contains three parts: the first one analyzes the operational factors that led to the accident, the second examines the equipment and whether they were working properly and a third one investigates human errors that might have caused the tragedy.

Although there are no conclusions, the report suggests some actions and procedures that might have contributed to the disaster.

The Air Force is investigating whether Lepore and Paladino knew well the jet they were piloting and complied with the rules that require a minimum number of training hours to operate the jet’s equipment.

The investigations determined that the Legacy’s transponder was turned off before the collision but it’s not known if the device was turned off by the pilots or it malfunctioned.

Whatever happened, the report has concluded that the transponder, which should have allowed the anti-collision system to work, came back to life 10 seconds after the shock with the Boeing. Without the transponder, the report says, the air controllers had no way to know the exact altitude of the plane.

Experts from the Aviation Accidents Investigation and Prevention Center (Cenipa) are analyzing a dialogue between the American pilots and the São José dos Campos air traffic control tower. It’s been reported that instructions given by a flight controller in São José might have led Lepore and Paladino to understand that they should fly at 37,000 feet till Manaus.

At take off the controller used the code "N600XL (the Legacy’s call sign). Clear, 370, Manaus," which indicates the plane should fly at 37,000 feet. He should have added at the end of the sentence: "as filed" or "according to flight plan." The flight plan called for changes of altitude in Brasí­lia and again in Mato Grosso.

Lepore and Paladino while getting close to Brasí­lia noticed that if they kept the 37,000 feet they would be in the wrong way of the airway. At that time, one hour before the collision, they tried to contact the Brasí­lia air control without success. 

Pilots and experts say that the Brasí­lia’s air controllers should have instructed the Boeing to change its route since they could not reach the Legacy. But they defend themselves saying that this would have been too risky and could have caused a series of accidents in the air. 

Some insist that the worst failure was for the American pilots not to follow the flight plan. Experts in Brazil say that in case of lack of communication the flight plan is sovereign. 

ExcelAire, the company that bought the Legacy, however, said in a note that  "The flight plan cleared by air traffic control at the time of departure required the Legacy to fly all the way to Manaus at 37,000 feet and, absent contrary directives from air traffic control, the Legacy was obligated to follow its cleared flight plan."

Colonel Rufino says  that the communication problems might have been caused by the transponder’s malfunctioning. He stated that there is no evidence though that the device was turned off by the American pilots:

"I am not sure it didn’t work. What I’m sure is that the Legacy’s calls were not received by the control tower. The informations didn’t arrive and there is an explanation for that. The transponder may be the culprit, but it also might be the Brasí­lia tower’s equipment. Everything is being analyzed."

Rufino also says that he doesn’t know why Brasí­lia didn’t tell the Legacy to maintain its original flight plan: "I cannot answer that yet. I need more information, I need to talk to the controllers. We will have all these answers," he concluded.


  • Show Comments (9)

  • Ralph M

    Brazil Air Tragedy
    There has been much written about the tragic mid-air collision over the Amazon region in Brazil on September 29th of this year. The media articles have taken as the first order of business the need to punish someone. This sells papers to the public, but does not solve the problem. It certainly does not undo the damage. The strong need for anyone connected with the situation to distance themselves from any responsibility is evident.

    There are many factors to consider. What seems important is to identify all factors that contributed to the accident with no consequences to those contributing information. Many persons may be involved. First, no one, on the ground or in the air intended for this to happen. I think everyone agrees on this.

    There was equipment onboard both planes that might have led to evasive action. That is secondary. The primary cause was the two planes were aimed straight at each other and no one in the air or on the ground recognized this situation. Other events put this in motion.

    Millions of flights were made safely for years before radar was available to monitor for potential hazardous traffic. Flight plan altitudes are just plans and do not matter once a route and altitude are assigned by Air Traffic Control. ATC does not suggest altitudes and routes. They assign it and it is mandatory that the assignment be followed, not just in Brazil, but worldwide.

    BTW, most air traffic control centers are not located in À¢€œTowers,À¢€Â but in windowless rooms that may be away from airports and connected to radio and radar equipment which feeds their displays of enroute traffic. Towers are for control, usually visual, when local traffic is in the vicinity of the airport.

    If the causes of this accident are decided incorrectly or not at all, then it is only a matter of time until another accident like it will occur. Please, please stop the emotion and determine the true facts.

    If you have read the book, À¢€œFate is the Hunter,À¢€Â you know there were many, many accidents and lives lost while the United States and other parts of the world, learned how to do it right. This led to the skills, equipment and procedures needed for the excellent system that exists in much of the world today. Most of us would agree there still are improvements to be made. It is a never-ending task.

    This is an opportunity for Brazil to examine thoroughly their system to determine what changes and improvements to make so there is not a repeat. Mistakes were made or the accident would not have happened. Who among us never makes one? The mature way is to find the real errors with a view to improving, not just to pointing fingers and avoiding responsibility.

    Remember that all of us are in this together! Yes, I live in the United States and I want very much for the citizens of Brazil to be safe as they travel. I hope any changes that need to be made are done so thoroughly and expeditiously.

    I appreciate the opportunity to enter this into

    Best regards to all,

    Ralph M.

  • Simpleton

    I am proud of the job the BAF is doing. Although the ambulance chasers are obviously displeased with the ligitimate and factual reporting to date, this inital report gives me confidence that they are and will ulimately do what is right for the long term benefit of all.

    What the judicial system has done under political and media pressure is still and will forever be abhorent. Let the poor Bast_ds go home to thier families like they should have been allowed to do after the initial med checkups and 2nd round of interviews. Take the on-duty controllers from Sao Jose, Brasilia and Manaus to Rio for a month or so segragated from thier homes and families so they can get well enough to be interviewed and proceed with working out what can be done / done differently to ensure this doesn’t happen again.

    Anyhow, the altimeter systems in both the EUA manufactured aircraft and the BZ manufactured aircraft (regardless of where the constituant components came from) are truely incredible. Had to be accurate within a couple of meters of each other out of 37,000 feet! IF the on aircraft transponder systems / ground surveilance systems that get their info from the transponders were not working, the controllers had a problem they needed to deal with that the lack of comprehended verbal communication with one of the two aircraft didn’t much help. Problems in the transponder systems on either aircraft (assumed to be constrained to the Legacy) or the altimeter systems data feed to the transponders (assumed to be neither) apparently left both aircraft more or less blind to each other except to the extent that two to four pilot’s with their eyes turned outward could have potentially observed.

  • ex pat

    “Here’s the link:

    “Check it out!”

    Already did…

  • news

    I think the brazilian military is being over diplomatic in this is issue with USA. I’ve read they are still analyzing the black box records and will disclose a report as they finish.

  • AAHB

    Independent investigation.
    If ever there was a need for an independent investigation, it is now. After reading the above article, it is clear the whole investigation is a shambles, how can we trust the investgators who leak the report before it’s due to be published? Contradictory accounts are coming from all angles and the report has done nothing to clear these up. I feel sorry for the American Pilots who are being held without charge, surely there are procedures in place to allow them to return home and be brought back if charges are made?

  • Paulo

    Attention Ex. Pat, Ch. C, and PFE
    I wrote a few comments about your postings under the title:

    Flight 1907: Brazil’s Air Force Rebuffs Colombian Pilot Who Panned Air Controllers

    Here’s the link:

    Check it out!

  • alltheway

    situation normal = Brasilians not caring about Brasilians, dead or alive

  • ex pat

    Not that it wasnÀ‚´t expected
    There are so many blundering omissions and cover-ups in this story; and to have come out with a preliminary analysis without talking with the controllers working on that fatal day is pure idiotic incompetence to the power of 10.

    Letˢ۪s look at this beauty of a quote again (below), because it needs to be posted OVER AND OVER AGAIN on the net. It is a classic example of how NOT to conduct an investigation.

    À¢€œRufino also says that he doesn’t know why BrasÀƒ­lia didn’t tell the Legacy to maintain its original flight plan: “I cannot answer that yet. I need more information, I NEED TO TALK WITH THE CONTROLLERS [my capitals – obviously].À¢€Â


    More than a month has passed, and no one has spoken with the controllers. Does this not rub folks the wrong way? If the pilots are obligated to remain in Brazil to answer questions on demand, then the controllers should be forced to respond, IMMEDIATELY, as well.

    I would suggest that the two American pilots go to the same medic (you can find him selling coconuts on the beach of Leblon under a banner saying À¢€œFree Shaman medical advice) that wrote the blank À¢€œno need to participate given-stress-and-other-medical-conditionsÀ¢€Â note to the ATCs, so that Jan and Lepore can finally get back home and leave the brilliant and thoroughly deductive Brazilian Military to fuddle about with their notes and crayons.

    HereÀ¢€™s another beautyÀ¢€¦..

    À¢€œPilots and experts [Not the Military] say that the BrasÀƒ­lia’s air controllers [run in part by the Military] should have instructed the Boeing to change it route since they could not reach the Legacy. But they [grunt À¢€“ the Military] defend themselves saying that this would have been too risky and could have caused a series of accidents in the air.À¢€Â

    Could the problems have developed any worse? A SERIES of accidents they say? HOW SO? How many flights during this time period use this route? And, finally, HOW DO THEY KNOW? They havenÀ¢€™t talked with ATC staff yet! Please explain, and not just spout off a simple À¢€œit wasnÀ¢€™t usÀ¢€Â retort.

    10 months is written in the article, but Col. Rufinho during his debrief (live for two hours on BandNews) stated that one year would be a more feasible estimate (remember weÀ¢€™re using the Brazilian concept of time here, so that could easily translate into 4 decades) to conclude the (oh how I hate using this word in this context) “investigation”. Does this mean the pilots should remain in Brazil for the entire length of this piss-poorly conducted investigation? I should hope NOT.

    Iˢ۪m starting to think the military are dragging their feet to avert any further Brazilian air traffic delays/problems (which by the own admissions will take months to sort out, regardless). A full disclosure today that ATC was in fact to blame for the accident would basically HAULT air travel over night, and for MONTHS to come. These pusillanimously nationalistic fat cats are out to save their own hides, and NOT shine a light on Brazilˢ۪s worst air disaster to date. A plague on all their homes!

  • ch.c.

    It still doesnt smell any better !
    – How can anyone believe that a commercial plane has no alti- meter and/or a GPS which have nothing to do with the transponder ????? No doubt in my mind the the US pilots knew every time at what height they were flying….transponder off or on or malfunctionning !!!!! The problem is thus not there !
    Also strange that the ATCs did not contact the Boeing and their explanations that it was too risky is even more strange….knowing the planes were above the Amazon…where there are not necessarily so many planes…at the same this route and in this area!

    There are far too many other contradictions in the explanations provided !

    It becomes more and more stinky and cloudy….on purpose !

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