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.


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