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GOL Crash Part 7  
User currently offlineDougbr2006 From Brazil, joined Oct 2006, 391 posts, RR: 0
Posted (7 years 6 months 1 week 1 day 13 hours ago) and read 7847 times:

Previous thread was excessively long and there is now some fresh information with regard to the CVR /FDR's

The Brazilian Air Force yesterday found the mounting base of the CVR and are intensifying the search of the immediate vicinity, raising hopes that this critical part of the aircraft may be found soon.

In Canada it is reported that the B737's FDR has been read and contains the last two hours of the B737's data. Data is now being analysed by the Canadian Transport Safety Board as an independent body requested by the Brazilian authorities to recover and independently analyse the units from both the B737 and the Legacy.

There is no information regarding when they anticipate revealing the results from the units currently being analysed.

Let us hope that the CVR of the B737 is found soon and the final piece of critical data can be added to finally ascertain what actually happened.

Also reported this morning by the Terra website is that the [MPF] Local Prosecutor of Matto Grosso is stating that there is a necessity to investigate the possibility of a ATC dead around the area where the accident happened. This was also reported on the Sunday night show Fantastico last Sunday by
the head of ANAC, he admitted that there are deficiencies of communication in or around the area between Brasilia and Manuas though radar cover was 100%. An ex accident investigator from the DAC also confirmed this problem exists.

[Edited 2006-10-14 17:16:02]

21 replies: All unread, jump to last
 
User currently offlineBaron95 From United States of America, joined May 2006, 1335 posts, RR: 9
Reply 1, posted (7 years 6 months 1 week 1 day 12 hours ago) and read 7821 times:

Why is it so hard to simply reveal the last altitude clearance acknowledged by the Legacy?

If it is climb an maintain FL370 - then ATC screwed up. If it is climb and maintain FL360 or FL380 or crossing xxx climb and maintain FL380 and they leveled off at FL370 then the Legacy crew screwed up.

The secondary questions are - Did ATC noticed and did all it could if both jets were or could be reasonably thought to be at the same altitude and did the TCAS on either aircraft provide an RA.

It is a simple as that - the fact that the Brazilian investigators and the ministry of defense are screwing around with wide ranging statements gives me great pause.

Don't they know that this is torture for the families involved?



Killer Fleet: E190, 737-900ER, 777-300ER
User currently offlineULMFlyer From Brazil, joined Sep 2006, 475 posts, RR: 1
Reply 2, posted (7 years 6 months 1 week 22 hours ago) and read 7540 times:

Quoting Baron95 (Reply 1):
The secondary questions are - Did ATC noticed and did all it could if both jets were or could be reasonably thought to be at the same altitude and did the TCAS on either aircraft provide an RA.

According to an article in Veja magazine published this weekend and entitled "Did ATC fail?" this is what happened over BSB based on [disclaimer] unnamed sources:

The Legacy transponder failed for the first time before crossing BSB. The data block displayed to the controller was: "3?0 = 370", where the "?" indicates loss of info, "=" cruise, and the right "370" what was in the flight plan. A little later it was working again "370 = 370". Unfortunately, there was an ATC shift change at the same time the Legacy was crossing BSB. The controller being relieved informed his substitute about the transponder problem. However, by the time this new controller got to his or her station, the transponder wasn't working again and the data block read "3?0 = 360", since the flight plan called for this altitude after BSB. And apparently, he or she wasn't informed that the Legacy was flying at FL370 a few minutes before.

Moreover, after losing radio contact with the Legacy soo after, Cindacta 1 FAILED to warn Cindacta 4 about the possible conflict. All primary radar returns were good and no lateral separation was provided between the aircraft.

So, answering your question, if the above info is correct, ATC made plenty of mistakes. If the Legacy had been previously cleared to fly at FL370 all the way (which I still don't believe, but is possible), then blame rests solely upon ATC. If no such clearance was issued, then both the crew and ATC will share the blame. Note that it seems that there were intermittent transponder failures, leading one to believe that the crew did not intentionally turn it off.

At this point, there is no reason to believe the investigators are trying to cover anything. Let's wait for the preliminary report that should be released soon.

For those concerned about the crew spending time in jail, a little piece of information that might be of interest: the crew of RG 254 (PP-VMK) that crashed in 1989 was found guilty of involuntary manslaughter charges in 2004. They were sentenced to 4 years in prison, but the sentence was immediately converted to an alternative one (e.g., community service) plus the payment of fines. They didn't spend a single day in jail.



Let's go Pens!
User currently offlineBaron95 From United States of America, joined May 2006, 1335 posts, RR: 9
Reply 3, posted (7 years 6 months 1 week 6 hours ago) and read 7239 times:

Quoting ULMFlyer (Reply 2):
The Legacy transponder failed for the first time before crossing BSB. The data block displayed to the controller was: "3?0 = 370", where the "?" indicates loss of info, "=" cruise, and the right "370" what was in the flight plan.

Thanks ULMF - this is very helpful info, and the first time I see something presented with relevant detail in this discussion.

I have a question though. Every one keeps on talking about the "flight plan altitude". Isn't the actual altitude assigned in a CLEARANCE what really matters. Here in the US, even if you are "cleared as filed" for your route ATC is still required to specifically give you altitude clearence. Obviously the Legacy didn't get a clearance to FL370 from departure. They probably had a few steps.

So why talk about the flight plan aititude clearance - even the Ministry of Defence harps on this. Isn't the ONLY issue the last altitude clearance acknowledged by the Legacy crew, regardless of what was in the flight plan? Is it even acceptable in Brazil to assign a flight the altitude "as filed"?

Please help clarify.

Thanks.



Killer Fleet: E190, 737-900ER, 777-300ER
User currently offlineWorldTraveler From , joined Dec 1969, posts, RR:
Reply 4, posted (7 years 6 months 1 week 5 hours ago) and read 7207 times:

People need to realize there are huge repercussions that will come from the findings of this investigation. No responsible government is going to issue a finding as to what happened until all the facts are in. As it appears in the Comair crash, there are multiple responsible parties for what happened. The Gol/legacy crash appears that it might be the same as well. It does no one any good to rush to judgment only to leave half of the truth hidden.

User currently offlinePPVRA From Brazil, joined Nov 2004, 8875 posts, RR: 40
Reply 5, posted (7 years 6 months 1 week 4 hours ago) and read 7107 times:

The guy responsible for the investigation is in Canada and due to return on Monday, so hopefully we will have new information available. Recently there hasn't been much new apart from identifying bodies and more searches.

Three bodies are still missing and the airforce is using cadaver dogs to try to locate them.

[Edited 2006-10-16 01:38:42]


"If goods do not cross borders, soldiers will" - Frederic Bastiat
User currently offlineULMFlyer From Brazil, joined Sep 2006, 475 posts, RR: 1
Reply 6, posted (7 years 6 months 1 week 2 hours ago) and read 7015 times:

Quoting Baron95 (Reply 3):
I have a question though.

I believe you're correct that what really matters is the last clearance given to the Legacy. I wouldn't know, however, if it's acceptable to assign an altitude "as filed" or if the regs follow the FARs in requiring ATC to specify the altitude, even if cleared as filed. My license only allowed be to fly as PIC in non-controlled airspace. It would be great to hear the input of pilots flying down there.

Another interesting question is what happens to the data block once a clearance different from the flight plan is issued. Does the controller manually reset the datablock to display the new altitude?



Let's go Pens!
User currently offlineSpeedbird128 From Pitcairn Islands, joined Oct 2003, 1648 posts, RR: 2
Reply 7, posted (7 years 6 months 6 days 21 hours ago) and read 6863 times:

Quoting ULMFlyer (Reply 6):
Another interesting question is what happens to the data block once a clearance different from the flight plan is issued. Does the controller manually reset the datablock to display the new altitude?

I am not sure on what system Brazil use (I have heard it's the Eurocat X/2000). If so, then yes - you have to reset the CFL (which is Cleared Flight Level) on the data block. Then next to it would have been the transponder level.

Now if the transponder had been off then the system would have produced a Flight Plan Track (synthetic track) where it expects the aircraft to be by using it's planned route. I do not know if it is possible to manually correlate a flight plan track with a primary return (in other words force a data block to attach to a flight plan track).

Now there is talk of 3?0. In all my years as ATC - I have never seen that. You either get no altitude, or if there at two aircraft on top of each other, then sometimes you will get strange data garble between the two, normally in my experience the altitudes swap.

At the end of the day though - it's tragic that this accident happened, but none of us (or very very few at most) were directly involved, and I hope that the investigation reveals the shortcomings of a system that led to an accident. This is not to punish those involved, but to prevent a future occurence.



A306, A313, A319, A320, A321, A332, A343, A345, A346 A388, AC90, B06, B722, B732, B733, B735, B738, B744, B762, B772, B7
User currently offlineLuckyEddie From Zimbabwe, joined Apr 2005, 63 posts, RR: 0
Reply 8, posted (7 years 6 months 6 days 13 hours ago) and read 6662 times:

Quoting Baron95 (Reply 3):
I have a question though. Every one keeps on talking about the "flight plan altitude". Isn't the actual altitude assigned in a CLEARANCE what really matters. Here in the US, even if you are "cleared as filed" for your route ATC is still required to specifically give you altitude clearence. Obviously the Legacy didn't get a clearance to FL370 from departure. They probably had a few steps.

Actually it may well matter. The ICAO lost comm procedure is to first of all maintain VMC if possible and land as soon as practicable. That is probably not really practical for an IFR aircraft at 370 so then the next step depends on timing. From the time that the crew realises comm is lost and has reset squawk to 7600 they must remain at their last assigned level for 20 minutes, or 7 minutes if under radar control. Thereafter they must adjust their level in accordance with the filed flightplan. What may be an issue here is a difference between FAA and ICAO procedures. A lot of good info from the ppruners on this here http://www.pprune.org/forums/showthr...php?p=2911638&posted=1#post2911638

Still it seems one of the biggest errors here was in allowing the 737 to maintain 370, regardless of what the legacy should have done. ATC had no way to confirm the lagacys altitude and so should have kept other traffic well away.


User currently offlineMD88Captain From United States of America, joined Nov 2001, 1329 posts, RR: 21
Reply 9, posted (7 years 6 months 6 days 12 hours ago) and read 6579 times:

So it may not be all the Legacy pilots fault? Possible ATC mistakes? I hope house arrest does not go on for months and months. Hopefully an honest assessment of the early evidence will yield a direction for the future of these two men. I'd just hate to see them lose time, jobs, and families only to be exoneratied in a few years.

User currently offlineBaron95 From United States of America, joined May 2006, 1335 posts, RR: 9
Reply 10, posted (7 years 6 months 6 days 6 hours ago) and read 6331 times:

Quoting MD88Captain (Reply 9):
I hope house arrest does not go on for months and months. Hopefully an honest assessment of the early evidence will yield a direction for the future of these two men. I'd just hate to see them lose time, jobs, and families only to be exoneratied in a few years.

I was in Brazil on a business trip last week and the Legacy pilots (and I heard their wives) were staying at the J.W. Marriott in Rio (where I was also staying), courtesy of the Amercian Consulate. A little media circus was outside with cameras pointed at the hotel.

We need an interim report from the investigators ASAP and these guys need to come home. Unless the interim report shows that they did something like turning off the transponder (therefore disabling TCAS), then this is nothing more than an accident and these guys can't be held any longer in Brazil.



Killer Fleet: E190, 737-900ER, 777-300ER
User currently offlineULMFlyer From Brazil, joined Sep 2006, 475 posts, RR: 1
Reply 11, posted (7 years 6 months 4 days 22 hours ago) and read 5942 times:

While the Minister of Defense continues to embarrass himself, the government and the country with his ridiculous and mistaken statements that ATC didn't do anything wrong, according to O Globo news service there are UNCONFIRMED reports of an ATC tape where the Legacy crew requests a descent from FL370 to FL360 about 55 Km before BSB (or whatever specific fix they were supposed to cross). And this request was DENIED by ATC.

Since we don't know the exact contents of the exchange, i.e., if the reply was, for example, "unable" or "unable but expect FL360..." (or even if it did indeed take place), and I don't know the exact procedures to be followed by the crew in each scenario, I'll let the speculation to experienced pilots. The CVR transcripts and DFDR information obtained in Canada are supposed to arrive in Brazil on Thursday. It's about bloody time the investigators release a preliminary factual report such as those issued by the NTSB. And let these guys go home if they just followed ATC instructions.



Let's go Pens!
User currently offlineMika From Sweden, joined Jul 2000, 2841 posts, RR: 4
Reply 12, posted (7 years 6 months 4 days 22 hours ago) and read 5915 times:

Quoting ULMFlyer (Reply 11):
a descent from FL370 to FL360

Isn´t FL360 widely regarded as a ´no fly zone´so to speak? Maybe i got it all wrong but i think i heard somewhere that FL360 is not used for commercial traffic. Someone please correct me if i´m wrong.


User currently offlineBaron95 From United States of America, joined May 2006, 1335 posts, RR: 9
Reply 13, posted (7 years 6 months 4 days 21 hours ago) and read 5886 times:

Quoting Mika (Reply 12):
Isn´t FL360 widely regarded as a ´no fly zone´so to speak? Maybe i got it all wrong but i think i heard somewhere that FL360 is not used for commercial traffic. Someone please correct me if i´m wrong.

In the dark ages yeah. Now any airplane equipped and certified for RSVM (Reduced Separation Vertical Minimuns, I think it stands for) can fly in 1,000 feet increments above FL290.



Killer Fleet: E190, 737-900ER, 777-300ER
User currently offlineGusNYC From United States of America, joined Nov 2005, 143 posts, RR: 5
Reply 14, posted (7 years 5 months 4 weeks 1 day 11 hours ago) and read 5179 times:

So, there are no news about the accident. I thought the results from Canada were going to be released today to the Brazilian authorities.

Gus


User currently offlineJerald01 From United States of America, joined Oct 2006, 161 posts, RR: 2
Reply 15, posted (7 years 5 months 4 weeks 1 day 10 hours ago) and read 5095 times:

1. I have never heard of FL360 being "off limits" for commercial acft. If it was, what was the reason?

2. RVSR = Reduced Vertical Separation Rules. Normally acft flying in the flight levels that this accident took place in are vertically separated by a minimum of 2,000 feet. When both ATC and ALL acft in the area are equipped with properly-operating specialized equipment, it is allowed to reduce that separation to only 1,000 feet.

3. It seems that the FL shown after the " = " sign would stand for "last assigned" altitude, not "as filed" altitude. The "last assigned" altitude would be more important to a receiving ATC controller in an adjacent sector than a "as filed" altitude because he/she would be able to quickly compare the left-hand FL and the right-hand FL to see what the acft is actually doing (going up, going down, staying level even though a different altitude had been assigned, etc.)

4. ATC controllers in adjacent sectors to the one the acft is actually flying in (usually) can see across the boundary of the two sectors and can (usually) read the data blocks of acft that are about to come into their sector. That's why it would be important to know what altitude the acft was assigned, rather than what he filed for. If the controller wants to know what the acft filed for he can pull that data up separately. If comms are lost with the acft, then the controller can manually input the proper authorized altitude (depending on the rules that are in effect for the area he/she is controlling [i.e., FAR, ICAO, etc.]



"There may be old pilots, and there may be bold pilots, but there are darn few green cows"
User currently offlineBaron95 From United States of America, joined May 2006, 1335 posts, RR: 9
Reply 16, posted (7 years 5 months 4 weeks 1 day 9 hours ago) and read 4994 times:

Quoting Jerald01 (Reply 15):
3. It seems that the FL shown after the " = " sign would stand for "last assigned" altitude, not "as filed" altitude. The "last assigned" altitude would be more important to a receiving ATC controller in an adjacent sector than a "as filed" altitude because he/she would be able to quickly compare the left-hand FL and the right-hand FL to see what the acft is actually doing (going up, going down, staying level even though a different altitude had been assigned, etc.)

4. ATC controllers in adjacent sectors to the one the acft is actually flying in (usually) can see across the boundary of the two sectors and can (usually) read the data blocks of acft that are about to come into their sector. That's why it would be important to know what altitude the acft was assigned, rather than what he filed for. If the controller wants to know what the acft filed for he can pull that data up separately. If comms are lost with the acft, then the controller can manually input the proper authorized altitude (depending on the rules that are in effect for the area he/she is controlling [i.e., FAR, ICAO, etc.]

Exactly - Thank you. All this talk by the Minister about the Legacy "Not being at its filed Flight plan altitude" is a nonsensical smoke screen. The fact is that ATC had, for at least some time prior to the crash, 2 planes at FL370 converging. We just need to know when they started working the conflict, and why it was not resolved in time and secondly why TCAS didn't provide an RA that was effective in averting the tragedy.



Killer Fleet: E190, 737-900ER, 777-300ER
User currently offlineBuyantUkhaa From Mongolia, joined May 2004, 2828 posts, RR: 3
Reply 17, posted (7 years 5 months 4 weeks 18 hours ago) and read 4666 times:

Finally I found the link I was referring to in thread 6:

Gol 738 - Legacy Midair: ATC Covering Their Tracks (by Baron95 Oct 20 2006 in Civil Aviation)

Has an interesting development.

BTW do other people also have trouble finding threads in the a.net archive? I typed "Legacy" into the search engine ans although the thread has the word Legacy in the title, the search engine didn't pick it up.



I scratch my head, therefore I am.
User currently offlineMrocktor From United States of America, joined Jan 2005, 1668 posts, RR: 50
Reply 18, posted (7 years 5 months 4 weeks 8 hours ago) and read 4461 times:

Quoting Jerald01 (Reply 15):
2. RVSR = Reduced Vertical Separation Rules

RVSM!


User currently offlineJerald01 From United States of America, joined Oct 2006, 161 posts, RR: 2
Reply 19, posted (7 years 5 months 4 weeks 7 hours ago) and read 4413 times:

Thank you, Mrocktor. I stand corrected. It is RVSM.

A more detailed description is: RVSM reduces the vertical separation between flight level (FL) 290–410 from 2000 ft to 1000 ft and makes six additional FL’s available for operation. The additional FL’s enable more aircraft to fly more time/fuel efficient profiles and provides the potential for enhanced airspace capacity. RVSM operators must receive authorization from the appropriate civil aviation authority. RVSM aircraft must meet required equipage and altitude-keeping performance standards. Operators must operate in accordance with RVSM policies/procedures applicable to the airspace where they are flying.



"There may be old pilots, and there may be bold pilots, but there are darn few green cows"
User currently offlineRobertS975 From United States of America, joined Aug 2005, 931 posts, RR: 0
Reply 20, posted (7 years 5 months 4 weeks 3 hours ago) and read 4300 times:
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Quoting ULMFlyer (Reply 11):



Quoting ULMFlyer (Reply 11):
While the Minister of Defense continues to embarrass himself, the government and the country with his ridiculous and mistaken statements that ATC didn't do anything wrong, according to O Globo news service there are UNCONFIRMED reports of an ATC tape where the Legacy crew requests a descent from FL370 to FL360 about 55 Km before BSB (or whatever specific fix they were supposed to cross). And this request was DENIED by ATC.

Since we don't know the exact contents of the exchange, i.e., if the reply was, for example, "unable" or "unable but expect FL360..." (or even if it did indeed take place), and I don't know the exact procedures to be followed by the crew in each scenario, I'll let the speculation to experienced pilots. The CVR transcripts and DFDR information obtained in Canada are supposed to arrive in Brazil on Thursday. It's about bloody time the investigators release a preliminary factual report such as those issued by the NTSB. And let these guys go home if they just followed ATC instructions.

Please correct me if this is wrong... is it true that in Brazil, ATC is run by the Air Force, and it is the Air Force that is responsible for accident investigation? So will the Brazilian Air Force be investigating itself? Also, I have read that in Brazil, aviation accident investigations are closed door affairs and not nearly as transparent as in the USA and Europe. If these statements are untrue or misleading, please give us the benefit of your first hand knowledge.


User currently offlineULMFlyer From Brazil, joined Sep 2006, 475 posts, RR: 1
Reply 21, posted (7 years 5 months 4 weeks 1 hour ago) and read 4220 times:

Quoting RobertS975 (Reply 20):
Please correct me if this is wrong

I suppose you're mostly correct. Everything in Brazil related to civil aviation has historically been run by the Air Force (mostly explained by years of a military dictatorship). The Department of Civil Aviation (DAC) was subordinated to the Air Force Command. However, things are changing now. DAC has been replaced by the Civil Aviation National Agency (ANAC), an independent civilian agency (the website has only very recently been updated). And over time one should expect ANAC to take on more functions. That said, for the time being, ATC remains under Air Force control, though there are civilian controllers in the system.

Similarly, accident investigation commissions, called CIAA, are still to be chaired by an Air Force officer (a pilot, BTW, not an infantry or other type of officer) with the minimum rank of major. This officer must be allocated to and working for ANAC at the time of the crash. The CIAA is not strictly an Air Force commision. It is composed of stake holders in all areas relevant to the accident: ATC, meteorology, infrastructure, engines, psychology, medical, maintenance, union representatives, manufacturers, etc. In the case of this crash, the NTSB is represented in the CIAA.

I guess you can say that during the course of the investigations, the CIAA is not as transparent as the NTSB Go Teams. They tend not to issue preliminary reports or factual information (which is bad in my opinion). However, the final report is made public as in any other country and any member of the CIAA is free to disagree with it.

So, while I can see the conflict of interest you have alluded to, let me just end by saying that historically the Air Force has always done a superb job in handling not only accident investigations, but also the whole civil aviation system in Brazil. And while it's desirable to move the whole system to civilian control, this can't be done quickly, since most of the knowledge resides in the Air Force due to path-dependencies. And to be honest with you, it kind of scares me to have a politician (hint: corruption) running the show here without the proper controls, checks and balances.

Hope this was informative.



Let's go Pens!
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