Gol Transportes Aéreos Flight 1907
Encyclopedia
Gol Transportes Aéreos Flight 1907 (ICAO: GLO 1907) was a Boeing 737-8EH
, registration PR-GTD, on a scheduled passenger flight from Manaus
, Brazil, to Rio de Janeiro
. On 29 September 2006, just before 17:00 BRT
, it collided in midair with an Embraer Legacy
business jet over the Brazilian state of Mato Grosso
. All 154 passengers and crew aboard the Boeing 737 were killed when the aircraft broke up in midair and 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.
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
. It was subsequently surpassed by TAM Airlines Flight 3054
, which crashed on 17 July 2007 with 199 fatalities. It was also the deadliest aviation accident involving a Boeing 737 (all series) aircraft at that time. It was subsequently surpassed by Air India Express Flight 812
, which crashed at Mangalore, India, on 22 May 2010 with 158 fatalities.
The accident was investigated by both the Brazilian Air Force
's Aeronautical Accidents Investigation and Prevention Center ( (CENIPA)) and the U.S. National Transportation Safety Board
(NTSB), with a final report issued on 10 December 2008. CENIPA concluded that the accident was caused by errors committed both by air traffic controller
s and by the American 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.
The Gol Transportes Aéreos
twin turbofan
Boeing 737-8EH aircraft, a new Short Field Performance variant, had been delivered to Gol on 12 September 2006, seventeen days and 234 hours of operation prior to the accident flight. Gol Flight 1907 (ICAO code "GLO 1907") departed Eduardo Gomes International Airport
in Manaus
on 29 September 2006, at 15:35 Brazil Standard Time
(BST), en route to Rio de Janeiro-Galeão International Airport, with a planned intermediate stop at Brasília International Airport
.
There were 148 passengers and six crew members on board the Boeing airliner. 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.
, was on a delivery flight by ExcelAire from the Embraer factory to the U.S. It departed from São José dos Campos-Professor Urbano Ernesto Stumpf 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.
The ExcelAire flight crew consisted of Captain Joseph Lepore, 42, and First Officer Jan Paul Paladino, 34, both U.S. citizens. 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
. 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.
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
.
almost head-on at 37000 feet (11,277.6 m), approximately midway between Brasilia
and Manaus
, near the town of Matupá, 750 kilometres (466 mi) southeast of Manaus.
The Boeing suffered major structural damage, losing nearly half of its left wing. This caused it to nosedive and enter an uncontrollable spin, which quickly led to an in-flight breakup and crash into an area of dense rainforest, 200 kilometres (124.3 mi) east of the municipality of Peixoto de Azevedo
. All 154 passengers and crew on board were killed and the aircraft was destroyed, with the wreckage scattered in pieces around the crash site.
The Embraer jet, despite serious damage to the left horizontal stabilizer and left winglet, was able to continue flying, though its autopilot disengaged and it required an unusual amount of force on the yoke to keep the wings level.
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 Cachimbo Airport
, part of Campo de Provas Brigadeiro Velloso
, a large military complex of the Brazilian Air Force
at about 160 kilometres (99.4 mi) from the collision point.
Passenger and journalist Joe Sharkey
described his experience aboard the Embraer in an article for The New York Times, titled "Colliding With Death at 37,000 Feet, and Living", filed on 1 October 2006:
(ANAC) officials detained and interviewed its flight crew. 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 from there to Ottawa, Canada, for analysis.
In an initial deposition, the Embraer flight crew testified that they were cleared to flight level
370, approximately 37000 feet (11,277.6 m) 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.
On 2 October, 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, 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. The Embraer crew were forced to remain in Brazil until their passports were released to them on 5 December 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."
Prior to their scheduled departure to the United States, the crew were formally charged by Brazilian Federal Police
with "endangering an aircraft", which 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". 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.
The Brazilian Air Force sent five fixed-wing aircraft and three helicopters to the region for an extensive search and rescue
(SAR) 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. The crash site of Gol Flight 1907 was spotted on 30 September by the BAF, at coordinates 10°29′S 53°15′W, 200 km (120 mi) east of Peixoto de Azevedo
, near Fazenda Jarinã, a cattle ranch. It was reported that rescue personnel had difficulty reaching the crash site due to the dense forest.
The Brazilian airport administrator 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. Brazilian President Luiz Inácio Lula da Silva
declared three days of national mourning.
The Flight Data Recorder
and a non-data part of the Cockpit Voice Recorder
from the Boeing 737 were found on 2 October 2006 and handed over to the investigators, who sent them to the Transportation Safety Board of Canada
(TSB) in Gatineau
, Quebec, Canada, for analysis. On 25 October 2006, after nearly four weeks of intensive searching in the jungle by about 200 Brazilian Army troops 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.
On 4 October, 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.
The recovery teams worked intensively for nearly seven weeks in a dense jungle environment, searching for and identifying the victims' remains. The final victim was recovered and identified by DNA testing
by 22 November 2006.
Aeronautical Accidents Investigation and Prevention Center (CENIPA) and the U.S. National Transportation Safety Board
(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.
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, 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, 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 scheduled 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. 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:
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:
This was the last two-way radio communication between the Embraer's crew and ATC prior to the collision.
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
. At that point the Embraer was just approaching the Brasilia VOR
. 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.
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, 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.
The Embraer, on the other hand, started calling Brasilia Center, 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. 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, 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.
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. At 17:00:30 Amazonic Center unsuccessfully attempted to contact the Embraer by radio.
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 transceiver
s in the area were not operational and thus the crew was unable to reach ATC on that frequency.
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.
At 17:18:03 the Embraer contacted the Cachimbo Airport (SBCC) tower directly to coordinate its emergency landing there, and landed safely at Cachimbo at 17:23:00.
(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. Federal Aviation Authority (FAA) to enhance flight safety. The NTSB reported that the Embraer apparently experienced a Traffic Collision Avoidance System
(TCAS) outage, unknown to its flight crew prior to the collision, according to the Cockpit Voice Recorder
(CVR):
The NTSB added that the design of the Embraer's avionics is such that the non-functioning of the TCAS that apparently occurred is shown by a small static white text message, which may not be noticeable by the flight crew. The NTSB noted:
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.
CENIPA concluded that the Embraer pilots also contributed to the accident with, among others, their failure to recognize that their transponder was inadvertently switched off, thereby disabling the collision avoidance system on both aircraft, as well as their overall insufficient training and preparation.
The NTSB further added the following contributing factors:
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." Aviation Week adds that "the Brazilian military operates that country's air traffic control system, conducted the investigation and authored the report."
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
slowdowns and strikes, and public safety concerns about Brazil's airport and air traffic infrastructure.
Historically, Brazil was ruled by its armed forces from 1964 until 1985. 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 Brazil's air traffic controllers are military non-commissioned officers, and all Area Control Center
s are run by the BAF.
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 and exacerbated their already poor labor relations with their military superiors. 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. In addition, the military's complete control of the country's aviation was criticized for its lack of public accountability.
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 aviation industry: major delays and disruptions in domestic and international air service, stranded passengers, canceled flights, and public demonstrations. Those who blamed various civilian and military officials for the growing crisis called for their resignation.
On 26 July 2007, after an even deadlier crash in Brazil—TAM Airlines Flight 3054
—claimed the lives of 199 people, President Luiz Inácio Lula da Silva
fired 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. On the same day, Lula appointed former Supreme Court
president Nelson Jobim
to replace Pires, and has vowed to improve Brazil's air traffic control system.
, 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. Other suits were subsequently filed on behalf of other victims, with similar allegations against ExcelAire and Honeywell. The victims' families also filed suits against other U.S. based defendants, including the two Embraer pilots, as well as Raytheon
, Lockheed Martin
and Amazon Tech (manufacturers of Brazil's air traffic control equipment), and ACSS (manufacturer of the Embraer's TCAS).
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:
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."
On 2 July 2008, U.S. District Court judge Brian Cogan
of the Eastern District of New York
dismissed the families' suits against all the U.S. based defendants under the premise of forum non conveniens
. Without ruling on the merits of the cases, and while allowing discovery
to continue, Cogan recommended the Brazilian court system as a more appropriate jurisdiction for the dispute.
, near the crash site of the Boeing, ruled that the two pilots and four controllers should be charged with "exposing an aircraft to danger."
On 8 December 2008, judge Mendes dismissed charges of negligence against the pilots, but left in place a charge of "imprudence". He also dismissed all charges against two of the four Brasilia-based controllers and reduced the charges against the other two, but supported bringing new charges against a fifth controller, based in São José dos Campos
, the Embraer's departure point.
On 12 January 2010, judge Mendes's ruling was overturned by judge Candido Ribeiro in a federal court in Brasilia, reinstating the negligence charges against the pilots. The pilots may appeal this latest ruling.
On 26 October 2010, a military court convicted air traffic controller Sgt. Jomarcelo Fernandes dos Santos, sentencing him to 14 months in jail for failing to take action when he saw that the Embraer's anti-collision system had been turned off. Santos will remain free pending the outcome of the appeal process. Four other controllers were acquitted for lack of proof.
On 16 May 2011, judge Mendes sentenced the two Embraer pilots to four years and four months of prison in a “semi-open” facility for their role in the collision, but the judge commuted the sentences to community service to be served in the United States. Brazilian authorities accused the pilots of turning off the Legacy’s transponder moments before the accident and turning it on again only after the crash, but it was denied by the crew in a deposition via videoconference. Mendes said in his sentence that pilots had failed to verify the functioning of equipment for more than an hour, a length of time he called “an eternity” in aviation.
On 17 May 2011, judge Mendes sentenced air traffic controller Lucivando Tiburcio de Alencar to a term of up to three years and four months but ruled he is eligible to do community service in Brazil instead. Another controller under trial, Jomarcelo Fernandes dos Santos, was acquitted on charges of harming Brazil's air transport safety.
Brazil aired A Tragédia do Vôo 1907 ("The Tragedy of Flight 1907"), a documentary about the disaster. In 2007 some family members of the Gol 1907 victims stated that they believed the documentary exhibited bias.
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).
Boeing 737 Next Generation
The Boeing 737 Next Generation, commonly abbreviated as Boeing 737NG, is the name given to the -600/-700/-800/-900 series of the Boeing 737 after the introduction of the -300/-400/-500 Classic series. They are short- to medium-range, narrow-body jet airliners...
, registration PR-GTD, on a scheduled passenger flight from Manaus
Manaus
Manaus is a city in Brazil, the capital of the state of Amazonas. It is situated at the confluence of the Negro and Solimões rivers. It is the most populous city of Amazonas, according to the statistics of Brazilian Institute of Geography and Statistics, and is a popular ecotourist destination....
, Brazil, to Rio de Janeiro
Rio de Janeiro
Rio de Janeiro , commonly referred to simply as Rio, is the capital city of the State of Rio de Janeiro, the second largest city of Brazil, and the third largest metropolitan area and agglomeration in South America, boasting approximately 6.3 million people within the city proper, making it the 6th...
. On 29 September 2006, just before 17:00 BRT
UTC-3
UTC−03:00 is an identifier for a time offset from UTC of −03:00.-As standard time :*Suriname*Falkland Islands*French Guiana*Brazil - East Northern and Northeastern States...
, it collided in midair with an Embraer Legacy
Embraer Legacy
|-See also:-External links:* * * *...
business jet over the Brazilian state of Mato Grosso
Mato Grosso
Mato Grosso is one of the states of Brazil, the third largest in area, located in the western part of the country.Neighboring states are Rondônia, Amazonas, Pará, Tocantins, Goiás and Mato Grosso do Sul. It also borders Bolivia to the southwest...
. All 154 passengers and crew aboard the Boeing 737 were killed when the aircraft broke up in midair and crashed into an area of dense rainforest
Rainforest
Rainforests are forests characterized by high rainfall, with definitions based on a minimum normal annual rainfall of 1750-2000 mm...
, while the Embraer Legacy, despite sustaining serious damage to its left wing and tail, landed safely with its seven occupants uninjured.
The accident, which triggered a crisis in Brazilian civil aviation
2006–2007 Brazilian aviation crisis
The 2006–2007 Brazilian aviation crisis was a crisis in Brazil's civil aviation system characterized by massive flight delays and cancellations, air traffic controller strikes and safety concerns about Brazil's airport and air traffic infrastructure. It ostensibly started after the crash of Gol...
, was the deadliest in that country's aviation history at the time, surpassing VASP Flight 168
VASP Flight 168
VASP Flight 168, a Boeing 727-212A, serial number 21347, registered PP-SRK, was a scheduled passenger flight from Rio de Janeiro, Brazil to Fortaleza on June 8, 1982, which crashed into terrain while descending into Fortaleza, killing all 137 people on board....
, which crashed in 1982 with 137 fatalities near Fortaleza
Fortaleza
Fortaleza is the state capital of Ceará, located in Northeastern Brazil. With a population close to 2.5 million , Fortaleza is the 5th largest city in Brazil. It has an area of and one of the highest demographic densities in the country...
. It was subsequently surpassed by TAM Airlines Flight 3054
TAM Airlines Flight 3054
TAM Airlines Flight 3054 was an Airbus A320 airliner, registration PR-MBK, operating as a scheduled domestic passenger flight between Porto Alegre and São Paulo, Brazil, which crashed upon landing during rain in São Paulo on July 17, 2007...
, which crashed on 17 July 2007 with 199 fatalities. It was also the deadliest aviation accident involving a Boeing 737 (all series) aircraft at that time. It was subsequently surpassed by Air India Express Flight 812
Air India Express Flight 812
Air India Express Flight 812 was a scheduled passenger service from Dubai to Mangalore which at around 01:00 UTC on 22 May 2010, overshot the runway on landing, fell over a cliff and caught fire, spreading wreckage across the surrounding hillside...
, which crashed at Mangalore, India, on 22 May 2010 with 158 fatalities.
The accident was investigated by both the Brazilian Air Force
Brazilian Air Force
The Brazilian Air Force is the air branch of the Brazilian Armed Forces and one of the three national uniformed services. The FAB was formed when the Army and Navy air branch were merged into a single military force initially called "National Air Forces"...
's Aeronautical Accidents Investigation and Prevention Center ( (CENIPA)) and the U.S. National Transportation Safety Board
National Transportation Safety Board
The National Transportation Safety Board is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine...
(NTSB), with a final report issued on 10 December 2008. CENIPA concluded that the accident was caused by errors committed both by air traffic controller
Air traffic controller
Air traffic controllers are the people who expedite and maintain a safe and orderly flow of air traffic in the global air traffic control system. The position of the air traffic controller is one that requires highly specialized skills...
s and by the American 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
Air traffic control
Air traffic control is a service provided by ground-based controllers who direct aircraft on the ground and in the air. The primary purpose of ATC systems worldwide is to separate aircraft to prevent collisions, to organize and expedite the flow of traffic, and to provide information and other...
errors.
Boeing aircraft and crew
Gol Transportes Aéreos
Gol Transportes Aéreos is a Brazilian airline based in Comandante Lineu Gomes Square, São Paulo City, Brazil....
twin turbofan
Turbofan
The turbofan is a type of airbreathing jet engine that is widely used for aircraft propulsion. A turbofan combines two types of engines, the turbo portion which is a conventional gas turbine engine, and the fan, a propeller-like ducted fan...
Boeing 737-8EH aircraft, a new Short Field Performance variant, had been delivered to Gol on 12 September 2006, seventeen days and 234 hours of operation prior to the accident flight. Gol Flight 1907 (ICAO code "GLO 1907") departed Eduardo Gomes International Airport
Eduardo Gomes International Airport
Brigadeiro Eduardo Gomes-Manaus International Airport , is the main airport serving Manaus, Brazil. It is named after the Brazilian politician and military figure Air Marshall Eduardo Gomes ....
in Manaus
Manaus
Manaus is a city in Brazil, the capital of the state of Amazonas. It is situated at the confluence of the Negro and Solimões rivers. It is the most populous city of Amazonas, according to the statistics of Brazilian Institute of Geography and Statistics, and is a popular ecotourist destination....
on 29 September 2006, at 15:35 Brazil Standard Time
UTC-3
UTC−03:00 is an identifier for a time offset from UTC of −03:00.-As standard time :*Suriname*Falkland Islands*French Guiana*Brazil - East Northern and Northeastern States...
(BST), en route to Rio de Janeiro-Galeão International Airport, with a planned intermediate stop at Brasília International Airport
Brasília International Airport
Brasília-Presidente Juscelino Kubitschek International Airport is the airport serving Brasília, Brazil. Since April 22, 1999 the airport is named after Juscelino Kubitschek de Oliveira , the 21st President of Brazil....
.
There were 148 passengers and six crew members on board the Boeing airliner. 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.
Embraer aircraft and crew
The twin turbofan Embraer Legacy 600 business jet, serial number 965 and registration N600XL, newly built by Embraer and purchased by ExcelAire Service Inc. of Ronkonkoma, New YorkRonkonkoma, New York
Ronkonkoma is a census-designated place on Long Island in the Town of Islip, Suffolk County, New York, United States. The population was 20,029 at the 2000 census...
, was on a delivery flight by ExcelAire from the Embraer factory to the U.S. It departed from São José dos Campos-Professor Urbano Ernesto Stumpf Airport (SJK), near São Paulo
São Paulo
São Paulo is the largest city in Brazil, the largest city in the southern hemisphere and South America, and the world's seventh largest city by population. The metropolis is anchor to the São Paulo metropolitan area, ranked as the second-most populous metropolitan area in the Americas and among...
, at 14:51 BST, and was on its way to Eduardo Gomes International Airport (MAO) in Manaus as a planned en route stop.
The ExcelAire flight crew consisted of Captain Joseph Lepore, 42, and First Officer Jan Paul Paladino, 34, both U.S. citizens. 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
Embraer ERJ 145 family
The Embraer ERJ 145 family is a series of regional jets produced by Embraer, a Brazilian aerospace company. Family members include the ERJ 135 , ERJ 140 , and ERJ 145 , as well as the Legacy business jet and the R-99 family of military aircraft. The ERJ 145 is the largest of the group...
jet aircraft for American Eagle Airlines
American Eagle Airlines
American Eagle Airlines is a brand name used by American Eagle Airlines, Inc. , based in Fort Worth, Texas, and Executive Airlines based in San Juan, Puerto Rico, in the operation of passenger air service as regional affiliates of American Airlines. All three airlines are wholly owned subsidiaries...
. Paladino had also served as first officer for American Airlines
American Airlines
American Airlines, Inc. is the world's fourth-largest airline in passenger miles transported and operating revenues. American Airlines is a subsidiary of the AMR Corporation and is headquartered in Fort Worth, Texas adjacent to its largest hub at Dallas/Fort Worth International Airport...
, 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.
The five passengers consisted of two Embraer employees, two ExcelAire executives, and The New York Times
The New York Times
The New York Times is an American daily newspaper founded and continuously published in New York City since 1851. The New York Times has won 106 Pulitzer Prizes, the most of any news organization...
business travel columnist Joe Sharkey
Joe Sharkey
Joe Sharkey is an American author and columnist for the New York Times. His columns focus mostly on business travel, while his non-fiction books focus on criminality. Sharkey also co-authored a novel. He has been the Assistant National Editor for the Wall Street Journal, the City Editor for the...
, who was writing a special report for Business Jet Traveler
Business Jet Traveler
Business Jet Traveler magazine is written for executives and high net worth individuals who regularly fly aboard private jets. Unlike "lifestyle" publications, Business Jet Traveler is a business publication containing articles on taxes, law and finance, new jet previews and CEO interviews, with...
.
Collision
Just before 17:00 BST, the Boeing airliner and the Embraer business jet collidedMid-air collision
A mid-air collision is an aviation accident in which two or more aircraft come into contact during flight. Owing to the relatively high velocities involved and any subsequent impact on the ground or sea, very severe damage or the total destruction of at least one of the aircraft involved usually...
almost head-on at 37000 feet (11,277.6 m), approximately midway between Brasilia
Brasília
Brasília is the capital city of Brazil. The name is commonly spelled Brasilia in English. The city and its District are located in the Central-West region of the country, along a plateau known as Planalto Central. It has a population of about 2,557,000 as of the 2008 IBGE estimate, making it the...
and Manaus
Manaus
Manaus is a city in Brazil, the capital of the state of Amazonas. It is situated at the confluence of the Negro and Solimões rivers. It is the most populous city of Amazonas, according to the statistics of Brazilian Institute of Geography and Statistics, and is a popular ecotourist destination....
, near the town of Matupá, 750 kilometres (466 mi) southeast of Manaus.
The Boeing suffered major structural damage, losing nearly half of its left wing. This caused it to nosedive and enter an uncontrollable spin, which quickly led to an in-flight breakup and crash into an area of dense rainforest, 200 kilometres (124.3 mi) east of the municipality of Peixoto de Azevedo
Peixoto de Azevedo
Peixoto de Azevedo is a city located in the state of Mato Grosso, Brazil. On September 30, 2006, the wreckage of the Brazilian Gol Transportes Aéreos Flight 1907 landed approximately east of the town....
. All 154 passengers and crew on board were killed and the aircraft was destroyed, with the wreckage scattered in pieces around the crash site.
With radio relay assistance from Polar Air Cargo
Polar Air Cargo
For the Russian aviation company see: Polar AirlinesPolar Air Cargo Worldwide, Inc. is an American cargo airline based in Purchase, Harrison, New York, USA. It operates scheduled all-cargo services to North America, Asia, Europe, and the Middle East...
Flight 71, a Boeing 747
Boeing 747-400
The Boeing 747-400 is a major development and the best-selling model of the Boeing 747 family of jet airliners. While retaining the four-engine wide-body layout of its predecessors, the 747-400 embodies numerous technological and structural changes to produce a more efficient airframe...
cargo aircraft flying in the area at the time, the Embraer's crew successfully landed the crippled jet at Cachimbo Airport
Cachimbo Airport
Cachimbo Airport is the military airport serving Campo de Provas Brigadeiro Velloso, a large Testing and Training Range complex of the Brazilian Armed Forces located in Serra do Cachimbo , in the southern part of Pará, Brazil....
, part of Campo de Provas Brigadeiro Velloso
Campo de Provas Brigadeiro Velloso
Campo de Provas Brigadeiro Velloso – CPBV is a large complex of the Brazilian Armed Forces located in Serra do Cachimbo , in the southern part of Pará, Brazil. The complex includes the Cachimbo Airport operated by the Brazilian Air Force...
, a large military complex of the Brazilian Air Force
Brazilian Air Force
The Brazilian Air Force is the air branch of the Brazilian Armed Forces and one of the three national uniformed services. The FAB was formed when the Army and Navy air branch were merged into a single military force initially called "National Air Forces"...
at about 160 kilometres (99.4 mi) from the collision point.
Passenger and journalist Joe Sharkey
Joe Sharkey
Joe Sharkey is an American author and columnist for the New York Times. His columns focus mostly on business travel, while his non-fiction books focus on criminality. Sharkey also co-authored a novel. He has been the Assistant National Editor for the Wall Street Journal, the City Editor for the...
described his experience aboard the Embraer in an article for The New York Times, titled "Colliding With Death at 37,000 Feet, and Living", filed on 1 October 2006:
Detention and charging of Embraer crew
Immediately after the Embraer's emergency landing at the Cachimbo Airport, BAF and Agência Nacional de Aviação CivilNational Civil Aviation Agency of Brazil
The National Civil Aviation Agency , also known as ANAC, is the Brazilian civil aviation authority, created in 2006...
(ANAC) officials detained and interviewed its flight crew. The officials also removed the two "black boxes
Black Box (transportation)
The term black box is a placeholder name used casually to refer to a collection of several different recording devices used in transportation: the flight recorders in aircraft, the event recorder in railway locomotives, the event data recorder in automobiles, message case in ships, and other...
"—Cockpit Voice Recorder
Cockpit voice recorder
A cockpit voice recorder , often referred to as a "black box", is a flight recorder used to record the audio environment in the flight deck of an aircraft for the purpose of investigation of accidents and incidents...
(CVR) and Flight Data Recorder
Flight data recorder
A flight data recorder is an electronic device employed to record any instructions sent to any electronic systems on an aircraft. It is a device used to record specific aircraft performance parameters...
(FDR)—from the Embraer, and sent them to São José dos Campos
São José dos Campos
São José dos Campos is a municipality and a major city in the state of São Paulo, Brazil and one of the most important industrial and research centers in Latin America. It is located in the Paraíba Valley, between the two most active production and consumption regions in the country, São Paulo ...
, São Paulo, and from there to Ottawa, Canada, for analysis.
In an initial deposition, the Embraer flight crew testified that they were cleared to flight level
Flight level
A Flight Level is a standard nominal altitude of an aircraft, in hundreds of feet. This altitude is calculated from the International standard pressure datum of 1013.25 hPa , the average sea-level pressure, and therefore is not necessarily the same as the aircraft's true altitude either...
370, approximately 37000 feet (11,277.6 m) above mean sea level
Above mean sea level
The term above mean sea level refers to the elevation or altitude of any object, relative to the average sea level datum. AMSL is used extensively in radio by engineers to determine the coverage area a station will be able to reach...
, by Brasilia ATC
Air traffic control
Air traffic control is a service provided by ground-based controllers who direct aircraft on the ground and in the air. The primary purpose of ATC systems worldwide is to separate aircraft to prevent collisions, to organize and expedite the flow of traffic, and to provide information and other...
, 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
Traffic Collision Avoidance System
A traffic collision avoidance system or traffic alert and collision avoidance system is an aircraft collision avoidance system designed to reduce the incidence of mid-air collisions between aircraft...
did not alert them to any oncoming traffic.
On 2 October, the Embraer's captain and first officer were ordered by the Mato Grosso
Mato Grosso
Mato Grosso is one of the states of Brazil, the third largest in area, located in the western part of the country.Neighboring states are Rondônia, Amazonas, Pará, Tocantins, Goiás and Mato Grosso do Sul. It also borders Bolivia to the southwest...
Justice Tribunal to surrender their passports pending further investigation. The request, made by the Peixoto de Azevedo
Peixoto de Azevedo
Peixoto de Azevedo is a city located in the state of Mato Grosso, Brazil. On September 30, 2006, the wreckage of the Brazilian Gol Transportes Aéreos Flight 1907 landed approximately east of the town....
prosecutor, 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. The Embraer crew were forced to remain in Brazil until their passports were released to them on 5 December 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."
Prior to their scheduled departure to the United States, the crew were formally charged by Brazilian Federal Police
Brazilian Federal Police
The Polícia Federal is the federal police force of Brazil subordinate to the Ministry of Justice, whose main assignments are the investigations of crimes against the Federal Government or its organs and companies, the combat of international drug trafficking and terrorism, and immigration and...
with "endangering an aircraft", which 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". 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.
Search and recovery operation
Search and rescue
Search and rescue is the search for and provision of aid to people who are in distress or imminent danger.The general field of search and rescue includes many specialty sub-fields, mostly based upon terrain considerations...
(SAR) operation. As many as 200 personnel were reported to be involved in the operation, among them a group of Kayapo people
Kayapo people
The Kayapo people are the Gê-speaking native peoples of the plain lands of the Mato Grosso and Pará in Brazil, south of the Amazon Basin and along Rio Xingu and its tributaries.In 2003, their population was 7,096....
familiar with the forest. The crash site of Gol Flight 1907 was spotted on 30 September by the BAF, at coordinates 10°29′S 53°15′W, 200 km (120 mi) east of Peixoto de Azevedo
Peixoto de Azevedo
Peixoto de Azevedo is a city located in the state of Mato Grosso, Brazil. On September 30, 2006, the wreckage of the Brazilian Gol Transportes Aéreos Flight 1907 landed approximately east of the town....
, near Fazenda Jarinã, a cattle ranch. It was reported that rescue personnel had difficulty reaching the crash site due to the dense forest.
The Brazilian airport administrator Infraero
Infraero
Empresa Brasileira de Infraestrutura Aeroportuária, Infraero in short, is a Brazilian government corporation created in 1972 and responsible for operating the main Brazilian commercial airports. In 2009, Infraero's airports carried 128,135,616 passengers and 1,114,754 tons of cargo and operated...
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
Abseiling
Abseiling , rappelling in American English, is the controlled descent down a rock face using a rope; climbers use this technique when a cliff or slope is too steep and/or dangerous to descend without protection.- Slang terms :...
(abseiled) to the crash site and local police who assisted in the SAR effort, confirmed that there were no survivors. Brazilian President Luiz Inácio Lula da Silva
Luiz Inácio Lula da Silva
Luiz Inácio Lula da Silva , known popularly as Lula, served as the 35th President of Brazil from 2003 to 2010.A founding member of the Workers' Party , he ran for President three times unsuccessfully, first in the 1989 election. Lula achieved victory in the 2002 election, and was inaugurated as...
declared three days of national mourning.
Flight data recorder
A flight data recorder is an electronic device employed to record any instructions sent to any electronic systems on an aircraft. It is a device used to record specific aircraft performance parameters...
and a non-data part of the Cockpit Voice Recorder
Cockpit voice recorder
A cockpit voice recorder , often referred to as a "black box", is a flight recorder used to record the audio environment in the flight deck of an aircraft for the purpose of investigation of accidents and incidents...
from the Boeing 737 were found on 2 October 2006 and handed over to the investigators, who sent them to the Transportation Safety Board of Canada
Transportation Safety Board of Canada
The Transportation Safety Board of Canada , officially the Canadian Transportation Accident Investigation and Safety Board is the agency of the Government of Canada responsible for maintaining...
(TSB) in Gatineau
Gatineau
Gatineau is a city in western Quebec, Canada. It is the fourth largest city in the province. It is located on the northern banks of the Ottawa River, immediately across from Ottawa, Ontario, and together they form Canada's National Capital Region. Ottawa and Gatineau comprise a single Census...
, Quebec, Canada, for analysis. On 25 October 2006, after nearly four weeks of intensive searching in the jungle by about 200 Brazilian Army troops equipped with metal detectors, the memory module of the Boeing's Cockpit Voice Recorder
Cockpit voice recorder
A cockpit voice recorder , often referred to as a "black box", is a flight recorder used to record the audio environment in the flight deck of an aircraft for the purpose of investigation of accidents and incidents...
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.
On 4 October, the recovery crews began moving the bodies to the temporary base established at the nearby Jarinã ranch. The BAF deployed a C-115 Buffalo
De Havilland Canada DHC-5 Buffalo
The de Havilland Canada DHC-5 Buffalo is a short takeoff and landing utility transport, a turboprop aircraft developed from the earlier piston-powered DHC-4 Caribou...
aircraft to transport the bodies to Brasília for identification.
The recovery teams worked intensively for nearly seven weeks in a dense jungle environment, searching for and identifying the victims' remains. The final victim was recovered and identified by DNA testing
Genetic fingerprinting
DNA profiling is a technique employed by forensic scientists to assist in the identification of individuals by their respective DNA profiles. DNA profiles are encrypted sets of numbers that reflect a person's DNA makeup, which can also be used as the person's identifier...
by 22 November 2006.
Investigation
The accident was investigated by the Brazilian Air ForceBrazilian Air Force
The Brazilian Air Force is the air branch of the Brazilian Armed Forces and one of the three national uniformed services. The FAB was formed when the Army and Navy air branch were merged into a single military force initially called "National Air Forces"...
Aeronautical Accidents Investigation and Prevention Center (CENIPA) and the U.S. National Transportation Safety Board
National Transportation Safety Board
The National Transportation Safety Board is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine...
(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
Honeywell
Honeywell International, Inc. is a major conglomerate company that produces a variety of consumer products, engineering services, and aerospace systems for a wide variety of customers, from private consumers to major corporations and governments....
avionics equipment installed in both planes.
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
Controlled airspace
Controlled airspace is an aviation term used to describe airspace in which ATChas the authority to control air traffic, the level of which varies with the different classes of airspace. Controlled airspace is established mainly for three different reasons:...
.
The Embraer's flight plan consisted of flying at FL370 up to Brasilia, on airway
Airway (aviation)
In aviation, an airway is a designated route in the air. Airways are laid out between navigational aids such as VORs, NDBs and Intersections ....
UW2, followed by a planned descent at Brasilia to FL360, proceeding outbound from Brasilia northwest-bound along airway UZ6 to the Teres fix, an aeronautical waypoint
Waypoint
A waypoint is a reference point in physical space used for purposes of navigation.-Concept:Waypoints are sets of coordinates that identify a point in physical space. Coordinates used can vary depending on the application. For terrestrial navigation these coordinates can include longitude and...
located 282 nm
Nautical mile
The nautical mile is a unit of length that is about one minute of arc of latitude along any meridian, but is approximately one minute of arc of longitude only at the equator...
(324 mi, 522 km) northwest of Brasilia, where a climb to FL380 was planned. According to the filed flight plan, the Embraer was scheduled 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
Air traffic control
Air traffic control is a service provided by ground-based controllers who direct aircraft on the ground and in the air. The primary purpose of ATC systems worldwide is to separate aircraft to prevent collisions, to organize and expedite the flow of traffic, and to provide information and other...
(ATC) to FL370 for the entire trip, all the way to Manaus. 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:
November Six Zero Zero X-ray Lima, ATC clearance to Eduardo Gomes, flight level three seven zero direct Poços de Caldas, squawk transponderTransponder (aviation)A transponder is an electronic device that produces a response when it receives a radio-frequency interrogation...
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:
| 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. |
| 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
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.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
Area Control Center
In air traffic control, an Area Control Center , also known as a Center, is a facility responsible for controlling instrument flight rules aircraft en route in a particular volume of airspace at high altitudes between airport approaches and departures...
. At that point the Embraer was just approaching the Brasilia VOR
VHF omnidirectional range
VOR, short for VHF omnidirectional radio range, is a type of radio navigation system for aircraft. A VOR ground station broadcasts a VHF radio composite signal including the station's identifier, voice , and navigation signal. The identifier is typically a two- or three-letter string in Morse code...
. 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.
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, 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.
The Embraer, on the other hand, started calling Brasilia Center, 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. 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, and it was confirmed that neither Traffic Collision Avoidance System
Traffic Collision Avoidance System
A traffic collision avoidance system or traffic alert and collision avoidance system is an aircraft collision avoidance system designed to reduce the incidence of mid-air collisions between aircraft...
(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
Transponder (aviation)
A transponder is an electronic device that produces a response when it receives a radio-frequency interrogation...
had ceased operating almost an hour earlier, at 16:02, rendering both planes unable to automatically detect each other.
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. At 17:00:30 Amazonic Center unsuccessfully attempted to contact the Embraer by radio.
Transceiver
A transceiver is a device comprising both a transmitter and a receiver which are combined and share common circuitry or a single housing. When no circuitry is common between transmit and receive functions, the device is a transmitter-receiver. The term originated in the early 1920s...
s in the area were not operational and thus the crew was unable to reach ATC on that frequency.
At 17:01:06 the Embraer established contact on the emergency frequency with a Boeing 747
Boeing 747-400
The Boeing 747-400 is a major development and the best-selling model of the Boeing 747 family of jet airliners. While retaining the four-engine wide-body layout of its predecessors, the 747-400 embodies numerous technological and structural changes to produce a more efficient airframe...
cargo aircraft, Polar
Polar Air Cargo
For the Russian aviation company see: Polar AirlinesPolar Air Cargo Worldwide, Inc. is an American cargo airline based in Purchase, Harrison, New York, USA. It operates scheduled all-cargo services to North America, Asia, Europe, and the Middle East...
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.
At 17:18:03 the Embraer contacted the Cachimbo Airport (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.NTSB Safety Recommendation
On 2 May 2007, the National Transportation Safety BoardNational Transportation Safety Board
The National Transportation Safety Board is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine...
(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. Federal Aviation Authority (FAA) to enhance flight safety. The NTSB reported that the Embraer apparently experienced a Traffic Collision Avoidance System
Traffic Collision Avoidance System
A traffic collision avoidance system or traffic alert and collision avoidance system is an aircraft collision avoidance system designed to reduce the incidence of mid-air collisions between aircraft...
(TCAS) outage, unknown to its flight crew prior to the collision, according to the Cockpit Voice Recorder
Cockpit voice recorder
A cockpit voice recorder , often referred to as a "black box", is a flight recorder used to record the audio environment in the flight deck of an aircraft for the purpose of investigation of accidents and incidents...
(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 shown 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 their 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.
CENIPA
On 10 December 2008, more than two years after the accident, the Aeronautical Accidents Investigation and Prevention Center (CENIPA) issued its final report, describing its investigation, findings, conclusions and recommendations. 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. 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.CENIPA concluded that the Embraer pilots also contributed to the accident with, among others, their failure to recognize that their transponder was inadvertently switched off, thereby disabling the collision avoidance system on both aircraft, as well as their overall insufficient training and preparation.
NTSB
The U.S. NTSB issued its own report on the accident, which was also appended to the CENIPA report with the following Probable Cause statement: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, arrived at disagreeing interpretations and conclusions. The CENIPA report concludes the accident was caused by mistakes made both by air traffic controllers and by 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.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." Aviation Week adds that "the Brazilian military operates that country's air traffic control system, conducted the investigation and authored the report."
Aviation crisis
The crash of Flight 1907 precipitated a major crisis of Brazil
Brazil
Brazil , officially the Federative Republic of Brazil , is the largest country in South America. It is the world's fifth largest country, both by geographical area and by population with over 192 million people...
's civil aviation
Civil aviation
Civil aviation is one of two major categories of flying, representing all non-military aviation, both private and commercial. Most of the countries in the world are members of the International Civil Aviation Organization and work together to establish common standards and recommended practices...
system, which included massive flight delays and cancellations, air traffic controller
Air traffic controller
Air traffic controllers are the people who expedite and maintain a safe and orderly flow of air traffic in the global air traffic control system. The position of the air traffic controller is one that requires highly specialized skills...
work-to-rule
Work-to-rule
Work-to-rule is an industrial action in which employees do no more than the minimum required by the rules of their contract, and follow safety or other regulations to the letter in order to cause a slowdown rather than to serve their purpose. This is considered less disruptive than a strike or...
slowdowns and strikes, and public safety concerns about Brazil's airport and air traffic infrastructure.
Historically, Brazil was ruled by its armed forces from 1964 until 1985. Since then, a civilian government
History of Brazil since 1985
The period of Brazilian history since 1985 corresponds to the contemporary epoch in the history of Brazil, since the end of the military regime that had ruled the country from 1964 until 1985 and the restoration of civilian government....
has taken over, but the country's airways are still (as of 2009) controlled and operated by the Brazilian Air Force
Brazilian Air Force
The Brazilian Air Force is the air branch of the Brazilian Armed Forces and one of the three national uniformed services. The FAB was formed when the Army and Navy air branch were merged into a single military force initially called "National Air Forces"...
(BAF) and run by generals, overseen by a civilian defense minister. Most of Brazil's air traffic controllers are military non-commissioned officers, and all Area Control Center
Area Control Center
In air traffic control, an Area Control Center , also known as a Center, is a facility responsible for controlling instrument flight rules aircraft en route in a particular volume of airspace at high altitudes between airport approaches and departures...
s are run by the BAF.
Amid rising tensions, the air traffic controllers began staging a series of work actions, including slowdowns, walkouts, and even a hunger strike
Hunger strike
A hunger strike is a method of non-violent resistance or pressure in which participants fast as an act of political protest, or to provoke feelings of guilt in others, usually with the objective to achieve a specific goal, such as a policy change. Most hunger strikers will take liquids but not...
. This led to chaos in Brazil's aviation industry: major delays and disruptions in domestic and international air service, stranded passengers, canceled flights, and public demonstrations. Those who blamed various civilian and military officials for the growing crisis called for their resignation.
On 26 July 2007, after an even deadlier crash in Brazil—TAM Airlines Flight 3054
TAM Airlines Flight 3054
TAM Airlines Flight 3054 was an Airbus A320 airliner, registration PR-MBK, operating as a scheduled domestic passenger flight between Porto Alegre and São Paulo, Brazil, which crashed upon landing during rain in São Paulo on July 17, 2007...
—claimed the lives of 199 people, President Luiz Inácio Lula da Silva
Luiz Inácio Lula da Silva
Luiz Inácio Lula da Silva , known popularly as Lula, served as the 35th President of Brazil from 2003 to 2010.A founding member of the Workers' Party , he ran for President three times unsuccessfully, first in the 1989 election. Lula achieved victory in the 2002 election, and was inaugurated as...
fired his defense minister, Waldir Pires
Waldir Pires
Francisco Waldir Pires de Sousa is a politician of Brazil. He is the former Minister of Defence for President Luis Ignácio "Lula" da Silva, fired due to gross incompetence and inaction during Brazil's aviation crisis of 2006-2007. At the time of the crisis, he was accused by some in Brazil of...
, who had been in charge of the country's aviation infrastructure and safety since March 2006, and was widely criticized for their failures. On the same day, Lula appointed former Supreme Court
Supreme Federal Tribunal
The Supreme Federal Court is the supreme court of Brazil, serving primarily as the Constitutional Court of the country. It is the highest court of law in Brazil for constitutional issues and its rulings cannot be appealed...
president Nelson Jobim
Nelson Jobim
Nelson Azevedo Jobim is a Brazilian jurist and politician. He served as the Minister of Defense of Brazil from 2007-2011. He is a distant relative of musician Antonio Carlos Jobim.-Early life:...
to replace Pires, and has vowed to improve Brazil's air traffic control system.
Civil litigation
On 6 November 2006, the families of ten of the deceased filed a lawsuit for negligence against ExcelAire and HoneywellHoneywell
Honeywell International, Inc. is a major conglomerate company that produces a variety of consumer products, engineering services, and aerospace systems for a wide variety of customers, from private consumers to major corporations and governments....
, 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. Other suits were subsequently filed on behalf of other victims, with similar allegations against ExcelAire and Honeywell. The victims' families also filed suits against other U.S. based defendants, including the two Embraer pilots, as well as Raytheon
Raytheon
Raytheon Company is a major American defense contractor and industrial corporation with core manufacturing concentrations in weapons and military and commercial electronics. It was previously involved in corporate and special-mission aircraft until early 2007...
, Lockheed Martin
Lockheed Martin
Lockheed Martin is an American global aerospace, defense, security, and advanced technology company with worldwide interests. It was formed by the merger of Lockheed Corporation with Martin Marietta in March 1995. It is headquartered in Bethesda, Maryland, in the Washington Metropolitan Area....
and Amazon Tech (manufacturers of Brazil's air traffic control equipment), and ACSS (manufacturer of the Embraer's TCAS).
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:
... 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."
On 2 July 2008, U.S. District Court judge Brian Cogan
Brian Cogan
Judge Brian M. Cogan is a United States district judge serving on the United States District Court for the Eastern District of New York. He was nominated by President George W. Bush on January 25, 2006, to a seat vacated by Frederic Block and confirmed by the United States Senate on May 4, 2006...
of the Eastern District of New York
United States District Court for the Eastern District of New York
The United States District Court for the Eastern District of New York is the federal district court whose jurisdiction comprises the entirety of Long Island and Staten Island...
dismissed the families' suits against all the U.S. based defendants under the premise of forum non conveniens
Forum non conveniens
Forum non conveniens is a common law legal doctrine whereby courts may refuse to take jurisdiction over matters where there is a more appropriate forum available to the parties...
. Without ruling on the merits of the cases, and while allowing discovery
Discovery (law)
In U.S.law, discovery is the pre-trial phase in a lawsuit in which each party, through the law of civil procedure, can obtain evidence from the opposing party by means of discovery devices including requests for answers to interrogatories, requests for production of documents, requests for...
to continue, Cogan recommended the Brazilian court system as a more appropriate jurisdiction for the dispute.
Criminal proceedings
On 1 June 2007, Brazilian federal judge Murilo Mendes indicted the two Embraer pilots and four Brasilia-based air traffic controllers for their alleged roles in the accident. Mendes, a judge in the small city of Sinop, Mato GrossoSinop, Mato Grosso
Sinop is a city in the Mato Grosso state of Brazil. The city was founded in 1974 and has become one of the most important cities in the state...
, near the crash site of the Boeing, ruled that the two pilots and four controllers should be charged with "exposing an aircraft to danger."
On 8 December 2008, judge Mendes dismissed charges of negligence against the pilots, but left in place a charge of "imprudence". He also dismissed all charges against two of the four Brasilia-based controllers and reduced the charges against the other two, but supported bringing new charges against a fifth controller, based in São José dos Campos
São José dos Campos
São José dos Campos is a municipality and a major city in the state of São Paulo, Brazil and one of the most important industrial and research centers in Latin America. It is located in the Paraíba Valley, between the two most active production and consumption regions in the country, São Paulo ...
, the Embraer's departure point.
On 12 January 2010, judge Mendes's ruling was overturned by judge Candido Ribeiro in a federal court in Brasilia, reinstating the negligence charges against the pilots. The pilots may appeal this latest ruling.
On 26 October 2010, a military court convicted air traffic controller Sgt. Jomarcelo Fernandes dos Santos, sentencing him to 14 months in jail for failing to take action when he saw that the Embraer's anti-collision system had been turned off. Santos will remain free pending the outcome of the appeal process. Four other controllers were acquitted for lack of proof.
On 16 May 2011, judge Mendes sentenced the two Embraer pilots to four years and four months of prison in a “semi-open” facility for their role in the collision, but the judge commuted the sentences to community service to be served in the United States. Brazilian authorities accused the pilots of turning off the Legacy’s transponder moments before the accident and turning it on again only after the crash, but it was denied by the crew in a deposition via videoconference. Mendes said in his sentence that pilots had failed to verify the functioning of equipment for more than an hour, a length of time he called “an eternity” in aviation.
On 17 May 2011, judge Mendes sentenced air traffic controller Lucivando Tiburcio de Alencar to a term of up to three years and four months but ruled he is eligible to do community service in Brazil instead. Another controller under trial, Jomarcelo Fernandes dos Santos, was acquitted on charges of harming Brazil's air transport safety.
Dramatization
Discovery ChannelDiscovery Channel
Discovery Channel is an American satellite and cable specialty channel , founded by John Hendricks and distributed by Discovery Communications. It is a publicly traded company run by CEO David Zaslav...
Brazil aired A Tragédia do Vôo 1907 ("The Tragedy of Flight 1907"), a documentary about the disaster. In 2007 some family members of the Gol 1907 victims stated that they believed the documentary exhibited bias.
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).
See also
- Vasp Flight 168VASP Flight 168VASP Flight 168, a Boeing 727-212A, serial number 21347, registered PP-SRK, was a scheduled passenger flight from Rio de Janeiro, Brazil to Fortaleza on June 8, 1982, which crashed into terrain while descending into Fortaleza, killing all 137 people on board....
– deadliest crash in Brazil prior to Flight 1907 - TAM Airlines Flight 3054TAM Airlines Flight 3054TAM Airlines Flight 3054 was an Airbus A320 airliner, registration PR-MBK, operating as a scheduled domestic passenger flight between Porto Alegre and São Paulo, Brazil, which crashed upon landing during rain in São Paulo on July 17, 2007...
– deadliest crash in Brazil to date - Varig Flight 254Varig Flight 254Varig Flight 254 was a Boeing 737-241, c/n 21006/398, registration PP-VMK, on a scheduled passenger flight from São Paulo, Brazil to Belém, Pará, Brazil, with several intermediate stopovers, on 3 September 1989. Prior to take off from Marabá, Pará, towards the final destination, the crew entered an...
– a crash in the same general area, where Cachimbo Air Base could have been used for emergency landing - 1996 Charkhi Dadri mid-air collision – another Flight 1907 involving an aviation accident. It is also the deadliest mid-air collision to date.
- 2002 Uberlingen mid-air collision
- Tenerife airport disaster – deadliest aircraft collision to date (on the ground)
- List of notable accidents and incidents on commercial aircraft
External links
- Aeronautical Accidents Investigation and Prevention Center
- Associação Familiares e Amigos Vôo 1907 (Family and friends of Flight 1907)
- Gol Transportes AéreosGol Transportes AéreosGol Transportes Aéreos is a Brazilian airline based in Comandante Lineu Gomes Square, São Paulo City, Brazil....
press releases - Cachimbo Air Base from Google Maps
- Cachimbo Air Base Web Site
- Statement by the International Federation Of Air Traffic Controllers' Associations, issued 24 November 2006 (PDF)
- Agencia Brasil slideshow of a memorial ceremony for the passengers on Gol 1907
- ExcelAire N600XL Cockpit Voice Recorder (CVR) audio clip, 72 MB MP3 file, contains entire 2-hour CVRCockpit voice recorderA cockpit voice recorder , often referred to as a "black box", is a flight recorder used to record the audio environment in the flight deck of an aircraft for the purpose of investigation of accidents and incidents...
recording; last two-way radio comm before collision at 00:17:55; last radio comm before collision at 1:12:30; collision at 01:23:50. - Gol Transportes Aéreos 1907 Cockpit Voice Recorder audio clip