M[_1_]
November 23rd 06, 04:39 AM
http://ntsb.gov/Pressrel/2006/061122a.htm
NTSB Advisory
National Transportation Safety Board
Washington, DC 20594
November 22, 2006
UPDATE ON BRAZILIAN INVESTIGATION INTO SEPTEMBER MIDAIR COLLISION OVER
AMAZON JUNGLE
The government of Brazil has asked the National Transportation Safety
Board to disseminate the following factual information on the progress
of its investigation into a midair collision over the Brazilian Amazon
jungle on September 29, 2006, between a Boeing 737-800 (PR-GTD)
operated by Gol Airlines of Brazil, and an Embraer Legacy 600 business
jet (N600XL) owned and operated by Excelaire of Long Island, New York.
The accident investigation is being conducted under the authority of
the Brazilian Aeronautical Accident Prevention and Investigation Center
(DIPAA). Under the provisions of ICAO Annex 13, the United States, as
state of registry and operator of the Excelaire Legacy, and state of
manufacture of the Boeing 737 and Honeywell avionics equipment in both
airplanes, has provided an accredited representative and technical
advisors for the investigation. The U.S. team includes the accredited
representative from the major aviation accident investigations division
of the NTSB, as well as technical advisors in operations, systems, air
traffic control, flight recorders, and aircraft performance. Additional
technical advisors from Boeing, Excelaire, Honeywell, and FAA have also
been included.
The accident occurred about 4:57 pm Brasilia standard time. The Boeing
737 was destroyed by in-flight breakup and impact forces; all 154
occupants were fatally injured. The wreckage of the 737 was located in
remote jungle terrain with very difficult access. Brazilian military
search and rescue personnel have located the flight recorders and all
significant portions of the wreckage except the outer portion of the
left wing. The Legacy N600XL experienced damage to its left wing and
left horizontal stabilizer and performed an emergency landing at the
Cachimbo Air Base, approximately 60 miles northwest of the collision
site. There was no further damage to the airplane, and the 2 crew
members and 5 passengers were not injured. The airplane remained at the
base and significant components have been tested and recovered from the
aircraft.
Visual meteorological conditions prevailed in the area of the accident.
Both aircraft were operating on instrument flight rules, on instrument
flight plans and clearances. The Boeing 737 was a scheduled domestic
air carrier flight enroute from the Eduardo Gomes International
Airport, Manaus, Brazil; to the Presidente Juscelino Kubitschek
Airport, Brasilia. The Legacy N600XL was enroute from the Prof. Urbano
Ernesto Stumpf airport, San Jose dos Campos, Brazil (SBSJ), to a
stopover in Manaus, and eventually enroute back to the U.S. This was
Excelaire's initial flight with this aircraft, taking delivery from the
Embraer factory and a planned flight to Excelaire's home base in New
York.
History of flights:
The Legacy N600XL departed SBSJ at about 2:51 pm. The filed flight plan
included a routing via the OREN departure procedure to Pocos beacon,
then airway UW2 to Brasilia VOR (BRS), airway UZ6 to Manaus. The cruise
altitude was filed as FL370, with a planned change to FL360 at BRS, and
to FL380 at the TERES navigational fix, approximately 282 miles north
of BRS.
After takeoff, N600XL was issued a number of interim altitudes during
climb, all of which were read back. The flight was cleared to proceed
direct to Araxa VOR (on airway UW2), and at 3:11 pm was cleared to
climb to FL370. At 3:33 pm, the airplane leveled at FL370.
At 3:35 pm, the Boeing 737 departed Eduardo Gomes airport, requesting
FL370 as a cruise altitude, and a routing via UZ6 to BRS. The airplane
reached FL370 at 3:58 pm. There were no anomalies in communications
with or radar surveillance of the Boeing 737 throughout the flight.
At 3:51 pm, an air traffic controller in the Brasilia ACC (CINDACTA 1)
instructed N600XL to change frequencies to the next controller's
sector. The crew of N600XL reported in on the assigned frequency that
the flight was level at FL370. ATC acknowledged and instructed the crew
to "ident" (flash their transponder). Radar indicates that the ident
was observed. This was the last two-way communication between N600XL
and ATC. At this time the airplane was approximately 40 nautical miles
south of BRS.
At 3:56pm the Legacy N600XL passed BRS level at FL370. There is no
record of a request from N600XL to the control agencies to conduct a
change of altitude, after reaching flight level 370. The airplane made
calls, but there is no communication in which it requested a change of
flight level. There is also no record of any instruction from air
traffic controllers at Brasilia Center to the aircraft, directing a
change of altitude.
When the airplane was about 30 miles north-northwest of BRS, at 4:02
pm, the transponder of N600XL was no longer being received by ATC
radar. A transponder reports a unique code, aiding radar
identification, and provides an accurate indication of the airplane's
altitude. Additionally, the transponder is a required component for the
operation of Traffic Collision Avoidance System equipment, commonly
called the TCAS system.
Between 3:51 pm and 4:26 pm, there were no attempts to establish radio
communications from either the crew of N600XL or ATC. At 4:26 pm the
CINDACTA 1 controller made a "blind call" to N600XL. Subsequently until
4:53 pm, the controller made an additional 6 radio calls attempting to
establish contact. The 4:53 call instructed the crew to change to
frequencies 123.32 or 126.45. No replies were received.
There is no indication that the crew of N600XL performed any abnormal
maneuvers during the flight. Flight Data Recorder information indicates
that the airplane was level at FL370, on course along UZ6, and at a
steady speed, until the collision. Primary (non-transponder) radar
returns were received corresponding to the estimated position of N600XL
until about 4:30 pm. For 2 minutes, no returns were received, then
returns reappeared until 4:38 pm. After that time, radar returns were
sporadic.
Beginning at 4:48 pm, the crew of N600XL made a series of 12 radio
calls to ATC attempting to make contact. At 4:53, the crew heard the
call instructing them to change frequencies, but the pilot did not
understand all of the digits, and requested a repeat. No reply from ATC
was received. The pilot made 7 more attempts to establish contact.At
4:56:54 pm the collision occurred at FL370, at a point about 460
nautical miles north-northwest of BRS, on airway UZ6.
There was no indication of any TCAS alert on board either airplane, no
evidence of pre-collision visual acquisition by any flight crew member
on either aircraft, and no evidence of evasive action by either crew.
Wreckage and damage examination indicates that it is likely the left
winglet of the Legacy (which includes a metal spar) contacted the left
wing leading edge of the Boeing 737. The impact resulted in damage to a
major portion of the left wing structure and lower skin, ultimately
rendering the 737 uncontrollable. Flight recorder information ceased at
an approximate altitude of 7,887 feet.
After the collision, the crew of N600XL made numerous further calls to
ATC declaring an emergency and their intent to make a landing at the
Cachimbo air base. At 5:02 pm, the transponder returns from N600XL were
received by ATC.
At 5:13 pm, an uninvolved flight crew assisted in relaying
communications between N600XL and ATC until the airplane established
communication with Cachimbo tower.
Investigative activities completed to date:
Flight recorders from both airplanes were recovered and downloaded at
the Transportation Safety Board of Canada (TSB) laboratories.
Transcriptions of the cockpit voice recorders (CVRs) were prepared (the
transcript of the Legacy's CVR was produced at the NTSB's laboratory in
Washington, D.C.) and data from flight data recorders obtained.
Initial interviews and medical examinations were conducted with the
crew of the Legacy. Air Traffic Control data was gathered. Preliminary
tests of the avionics equipment on the Legacy were performed. Wreckage
of the 737 was examined.
Future investigative activity:
Additional investigative work will include laboratory tests of the
avionics components removed from the Legacy, an examination of the
operating procedures of the avionics, interviews with ATC personnel,
examination of ATC practices and comparison between Brazilian and FAA
procedures, a technical examination of ATC communication and
surveillance systems, and further examination of the training provided
to the operators.
The Investigator in Charge estimates a 10-month timeline for the
investigation. The first phase, data gathering is estimated to take
approximately 45 days, although some further data gathering remains to
be completed. Analysis of the data is estimated to take 90 days
followed by a preliminary report with conclusions 120 days afterward.
Preparation of the final report and review by involved parties and
States is estimated at a further 30 days each.
Brazilian Contact: Brazilian Aeronautical Accident Prevention&
Investigation Center 55-61-3329-9160
NTSB Media Contact: Ted Lopatkiewicz (202) 314-6100
NTSB Advisory
National Transportation Safety Board
Washington, DC 20594
November 22, 2006
UPDATE ON BRAZILIAN INVESTIGATION INTO SEPTEMBER MIDAIR COLLISION OVER
AMAZON JUNGLE
The government of Brazil has asked the National Transportation Safety
Board to disseminate the following factual information on the progress
of its investigation into a midair collision over the Brazilian Amazon
jungle on September 29, 2006, between a Boeing 737-800 (PR-GTD)
operated by Gol Airlines of Brazil, and an Embraer Legacy 600 business
jet (N600XL) owned and operated by Excelaire of Long Island, New York.
The accident investigation is being conducted under the authority of
the Brazilian Aeronautical Accident Prevention and Investigation Center
(DIPAA). Under the provisions of ICAO Annex 13, the United States, as
state of registry and operator of the Excelaire Legacy, and state of
manufacture of the Boeing 737 and Honeywell avionics equipment in both
airplanes, has provided an accredited representative and technical
advisors for the investigation. The U.S. team includes the accredited
representative from the major aviation accident investigations division
of the NTSB, as well as technical advisors in operations, systems, air
traffic control, flight recorders, and aircraft performance. Additional
technical advisors from Boeing, Excelaire, Honeywell, and FAA have also
been included.
The accident occurred about 4:57 pm Brasilia standard time. The Boeing
737 was destroyed by in-flight breakup and impact forces; all 154
occupants were fatally injured. The wreckage of the 737 was located in
remote jungle terrain with very difficult access. Brazilian military
search and rescue personnel have located the flight recorders and all
significant portions of the wreckage except the outer portion of the
left wing. The Legacy N600XL experienced damage to its left wing and
left horizontal stabilizer and performed an emergency landing at the
Cachimbo Air Base, approximately 60 miles northwest of the collision
site. There was no further damage to the airplane, and the 2 crew
members and 5 passengers were not injured. The airplane remained at the
base and significant components have been tested and recovered from the
aircraft.
Visual meteorological conditions prevailed in the area of the accident.
Both aircraft were operating on instrument flight rules, on instrument
flight plans and clearances. The Boeing 737 was a scheduled domestic
air carrier flight enroute from the Eduardo Gomes International
Airport, Manaus, Brazil; to the Presidente Juscelino Kubitschek
Airport, Brasilia. The Legacy N600XL was enroute from the Prof. Urbano
Ernesto Stumpf airport, San Jose dos Campos, Brazil (SBSJ), to a
stopover in Manaus, and eventually enroute back to the U.S. This was
Excelaire's initial flight with this aircraft, taking delivery from the
Embraer factory and a planned flight to Excelaire's home base in New
York.
History of flights:
The Legacy N600XL departed SBSJ at about 2:51 pm. The filed flight plan
included a routing via the OREN departure procedure to Pocos beacon,
then airway UW2 to Brasilia VOR (BRS), airway UZ6 to Manaus. The cruise
altitude was filed as FL370, with a planned change to FL360 at BRS, and
to FL380 at the TERES navigational fix, approximately 282 miles north
of BRS.
After takeoff, N600XL was issued a number of interim altitudes during
climb, all of which were read back. The flight was cleared to proceed
direct to Araxa VOR (on airway UW2), and at 3:11 pm was cleared to
climb to FL370. At 3:33 pm, the airplane leveled at FL370.
At 3:35 pm, the Boeing 737 departed Eduardo Gomes airport, requesting
FL370 as a cruise altitude, and a routing via UZ6 to BRS. The airplane
reached FL370 at 3:58 pm. There were no anomalies in communications
with or radar surveillance of the Boeing 737 throughout the flight.
At 3:51 pm, an air traffic controller in the Brasilia ACC (CINDACTA 1)
instructed N600XL to change frequencies to the next controller's
sector. The crew of N600XL reported in on the assigned frequency that
the flight was level at FL370. ATC acknowledged and instructed the crew
to "ident" (flash their transponder). Radar indicates that the ident
was observed. This was the last two-way communication between N600XL
and ATC. At this time the airplane was approximately 40 nautical miles
south of BRS.
At 3:56pm the Legacy N600XL passed BRS level at FL370. There is no
record of a request from N600XL to the control agencies to conduct a
change of altitude, after reaching flight level 370. The airplane made
calls, but there is no communication in which it requested a change of
flight level. There is also no record of any instruction from air
traffic controllers at Brasilia Center to the aircraft, directing a
change of altitude.
When the airplane was about 30 miles north-northwest of BRS, at 4:02
pm, the transponder of N600XL was no longer being received by ATC
radar. A transponder reports a unique code, aiding radar
identification, and provides an accurate indication of the airplane's
altitude. Additionally, the transponder is a required component for the
operation of Traffic Collision Avoidance System equipment, commonly
called the TCAS system.
Between 3:51 pm and 4:26 pm, there were no attempts to establish radio
communications from either the crew of N600XL or ATC. At 4:26 pm the
CINDACTA 1 controller made a "blind call" to N600XL. Subsequently until
4:53 pm, the controller made an additional 6 radio calls attempting to
establish contact. The 4:53 call instructed the crew to change to
frequencies 123.32 or 126.45. No replies were received.
There is no indication that the crew of N600XL performed any abnormal
maneuvers during the flight. Flight Data Recorder information indicates
that the airplane was level at FL370, on course along UZ6, and at a
steady speed, until the collision. Primary (non-transponder) radar
returns were received corresponding to the estimated position of N600XL
until about 4:30 pm. For 2 minutes, no returns were received, then
returns reappeared until 4:38 pm. After that time, radar returns were
sporadic.
Beginning at 4:48 pm, the crew of N600XL made a series of 12 radio
calls to ATC attempting to make contact. At 4:53, the crew heard the
call instructing them to change frequencies, but the pilot did not
understand all of the digits, and requested a repeat. No reply from ATC
was received. The pilot made 7 more attempts to establish contact.At
4:56:54 pm the collision occurred at FL370, at a point about 460
nautical miles north-northwest of BRS, on airway UZ6.
There was no indication of any TCAS alert on board either airplane, no
evidence of pre-collision visual acquisition by any flight crew member
on either aircraft, and no evidence of evasive action by either crew.
Wreckage and damage examination indicates that it is likely the left
winglet of the Legacy (which includes a metal spar) contacted the left
wing leading edge of the Boeing 737. The impact resulted in damage to a
major portion of the left wing structure and lower skin, ultimately
rendering the 737 uncontrollable. Flight recorder information ceased at
an approximate altitude of 7,887 feet.
After the collision, the crew of N600XL made numerous further calls to
ATC declaring an emergency and their intent to make a landing at the
Cachimbo air base. At 5:02 pm, the transponder returns from N600XL were
received by ATC.
At 5:13 pm, an uninvolved flight crew assisted in relaying
communications between N600XL and ATC until the airplane established
communication with Cachimbo tower.
Investigative activities completed to date:
Flight recorders from both airplanes were recovered and downloaded at
the Transportation Safety Board of Canada (TSB) laboratories.
Transcriptions of the cockpit voice recorders (CVRs) were prepared (the
transcript of the Legacy's CVR was produced at the NTSB's laboratory in
Washington, D.C.) and data from flight data recorders obtained.
Initial interviews and medical examinations were conducted with the
crew of the Legacy. Air Traffic Control data was gathered. Preliminary
tests of the avionics equipment on the Legacy were performed. Wreckage
of the 737 was examined.
Future investigative activity:
Additional investigative work will include laboratory tests of the
avionics components removed from the Legacy, an examination of the
operating procedures of the avionics, interviews with ATC personnel,
examination of ATC practices and comparison between Brazilian and FAA
procedures, a technical examination of ATC communication and
surveillance systems, and further examination of the training provided
to the operators.
The Investigator in Charge estimates a 10-month timeline for the
investigation. The first phase, data gathering is estimated to take
approximately 45 days, although some further data gathering remains to
be completed. Analysis of the data is estimated to take 90 days
followed by a preliminary report with conclusions 120 days afterward.
Preparation of the final report and review by involved parties and
States is estimated at a further 30 days each.
Brazilian Contact: Brazilian Aeronautical Accident Prevention&
Investigation Center 55-61-3329-9160
NTSB Media Contact: Ted Lopatkiewicz (202) 314-6100