Boeing 737 / Business Jet Collision in Brazil

On September 29^th 2006 two aircraft traversing the Amazon jungle were involved in an apparent midair collision.The brand new Boeing 737-800 with 154 passengers and crew crashed in a remote part of the Amazon jungle, while the brand new Embraer Legacy 600 business jet with 7 passengers and crew on board made an emergency landing at a nearby military airfield.

The tailplane of the Boeing jet was apparently damaged causing the jet to spiral out of control breaking up and crashing in the Amazon jungle. The business jet suffered some damage to the left winglet and left horizontal stabilizer. Rescue workers had to clear landing spots in the jungle for the rescue helicopters to land.

The crew and passengers of the business jet said they felt a “jolt”, saw a shadow and thought their aircraft had been hit by falling debris. Over the Amazon jungle radar coverage is not good; however, both aircraft were equipped with TCAS (Traffic Collision Avoidance System) systems which should have alerted each aircraft to the other aircrafts presence.

I have flown aircraft with TCAS installed and can tell you that you would not miss the proximity warning signal. In addition, both aircraft were under air traffic control and had received instructions from the ground on the route and altitude to fly. The apparent collision occurred in or near an overlapping radar coverage area where two different air traffic control facilities share responsibility. Apparently the Boeing and the Legacy were being controlled by different facilities.

Authorities in Brazil said the Boeing was assigned 37,000 and the Legacy 36,000; however, there are reports that the air traffic controllers lost radio contact with the Legacy aircraft just prior to the collision.

Now the interesting part: both pilots (John Lepore and Jan Paladino) have been detained by the Brazilian authorities, and their passports seized. Brazilian authorities claim that the Legacy crew turned off their transponder to perform “pilot tricks” which the air traffic controllers could not detect.

To confuse matters further, the manufacturer of the transponder on board the business jet may have had a deficiency which would cause the transponder to go into standby mode if the flight crew took longer than five (5) seconds to change the air traffic control assigned code. In turn this would cause improper operation of the TCAS system aboard the aircraft. Honeywell, the manufacturer of the transponder on board the business jet, said the one installed on this aircraft was not subject to this problem and that Honeywell had long ago issued a software upgrade to fix this problem.

The pilots remain in Brazil even though not charged with any crime. Their passports have been seized and they can not leave the country until the investigation is concluded.

At the upper altitudes it is very difficult to see converging aircraft, and particularly difficult to judge a converging aircraft altitude. Depending on the angle of convergence you may never even see the other aircraft. The “see and be seen” rule does not work well at these altitudes, and therefore reliance upon other means of separation are required. TCAS and air traffic control help, but in the end some accidents simply can not be avoided through human intervention.

We wait to see what the Brazilian authorities decide the cause of this accident was, and what they will do with the American pilots. Hopefully they will be more interested in the cause than in retribution and blame.

In the meantime keep your wings straight and level.

“Crusty Captain”

Mid Air Collision over the Amazon in Brazil

On September 29th, 2006 a brand new Boeing 737-800 with 155 sould on board crashed in a remote section of the Amazon killing all on board. Initial reports claim that the Boeing collided with a new business jet, an Embraer Legacy Jet. The seven souls on board the Legacy Jet were uninjured.

Consider this - brand new aircraft, equipped with the very latest technology, collide in a remote area resulting in 155 deaths. Each aircraft was equipped with TCAS (Traffic Collision Avoidance System) equipment which should have given ample warning of another aircraft in close proximity. I have flown aircraft with TCAS, and I can tell you that you will not miss the warnings.

Initial reports tell us that each aircraft was being controlled by a different air controller in different cities. The Boeing was cleared to fly at 37,000 feet, and the business jet was cleared to climb from 35,000 feet to 39,000 feet. However, the crew of the Legacy business jet claim they were cleared to fly at 37,000 feet. Once the "black boxes" are recoved and analyzed that matter should be cleared up.

Once agan we have well qualified pilots, well trained, flying modern well equipped aircraft, and still we have a fatal accident. Could the pilots have missed the warnings? The Boeing apparently lost its tailplane, and the Legacy business jet had damage to it when the crew post flighted the aircraft after an emergency landing. Could the controllers have miscommunicated? Did they not co-ordinate altitudes for the aircraft? Even so, how could these two aircraft get close enough to collide and no one know? Surely one of the crews would have noticed the TCAS alarm.

My bet is that the accident is the result of the usual - human error. Someone was not focused on the task at hand, was inattentive, distracted or simply not paying attention. Remember that newspaper rolled up my instructor used to hit my head with? I still feel it from time to time. The rule is never stop paying attention, even to the smallest details. Flying airplanes can be fun, but it is always dangerous.

Keep your wings level and fly safe!

"Crusty Captain"

Can outdated paper charts really cause an aircraft accident?

The latest from Comair regarding the crash of flight 5191 is that the crew had outdated charts for the airport, and that due to construction at the Blue Grass airport they may have been confused. Newspapers talk about the missing air traffic controller, and everyone is looking for someone or something to blame. Human nature, I guess.

However, let's examine this a bit closer. Who has the most interest in assigning blame ? The airline? The insurance company. The flight crew? The air traffic controllers? The Blue Grass airport? Could a piece of paper really cause an aircraft to crash on takeoff?


Well, let's take a look. The insurance company will typically provide a limit of liability on an aircraft like this somewhere between $ 100,000,000 and $ 500,000,000 - a lot of money, right? Well, most insurance carriers split up or share the risk with other insurance companies. For example, let's say the primary insurance company takes the first $ 10,000,000 of liability, and then purchases excess liability coverage from another carrier, or reinsurer. So, their liability is limited to just $ 10,000,000 - certainly an acceptable level of risk/reward to stay in business.

Then, the first reinsurer may take the limit from $ 10,000,000 to $ 50,000,000. Not too tough because they can provide that limit across many air carriers, so their maximum exposure is $ 40,000,000. From $ 50,000,000 to $ 100,000,000 another reinsurer takes that risk, and so on.

So, none of the insurance carriers are going out of business because of this loss, and they WILL pay! No reason to worry about blame here.

The flight crew? Well, Part 91 of the Federal Aviation Regulations (FAR's) Section 91.3 - Responsibility and authority of the pilot in command states "(a) The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft." Not much wiggle room here, is there? And, I guarantee you that the pilot(s) are extremely distressed and would not dodge responsibility even if they could. Nothing here to gain from blaming someone/something else.

The air traffic controllers? Again, looking at FAR 91.3 (a) it simply is not their responsibility. One, two or three controllers might not have made a difference, but in any case it is still the flight crews responsiblity.

The Blue Grass airport? Well, under the FAR's they are required to issue NOTAMS when there are activities on the airport which affect airport operations. NOTAMS are Notices to Airmen which the pilot in command is required to read and understand before undertaking operations at the airport. These are usually provided in the briefing packet the pilot gets prior to takeoff, and in many cases are broadcast over the ATIS (Air Traffic Information System) frequency at the airport, and which flight crews should always listen to.

So, where does that leave us? The airline. Yes, they have a vested interest in assigning blame anywhere but on the airline and the flight crew. After all, they are in the business of providing safe transportation to the public. If the public believes the airline and/or its employees are unsafe, it will affect the bottom line. Therefore, the out of date chart is to blame. But, who provides those charts to the crew? Ah ha, the airline.
Back to square one.

I am not judging, nor opining as to the actual cause of the accident, but in the end we are left with FAR 91.3 (a). What do you think?

FLy safe - Crusty Captain

Are aircraft accidents similar in cause?

On June 27, 2005 an aircraft piloted by John T. Walton, son of Wal-Mart founder Sam Walton, crashed in the Grand Teton National Park in Wyoming. What most people don’t know, however, is that John Walton was an accomplished pilot with over 9,400 hours of flying time, and that he flew his own Cessna Citation CJ single pilot jet aircraft.

However, he did not die in the Citation Jet. Rather, his interest in aviation was quite broad, and that the aircraft he was flying was an experimental category light sport aircraft (LSA) which he assisted in building. The aircraft was a CGS Hawk Two Place Arrow ultra light aircraft constructed of aluminum tubing and covered with Dacron. The windshield was Lexan and sewn into the Dacron fabric.

Mr. Walton had a number of small incidents with this aircraft after he purchased it. For example, when he took delivery of the aircraft in West Virginia he performed several flights in the aircraft. On one of these flights he left a cordless drill on top of the engine which fell off during flight and damaged the aircraft’s propeller.

A second incident occurred when the pilot was transporting the aircraft to Wyoming and landed in Burwell, Nebraska to refuel. During his takeoff a piece of luggage fell from the rear of the airplane and returned to the airport to retrieve the luggage. Apparently the landing gear of the aircraft was damaged upon landing back at the airport. He then completed his flight to Jackson, Wyoming.

Although he had been offered on-site assistance from the aircraft manufacturer, Mr. Walton decided to repair the aircraft himself. The accident flight was the third one since the hard landing in Nebraska and since the subsequent repairs. It appears that the pilot experienced control movement problems which led to the fatal accident.

An examination of the wreckage at the accident site uncovered an inspection mirror which had been severely damaged, having been bent in half like a taco, as if it had jammed somewhere in the aircraft. While it was not possible to determine if the mirror had jammed in the controls, it seems a possible explanation given the previous incidents which occurred with this pilot.

This leads me to the tie-in with the Comair 5191 accident. Again, most accidents occur before the pilot ever gets into the aircraft. Having a personal wealth of over $ 18 Billion and plenty of piloting time (9,400 hours) does not insure that you will not get bitten in the ass by a silly mistake.

Keep your wings level and your eyes moving!

Crusty Captain.