Air Emergency (2003–…): Season 5, Episode 10 - Radio Silence - full transcript
A business jet on a delivery flight from Brazil to the US is shaken by a massive hit over the Amazon rainforest. The pilots manage to land the damaged aircraft, but they soon find out that they had a mid-air collision with a passenger jet.
A luxury jet on its maiden voyage
is jolted in mid-air.
The plane has lost a part of its wing.
The crew struggles to land the badly damaged plane
But the trouble isn't over
when they hit the ground
The crew is detained
and questioned by police
Somehow, this small plane
has triggered the worst crisis
in Brazilian aviation history.
Brokkenpiloten Seizoen 5 Editie 10
Phantom strike (Radio Silence)
September the 29th, 2006
In Sao José Dos Campos, Brazil
Three, two, one
It is a big day at EMBRAER headquarters
The Brazilian aviation-firm has just sold
a brand-new private jet to ExcelAire
a US charter company.
The price-tag:
$25,000.000
It is a beautiful airplane
It was a beautiful little ceremony,
that EMBRAER had in the hangar
just before we got on the plane
The guys from ExcelAire were particularly proud.
The legacy is a modified regional jet
The cabin redesigned for comfort.
It can seat up to 30 people
In in its first 4 years of service,
EMBRAER has delivered almost 100
of these sleek business-jet
ExcelAire will use the jet
to fly customers around the world
But first,
the company has to get the plane up to the US
Joseph Lapore and Jan Paul Paladino
will be at the controls
for the jet's maiden voyage.
They've been down in Brazil for a couple of weeks
getting familiar with the new plane
Joe Sharkey is a reporter for the New York Times
He has been offered a free ride home
We were delivering an airplane
My role was hitchhiker
and they kindly invited me along
The Legacy jet is heading to Manaus
in Northern Brazil
a stop-over on its way to New York
Half an hour after take off,
the Legacy is flying over the heart of Brazil
The country-side stretches out below
The view out of the window is spectacular.
I glanced out, I was amazed
Just to the horizon, nothing but tree-tops.
And I just remember how pretty is looked
At 3:50 PM, the Legacy jet
makes contact with controllers
of the Brazilian
Area Control Centre
still nearly 100 km away.
'Brasilia, N 600 XL
we are at a level of 27000 ft, good afternoon
75 % of the country's air traffic is handled
by the controllers in this room
The traffic volume is larger
than in any other control centre in the country.
One of the many planes they
will be dealing with today
is the Legacy jet
Every flight that is handled by Brasilia ACC
appears on computer screens as a small circle
moving in the direction of the plane
The computer also displays the plane's
actual and planned altitudes
N600XL, what ident
Roger
Paladino sends out a signal
Controllers use it to confirm
that the data on their screen is coming
from the plane they think it is
An hour later the flight has settled
into a familiar routine
Most of us were settled down,
everybody was working
and it was just a very
calm and peaceful time
I was transcribing notes
from one of the interviews
from the EMBRAER-tour
Brazilian N600XL
But in the cockpit,
Paladino is having trouble getting back
in touch with Air traffic Controllers
in Brasilia
He cannot raise controllers
on the frequency he used,
almost an hour ago.
He tries other channels
Brasilia, N600XL
After 12 attempts,
Paladino finally gets in touch
with Brasilia ACC
This time with a
different controller
who provides radio-frequencies
for future-contact
The Legacy loses radio contact again
As the pilots try
to restore communication with Brasilia
the plane continues to power through the sky.
It is just minutes before 5 O 'Clock
Suddenly there was the loudest bang
I've ever heard in my life
The concussion itself seemed to affect
every atom in my body
'What the hell is that?'
'We are in an emergency'
No one is sure what has happened to the jet
but when Joe Sharkey looks out of the window,
he is stunned by what he sees.
The end of the wing was chopped off
and it was serrated
It looked like it was chewed off
It became clear that we were in very big trouble
ExcelAire Vice President Ralph
McCaly rushes to the window
for a look at the damage
I said to Ralph: 'How bad is it?'
He looked at me and he said: 'It is bad'
With more experience flying this type of plane,
copilot Paladino takes over control
of the limped jet
Just let me fly the thing, Dude
The crew still can't make contact with controllers
N600XL, we declare an emergency!
Do we have a wing-tip?
'No!'
'Dammed'
The entire tip of the Legacy's wing is breaking up
That affects airflow
and is making the plane hard to control
As the plane begins to descend,
passengers in the back are worried
that the damaged wing is getting worse
Our main concern was that wing
but it has taken such a hit
that the structural integrity of the wings
was obviously a question
The leading edge was separating.
With so much damage to the wing,
the pilots cannot turn sharply.
Too much stress could rip the wing right of
We were in a position where we realized
we were going to die
I thought of my wife
I said well, what can I do
is I can write a note to my wife
which I did, I took my reporter's notebook
and I wrote a short note, saying that I loved her
Well just saying what I could
The Amazon is a bad place to land a plane
It is a dense jungle for as far as the eye can see
There is nothing down there but trees.
And I thought:
Where are they going to put this airplane down?
Just hours into its maiden voyage,
the badly damaged jet is going down.
Paladino and the Pose flying
will soon be analysed and
debated throughout Brazil
The verdict against them will be harsh.
Please answer, N600XL
The crew of the Legacy jet searches desperately
for a place to land their crippled plane.
Captain Joseph Lapor
finds a small military base on his chart
N600XL we have an emergency.
State your emergency
N600XL we declare an emergency,
We need to land at SBCC, is that your report?
Confirmative
Finding an airport was a stroke of luck
but the crew's trouble are far from over
Now they have to get the damaged jet
safely on the ground.
Jan Paul Paladino and Joseph Lepore
cannot configure their plane
for a routine landing
Extending flaps increases the size of the wing
Since a bigger wing can generate more lift
pilots can slow down to land
'Good?'
With all the damage
they have sustained,
the crew doesn't want to put
too much pressure on their wing
They won't be able to extend their flaps
until the last moment
They will have to land faster than usual
I see these trees now in a ground battle
I hope this runway doesn't run out
Paladino hits the brakes hard
Then, finally the plane begins to slow.
And then, finally we just did come to a hold
and then there is that
beautiful silence that occurs
when the engines shut down
Everything was just quiet again
For more than 25 minutes,
the business jet has flown
with a part of its wing torn off
There is also damage to the plane's tail
Somehow, high over the rainforest,
something tore into the plane
The bizarre day takes another strange twist
Because they have landed at a military base,
soldiers confiscate the
passports of everyone on board.
That's the point which I realized
that we were in custody
I don't think the others on the
airplane had the immediate sense
that this was a custodial situation.
Along with the two pilots,
the jet's passengers are taken
to the nearby airbase
The emergency on-board the Legacy jet
has thrown Brasilia ACC into therm oil
But it is not the only problem
controllers there are facing.
Another plane they are expecting to see
hasn't shown up
Gol Flight 1907 should be on radar in Brasilia.
The missing flight
is a Boeing 737
with 154 people on board.
It has been in the air for 2 hours
and should be nearing Brasilia
But controllers there can't find any trace
of that plane
'Manaus'
there isn't any Gol
'It is on its way
They check its status with
controllers in Manaus
who were last in
contact with the plane
Anxiety was high
and controllers were
confused about what to say
They didn't know what was happening
Deep in the Amazon,
those who were on the ExcelAire jet are also
struggling to figure out what happened
We hit something, that is all I know
Maybe it was a condor
It was 37000 ft
Maybe it was a military jet
No, I think the plane must have exploded
As they are trying to piece together
the day's strange events,
the group gets some shocking news
A Gol flight has crashed
It is the plane that is been missing
I just heard, a 737 went down
near the Amazon where we were
It was like a thunderclap
The world changed immediately
And Joe and Jan were just stricken
I don't think I've ever
seen 2 more anguished man
in my life.
The Gol flight crashed right
where the Legacy lost a piece of its wing.
It cannot be a coincidence.
Approx. 100 km from the military base,
the wreckage of Gol Flight 1907 has been found.
The greatest difficulty involved
the fact that the plane fell straight down
When it hit the ground, the trees covered it up
making it hard to get to.
The shattered remains of the plane
littered the jungle floor
The news hits controller in Brasilia
extremely hard
They had just realized
that the worst thing that could happen
in their control, happened
People were crying,
a lot of people had to be dragged out of the room
Things were not under control in the room.
Over the next several days,
troops pour over the scene of the Gol-crash
The dense jungle slows their process.
A make-shipped helicopter landing path
is carved out of the jungle
It is becoming increasingly clear
that no one has survived.
154 people are killed
At the time it is the worst crash
in the history of Brazilian aviation
What had happened in the skies above the Amazon?
Investigators face a mammoth job.
Colonel Rufino Ferreira is in charge
of the investigation of the Gol-crash
An investigator always has to keep an open mind
You cannot start with any preconceived ideas
When we arrived at the location of the accident
the only thing we know for sure
was that we have found the plane that was missing
The wreckage of the Gol-jet is spread
over more than 2 km's.
The wide-spread debris
tells investigators
that the plane ripped apart
before crashing to the ground.
There was practically no damage,
caused by the impact with the ground
The plane had already fallen apart
On October, the 2nd,
just three days after the crash,
the flight data recorder is found.
Most of the Cockpit Voice Recorder
is also recovered
except for one critical part.
In this accident, the impact was so strong,
that the module separated from the recorder
Modern voice recorders don't use tape.
Conversations are recorded digitally
onto a memory module.
But that part of the Gol-CVR has broken free.
Without it, the rest of the CVR is useless.
While the search for the module continues
Ferreira looks for the information from the 737's
Flight Data Recorder.
He learns that the plane was flying at 37000 ft
It was on course and flying level
at its assigned altitude
Then, without warning,
the plane pitched over and
plummeted toward the ground
Whatever happened, it was sudden and catastrophic
The data recorder tells Ferreira that
the plane spun 11 times
before it hit the ground
Manaus
I can't see Gol
there isn't any Gol
It is on its way
So it is ready in my area?
Over half an hour
Police investigators
want to know
what Air Traffic
Controllers can tell them
about Gol Flight
1907's final minutes
'There was no Mayday
in fact, we never had contact with the Gol's jet
Controllers say there was no warning
that the jet was in trouble
It simply vanished.
Colonel Ferreira studies
air traffic control data
from the day of the accident.
There is no sign of the Gol Flight
But the readings from the smaller Legacy jet
captures his attention
It seems to be flying erratically.
Instead of keeping to a single altitude
the radar shows it is flying
up and down dangerously
Perhaps the private jet pilots
were testing out their new plane
by climbing and
descending quickly
They may have collided with the Gol-jet
as a result of their reckless flying
When that information leaks out
to the country's newspapers
it makes front-page news
The population thought
it was unjust
that a smaller aircraft was able
to make an emergency landing
while the larger aircraft with 154 people
fell into the Amazon
and everyone died
Neither Lepor, nor Paladino are officially charged
But they are confined to a hotel room at Brazil,
while the investigation continues.
Ferreira interviews the two pilots
about what they did
and what they saw
Look, we are proceeding North West
on course to Manaus at 37000 ft
Okay, we were attempting to contact
to Brazilian control
'Were you changing altitude?'
'No!'
I was on the plane
had the plane been flying erratically
or doing looptiloops or whatever it was
I think I would have a pretty good story
for the New York Times
'did you say you were flying at 37000 ft?
''Yes! that is right, 37000 ft
We never moved from that
When he reviews the information from the Legacy's
Flight Data Recorder,
Ferreira confirms the pilots' story
Although the ground radar shows
the Legacy is flying wildly,
the data from the plane shows
that they didn't change altitude at all
But there is something shocking
about the Legacy's path
The business jet is flying North to Manaus
The Gol flight South from Manaus.
Ferreira can see that
both planes were flying at the same altitude,
37,000 ft
He makes a horrifying discovery
For some reason,
the two planes were on a collision course.
Air traffic is typically routed
along specific corridors through the sky
Essentially highways in the air
But planes travelling in opposite directions
are supposed to be separated by at least 1000 ft
The airway-system
for instance between Brasilia and Manaus
is very simple
It makes airplanes fly North-bound
maintaining even levels
and airplanes flying South-bound
maintaining odd levels
But somehow,
the Legacy jet and the Gol 737 were
travelling down the same Arial highway
in opposite directions
For long minutes
they were heading straight for each other
It seems more and more likely
that the two planes collided
At the crash-site,
workers find support for
this incredible theory
The left wing of the Gol flight is recovered
Investigators discover
that about halfway along the wing,
it is sliced clean through
Non of the other wreckages are sliced this way
The precise nature of the cut
tells Ferreira that this is not damaged
what is caused by impact with the ground.
The damage on the left
wing clearly shows
that it was caused by
collision with another plane
The badly damaged wing would have send the 737
into a spiral dive
The pilots would have had no way of controlling it
The sudden spiral motion
would have pulled the plane apart
It's the reason the wreckage is spread
over such a wide area
Ferreira finds the most conclusive
evidence of the collision
on the Legacy's damaged wing
On the Legacy, we found very small pieces of paint
that came from the Gol wing
Together,
the planes had a combined speed of 1600 km/hour
At that speed,
the wing-tip of the small jet
easily sliced through the 737
Colonel Ferreira now understands
what caused the Gol jet to crash
but he doesn't know why
How had the two jets ended up
in the exact same airspace
without anybody noticing?
Investigators in Brazil now realize
that they are dealing with something very unusual.
A mid-air collision is a very rare event
in aviation
and it should not have happened
with two very modern new aircraft
the situation becomes more complicated
when investigators study a critical document
The Legacy's flight plan
Flight plans are filed by using a standard formats
the same all over the world
The format contain the flight number,
as well as requested flight level or altitude
According to this document,
when it collided with the Gol flight
the execute jet wasn't expected to be at 37000 ft
The Legacy's flight plan called
for the jet to fly at 37000 ft
only until it reached Brasilia
Them descend to 36000 ft
But the collision took place
850 km North West of Brasilia
well passed the point
where the Legacy was supposed to descend
So, why hadn't the Legacy followed its flight plan?
The flight plan calls for you to descent
to 36000 ft at Brasilia.
Why didn't you?
Before we took off,
we were cleared for 37000 ft
all the way to Manaus
That is what we did sir,
I don't know where you get the information from
We followed the rules
we were not told to descend
we did not descend
Colonel Ferreira needs to check
the story that the crew is telling
He wants to know exactly what
they were told by controllers
when they took off from Sao José Dos Campos.
The Legacy's last instruction was
to fly all the way to Manaus
at 37000 ft.
The pilots obey that instruction
even though it differed
from their flight plan
Air Traffic Control always can deviate
from the flight plan
because they have best knowledge
of the actual traffic situation.
Leaving Manaus,
the Gol-jet was also cleared to fly at 37000 ft.
Both planes were assigned the same altitude
by controllers at opposite ends of the country.
Once we were certain that
both planes were flying at the same altitude
we knew for sure there would
be a lot to investigate
on the site of Air Traffic Control.
Ferreira turns his attention to conversations
between controllers in Brasilia
and the Legacy jet.
The CVR from the Legacy gives investigators
a remarkably detailed look
into what happened on the private jet
The brand-new Legacy-jet has
a state of the art recorder
that captures 2 hours of conversation.
The Cockpit Voice Recorder was
probably the most important component
on the investigation
At 3:50 PM,
the crew is told to chance radio-frequencies
and get in touch with the controller,
monitoring their flight
125.05, Good day
'Good day'
At this point the Legacy jet
is approaching Brasilia
But the crew never receives any instructions
regarding their altitude.
'Brasilia, N600XL, level 370,
good afternoon'
'N600XL'
When the Legacy overflew Brasilia
at flight level 370, according to the flight plan
it should have descended to 36000 ft,
but the controller simply forgot
to give the order to the Legacy
to descend to 36000 ft
The pilots would have assumed
they were meant to stay at 370
37000 ft.
No airplane should ever chance altitude
without receiving instructions
from Air Traffic Control
To discover why controllers didn't give
that crucial instruction
Colonel Ferreira takes a
closer look at the technology,
used to monitor the traffic over Brazil.
So, can you call up the Legacy jet screen for me?
On the radar screen,
we see the altitude, speed,
and the transponder information of each plane.
Each flight has an individual code, assigned to it
that helps controllers track it
Underneath that,
there are 2 separate numbers.
On the left, the plane's actual altitude
On the right,
the altitude the plane is supposed to be at
according to its flight plan
As the Legacy jet passed over Brasilia,
the number on the right,
the planned altitude, changed.
The computerized system automatically updated it
According to the flight plan,
at this point the plane was
supposed to descend to 36000 ft
360.
only Brazilian Air Traffic Control system is using
this kind of design
In other parts of the world,
this update has to be done manually
The computer changed a single number
which led to a critical error.
Without much experience
with the computerized system,
the controller mistook the new planned altitude
for the plane's actual altitude.
The system changed it automatically
from the authorized altitude
to the planned altitude
which made the controller believe
the Legacy was flying at 360.
Police investigators talk with
the controller who was on duty,
when the number changed on the screen
shortly after that, I had a break
He tells police about a critical mistake
on his part
you have 5 aircraft, the Legacy, is at 360
Before leaving,
he handed its flight off to another controller,
telling him where he thought the Legacy was flying
I believed it was at 360,
and that is what I told him
When the new controller took over,
the one being relieved gave him the
Legacy's altitude-information,
according to the flight plan, 360.
But the jet was actually flying at 1000 ft higher
right in the path of the Gol-flight.
Colonel Ferreira studies transcripts
of conversations on-board the Legacy
and finds that the crew was having
their one difficulties
during the flight
'How much longer, guys?'
'That is a good question, Ralph'
The crew seems unfamiliar
with some of the jet's advanced systems
I'm still working out
how to work this flight management system
'Where is the one that gives us Total Time?'
My impression is
that the pilots were trying to
learn their aircraft's system
during the flight
Investigators also uncover a break-down
in communications
After a brief conversation
between the Legacy-jet and Brasilia ACC,
Colonel Ferreira notices
something extremely unusual
For almost an hour,
the Legacy pilots don't talk
to anyone on the ground
Paladino did try to get hold of ground control
but he couldn't get through.
He then tried the back-up frequencies,
listed on his navigation-charts.
His only contact a single, garbled message
Both pilots and Air Traffic Controller
should have been more concerned
of maintaining two-way contact
all the time.
This is their duty
Had pilots and controllers spoken,
they might have discovered
that the Legacy was flying North
in a corridor that was reserved
for South-bound traffic.
As the public learns about the mistakes
in the Air Traffic Control Centre
there is growing pressure to make some changes.
We wanted to understand
what had happened to these people
inside the Control Room
Controllers should have been able
to see on the radar screens
that these two airplanes were flying
in a collision course.
Brazilian Air Traffic control
is one of the last in the world
to be run largely by the country's military.
Since they are run by the military,
by Brazilian Air force,
we did not have complete access to information
except for what was released
As fingers are pointing at controllers,
many of them come forward
with stories of overwork and poor training
They complain that they weren't well trained
in English language
which is the international aviation language
also they had complained about their equipment
In fact, the controller who incorrectly
reported the Legacy's altitude
had been on the job for only a year.
A valuable piece of the puzzle is still missing
Investigators still don't know what happened
during the final minutes of the Gol flight
Soldiers have been scouring
the Amazon jungle with metal detectors,
looking for the plane's missing memory module
Almost a month after the crash,
they find it.
Colonel Ferreira hopes to hear some reason
why the Gol crew wasn't able to avoid colliding
with an oncoming jet.
Gol 1907, contact Brasilia ACC on 125.2
Thanks very much Brasilia 125.2
Gol 1907
There are no alarms before the collision.
No warning
that they were flying straight for another jet
Pilots rely on Air Traffic Controllers
to keep other planes out of their path.
They spend much of their time
monitoring their instruments
Not the skies ahead.
At the speed they are travelling they
only have to look away for a few second
to miss an approaching plane
There are no issues of communication
and no misunderstanding between the pilots
and the ATControl
They had no idea what had just happened
with their plane
in far until the end to regain control
For less than a minute,
the pilots struggle for control
but there is nothing they can do
But why were there no warnings?
Both planes were equipped with a safety feature,
designed to prevent exactly this type of accident.
Ferreira now needs to know why that system failed
Earlier in the investigations,
strange radar images suggested
that the Legacy pilots
were flying wildly over the Amazon.
Now, those suspicions are vanished.
But Ferreira revisits the
fluctuating radar-data,
to understand why neither plane knew
the other was coming.
To try to understand
this last piece of the puzzle,
Colonel Ferreira returns
to the radar display
that AT controllers saw on the day of the crash
Instead of displaying just the expected altitude
and the actual altitude,
the letter 'Z' is between them
The 'Z' on the AT controllers' screens
indicates that the
airplane he is looking at
has lost its transponder.
Modern commercial aircraft
are equipped with transponders
Like small radio stations
they broadcast information
on the plane's altitude and flight number
This information is received by computers
on the ground
and instantly displayed on the screens
of AT Controllers
In Brasilia, if the transponder fails,
so-called primary radar takes over automatically.
Signals are send out from the
ground that hit the target
and return.
Those readings are wildly inaccurate
The inaccuracy of the radar,
tracking the Legacy jet
explains why its altitude appeared to be rising
and falling
Investigators discover
that the transponder wasn't sending
out signals for more than 50 minutes
before the crash.
But controllers didn't notify the pilots
That may be because they didn't notice
the subtle change.
There is an even more critical role,
played by the transponder
It doesn't just beam information
to controllers on the ground,
but to other planes as well
All commercial aircraft are
equipped with a warning system,
called TCAS
The Traffic Collision Avoidance System.
TCAS picks up a signal
from an oncoming plane's transponder.
and issues a warning if it is too close
If either plane's transponder is OFF,
the system won't work!
Ferreira discovers
that the Legacy's transponder
was working early in the flight
and after the collision
But for more than 50 critical minutes,
it was silent.
How had a state of the art jet ,
just off the factory floor
developed problems with its transponder?
Investigators examine
the Legacy jet's transponder unit.
They discover that the system which controls it,
had a troubled history.
It had been installed on a different plane
but removed, because it wasn't working.
It was repaired, and then placed on the jet,
that was sold to ExcelAire
Investigators have the system tested.
But even with its suspicious past,
after the crash they can find no obvious problems
with the plane's transponder.
Now, this is the layout now,
the wiring of Legacy jet
Colonel Ferreira does notice
something potentially dangerous
about the design of the cockpit
If the pilot uses the build in footrest
during flight,
his toes can come in contact with the buttons
on the transponder
'It looks like in STANDBY mode'
And when the transponder goes into STANDBY,
it would be difficult for pilots to notice
'There is no alarm?'
A small yellow warning light
is the only indication
that the transponder isn't ON.
It was not easy for the pilots to detect that
because it is not hooked up
with the Central Warning and Alert System
But the pilots of the Legacy jet
do not remember using the plane's footrest.
Investigators suspect
that one of the pilots may have
turned the transponder OFF
by mistake
The most probable scenario is that by accident
one of the pilots temporarily
turned OFF the equipment
as he tried to familiarize himself
with the technology on board.
However, the transponder went OFF,
at a critical moment
the crew had no last safety system to warn them
that they were flying right at a 737
Even though the TCAS system on the Gol plane
was working,
there was no signal
from the approaching jet for it to receive.
Closing in on each other at 1600 km/hour
the pilots never saw each other coming.
Brazil's Air Traffic Control system
would undergo some radical changes
as a result of the collision
But those systems would not come without a fight.
The investigation into the
crash of Gol Flight 1907
has uncovered dangerous problems with
Brazil's Air Traffic Control system
Two planes were assigned to
fly at the same altitude
in the same airspace.
Overworked and inexperienced
controllers in Brasilia
neglected to instruct the Legacy jet
to descend to 36000 ft
Then, they mistook the Legacy's planned altitude
for its actual altitude.
To make matters worse,
the Legacy pilots,
unfamiliar with Brazilian airspace,
were unable to make contact
with controllers on the ground.
and somehow the transponder,
which broadcasts their location in the sky
went silent
which controllers in Brasilia failed to notice.
A multi billion dollar Air Traffic Control system,
designed to keep planes apart,
had failed to detect two planes
on a collision course
One by one, a series of human errors occurred
and all of the defence systems that exist
to avoid these errors
were defeated.
A month after the crash of the Gol passenger plane
controllers begin a 'work to rule campaign
They want to draw attention to problems
with the system.
Once they did start working to the rules
and not stretching them anymore
this triggered what we call
'The Aviation Crisis in Brazil'
At a certain point,
maybe 40% of the flights in all
of Brazil had over an hour delays
Following the crash and the work slowed down,
changes start being made.
There is been a lot of changes
in Brazilian aviation
after the accident.
specifically with Air Traffic Control.
The air force had to admit that
they had a shortage of controllers
and also there is a higher degree of accountability
In the United States,
the FAA issues two recommendations
as a result of the tragedy
Pilots flying Legacy jets are
warned of the possibility
that putting their
feet up in the cockpit
could accidently turn off the transponder.
And manufacturers are told
that an alarm should sound
if the TCAS system shuts OFF.
The controllers who were involved in the crash
are charged with varying
degrees of manslaughter
But those criminal charge worry people
who are closely involved with the disaster.
An investigation like ours,
which focusses on prevention
suffers huge setbacks when there is pressure
to late charges.
By blaming people we might be creating a culture
where people will not come forth and be honest
about failures and mistakes.
And when we try to hide that,
they've got sucked under the carpet.
and soon enough will come out again.
No controller leaves his
home in the morning
thinking he is going to crash a plane.
And so the criminalization only
interferes with investigation
that can prevent further accidents
More than 2 months after the crash,
the crew of the Legacy
jet is finally allowed
to return to the United States
Joe and Jan barely get out of the country
There was an attempt
to hold them under a coupled
together initial criminal charge of
'Failing to ensure the
safety of Brazilian skies'
Well, you are all grateful for the safe return
of Joe and Jan
And everyone on board the Legacy :
you all are sadden by this tragedy
which took many innocent lives
More than a year
after the accident,
the Legacy jet that survived
the mid-air collision
was still at the airfield in the Amazon.
Its maiden voyage cuts short
by a tragic series of technological
and human errors.
Subtitles
Rein Croonen
is jolted in mid-air.
The plane has lost a part of its wing.
The crew struggles to land the badly damaged plane
But the trouble isn't over
when they hit the ground
The crew is detained
and questioned by police
Somehow, this small plane
has triggered the worst crisis
in Brazilian aviation history.
Brokkenpiloten Seizoen 5 Editie 10
Phantom strike (Radio Silence)
September the 29th, 2006
In Sao José Dos Campos, Brazil
Three, two, one
It is a big day at EMBRAER headquarters
The Brazilian aviation-firm has just sold
a brand-new private jet to ExcelAire
a US charter company.
The price-tag:
$25,000.000
It is a beautiful airplane
It was a beautiful little ceremony,
that EMBRAER had in the hangar
just before we got on the plane
The guys from ExcelAire were particularly proud.
The legacy is a modified regional jet
The cabin redesigned for comfort.
It can seat up to 30 people
In in its first 4 years of service,
EMBRAER has delivered almost 100
of these sleek business-jet
ExcelAire will use the jet
to fly customers around the world
But first,
the company has to get the plane up to the US
Joseph Lapore and Jan Paul Paladino
will be at the controls
for the jet's maiden voyage.
They've been down in Brazil for a couple of weeks
getting familiar with the new plane
Joe Sharkey is a reporter for the New York Times
He has been offered a free ride home
We were delivering an airplane
My role was hitchhiker
and they kindly invited me along
The Legacy jet is heading to Manaus
in Northern Brazil
a stop-over on its way to New York
Half an hour after take off,
the Legacy is flying over the heart of Brazil
The country-side stretches out below
The view out of the window is spectacular.
I glanced out, I was amazed
Just to the horizon, nothing but tree-tops.
And I just remember how pretty is looked
At 3:50 PM, the Legacy jet
makes contact with controllers
of the Brazilian
Area Control Centre
still nearly 100 km away.
'Brasilia, N 600 XL
we are at a level of 27000 ft, good afternoon
75 % of the country's air traffic is handled
by the controllers in this room
The traffic volume is larger
than in any other control centre in the country.
One of the many planes they
will be dealing with today
is the Legacy jet
Every flight that is handled by Brasilia ACC
appears on computer screens as a small circle
moving in the direction of the plane
The computer also displays the plane's
actual and planned altitudes
N600XL, what ident
Roger
Paladino sends out a signal
Controllers use it to confirm
that the data on their screen is coming
from the plane they think it is
An hour later the flight has settled
into a familiar routine
Most of us were settled down,
everybody was working
and it was just a very
calm and peaceful time
I was transcribing notes
from one of the interviews
from the EMBRAER-tour
Brazilian N600XL
But in the cockpit,
Paladino is having trouble getting back
in touch with Air traffic Controllers
in Brasilia
He cannot raise controllers
on the frequency he used,
almost an hour ago.
He tries other channels
Brasilia, N600XL
After 12 attempts,
Paladino finally gets in touch
with Brasilia ACC
This time with a
different controller
who provides radio-frequencies
for future-contact
The Legacy loses radio contact again
As the pilots try
to restore communication with Brasilia
the plane continues to power through the sky.
It is just minutes before 5 O 'Clock
Suddenly there was the loudest bang
I've ever heard in my life
The concussion itself seemed to affect
every atom in my body
'What the hell is that?'
'We are in an emergency'
No one is sure what has happened to the jet
but when Joe Sharkey looks out of the window,
he is stunned by what he sees.
The end of the wing was chopped off
and it was serrated
It looked like it was chewed off
It became clear that we were in very big trouble
ExcelAire Vice President Ralph
McCaly rushes to the window
for a look at the damage
I said to Ralph: 'How bad is it?'
He looked at me and he said: 'It is bad'
With more experience flying this type of plane,
copilot Paladino takes over control
of the limped jet
Just let me fly the thing, Dude
The crew still can't make contact with controllers
N600XL, we declare an emergency!
Do we have a wing-tip?
'No!'
'Dammed'
The entire tip of the Legacy's wing is breaking up
That affects airflow
and is making the plane hard to control
As the plane begins to descend,
passengers in the back are worried
that the damaged wing is getting worse
Our main concern was that wing
but it has taken such a hit
that the structural integrity of the wings
was obviously a question
The leading edge was separating.
With so much damage to the wing,
the pilots cannot turn sharply.
Too much stress could rip the wing right of
We were in a position where we realized
we were going to die
I thought of my wife
I said well, what can I do
is I can write a note to my wife
which I did, I took my reporter's notebook
and I wrote a short note, saying that I loved her
Well just saying what I could
The Amazon is a bad place to land a plane
It is a dense jungle for as far as the eye can see
There is nothing down there but trees.
And I thought:
Where are they going to put this airplane down?
Just hours into its maiden voyage,
the badly damaged jet is going down.
Paladino and the Pose flying
will soon be analysed and
debated throughout Brazil
The verdict against them will be harsh.
Please answer, N600XL
The crew of the Legacy jet searches desperately
for a place to land their crippled plane.
Captain Joseph Lapor
finds a small military base on his chart
N600XL we have an emergency.
State your emergency
N600XL we declare an emergency,
We need to land at SBCC, is that your report?
Confirmative
Finding an airport was a stroke of luck
but the crew's trouble are far from over
Now they have to get the damaged jet
safely on the ground.
Jan Paul Paladino and Joseph Lepore
cannot configure their plane
for a routine landing
Extending flaps increases the size of the wing
Since a bigger wing can generate more lift
pilots can slow down to land
'Good?'
With all the damage
they have sustained,
the crew doesn't want to put
too much pressure on their wing
They won't be able to extend their flaps
until the last moment
They will have to land faster than usual
I see these trees now in a ground battle
I hope this runway doesn't run out
Paladino hits the brakes hard
Then, finally the plane begins to slow.
And then, finally we just did come to a hold
and then there is that
beautiful silence that occurs
when the engines shut down
Everything was just quiet again
For more than 25 minutes,
the business jet has flown
with a part of its wing torn off
There is also damage to the plane's tail
Somehow, high over the rainforest,
something tore into the plane
The bizarre day takes another strange twist
Because they have landed at a military base,
soldiers confiscate the
passports of everyone on board.
That's the point which I realized
that we were in custody
I don't think the others on the
airplane had the immediate sense
that this was a custodial situation.
Along with the two pilots,
the jet's passengers are taken
to the nearby airbase
The emergency on-board the Legacy jet
has thrown Brasilia ACC into therm oil
But it is not the only problem
controllers there are facing.
Another plane they are expecting to see
hasn't shown up
Gol Flight 1907 should be on radar in Brasilia.
The missing flight
is a Boeing 737
with 154 people on board.
It has been in the air for 2 hours
and should be nearing Brasilia
But controllers there can't find any trace
of that plane
'Manaus'
there isn't any Gol
'It is on its way
They check its status with
controllers in Manaus
who were last in
contact with the plane
Anxiety was high
and controllers were
confused about what to say
They didn't know what was happening
Deep in the Amazon,
those who were on the ExcelAire jet are also
struggling to figure out what happened
We hit something, that is all I know
Maybe it was a condor
It was 37000 ft
Maybe it was a military jet
No, I think the plane must have exploded
As they are trying to piece together
the day's strange events,
the group gets some shocking news
A Gol flight has crashed
It is the plane that is been missing
I just heard, a 737 went down
near the Amazon where we were
It was like a thunderclap
The world changed immediately
And Joe and Jan were just stricken
I don't think I've ever
seen 2 more anguished man
in my life.
The Gol flight crashed right
where the Legacy lost a piece of its wing.
It cannot be a coincidence.
Approx. 100 km from the military base,
the wreckage of Gol Flight 1907 has been found.
The greatest difficulty involved
the fact that the plane fell straight down
When it hit the ground, the trees covered it up
making it hard to get to.
The shattered remains of the plane
littered the jungle floor
The news hits controller in Brasilia
extremely hard
They had just realized
that the worst thing that could happen
in their control, happened
People were crying,
a lot of people had to be dragged out of the room
Things were not under control in the room.
Over the next several days,
troops pour over the scene of the Gol-crash
The dense jungle slows their process.
A make-shipped helicopter landing path
is carved out of the jungle
It is becoming increasingly clear
that no one has survived.
154 people are killed
At the time it is the worst crash
in the history of Brazilian aviation
What had happened in the skies above the Amazon?
Investigators face a mammoth job.
Colonel Rufino Ferreira is in charge
of the investigation of the Gol-crash
An investigator always has to keep an open mind
You cannot start with any preconceived ideas
When we arrived at the location of the accident
the only thing we know for sure
was that we have found the plane that was missing
The wreckage of the Gol-jet is spread
over more than 2 km's.
The wide-spread debris
tells investigators
that the plane ripped apart
before crashing to the ground.
There was practically no damage,
caused by the impact with the ground
The plane had already fallen apart
On October, the 2nd,
just three days after the crash,
the flight data recorder is found.
Most of the Cockpit Voice Recorder
is also recovered
except for one critical part.
In this accident, the impact was so strong,
that the module separated from the recorder
Modern voice recorders don't use tape.
Conversations are recorded digitally
onto a memory module.
But that part of the Gol-CVR has broken free.
Without it, the rest of the CVR is useless.
While the search for the module continues
Ferreira looks for the information from the 737's
Flight Data Recorder.
He learns that the plane was flying at 37000 ft
It was on course and flying level
at its assigned altitude
Then, without warning,
the plane pitched over and
plummeted toward the ground
Whatever happened, it was sudden and catastrophic
The data recorder tells Ferreira that
the plane spun 11 times
before it hit the ground
Manaus
I can't see Gol
there isn't any Gol
It is on its way
So it is ready in my area?
Over half an hour
Police investigators
want to know
what Air Traffic
Controllers can tell them
about Gol Flight
1907's final minutes
'There was no Mayday
in fact, we never had contact with the Gol's jet
Controllers say there was no warning
that the jet was in trouble
It simply vanished.
Colonel Ferreira studies
air traffic control data
from the day of the accident.
There is no sign of the Gol Flight
But the readings from the smaller Legacy jet
captures his attention
It seems to be flying erratically.
Instead of keeping to a single altitude
the radar shows it is flying
up and down dangerously
Perhaps the private jet pilots
were testing out their new plane
by climbing and
descending quickly
They may have collided with the Gol-jet
as a result of their reckless flying
When that information leaks out
to the country's newspapers
it makes front-page news
The population thought
it was unjust
that a smaller aircraft was able
to make an emergency landing
while the larger aircraft with 154 people
fell into the Amazon
and everyone died
Neither Lepor, nor Paladino are officially charged
But they are confined to a hotel room at Brazil,
while the investigation continues.
Ferreira interviews the two pilots
about what they did
and what they saw
Look, we are proceeding North West
on course to Manaus at 37000 ft
Okay, we were attempting to contact
to Brazilian control
'Were you changing altitude?'
'No!'
I was on the plane
had the plane been flying erratically
or doing looptiloops or whatever it was
I think I would have a pretty good story
for the New York Times
'did you say you were flying at 37000 ft?
''Yes! that is right, 37000 ft
We never moved from that
When he reviews the information from the Legacy's
Flight Data Recorder,
Ferreira confirms the pilots' story
Although the ground radar shows
the Legacy is flying wildly,
the data from the plane shows
that they didn't change altitude at all
But there is something shocking
about the Legacy's path
The business jet is flying North to Manaus
The Gol flight South from Manaus.
Ferreira can see that
both planes were flying at the same altitude,
37,000 ft
He makes a horrifying discovery
For some reason,
the two planes were on a collision course.
Air traffic is typically routed
along specific corridors through the sky
Essentially highways in the air
But planes travelling in opposite directions
are supposed to be separated by at least 1000 ft
The airway-system
for instance between Brasilia and Manaus
is very simple
It makes airplanes fly North-bound
maintaining even levels
and airplanes flying South-bound
maintaining odd levels
But somehow,
the Legacy jet and the Gol 737 were
travelling down the same Arial highway
in opposite directions
For long minutes
they were heading straight for each other
It seems more and more likely
that the two planes collided
At the crash-site,
workers find support for
this incredible theory
The left wing of the Gol flight is recovered
Investigators discover
that about halfway along the wing,
it is sliced clean through
Non of the other wreckages are sliced this way
The precise nature of the cut
tells Ferreira that this is not damaged
what is caused by impact with the ground.
The damage on the left
wing clearly shows
that it was caused by
collision with another plane
The badly damaged wing would have send the 737
into a spiral dive
The pilots would have had no way of controlling it
The sudden spiral motion
would have pulled the plane apart
It's the reason the wreckage is spread
over such a wide area
Ferreira finds the most conclusive
evidence of the collision
on the Legacy's damaged wing
On the Legacy, we found very small pieces of paint
that came from the Gol wing
Together,
the planes had a combined speed of 1600 km/hour
At that speed,
the wing-tip of the small jet
easily sliced through the 737
Colonel Ferreira now understands
what caused the Gol jet to crash
but he doesn't know why
How had the two jets ended up
in the exact same airspace
without anybody noticing?
Investigators in Brazil now realize
that they are dealing with something very unusual.
A mid-air collision is a very rare event
in aviation
and it should not have happened
with two very modern new aircraft
the situation becomes more complicated
when investigators study a critical document
The Legacy's flight plan
Flight plans are filed by using a standard formats
the same all over the world
The format contain the flight number,
as well as requested flight level or altitude
According to this document,
when it collided with the Gol flight
the execute jet wasn't expected to be at 37000 ft
The Legacy's flight plan called
for the jet to fly at 37000 ft
only until it reached Brasilia
Them descend to 36000 ft
But the collision took place
850 km North West of Brasilia
well passed the point
where the Legacy was supposed to descend
So, why hadn't the Legacy followed its flight plan?
The flight plan calls for you to descent
to 36000 ft at Brasilia.
Why didn't you?
Before we took off,
we were cleared for 37000 ft
all the way to Manaus
That is what we did sir,
I don't know where you get the information from
We followed the rules
we were not told to descend
we did not descend
Colonel Ferreira needs to check
the story that the crew is telling
He wants to know exactly what
they were told by controllers
when they took off from Sao José Dos Campos.
The Legacy's last instruction was
to fly all the way to Manaus
at 37000 ft.
The pilots obey that instruction
even though it differed
from their flight plan
Air Traffic Control always can deviate
from the flight plan
because they have best knowledge
of the actual traffic situation.
Leaving Manaus,
the Gol-jet was also cleared to fly at 37000 ft.
Both planes were assigned the same altitude
by controllers at opposite ends of the country.
Once we were certain that
both planes were flying at the same altitude
we knew for sure there would
be a lot to investigate
on the site of Air Traffic Control.
Ferreira turns his attention to conversations
between controllers in Brasilia
and the Legacy jet.
The CVR from the Legacy gives investigators
a remarkably detailed look
into what happened on the private jet
The brand-new Legacy-jet has
a state of the art recorder
that captures 2 hours of conversation.
The Cockpit Voice Recorder was
probably the most important component
on the investigation
At 3:50 PM,
the crew is told to chance radio-frequencies
and get in touch with the controller,
monitoring their flight
125.05, Good day
'Good day'
At this point the Legacy jet
is approaching Brasilia
But the crew never receives any instructions
regarding their altitude.
'Brasilia, N600XL, level 370,
good afternoon'
'N600XL'
When the Legacy overflew Brasilia
at flight level 370, according to the flight plan
it should have descended to 36000 ft,
but the controller simply forgot
to give the order to the Legacy
to descend to 36000 ft
The pilots would have assumed
they were meant to stay at 370
37000 ft.
No airplane should ever chance altitude
without receiving instructions
from Air Traffic Control
To discover why controllers didn't give
that crucial instruction
Colonel Ferreira takes a
closer look at the technology,
used to monitor the traffic over Brazil.
So, can you call up the Legacy jet screen for me?
On the radar screen,
we see the altitude, speed,
and the transponder information of each plane.
Each flight has an individual code, assigned to it
that helps controllers track it
Underneath that,
there are 2 separate numbers.
On the left, the plane's actual altitude
On the right,
the altitude the plane is supposed to be at
according to its flight plan
As the Legacy jet passed over Brasilia,
the number on the right,
the planned altitude, changed.
The computerized system automatically updated it
According to the flight plan,
at this point the plane was
supposed to descend to 36000 ft
360.
only Brazilian Air Traffic Control system is using
this kind of design
In other parts of the world,
this update has to be done manually
The computer changed a single number
which led to a critical error.
Without much experience
with the computerized system,
the controller mistook the new planned altitude
for the plane's actual altitude.
The system changed it automatically
from the authorized altitude
to the planned altitude
which made the controller believe
the Legacy was flying at 360.
Police investigators talk with
the controller who was on duty,
when the number changed on the screen
shortly after that, I had a break
He tells police about a critical mistake
on his part
you have 5 aircraft, the Legacy, is at 360
Before leaving,
he handed its flight off to another controller,
telling him where he thought the Legacy was flying
I believed it was at 360,
and that is what I told him
When the new controller took over,
the one being relieved gave him the
Legacy's altitude-information,
according to the flight plan, 360.
But the jet was actually flying at 1000 ft higher
right in the path of the Gol-flight.
Colonel Ferreira studies transcripts
of conversations on-board the Legacy
and finds that the crew was having
their one difficulties
during the flight
'How much longer, guys?'
'That is a good question, Ralph'
The crew seems unfamiliar
with some of the jet's advanced systems
I'm still working out
how to work this flight management system
'Where is the one that gives us Total Time?'
My impression is
that the pilots were trying to
learn their aircraft's system
during the flight
Investigators also uncover a break-down
in communications
After a brief conversation
between the Legacy-jet and Brasilia ACC,
Colonel Ferreira notices
something extremely unusual
For almost an hour,
the Legacy pilots don't talk
to anyone on the ground
Paladino did try to get hold of ground control
but he couldn't get through.
He then tried the back-up frequencies,
listed on his navigation-charts.
His only contact a single, garbled message
Both pilots and Air Traffic Controller
should have been more concerned
of maintaining two-way contact
all the time.
This is their duty
Had pilots and controllers spoken,
they might have discovered
that the Legacy was flying North
in a corridor that was reserved
for South-bound traffic.
As the public learns about the mistakes
in the Air Traffic Control Centre
there is growing pressure to make some changes.
We wanted to understand
what had happened to these people
inside the Control Room
Controllers should have been able
to see on the radar screens
that these two airplanes were flying
in a collision course.
Brazilian Air Traffic control
is one of the last in the world
to be run largely by the country's military.
Since they are run by the military,
by Brazilian Air force,
we did not have complete access to information
except for what was released
As fingers are pointing at controllers,
many of them come forward
with stories of overwork and poor training
They complain that they weren't well trained
in English language
which is the international aviation language
also they had complained about their equipment
In fact, the controller who incorrectly
reported the Legacy's altitude
had been on the job for only a year.
A valuable piece of the puzzle is still missing
Investigators still don't know what happened
during the final minutes of the Gol flight
Soldiers have been scouring
the Amazon jungle with metal detectors,
looking for the plane's missing memory module
Almost a month after the crash,
they find it.
Colonel Ferreira hopes to hear some reason
why the Gol crew wasn't able to avoid colliding
with an oncoming jet.
Gol 1907, contact Brasilia ACC on 125.2
Thanks very much Brasilia 125.2
Gol 1907
There are no alarms before the collision.
No warning
that they were flying straight for another jet
Pilots rely on Air Traffic Controllers
to keep other planes out of their path.
They spend much of their time
monitoring their instruments
Not the skies ahead.
At the speed they are travelling they
only have to look away for a few second
to miss an approaching plane
There are no issues of communication
and no misunderstanding between the pilots
and the ATControl
They had no idea what had just happened
with their plane
in far until the end to regain control
For less than a minute,
the pilots struggle for control
but there is nothing they can do
But why were there no warnings?
Both planes were equipped with a safety feature,
designed to prevent exactly this type of accident.
Ferreira now needs to know why that system failed
Earlier in the investigations,
strange radar images suggested
that the Legacy pilots
were flying wildly over the Amazon.
Now, those suspicions are vanished.
But Ferreira revisits the
fluctuating radar-data,
to understand why neither plane knew
the other was coming.
To try to understand
this last piece of the puzzle,
Colonel Ferreira returns
to the radar display
that AT controllers saw on the day of the crash
Instead of displaying just the expected altitude
and the actual altitude,
the letter 'Z' is between them
The 'Z' on the AT controllers' screens
indicates that the
airplane he is looking at
has lost its transponder.
Modern commercial aircraft
are equipped with transponders
Like small radio stations
they broadcast information
on the plane's altitude and flight number
This information is received by computers
on the ground
and instantly displayed on the screens
of AT Controllers
In Brasilia, if the transponder fails,
so-called primary radar takes over automatically.
Signals are send out from the
ground that hit the target
and return.
Those readings are wildly inaccurate
The inaccuracy of the radar,
tracking the Legacy jet
explains why its altitude appeared to be rising
and falling
Investigators discover
that the transponder wasn't sending
out signals for more than 50 minutes
before the crash.
But controllers didn't notify the pilots
That may be because they didn't notice
the subtle change.
There is an even more critical role,
played by the transponder
It doesn't just beam information
to controllers on the ground,
but to other planes as well
All commercial aircraft are
equipped with a warning system,
called TCAS
The Traffic Collision Avoidance System.
TCAS picks up a signal
from an oncoming plane's transponder.
and issues a warning if it is too close
If either plane's transponder is OFF,
the system won't work!
Ferreira discovers
that the Legacy's transponder
was working early in the flight
and after the collision
But for more than 50 critical minutes,
it was silent.
How had a state of the art jet ,
just off the factory floor
developed problems with its transponder?
Investigators examine
the Legacy jet's transponder unit.
They discover that the system which controls it,
had a troubled history.
It had been installed on a different plane
but removed, because it wasn't working.
It was repaired, and then placed on the jet,
that was sold to ExcelAire
Investigators have the system tested.
But even with its suspicious past,
after the crash they can find no obvious problems
with the plane's transponder.
Now, this is the layout now,
the wiring of Legacy jet
Colonel Ferreira does notice
something potentially dangerous
about the design of the cockpit
If the pilot uses the build in footrest
during flight,
his toes can come in contact with the buttons
on the transponder
'It looks like in STANDBY mode'
And when the transponder goes into STANDBY,
it would be difficult for pilots to notice
'There is no alarm?'
A small yellow warning light
is the only indication
that the transponder isn't ON.
It was not easy for the pilots to detect that
because it is not hooked up
with the Central Warning and Alert System
But the pilots of the Legacy jet
do not remember using the plane's footrest.
Investigators suspect
that one of the pilots may have
turned the transponder OFF
by mistake
The most probable scenario is that by accident
one of the pilots temporarily
turned OFF the equipment
as he tried to familiarize himself
with the technology on board.
However, the transponder went OFF,
at a critical moment
the crew had no last safety system to warn them
that they were flying right at a 737
Even though the TCAS system on the Gol plane
was working,
there was no signal
from the approaching jet for it to receive.
Closing in on each other at 1600 km/hour
the pilots never saw each other coming.
Brazil's Air Traffic Control system
would undergo some radical changes
as a result of the collision
But those systems would not come without a fight.
The investigation into the
crash of Gol Flight 1907
has uncovered dangerous problems with
Brazil's Air Traffic Control system
Two planes were assigned to
fly at the same altitude
in the same airspace.
Overworked and inexperienced
controllers in Brasilia
neglected to instruct the Legacy jet
to descend to 36000 ft
Then, they mistook the Legacy's planned altitude
for its actual altitude.
To make matters worse,
the Legacy pilots,
unfamiliar with Brazilian airspace,
were unable to make contact
with controllers on the ground.
and somehow the transponder,
which broadcasts their location in the sky
went silent
which controllers in Brasilia failed to notice.
A multi billion dollar Air Traffic Control system,
designed to keep planes apart,
had failed to detect two planes
on a collision course
One by one, a series of human errors occurred
and all of the defence systems that exist
to avoid these errors
were defeated.
A month after the crash of the Gol passenger plane
controllers begin a 'work to rule campaign
They want to draw attention to problems
with the system.
Once they did start working to the rules
and not stretching them anymore
this triggered what we call
'The Aviation Crisis in Brazil'
At a certain point,
maybe 40% of the flights in all
of Brazil had over an hour delays
Following the crash and the work slowed down,
changes start being made.
There is been a lot of changes
in Brazilian aviation
after the accident.
specifically with Air Traffic Control.
The air force had to admit that
they had a shortage of controllers
and also there is a higher degree of accountability
In the United States,
the FAA issues two recommendations
as a result of the tragedy
Pilots flying Legacy jets are
warned of the possibility
that putting their
feet up in the cockpit
could accidently turn off the transponder.
And manufacturers are told
that an alarm should sound
if the TCAS system shuts OFF.
The controllers who were involved in the crash
are charged with varying
degrees of manslaughter
But those criminal charge worry people
who are closely involved with the disaster.
An investigation like ours,
which focusses on prevention
suffers huge setbacks when there is pressure
to late charges.
By blaming people we might be creating a culture
where people will not come forth and be honest
about failures and mistakes.
And when we try to hide that,
they've got sucked under the carpet.
and soon enough will come out again.
No controller leaves his
home in the morning
thinking he is going to crash a plane.
And so the criminalization only
interferes with investigation
that can prevent further accidents
More than 2 months after the crash,
the crew of the Legacy
jet is finally allowed
to return to the United States
Joe and Jan barely get out of the country
There was an attempt
to hold them under a coupled
together initial criminal charge of
'Failing to ensure the
safety of Brazilian skies'
Well, you are all grateful for the safe return
of Joe and Jan
And everyone on board the Legacy :
you all are sadden by this tragedy
which took many innocent lives
More than a year
after the accident,
the Legacy jet that survived
the mid-air collision
was still at the airfield in the Amazon.
Its maiden voyage cuts short
by a tragic series of technological
and human errors.
Subtitles
Rein Croonen