Flight 1907: lessons to be learned

IDENTIFYING THE CULPRITS VERSUS IDENTIFYING THE CAUSES: FLIGHT 1907: LESSONS TO BE LEARNED

* Vuelo 1907: lecciones que aprender

Immediately after the serious collision between two planes over the Amazon, the airline involved presented an interesting point of view, recalling that at times like this speculations and unconfirmed versions usually abound. These speculations and rumors increase the anguish of families and complicate the investigation of the circumstances of the accident. The company recommends that the public only give credit to information confirmed by the authorities.

In the night of 29 September 2006 the airline announced that flight number 1907, which had departed at 15:35 from Manaus and was scheduled to land in Brasilia at 18:12, was long overdue. The last contact with the aircraft had occurred at 17:00. The plane was a B737-800 Short Field Performance, and has been received brand new from the manufacturer just two weeks earlier.

The next day, wreckage from the aircraft were located near Peixoto de Azevedo, in the Amazon jungle.

POINT OF VIEW OF THE MANUFACTURER OF THE SMALLER AIRCRAFT

The smaller aircraft's manufacturer reported that it was informed of a mid-air collision over the Amazon of an EMB-135BJ Legacy 600, owned by one of its costumers, during its delivery flight to abroad. The plane managed to land without casualties.

The manufacturer has offered to cooperate with the authorities, in any possible way, in the investigation of the cause of this accident. A spokesperson for the company conveyed that they will not comment on rumors or other reports.

POINT OF VIEW OF THE LOCAL AUTHORITIES

The minister of Defense, responsible for both military aviation and civil aviation, insisted that the airspace control system was in good working order, and it was not for lack of communications that the accident happened. On the declaration of a foreign journalist who was traveling on the smaller plane, that the airspace control in the Amazon region is terrible, the minister insinuated that that idea is superficial and irresponsible. The minister raised no doubt that the airspace control system complied with its duty and considered the pilot of the smaller plane superficial and irresponsible when the latter disclosed categorically that he had to fly at 37 000 feet.

A judge at Peixoto de Azevedo determined the confiscation of the passports of the pilot and copilot, both foreigners, and prohibited them from leaving the country. And a court in the nation's capital seized the smaller aircraft for the payment of future compensations. 

POINT OF VIEW OF THE LOCAL PRESS

With each passing day, the two major local newspapers and the largest local television network were informing of the following versions about the accident: the flight plan may have indicated that the smaller plane should have changed altitude when passing over Brasilia, something that did not happen. The smaller plane was traveling at 37 000 feet (nearly 11,2 kilometers high) the wrong way in the B737’s route. The main hypothesis focuses in human error, either by virtue of a flight controllers' mistake, or because of a non adherence to the flight plan by the smaller plane, or by a deficient operation of this latter aircraft by its crew. (Lívia Marra, with Gabriela Manzini and Renato Santiago, Folha de São Paulo, 5 October 2006). 

Every information purportedly from the federal aeronautical branch shows that the foreign pilots were flying the smaller plane with its transponder (a device that identifies the plane on radar and provides information about altitude, and is integrated into the anti-collision warning system) turned off. Unnamed experts from the federal aeronautical branch don’t have any doubt that the smaller plane sort of cheated the flight controllers. (Globo, quoting Agência Estado, 3 October 2006, updated 4 October 2006). 

The controllers were thinking that the smaller plane would not dare to disobey certain (non-identified) rules, and so supposedly the controllers did not need to warn the B737 about the existence of somebody in their route. A communications failure described as improbable might have happened, but in that case, according to the unnamed source the rule is to follow the flight plan. These unnamed officials purportedly want to know also why the transponder started working again right after the collision, and why the pilot was able to call after that, asking for help, as if a miracle had taken place. A supposedly more serious and mysterious aspect was that some people in the federal aeronautical branch want to know why the smaller plane’s pilot did not answer the numerous calls from the controllers, up to the moment of collision. An unidentified officer was in favor of the opinion that very probably the pilot had turned the volume down. (O Estado de São Paulo, with collaboration by Bruno Tavares, Liège Albuquerque and Roberto Komatsu, 4 October 2006).

One speculation is that they had done something so unbelievable as disconnecting the transponder in order to perform some aerobatics, undetected by the flight controllers, supposedly to display the aircraft to the new owners. The pilots deny this. The pilots also informed that after landing the equipment was working OK. (Lívia Marra, with Gabriela Manzini and Renato Santiago, Folha de São Paulo, 5 October 2006).

An unidentified officer purportedly evaluates that 98% of the fault is attributable to the foreign pilots and 2% to the local controllers. They concede that other factors also contributed to the accident, such as possible errors from the flight controllers, and the fact that the smaller plane purportedly entered the airway in the wrong way, but the so-called preliminary conclusion from the federal aeronautical branch’s (unnamed) experts (before having the data from the aircraft's flight recorders) is that the transponder disconnection caused the accident. (Globo, quoting Agência Estado, 12 October 2006).

End of these few (among many) versions narrated in these important media outlets.

THE POINT OF VIEW OF THE SMALLER PLANE’S OWNERS

The lawyer hired to defend the air charter company which owns the smaller plane reminded that premature conclusions, based on leakage of documents that should be kept confidential, do not contribute to the investigative process, and that the finalization of this very investigative process will answer the many unsolved issues.

POINTS OF VIEW FROM INTERNET DISCUSSION FORUMS

These forums can be interesting, if one takes them as pastimes, and as means of testing one’s knowledge, with no pretension of finding the truths of the events simply by analyzing what appears in the press. Usually, forum membership is multi-national, and many members are professionally involved with aviation. The version of the events that appears more readily on http://www.airdisaster.com is the following: the smaller plane, going to Manaus, lost contact with the air controllers (wrong frequency?). The pilots tried to warn the controllers by setting the code 7600 in the transponder, but accidentally, they turned it into stand-by mode (due to improper equipment design?). This foreign crew, unaccustomed to local procedures, then followed their own country’s rules so they remained at 37 000 feet (their last altitude cleared by the controllers). The controllers, knowing that the smaller plane should change altitude, and maybe misinformed by inaccurate radar information, believed that the smaller plane was actually flying at 36 000 feet. Therefore they did not move the B737 (which was coming in at 37 000) out of the way.

With the smaller plane’s transponder set in stand-by, the anti-collision warning system did not go off in any of the two planes. They collided nearly head-on: the tip of the smaller plane’s left wing clipped off one third of the B737’s left wing, rendering the jetliner uncontrollable. Throughout the fall, the bigger plane broke up in several pieces, due to excessive aerodynamic forces. The smaller plane’s crew entered the code 7700 in the transponder (emergency), reactivating it without realizing. Eventually, they were able to get in communication with a cargo plane, which helped them perform an emergency landing.

One forum member concludes that there is no doubt that all this is pure speculation, but anyway is a speculation that makes sense and (if examined carefully) does not contradict the partial reports made public to that date.

SOME POINT OF VIEW FROM LAWYERS

Due to reports that some families are being stalked, by people carrying offers to sue the parties involved for compensations, the local bar association has warned its members that that kind of behavior is reproachable, and constitutes an infraction.

Lawyer César Mazzoni, a pilot himself and an aeronautical law specialist, writes that in cases such as this, the Ministry of Defense’s Center for Accident Prevention and Investigation (CENIPA, for its Portuguese initials) initiates a careful investigation in order to discover the causes, and then releases a report for the entire aeronautical community, as a way of avoiding new accidents. The report shall not blame anyone, but this does not prevent that, after its release, the culpability of those involved be questioned in a court of civil law, and compensation be sought. Lexi Hazam, a foreign attorney hired by a group of families, illuminated us that the determination of who has greater or lesser responsibility for the accident is competence of the jury, not the attorneys’.

THE AIR CRASH INVESTIGATOR’S POINT OF VIEW

The airline reported that its technical vice president is accompanying the investigation. The smaller plane’s manufacturer also sent technicians.

Due to the smaller plane’s registration number, the citizenship of its pilots, and the B737’s country of manufacture, the National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA) and the bigger plane’s manufacturer all sent investigators, in order to assist the local investigators. They make it clear that all information about the progress of the investigations shall be released by the local CENIPA.

A NTSB handbook reminds investigators that journalists want to know the causes of the accident, but they are not familiarized with the procedures regarding the determination of the probable cause. Investigators shall not speculate, and they shall limit themselves to present the facts obtained so far. The handbook warns investigators that spreading information that has not been officially cleared by the Board is a violation of regulations, and can be considered a criminal act.

Renowned and respected Flight Safety Foundation urged the local government to stay strong in face of the immense public pressure, and continue to respect the integrity of the investigation, and do not rush to judge the various players in this accident.

The Flight Safety Foundation joined the country in mourning this terrible loss of lives, but strongly urged everyone to allow the local Center for Accident Prevention and Investigation perform its job without interferences, so that accidents like this may be avoided in the future.

Aldo Loup.

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First published in ABC Color, on 15 October 2006. Photograph: Air Force personnel holding the flight data recorder of Flight 1907's B737-800 SFP. Credit: Alessandro Silva / Força Aérea Brasileira, via CENIPA / ANAC / Agência Brasil.