Wednesday, May 23, 2007
Brazil: The End Game
Right: Amazon site where 737 went down, via Wikipedia
Below: Legacy 600 at jungle air strip after the crash.
Sometimes I have faith that reason will prevail, the truth will out and crucial lessons will be learned about the dangers of a rush to judgment, and particularly to assign criminal blame, in aviation disasters. The signs are increasing that Brazil will not be able to continue blaming the two American pilots while maintaining that its air-traffic control system is well run.
That cat, I would say to my adversaries in Brasilia, has been out of the bag for some months now.
Which brings me back to what caused me to blog so obsessively on this issue, once I was home in early October.
Alone, among media colleagues who cautioned that the investigations must lurch to their ultimate conclusions, whenever that might be, I have been pointing out since the day I got out of custody in Brazil that Brazilian air-traffic control was in a crisis.
Pilots told me this, again and again -- in the days before we all found out the truth.
In the jungle, where I was among the seven American survivors held in custody, a Brazilian Air Force colonel told me this, the day after the collision. "What happened?" I said, as we stood looking at the damaged Legacy 600 business jet that had somehow managed to land after a collision that all aviation experience says no one could have survived.
"Shit happens," he told me in English. He paused for a while and said, "This was air traffic control."
You may not recall, but I certainly do, the first week in October, after I casually mentioned on CNN that international pilots were wary of radar and radio blind zones in Brazil, and also were cautious of Brazil's shaky air-traffic control system and of the fact that controllers were not especially adept at speaking English, which is the agreed-upon language of international aviation.
The response in Brazil to my comment about their air-traffic control system was explosive. The personal response to me was staggering. I labeled a paid agent of American imperialism (not true, at least as far as the pay goes, and I would argue not an imperialist either).
I was denounced as an "assassin." My family was threatened. A journalist writing about sensitive topics gets used to anonymous threats -- but some of the ones I received were explicit and frightening, and even mentioned that my home address was readily available. For months, futile gesture that it would have been, I kept a Louisville Slugger baseball bat next to my bed, with another one next to the front door.
Meanwhile, and unrelentingly, the Brazilian authorities insisted that their air-traffic control system -- which had supposedly been brought up to world standards in a billion-plus contract with an American supplier -- was utterly without fault.
It wasn't until a few months ago that the reality of Brazil's shoddy air-traffic control system was acknowledged.
And, as I said, it isn't just Brazil. As bluntly reported Sunday by MercoPress, a pan-Latin American news service based in Uruguay:
"Pilots and air traffic controllers have warned that shoddy safety systems could be putting passengers at risk in South America`s two largest countries, prompting an international outcry for rapid overhauls of the organizations that manage air transit in Argentina and Brazil."
And here, via our intrepid Sao Paulo bureau chief Richard Pedicini, is an indication from today's O Estado de S. Paulo that the Federal Police are rethinking their position, disclosed last week, that the pilots were to blame and that any investigation into air traffic control's role was strictly up to the military.
The military runs air traffic control, has a clear motivation for protecting turf and budget, and has a terrible record of trying to scapegoat the Americans from day one, before investigations even began. Its top leaders have disgraced themselves with a string of asinine statements, many issued by the Defense Minister, Wonderful Waldir Pires, such as the utterly delusional charge that the American pilots had been performing illegal stunt maneuvers in the Amazon skies, causing the disaster.
Now that reason seems to be at least in gear, the next logical step (remember, I am operating here on faith, and I am not comfortable with faith) would be to concede that the horrible chain of errors and system failures on the ground (which are not in dispute) was the cause of this accident; to absolve the American pilots of blame; and to avoid pinning criminal blame on individual air-traffic controllers who made errors using poor navigational and radio equipment and working in an unsafe environment.
The system was at fault. The Brazilian air-traffic control system caused that crash.
So fix the system; get the bumbling military out of commercial air-traffic control; deal with the victims' relatives liability claims in Brazil, where they belong -- and move on. If it does that, the Brazilian government will be seen as a first-world nation honorably and firmly reinforcing principles that underpin air-traffic safety all over the world. It if chooses the course of scapegoating the pilots and failing to acknowledge and fix its faulty air-traffic control system, Brazil will look like a sad-sack third-world joke, still jerked around by the military a full 25 years after the military dictatorship in Brazil ended.
Translated from O Estado:
"May 23, 2007
Controllers were alerted over Gol accident, Federal Police Say
Inquiry into accident informs that Cindacta-1 screen showed three
warnings and sergeants did not take any measures and controllers
didn't follow rules.
SÃO PAULO - The inquiry by the Federal Police of Mato Grosso into the
Gol Flight 1907 accident leaves no doubts: the controllers of the
Brazilian air traffic control center (Cindacta-1) received three
warnings that the Legacy jet was not flying at the planned altitude
and did not take measures to avoid the collision with the Gol Boeing.
Besides the accusation of the American pilots Joe Lepore and Jan Paul
Paladino, the investigation also points to "involuntary conduct" of
four controller sergeants directly involved in the jet's monitoring.
The collision between the Gol Boeing and the Legacy jet, on September
29, 2006, caused the death of 154 people.
In the 41-page report, to which O Estado had access, police inspector
Renato Sayão Dias indicated that the controllers "failied to apply the
rules of the air". The first to err, according to the Federal Police,
was sergeant João Batista da Silva. A worker in the São José dos
Campos tower, it was he who transmitted the flight authorization to
the Legacy pilots, without mentioning the different levels along the
Sergeants Leandro José Santos de Barros, Jomarcelo Fernandes dos
Santos and Lucivando Tibúrcio de Alencar, all of Cindacta-1, are also
cited. In the view of the Federal Police, this controllers infringed
items of ICA 100-12 - aeronautic rules - and had improper conduct in
the face of the problem. To show the airmen's responsibility, the
Federal Police annexed to the final report the radar images made
moments before the collision - the same images divulged by the Air
Force on Saturday.
"I do not know where the police got this from, but I can guarantee the
controllers did not have access to those data", reaffirmed the
vice-president of the Brazilian Federation of Associations of Air
Traffic Controllers, Moisés Almeida. "There is a blind spot in that
area, in radio as well as radar." The Air Force command, however,
denies the existence of uncovered spots in air space. It also informed
that no equipment presented defects.
As they are military personnel, the controllers should be investigated
by the Military Prosecutors' Office. Military prosecutor Giovanni
Rattacaso, however, has already said that the Federal Police
investigation should serve as as basis for a Military Police Inquiry
Lawyer Fábio Tomás de Souza, defender of the controller sergeants,
alleges that technical failures induced the controllers to err. "This
will be the principal thesis of the defense", Sousa advanced. The
lawyer also criticized the release of the radar images. "The Air Force
is looking for an escape hatch. They put a Colonel-Aviator to speak,
but he understands nothing of the system."
What the Federal Police inquiry says;
What each controller supposedly did say on the day of the accident
Sgt. João Batista da Silva: transmitted the flight authorization to
the Legacy pilots, without mentioning the different flight levels
along the trajectory.
Sgt. Leandro José Santos de Barros: perceived that the jet's
information was incomplete on the radar and considered this normal.
Even without having certainty of the altitude, he acted as if the jet
was at 36,000 feet, when, in fact, it was flying at 37,000.
Sgt. Jomarcelo Fernandes dos Santos: communicated with the jet, having
verified that the aircraft was flying at 37,000 feet, but made no
observation to that effect. For seven minutes, he should have observed
that the Legacy was flying at 37,000 feet - and not at 36,000 -,
because the information was visible on the screen. He was not alarmed
at the loss of the secondary radar signal - which supplied the
altitude with precision. He did not take the measures foreseen - which
oblige the controller to inform when the transponder becomes
inoperative, communicating to the next control center (Manaus) for
measures to be taken and demanding that the pilot verify the operation
of the transponder. He told the controller who relieved him that the
jet was flying according to the flight plan.
Sgt. Lucivaldo Tibúrcio de Alencar: he received the jet at the level
of 36,000 feet and, even without information from the secondary radar [and], did not question the exact altitude. He made 8 attempts at contact
with the jet, but did not take the measures foreseen in case of
My Note: Rest assured, some of the stooges for the Defense Department among the Brazilian media (and they are legion) will rush to deflect the impact this story will have on public opinion in Brazil. The representatives of the families of the 154 passengers on the Gol flight who tragically died are especially determined to keep the focus on the American pilots, in order to have the civil suits tried in the United States. They're well aware of the relative futility of suing the Brazilian military.