EPOCA : We remain on collision course
Nearly five years after the Flight 1907 accident, three people were convicted for negligence. But the environment that allowed the tragedy has changed little.
HUMBERTO MAIA JUNIOR, LEONEL ROCHA and LETÍCIA FENILI
One of the worst tragedies in Brazilian commercial aviation, the crash of the Gol Boeing that was performing Flight 1907 in September of 2006, received last week two awaited judgments from the Courts. On Monday the 16th, the American pilots of the Legacy jet which collided with the airliner over the Amazon were convicted to four years and four months in jail. The penalty given to Joseph Lepore and Jan Paul Paladino was substituted for community service, which can be served in the United States, where both live. Three days later, Federal judge Murilo Mendes, of Sinop, Mato Grosso, sentenced controller Lucivando Tiburcio to three years and two months of jail for incompetence. In the same judgment, air traffic controller and ex-Air Force sergeant Jomarcelo Fernandes dos Santos was absolved of the accusation of negligence.
Pilots Joseph Lepore and Jan Paladino. The two were convicted for the crash of Flight 1907, but a report by DECEA (above) shows that the problems prevailing at the time of the accident remain.
The decisions mean little for the critical sector of Brazilian air traffic control. The courts consider that those responsible for the accident, in which 154 people died, had no intent to kill. They were only negligent within a chain of command which showed itself permeable to error and to carelessness. Almost five years later, there are motives to believe that a similar disaster can happen again. The Manaus-Brasilia-Rio de Janeiro flight's code was changed to 1587. But a confidential Air Force report, obtained by ÉPOCA, shows that little has changed in the Brazilian structure responsible for guaranteeing the safety of passengers and crews in the country's skies.
“Two air traffic incidents occurred in ten minutes"- Luis Nascimento, colonel-aviator
In 2006, investigations showed that air traffic control suffered from a lack of professionals, who were overworked. There were failures of the radars spread around the country and difficulties in communicating with airplane pilots. In the two-page document, produced on October 21 of last year by the Department of Air Space Control (DECEA) colonel-aviator Luiz Ricardo de Souza Nascimento relates his concern about the same problems. The text affirms that, two days before, four airplane had almost collided when flying over Guarulhos Airport, in São Paulo. There were two incidents in less than ten minutes involving the same controllers. "Recently, 02 (two) air traffic incidents occurred in one of the busiest TMNAs (Guarulhos terminal) in the country in a short span of time, less than 10 (ten) minutes, involving the same ATCO (controllers) operating grouped sectors and an elevated number of aircraft, since some of them had been detoured”, said the document. Translated from technical jargon, the text affirms that, with many airplanes to monitor, the controllers had not managed to handle the work. Because of this, some of the aircraft had to make risky maneuvers to avoid a collision. With the controllers' incapacity to warn all of them, the pilots made their maneuvers thanks to an electronic anticollision warning system. Called TCAS, this resource obliges the pilot to make evasive maneuvers in situations of risk.
In their work routine, each controller guides a group of about 14 aircraft, called a "sector". When this group grows too large, another controller is called to help, in an operation known as "sector ungrouping". On that day in October 2010, after the first incident, new controllers were urgently summoned to perform the "ungrouping", that is, to divide the work in the operations of takeoffs and landings. But they did not arrive in time to avoid the second incident. By luck, nothing more serious happened.
Gol Flight 1907 Boeing 737, in Serra do Cachimbo, in Mato Grosso. The 154 people aboard died.
The report by DECEA, an Air Force organ, further says that not even one of the oldest and most common of the systems of communication between airplane and control tower, done by VHF radio, worked. “One of the aircraft involved did not even manage to maintain radio communication with the APP (approach control) due to the congestion of of the VHF frequency", it said. In the report, colonel Nascimento asked DECEA to take measures. "The matter discussed here is very serious and demands the personal efforts of the heads of Sipacea (Aviation Accident Prevention System) and the ATC (air traffic control) organs, in the sense of putting mitigating measures into place, in order to avoid possible irreversible events with harmful consequences." Sought out by ÉPOCA to comment on the document, the Air Force had not responded by the closing of this edition.
In 2008, the Air Force organ responsible for investigating and avoiding aeronautic accidents (CENIPA), finished a report with suggestions to avoid the failures that lead to the collision between the Gol airplane and the Legacy executive jet. They included the adoption of measures to assure that the controllers had mastery of English (to facilitate communication with foreign pilots) investment in the purchase of equipment and software for monitoring aircraft and more training for controllers. Changes were made, some for the worse. There have been improvements in relation to 2006, but today's air traffic is more complex. “We have a stage that is set for the occurrence of new problems", said Edleuzo Cavalcante, president of the Brazilian Association of Air Traffic Controllers (ABCTA). According to Cavalcante, after the accident with the Gol flight, DECEA invested in modernization and replacement of equipment, but little was invested in personnel. The School for Training Sergeants (CFS), in Specialization in Air Traffic Control (BCT), trains about 150 students a year. According to the association, that number is only sufficient to replace the controllers who leave the profession.
Cavalcante further affirms that today controllers work more. In 2006, the limit established was 144 hours per month. "Now, in practice, they're working 170 hours, plus a 24-hour shift in which the military controller has to remain ready on call." On the eight-hour continuous shifts, in theory the controller should remain at most two hours in front of the radar console, with a one hour break. More time that this leads to mental fatigue. The controller follows up to 14 aircraft, and each one of them has various items of information - such as route, altitude, location, velocity - which appear in small letters. "Tiredness make it difficult to visualize dangerous situations", says Cavalcante. “Some 90% today work up to four hours straight."
For more critical situations, it would be ideal to have available experienced professionals qualified to deal with situations in which there is little margin for error. Does this happen? No, according to a controller who worked for 15 years training personnel. "Among those now working, 70% to 80% have no more than four years' experience. " He said that even the rookies, with two years of experience, are working in supervisory roles "that used to occupied by controllers with a minimum of ten years' experience". Although the training course has been lengthened from a year and a half to two years, the student have lost training and simulation hours. According to the controllers' association, the hands-on training time required has dropped from 300 hours to 60. “Since the Gol accident, the number of controllers trained has increased, but not the quality. And the tendency is for it get worse, because the experienced ones will retire”, affirmed Leo Frankel, Gol pilot with 40 years' experience.
Another important training failure is the mastery of English. In 2007, the International Civil Aviation Organization (ICAO, in English abbreviation) performed an audit in Brazil and found that only 5% of controllers had level 4 English - the minimum acceptable - on a scale that goes from 1 to 6. “The Air Force promised to raise to 80% the number of level 4 controllers by 2014 (the year of the soccer World Cup, when the number of foreign aircraft landing in Brazil will increase)", said the ex-instructor of air traffic control. In the report on the Boeing accident, CENIPA recommended to ExcelAire, the American air charter firm which had come to Brazil to fetch the Legacy involved in the collision, that in the future it turn over this task to pilots with knowledge of Brazilian flight rules. But for failure to follow the recommendation, no punishment is specified.
Jorge Barros, ex-Cenipa accident expert, says that the search for greater safety is being pursued by shrinking air space. He affirmed that, in 2007, to reduce the controllers' excessive workload, DECEA limited the circulation of small planes, which depend on non-instrument flight, to a ceiling of 7,500 feet - far from the commercial airliners. This is not the case for business jets like the Legacy, whose permitted traffic range remains the same. “International rules permit airplanes flying under visual rules to reach 14,500 feet. The change is typical of those who don't have enough controllers." The fine for those who disobey the new rule ranges from R$ 5,000 to R$ 20,000 [US $ 3,000 to $12,000].
The route that the Gol Boeing took, from Manaus to Brasilia, is known for having areas where radar scanning is faulty. According to Barros, of the country's approximately 150 radars, 20% are out of service. “Maintenance is expensive and difficult, because some radars are in places that are hard to reach, and DECEA does not have funds to maintain them", he affirms. To decrease the lack of control in Brazilian airspace, the specialist suggested in investing in ADS-B technology, a system similar to GPS which detects aircraft in real time. “Since 2006, all American aircraft have this technology. In Europe, the implantation should be finished in 2012. Brazil is still crawling." The technology allows the pilot to know the position of other airplanes, which diminishes dependence on air traffic controllers. According to Barros, the adoption of this system by Brazil could reduce by 20% the number of flight controllers needed to insure that new tragedies do not happen.