sexta-feira, 26 de abril de 2013

(English text) PETERKA: Flight 1907: basic mistakes by the north-american pilots who killed 154 people

Introduction from ATC BRASIL:

We were asked to publish the English text as well on this Blog (the Portuguese version was published before)
Here is the English version/translation made either by the author and/or by somebody mandated by him.

This is the opinion of Expert PETERKA and does not reflect the opinion and the views of this Blog.
But it's for sure a source of reflection and discussion, despite the fact that it contains some basic errors or facts.
For instance it's not disputed that the Transponder and TCAS of N600XL were on and fully operational until passing Brasilia/BRS.
This is an undisputed fact.

We wish good reading!

Flight 1907: basic mistakes by the north-american pilots who killed 154 people

By Roberto Peterka, technical assistant of MPF in the criminal charges of Flight 1907.

In that afternoon of the beginning of spring, the aircraft that would transport 154 people taking off in Manaus, would take all these people to their last action of their lives. The pilot had solicited and was answered by Air Traffic Control to take off in a lower altitude than the one stipulated by the repetitive flight plan of the company.

They were also unaware that another aircraft, of smaller size, with north-American documents, was flying in an irregular fashion opposite to the Brazilian aircraft in the same airspace, and that this would cause a crash, making this the biggest “in-air-collision” in Brazilian air space, where all the occupants of flight 1907 died.

But why this accident happened? Why the American pilots disregard many legal and safety procedures to make their flight happen? Everyone knows, since their first steps in aviation, that a flight cannot iniate without having a few elementary norms fulfilled, starting with training of the kind of aircraft Will be piloted. These two American pilots were unfit in training to pilot this aircraft.

Another important point is to check the aircraft’s documentation. If it is ready to fly; what kind of flight it can perform and if its crew comply with the legal requisites to fly under certain special circumstances of air space.

This flight should not have been made in the manner it was flown. This American aircraft could not have flown under the conditions of minimal vertical separation, due to the fact that it did not have authorization to do so. Therefore, the aircraft should not be in that place when it crashed with flight 1907. This condition of not being authorized should have been informed to Air Traffic Control, but it was not. If this situation would have been informed, flight 1907 would not have been authorized to fly in the altitude that it had solicited!

Before taking off, the pilot must make a meticulous plan of what the pilot will execute. This plan includes: analyzing all the geographical points in which it will pass [horizontal navigation], the meteorological conditions of the route, in its destiny, and an alternative airport, in case its destiny do not allow landing.

Today, technology allows this kind of planning to be made by computers however, it demands that the pilot examines it to approve, or disapprove of it. This plan made by a computer, served as base to a presentation of the flight plan had two level alterations. One in Brasilia, and another one in a virtual point called aeronautical fixed point. We can simplify these steps in just one thought: “The flight that you will do, you have done it. All you have to do now is to execute what you have planned”. This plan was also considered inefficient.

Right after they turned on the engines and were getting ready to takeoff, the American pilots did not fulfill other safety and legal procedures as well.

They did not turn on the anti-collision device [TCAS]. This equipment serves as warning sign of proximity of another aircraft with a potential of collision. The velocities these modern aircrafts take these days make it impossible for a person to visualize one aircraft approaching. This technology could be considered the electronic eye of the pilots.

This equipment was turned on only after the crash, when the pilots talked among themselves, as it was registered on the dialog Box [Black Box] that this equipment [TCAS] was turned off.

Another equipment turned off after crossing Brasilia was the transponder that sends signals to Air Traffic Control and for anti-collision devices of other aircrafts, transmitting geographical location, flight altitude, the direction, and the speed of the airplane sending this information.

This important safety device was only turned on again after the conversation between the pilots about the TCAS being turned off. Coincidently, less than a minute after this conversation, information sent by the American airplane began to appear in all radars, and the black box began operate. Before the collision and even with all the equipments turned on by the crew of flight 1907, confirmed by the black box, the airplane could not identify another aircraft in a collision course, due to the fact that the other airplane had all the paramount equipments to do so turned off!

sábado, 20 de abril de 2013

Analyzing some details of the fatal mid-air collision: Adherence to Flight Plan

Our last post has stirred some reactions, as well as some comments.
This is excellent news – as discussing a problem/issue always means that knowledge and “awareness” is gained and views are exchanged.

The group of the association of the families and friends of Flight 1907 has commented the following:

We believe you have failed to consider a detail as the initial flight plan of GOL WAS 41000 feet. And they have asked permission and were cleared at 37000 ft on this route. So, there was no flight plan at 37000 for this route. The Legacy – according its flight plan – should have been at 36000 on this route. They didn’t ask for and didn’t receive clearance to change level. So they would have been at 36 and Gol would be at 37. They simply didn’t follow the flight plan. Furthermore 37000 ft in direction of Manaus is OPPOSITE TO THE FLOW of the AIRWAY.

So, let’s technically analyze some of these points made by the president of this association:

What is a Flight Plan (FPL)?

It is a specified information provided to air traffic services units, relative to an intended flight or portion of a flight of an aircraft (ICAO Annex 2 / ICAO Doc 4444).

The difficulty starts as “Flight Plan” has many meanings and definitions (by ICAO).

There are several flight plan types:

Filed Flight Plan (FPL).
Flight Plan Filed in the Air (AFIL).
Supplementary Flight Plan (SPL)
Actual Flight Plan (AFL)
Current Flight Plan (CPL)
Repetitive Flight Plan (RPL)

The Filed Flight Plan is the flight plan as filed (deposited) by the pilot in command, the aircraft dispatcher, or any other mandated agency/agent.

A Current flight plan (CPL) is a filed flight plan with amendments and clearances included (e.g. in flight and in two-way contact with ATC).

An Actual Flight plan is amended and corrected by time – according to the estimates and the progress of the flight.

A repetitive flight plan may be used for IFR flights with a high degree of stability over the same days of consecutive weeks on at least 10 occasions.

A good example of the difference between FPL (filed flight plan) and current flight plan (CPL) is what happened with flight GLO 1907 with Centro Amazônico of Manaus.

They had requested FL 410 in the FPL/RPL, but the pilots have requested FL 370 instead of 41000 ft via radio. So, clearance was given to climb to 37000 ft only = CFL = Current Flight Plan. And the Manaus controllers have changed and adapted the flight plan in their ATC – system (X-4000) accordingly.

Now, for N600XL the same has occurred:


This is by now the current flight plan (CPL) as cleared by ATC.
The FPL (which was filed is “amended”). The flight plan was adapted and “corrected” by ATC – this is now the valid and current flight plan.

CENIPA writes the following in its final report:

It is common that, when duly authorized by ATC, aircraft maintain flight levels different from the recommended standard and, provided there is not a conflict, controllers may authorize such procedures for the benefit of the traffic flow. Therefore, flying in a direction opposite to the normal traffic flow would not be incorrect, provided a coordination was made by the controllers and pilots, prior to performing such a procedure.

Our comment:

Yes, and we believe the following has happened with the Brazilian ATC-system:
The above clearance was issued by SBSJ TWR (following a telephone-coordination between Brasilia ACC).
FL 370 until Manaus was cleared, but the Filed Flight Plan (FPL) was not correctly updated/amended to become a CFL (Current Flight Plan) in the ATC-system. So, the Flight Data Processing System (FDPS) of Brasilia and X-4000 remained in the “ancient” state – FPL-state, and so not updated and/or corrected. This is also the reason why the ATC-system started to change automatically (and erroneously) the levels of N600XL after BRS.

This is what is called a “systemic error”. True, it’s for sure a non-error tolerant system-design.

For the operation of flights, ICAO says the following:

An aircraft shall adhere to the …

current flight plan; or
the applicable portion of a current flight plan; or
the applicable portion of a current flight plan submitted for a controlled flight unless

a request for change has been made and clearance obtained from the appropriate air traffic control unit; or

………………. unless an emergency situation arises which necessitate immediate action by the aircraft, in which event, as soon as circumstances permit, after such emergency authority is exercised, the appropriate ATS unit shall be notified of the action taken, and that this action has been taken under emergency authority.

In the US/FAA the following is valid and applicable:

(i) The altitude or flight level assigned in the last ATC clearance received;

Our conclusion: It’s untrue to say that the pilots of N600XL didn’t follow their Flight Plan.

And one aspect which we will discuss in a future post is the comment that N600XL flew "contra mão" - opposite direction, as the Brazilian love to say.

But can you fly "contra mão" in a radar sector - where "vigilâcia radar" is provided and guaranteed.
And so flights are "under radar ontrol" and are "identified" and "sob vigilância radar?

……………. More to come! Interesting discussions lying ahead of us! And comments are always welcome!

ATC Brasil

segunda-feira, 8 de abril de 2013

Associação dos familiares do vôo 1907, ela usa o "perito" Peterka - triste a falta de conhecimento dele!

Voo 1907: os erros básicos dos pilotos norte-americanos que mataram 154 pessoas

Por Roberto Peterka, assistente técnico do MPF na ação criminal do Voo 1907

Naquela tarde de início de primavera, o avião que realizaria o voo 1907 se preparava para decolar de Manaus, com 154 pessoas a bordo, sem saberem que esta seria a última etapa de suas vidas.

O piloto solicitou e foi atendido pelo Controle de Tráfego Aéreo para realizar o voo em altitude menor do que a estipulada no plano de voo repetitivo da empresa.

Desconheciam também que outro avião, de menor porte, de matrícula norte-americana, nesse momento, se encontrava, de forma irregular, na contramão da aerovia, em voo no sentido contrário e os abalroaria causando o maior acidente aéreo brasileiro do tipo “colisão em voo”, onde todos os ocupantes do voo 1907 pereceram.

Comentário : Os pilotos da Gol receberam uma altitude 37000 pés pelo contrôle do tráfego aéreo de Manaus (em vez de 41000 ft que era pedido no plano de vôo repetitivo) : Tudo em ordem e perfeito segundo o perito Peterka.
Agora os pilotos americanos receberam 37000 pés pelo contrôle aéreo de Brasilia – e de repente tudo foi errado. Como compreender isto?

E porque esse acidente aconteceu? Por que os pilotos norte-americanos desprezaram várias normas legais e de segurança na realização desse voo.

Todos aprendem, desde os primeiros passos na aviação, que um voo não pode iniciar sem que cumpramos algumas normas elementares, a começar pelo treinamento no tipo de avião que vamos pilotar. Esses pilotos foram considerados com o treinamento deficiente nesse avião.

Comentário : Foi Embraer mesmo que formou e « liberou » os pilotos – porque não acusar e processar Embaer?

Outro ponto importante é verificar a documentação da aeronave. Se ela está liberada para voo; que tipo de voo pode realizar e se ela e a tripulação atendem a requisitos legais de voarem sob certas circunstâncias especiais no espaço aéreo. Este voo não poderia ter sido realizado na forma que o foi. Essa aeronave não poderia voar sob condições de separação vertical mínima reduzida, pois não tinha essa autorização, portanto não deveria estar naquela situação quando colidiu com o voo 1907. Essa condição de não estar autorizada deveria, obrigatoriamente, ter sido informada ao Controle de Tráfego Aéreo, o que não foi realizado. Caso fosse informado essa condição o voo 1907 não teria sido autorizado a voar no nível de voo que solicitou!

Comentário: Esta aeronave era de matricula norte-americana (N600XL), então as regras americanas da FAA ficam aplicaveis por obter o estatuo RVSM. O Brasil reconhece (via a OACI) a autoridade americana da FAA = tudo em ordem.

Ainda antes de iniciar o voo, o piloto deve realizar um planejamento criterioso do que vai executar. Esse planejamento inclui analisar os pontos geográficos por onde vai passar (navegação horizontal) e em que altitude vai passá-los (navegação vertical), além das condições meteorológicas na rota, no destino e no aeroporto alternativo, caso o do seu destino não permita o pouso.

Atualmente a tecnologia permite que esse planejamento seja efetuado por computadores, entretanto, exige que o piloto o examine e aprove ou o rejeite. Nesse planejamento realizado pelo computador e que serviu de base para apresentação do plano de voo constavam duas alterações de níveis. Uma em Brasília e outra em um ponto virtual chamado fixo aeronáutico. Podemos resumir essas etapas a serem realizadas antes do voo numa frase: “O voo que vai fazer, você já fez, agora somente vai executar o que planejou”. Esse planejamento também foi considerado deficiente!

Comentário: A navegação vertical do plano de vôo se faz sempre com as “clearances” do controle do tráfego aéreo. Isto é um feito incontestável.

Já depois de acionar os motores e se prepararem para decolar, os pilotos norte-americanos também não cumpriram outras normas legais e de segurança. Deixaram de ligar o equipamento anti-colisão (TCAS), que serve justamente de alerta sobre a proximidade de outra aeronave com risco de colisão.

Comentário : mais uma fabulação do Peterka. E bem comprovado que o TCAS (e o transponder Mode-S) do N600XL funcionaram sem problemas desde SBSJ até o VOR de BRS.

As velocidades desenvolvidas pelos aviões modernos não permite o ser humano visualizar a aproximação dessas aeronaves. Daí a tecnologia ter desenvolvido esse equipamento que alerta, ambas as aeronaves, quando em condição de aproximação perigosa. Pode ser considerado o olho eletrônico dos pilotos.

Esse equipamento foi ligado apenas após a colisão quando os pilotos comentaram entre si, como está registrado na caixa de diálogos na cabine (caixa preta), que esse instrumento (TCAS) estava desligado (off).

Outro equipamento que foi desligado após passar por Brasília, foi o transponder que emite sinais para o Controle de Tráfego Aéreo e para os sistemas anti-colisão de outras aeronaves, transmitindo a posição geográfica, o nível de voo, o rumo e a velocidade deste avião emissor.

Também esse importante equipamento de segurança somente foi religado após a conversa dos pilotos que o TCAS estava desligado. Coincidentemente, menos de um minuto após essa conversa, surgiram nas telas dos radares todas as informações emitidas pela aeronave norte-americana. Juntamente a isso, a caixa de registros dos parâmetros de voo (caixa preta) que o TCAS se tornou operante.

Antes da colisão mesmo com o TCAS ligado na aeronave do voo 1907, confirmado pelo registro na caixa preta, este não pode identificar a outra aeronave em rumo de colisão porque esta se encontrava com os equipamentos imprescindíveis para isso, desligados!

Nota da Associação:

Vale lembrar que está comprovado pelo CENIPA através da caixa de voo que: a- os pilotos americanos (Lepore e Paladino) do Legacy levantaram voo com o TCAS (aparelho anticolisão) desligado; b- que os mesmos pilotos americanos do Legacy desligaram o TRANSPONDER; c- assim como voaram em espaço aéreo RVSM sem autorização (LOA); d- e também voaram na contramão da via.

Além disso, está também comprovado pelo CENIPA através da CAIXA de VOZ que:

a- os pilotos americanos do Legacy não tinham treinamento completo para este tipo de aeronave;
b- o piloto LEPORE não tinha habilitação para este tipo de aeronave;
c- os pilotos americanos não respeitaram o PLANO DE VOO;

Por tudo isto a ANAC/DECEA autuaram, administrativamente, os pilotos americanos Lepore e Paladino junto à FAA/EUA; que ainda não cumpriram tal determinação uma vez que os dois pilotos continuam voando; um pela American Airlines e outro pela Excel Aire. Na área criminal a justiça brasileira já condenou os pilotos americanos pela tragédia em segunda instância. Outro ponto muito importante é o precedente de cassação do FAA de outubro de 2009 que temos; em que um caso bem menos grave ocorreu em solo americano e mesmo assim a entidade cassou os breves dos pilotos sumariamente apenas por colocar em risco a vida de americanos.