Brazilian AirTragedy: Blame the Software, the Radar and the Radio Too

    Two air traffic controllers who monitored the Legacy executive jet that collided with the Boeing 737 over the Brazilian Amazon killing all 154 people aboard talked to Brazil’s weekly magazine Época about the accident and indicated the trouble with the control tower equipment was a decisive factor in the tragedy.

    Both men, who work for the Air Force as most flight controllers in Brazil, agreed to give their version of what occurred in the control tower after the Boeing 737 disappeared from the radar with the condition that they might remain anonymous.

    One of them was responsible for monitoring the jet piloted by two Americans while the plane was in the Brazilian capital Brasí­lia’s air space. í‰poca magazine calls him controller A. The other man, controller B, was working in the same room and he also witnessed his colleagues’ drama, in the afternoon of September 29.

    Controller A expressly mentions a blind zone in the Amazon where the Boeing coming from Manaus to Brasí­lia and exactly on the same path as the Legacy could not be seen:

    "… The Gol flight had left Manaus’ area at 3:35 pm and should enter Brasí­lia’s area at 3:50 pm, that is, 15 minutes later. Just time enough to cross the blind zone. It was already 5:20 pm and nothing, the aircraft still wasn’t on the radar. Then I asked the controller who was on the monitor: what happened? He said: ‘The plane hasn’t showed up and we are in contact with Manaus’.

    "Before this fact everything was normal. After the aircraft’s disappearance, every one was feeling down. I saw one of the team members shaking the head, almost crying. Other supervisors asked to leave their own monitor to try to help the two supervisors. That’s when all other work regions started to concentrate on the accident zone.

    "Lots of officers appeared and then we noticed that the worst had occurred. The air became tense. There were people crying and asking to leave. The supervisor asked the team who was going to take our place, at 9:30 pm to arrive earlier. The supervisors were asking people to calm down, but nobody was able to work."

    Says Controller B: "One of the women controllers for the Rio de Janeiro region started to cry. Then the whole center felt touched. We needed a psychologist at that time, but no one showed up. The officers who were present didn’t know what was happening. I don’t know, maybe they didn’t want to believe.  They didn’t know how to deal with the situation. There was even an argument between controllers and officers. Nobody knew what to say."

    According to Controller A, people on Cindacta 1, Brasí­lia’s control center, were sure that the Boeing and the Legacy were in different altitudes:

    "The Legacy’s flight was normal. We only suspected something was wrong when the Gol’s plane disappeared. When the Legacy landed in Cachimbo (Cachimbo Air Base in the state of Pará) it informed that it was forced into an emergency landing because it had hit something. Then the controller said: ‘How come, if he was at 360 (36,000 feet)? There no way they could crash.’

    "In our chart, the Legacy was at 360. In the radar presentation, it was at 360. Then people say that we and the supervisor didn’t do a thing and that the Legacy had transponder’s trouble. You know why we didn’t do a thing? Because we visualized the Legacy at 360 and not 370 (37,000 feet). As the plane had trouble in the transponder, we couldn’t get the data from the jet, but only from our system."

    Controller B: "Our intention when contacting the Legacy was to warn that the transponder was down, and finish our task because the plane was going to enter an area not covered by radar and give them the next sector’s frequencies. That’s all we wanted to tell: ‘Talk to Manaus, and your equipment has trouble’. Nothing else."

    The software should be blamed, says Controller B: "We get a record showing the proposed and the authorized flight level. It was this that induced the controller into error. The record showed the flight level they were at, 370. And the flight level after  Brasí­lia, 360. When the plane got to Brasí­lia, the level that was requested showed up as authorized. This level was sent automatically to us.

    "This is something converted automatically by the software. And we had called attention to this problem a long time ago. Then the software threw in our screen the requested flight level as if it were the authorized one. When this happened, what we saw was: Legacy 360, and not 370. As the secondary radar was not picking up the transponder information, the primary radar, which oscillates a lot, showed the jet at 360. I even remember that one of the controllers asked: ‘What is the Legacy’s level?’. And the other said: ‘360’. "

    If they knew something was wrong it would have been easy to change the Boeing’s route, said Controller A. All they had to do was to call Manaus and ask them to tell the Boeing to change its course. "People ask, why haven’t you done this or that? Because for us everything was normal. If we put on paper all the similar situations we have faced we could write a book." And Controller B adds: "I have been in about 10 situations like this in my 13 years of experience."

    They also deny the Air Force information that there was no communication problem that day. Says Controller B: "This rainy season is a chaos. If you go to Brasí­lia’s control center now, you will see a madhouse. Cuiabá’s sector has three coverage frequencies. All of them have shortcomings. Communication is not clear. This is very dangerous. If the frequency is lacking, it doesn’t work. I cannot give instructions with echo,  I cannot talk and get a truncated answer. The instruction has to be clear."

    The controllers say that antennas in forest areas don’t work due to interference. The solution for them would be to do everything using satellite. As proof of the bad frequency in the area they mention a conversation of a TAM pilot the day after the accident.

    Controller A reproduces the communication: "Brasí­lia, for half an hour I have been trying to talk to you in all the frequencies, but I can’t make contact." This is there, recorded. But nobody is going to show this. They might even have erased it. Who is going to prove that it was there. The TAM pilots could. But they don’t want to talk, because even being civilians, they might be penalized by the Air Force."

    Controller B says that some equipment is modern, but everything is badly cared for: "Technicians say that often the equipment works with improvised patches. When there is a problem, a technician patches a wire, some palliative thing that can cause problem any minute.

    "Cindacta 1 is a shell. Whoever sees our center thinks that everything is modern, but we need investment in the main system: antennas and radars, which send information to the base. In the United States the monitors are old, but the frequencies and the antennas rarely fail."

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    • Show Comments (7)

    • me

      Enforcing laws? In Brazil?
      Enforcing laws? In Brazil? I am afraid this will never, ever, be possible.

      Why? In my humble opinion, and according to what I have seen, this people lacks a certain degree of seriousness, and is incapable in seeing the large picture of importance of laws to the general well-being of society. It’s a vale-tudo society, where killing a person is similar to wrongful parking in Europe.

      Living a short time here, I came to understand that Brazil is actually I wild, wild, jungle (even in big cities), covered by thin veneer of civilization (because you can stil buy cars, buildings, etc).

      Did you know the percentage of unsolved murders in Rio? 95%. In short, you can kill somebody, without worrying. Something that is imaginable in any other civilized country. And which started to give me nightmares, knowing that I can be swallowed by night just by walking on the street here.

      Just like in a jungle.

    • Marc

      Law enforcement
      Law enforcement over here…

      Am a Dutch engineer living in Brazil for three years by now and…
      [quote]first off it would be a real good start to ENFORCE the laws that exist in brazil, afterall, if laws are not enforced, what good are they?[/quote]
      Enforcing existing laws indeed is the first thing this country needs. Every friday crowds gather to drink beer in the backs of their pickup trucks next to a local gas station and leave driving drunk. I still have to see the first time the police mounts a road barrier and stops everybody for doing an alcohol test. Unbelievable, especially as accident rates because of drunk driving are high.
      And it is like this with enforcement of all laws, wether it being laws against cutting down forest, working conditions, money laundering, anything. The laws are there but nobody cares about enforcing them. But well, who knows one day this country will see the light…

      (although with politicians who primirily care about themselves and not about their country that might take a while…)

    • bo

      How brazil(ians) can do better..
      first off it would be a real good start to ENFORCE the laws that exist in brazil, afterall, if laws are not enforced, what good are they?

    • Dennis J Farquharson

      How can we do better?
      As an American who lives in Brazil and has developed a great affection for its people, I so much appreciate the spirit of the comment by alltheway. Like each of us as individuals, societies need to engage in introspection, celebrate our strengths, face our weaknesses, work to find consensus and make way for progress. We often seem to have an allergy to rules and being serious about public safety. I am struck for example by the dangerous way in which pharmaceutical products are distributed, crowd management at public events like football games carnival and the like, deaths resulting from drunk driving and negligence in maintaining highways. How can we do better? Defensiveness, public passivity and resistance to accountability and the rule of law is not the answer.

    • bo

      blame, blame, blame…
      Not one brazilian, nor brazilian company or entity has ever excepted blame for anything. It’s ALWAYS someone else’s fault. Do you think this will be any different?

      Lies, coverups, denials…typical brazilian behavior.

    • Robert

      A Super team
      These are “”Professional”” When they were all “”crying”” with big horse tears in their eyes who was watching the monitors for the other planes in the sky?
      Brazil was fast to blame the gringo “USA” but they were slow, after crying all over to blame themselves.

    • alltheway

      The true test of maturity in people or management or a system is whether they adapt and grow and improve based upon past results or blame others and not change. Seems to be room for improvement here in all 3 of these areas. In the end what is important is whether Brasil defines what needs improvement and makes the necessary long term improvements or just blames someone else for their problems and leaves things as they are. The lives of their citizems are entrusted to them and over time if processes, people and management does not change AVOIDABLE deaths will reoccur and that is a sign of a failed system and a betrayal of public trust..

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