cover
Two brand new aircraft collided at a height of 10,000 meters
One was killed and killed, and one plane was destroyed and killed
became the most painful air crash in Embraer's history at that time.
So what happened back then?
Let’s travel back to 2006 first and take you to re-examine the causes and consequences of this air crash.
006·Emma Airlines
Emma Airlines (Embraer S.A), founded in 1969.
Emma Airline Industry Corporation
business scope includes the design and manufacturing of commercial aircraft, business aircraft and military aircraft, as well as aviation services. It is the world's largest regional passenger aircraft manufacturer.
regional aircraft usually fly between cities with short distances and small passenger capacity. The opposite of regional aircraft is the trunk passenger aircraft . It mainly runs in big cities, carries many passengers, flies far, and has a large aircraft model.
regional aircraft distance is short
Internationally, the main manufacturers of trunk aircraft are Airbus and Boeing , and the main manufacturers of regional aircraft are Bombardier Airlines and Embraer.
On September 29, 2006, Embraer delivered a brand new business jet Legacy 600 to American Air Excellence.
This aircraft is designed to meet the needs of the official aviation market. It is equipped with winglets and a large-capacity fuel tank. The maximum range can reach 6,000 kilometers and can accommodate 16 passengers.
has become the "new favorite" of rental companies due to its increased range, low fuel consumption, ease of maintenance and attractive price.
Legacy 600
For the convenience of narrative, we will call this Legacy 600 delivered as " small aircraft ".
Delivery of aircraft, the manufacturer Embraer provides door-to-door delivery services.
But the buyer Excellent Airlines is engaged in various charter flights, aircraft management, maintenance and other businesses. It also has experienced and well-trained pilots, so they decided to pick up the goods at home.
In order to drive the plane home as soon as possible, the pickup time was specially advanced by one day.
The two American pilots of Excellence Airlines were on the flight mission. The captain was Joseph Lepore (Joseph Lepore)
Joseph Lepore
2 years old, worked as a commercial pilot for more than 20 years and had 9388 hours of flight experience.
There were only 5.35 hours on the Legacy 600, but he had received training on similar aircraft before and had perfectly handled two air emergency incidents in his career.
Deputy Captain Jan Paladino (Jan Paladino)
Jan Paladino
4 years old, has been a commercial pilot for 10 years and has 6400 hours of flight experience.
Although he only had 3.5 hours on the Legacy 600, he flew as co-pilot on Embraer's ERJ-145 model and 371 hours as captain.
and Legacy 600 developed from the ERJ-145 series , so in a sense, he has more experience on this plane than the captain. This is the first time he and the captain have a cooperation flight.
There are five passengers on the flight, two Embraer employees, two executives of the Excellence Airlines and a writer in the " New York Times " business travel column.
passengers on the plane
small aircraft will take off from Saint Jose dos Campos Airport in Brazil.
After stopping at Manaus , Fort Lauderdale International Airport in Florida, USA, and finally arrived at its destination, Long Island MacArthur Airport in New York.
In order to avoid crossing the Amazon forest at night, after the delivery ceremony, they will set off as soon as possible and started the first flight to Manaus at 14:51 local time (UTC, 17:51).
Accompanied by the rumbling engine sound, this brand new aircraft slowly glided on the airport runway One, accelerated, and finally took off to the air and flew northward.
Take off
The whole journey is about 3 hours and 40 minutes. Passengers only need to take a nap in the comfortable cockpit of the plane or read the news, and they can reach their destination without realizing it.
emergency landing
Compared with the leisurely passengers in the cabin, the two pilots in the cockpit were still a little nervous when facing this brand new plane.
After all, the two of them had less than 9 hours on this plane, and they were not very familiar with the flight system of this plane.
However, with their driving experience, they are enough to cope with this challenge, and there is no big problem.
Flying smoothly
The aircraft climbed to a cruising altitude of 11,000 meters (37,000 feet) for 42 minutes after taking off, and began a smooth cruising flight. The two pilots were not idle.
While they were paying attention to the autopilot, they took out their computers to calculate whether the plane could fill up the fuel and fly directly from Manaus to Florida the next day.
Also, before taking off, they learned that only some runways at Manaus International Airport can provide aircraft with takeoff and landing, so they must study it before landing. After everything was done, the captain went to the bathroom and the deputy captain took over the plane.
Deputy Captain took over the plane
6:48:15:
After being busy for 57 minutes without contacting the ground, the deputy captain suddenly found that it was impossible to use the radio to contact the ground control center normally, which made him feel a little uneasy.
6:50:55:
After leaving for 16 minutes, the captain returned to the cockpit and took over the driving rights. The deputy captain began to change different frequencies and found ways to contact the ground.
6:53:39:
After more than a dozen attempts, the deputy captain finally contacted the Brasilia air traffic control guy.
Air traffic control guy is vague in his words
It only takes three seconds. Air traffic control guy told him that the plane was about to be handed over to Amazon Control Center and he needed to change the radio frequency.
But because the signal is interfered with, the last two digits of the radio frequency to be changed was interrupted before he could hear clearly.
When he was about to ask again, a loud noise interrupted the plane's smooth cruise, and the autopilot disconnected.
The plane began to shake violently, and the alarm sounded loudly in the cockpit. Before the pilot could figure out what was going on, someone suddenly shouted in the cabin.
"The winglet on the left side of the plane is missing!"
At this time, it was no longer enough to consider what the plane hit. The only thing the two pilots thought of at this time was to control the plane first, and safe landing was the king.
At this time, the deputy captain looked at the captain who was even more nervous than himself and proposed that he would fly the plane. After weighing the pros and cons, the captain
agreed to hand over the aircraft's right to the deputy captain who is more familiar with the aircraft. He monitored the aircraft, was responsible for radio communications, and found a place to land in the Amazon rainforest that could not be seen at a glance.
soon found the nearest landing point on the aviation map, called Kachimbo Airport, a small military airport in Brazil, .
Kaqinbo Airport
Fortunately, during their forced landing, a passing cargo plane provided them with radio relay assistance, which allowed them to communicate smoothly and eventually made a successful emergency landing.
After the plane stopped, seven people walked off the plane with lingering fear. They looked at the damaged left wing and tail wing of the new plane. Before they could be happy about the successful successful thrilling landing, they were controlled by the Brazilian Air Force who was rushed.
missing plane
small plane was landing urgently, a Brasilian air traffic control guy noticed that a 737 passenger plane that was about to dock suddenly disappeared from the surveillance radar screen without sending any distress signal.
radar
After trying various ways to contact him, he found that the missing place of the Boeing 737 passenger plane happened to be in the airspace where the small plane had an accident.
So he reported the situation to his superiors. After learning about the situation, the control center speculated that the two planes might have collided in this airspace.
immediately launched the emergency response plan, and set up a search and rescue team as soon as possible, dispatching several Air Force transport aircraft and helicopters to the area where the Boeing 737 passenger plane disappeared.
Boeing 737
This Boeing 737 passenger plane is a plane that the Brazilian Gore Airlines just picked up from the manufacturer 17 days ago. Because it is a new plane, Gore Airlines specially arranged two experienced pilots to fly the flight.
Captain is 44-year-old Decio Chaves (Decio Chaves), who has 15,498 hours of flight experience.
Decio Chavez
13,521 hours were on the Boeing 737, and he was also the Boeing 737 flight instructor of Gore Airlines.
is also experienced with his partner's deputy captain (29-year-old Tiago Jordão), and has 3081 hours on Boeing 737.
Deputy Captain
For the convenience of narration, we abbreviated this aircraft as " large aircraft ".
large aircraft was operated this time by Gore Airlines Flight 1907, which took off from Manaus Eduardo Gomez International Airport at 15:35, and flew southeast along UZ6 route at an altitude of 37,000 feet.
stopped at Brasilia International Airport and then flew to Rio de Janeiro Galeon International Airport. There are 148 passengers and 6 crew members on the
.
lift-off
Everything is normal from the time it takes off until it loses contact. As time passed by minute by minute, hope gradually faded, and the plane did not arrive at its destination as promised, and it was very likely that it had crashed.
On September 30, 2006, early in the morning of the second day of the incident, Brazilian officials once again increased their search efforts. Soon, the wreckage of a large plane was found near a Indian tribe in the state of Mato Glosso.
Since the aircraft wreckage is distributed in the dense rainforest and has a very wide scattered area, it is speculated that the large aircraft had disintegrated in the air before it crashed into the ground. If this is the case, there will be no survivors. After several days of search, this was finally confirmed. None of them survived. The crash of flight
907 became the worst air crash in Brazil's history at that time.
Not to mention the whole world, people in Brazil must have been paying attention to this matter at that time. After confirming that the large plane had crashed, the investigation of the air crash accident became the focus of people's attention.
air crash investigation
It is currently confirmed that two brand new passenger planes were cruising and flying in the same airspace, an accident occurred, the small plane successfully landed in an emergency, and the large plane was destroyed and people were killed.
Two brand new passenger planes
did not receive any alarm or distress signals before the accident. Both aircraft were equipped with advanced air collision prevention system .
Whether they collided in the air or were accidents caused by overreaction, everything has not been clarified yet.
investigation team took off the black box on the small plane and sent it to a professional laboratory for decoding.
Two black boxes on large aircraft (cockpit voice recorder (CVR) and flight data recorder (FDR) were also found one after another on the third day of the accident.
black box
Due to severe damage to the voice recorder for the cockpit, the internal voice storage module was lost.
Later, Brazil's official dispatched about 200 army soldiers equipped with metal detector , After nearly a month, I finally found a voice storage module 20 cm underground in the area where the plane crashed.
Metal detection
If the decoding work goes well, the data in " black box " will be cracked soon.
Search work is carried out in a intensive and orderly manner, and the accident investigation team also needs to do meteorological, maintenance, air traffic control and other meter In-depth investigations are conducted one by one.
According to meteorological data provided by the Brazilian meteorological department, the airspace where the two aircraft had accidents was almost cloudless, so the weather factor can be ruled out first.
meteorological data
. Both aircraft are new aircraft, and there is no record of fault repair before takeoff, which theoretically has nothing to do with maintenance.
But as the investigation deepened, the investigation team found some unusual places: the left wing of
The broken left wing of
The left wing of the large aircraft was found at the crash site. The wing was almost broken from the middle, and the fracture surface was very smooth. It was not like it was broken during the crash, but more like it was cut by a sharp blade.
The investigation team found it on the left wing of the small aircraft. The trace amount of paint, after identification, these paints are from the wings of large aircraft.
left wing of small aircraft
From this discovery, it can be inferred that the sharp blade of the left wing of large aircraft is the winglet lost on the left wing of small aircraft.
Civil aviation passenger aircraft usually maintains a cruising speed at high altitudes of 800-900 km/h, such an amazing speed , the winglets of the small aircraft are indeed easy to cut off the wings of the large aircraft.
After losing nearly half of its left wing, the large aircraft stalled and crashed within about one minute.
Judging from the voice record of the cockpit of the large aircraft, the aircraft was not clear until the plane crashed, and the two pilots of unknown circumstances were working hard to control the aircraft.
traveled opposite the same route
investigation team found that the collision between the two aircraft was on the 37,000-foot height layer of the UZ6 route between Manaus and Brasilia.
traveled opposite the same route and
route is equivalent to a three-dimensional highway in the air, with left and right width and upper and lower height restrictions.
is in the up and down direction, in order to ensure the aircraft The altitude interval during flight, and the effective altitude of the route is divided into altitude layers, and each altitude layer only allows the aircraft to fly in one direction in the prescribed direction.
According to the rules, flights from north to south to Brasilia Airport must be maintained at an "odd" flight altitude layer. For example: FL350, FL370
schematic diagram
.Flights from south to north to Manaus Airport must be maintained at an "even" flight altitude layer, such as: FL360, FL380.
According to the flight plan submitted by the two aircraft of all sizes, it can be seen that after the two aircraft take off, the cruise altitude is 37,000 feet.
But be careful~ Large aircraft can be kept at this altitude all the way until they reach Brasilia, while small aircraft have three different flight altitudes.
flew to Brasilia at 37,000 feet after taking off. Once you reach the Brasilia controlled area, you must go down 36,000 feet to maintain it.
The small aircraft has three different flight altitudes
Flying all the way to a waypoint located 522 kilometers northwest of Brasilia, then climb to an altitude of 38,000 feet to head to Manaus.
flight data shows that the large plane flying south flew along the UZ6 channel after takeoff and climbed to a cruising altitude of 37,000 feet in 25 minutes. Until the collision occurs, it is flying step by step without any problems.
The result collided at this altitude, which only means that the small aircraft flying north of ran to the wrong altitude in violation of the rules, and it should not appear in the "odd" flight altitude layer.
The two pilots on the small plane shouted injustice and refused to admit this conclusion about illegal driving.
They said that after the plane took off, they obtained permission to fly to Manaus at an altitude of 37,000 feet, and they never received instructions to change the altitude before the accident.
Voice record
Cockpit voice record shows that when the small aircraft took off, the pilot made a misjudgment because the navigation terms given by the air controller were not standardized.
believes that from takeoff to landing, it must be maintained at an altitude of 37,000 feet.
Pilot misjudged the
When the aircraft was handed over to Brasilia, the pilot confirmed the flight altitude of 37,000 feet to the air controller in Brasilia.
The space-time tube guy did not give a command to reduce the flight altitude . He only asked the pilot to change the radio frequency and pressed the "Recognition" button on the transponder .
This button helps air traffic controllers clearly identify the aircraft on the radar screen and verify the position and altitude of the aircraft.
This call to confirm the altitude was the last two-way radio communication between the small aircraft of and the Brasilian air traffic control before the collision, and ended with the air traffic control officer not asking or talking about the flight altitude.
The small aircraft continued to fly at an altitude of 37,000 feet for nearly an hour until the collision occurred.
Usually pilots need to strictly abide by the air traffic controller's arrangements, so that you can go up and down, because they better understand the actual traffic situation.
The finger of the problem was pointed at the air traffic controllers. Why didn’t they issue instructions to change the height?
Air Controller
When the small plane entered Brasilia, two air controllers handed over the shift. It was normal to change shifts, but something that was out of reach during shifts was abnormal.
When the small aircraft passes through Brasilia, it is displayed on the radar screen in the center of the navigation control. There is a "+" in a circle, and information such as flight number, altitude and transponder code will be displayed on the right side of the icon.
The display on the radar screen
is in the line indicating the altitude. The number on the left is the actual altitude of the aircraft, and the right is the altitude that the aircraft needs to fly according to the flight plan.
When the actual flight altitude is inconsistent with the planned flight altitude, the air traffic controller must notify the aircraft to change the altitude.
When the air controller who was about to get off work saw the small plane enter the airspace he managed, the computer system automatically updated the altitude data of the small plane, from 370=370 to 370=360.
sees the data changes, and the air traffic controller waiting to get off work has a very clear brain circuit. takes the planned height as the actual height for granted.
believed that the aircraft's altitude had fallen from 37,000 feet to 36,000 feet and handed over this error message to the air traffic controller on the next shift.
Look at this picture again. When the shift is handed over, the plane will transfer from Zone 5 to Zone 7.
The air traffic controller who can hand over the shift provided the small aircraft with the radio frequency in Area 9, and in this case he did not follow the air traffic controller who took over his shift.
schematic diagram
also did not correctly program all the frequencies and emergency frequencies in Zone 7, resulting in the air traffic controller who took over another shift discovered the problem 30 minutes before the collision, but could not contact the pilot.
At that time, the pilot on the small plane could not contact the ground air traffic control, which was the reason. What is further from the original plot is that until the collision, the air traffic controller did not take effective emergency measures as required. It was just that " blindly hitting " on a very busy frequency. Those who are determined to contact the plane.
In short, it is various human factors that cause the two aircraft to travel opposite each other
But even so, the last protective barrier on the aircraft, the air collision prevention system (TCAS), why is it blind and dumb again? Before the collision between the two aircraft, the aerial anti-collision systems did not issue a warning, why the system failed?
The investigation team found the answer from the radar data of the Navigation Traffic Center.
15 minutes before the two air controllers in Brasilia handed over, the "=" between the altitude data of the small plane on the radar screen became "Z" , which means that the transponder on the small plane was turned off.
transponder is turned off
transponder is an electronic device that can automatically respond when a radio inquiry signal is received.
It helps air traffic controllers identify aircraft and keep space between aircraft. The operation of
air collision avoidance system (TCAS) is also based on detecting signals transmitted between transponders .
During flight, the transponder will actively send signals to the ground and nearby aircraft and receive signals from nearby aircraft.
When the two aircraft are too close, the anti-collision system will warn the pilot. When the warning level exceeds the limit, the anti-collision system will give collision avoidance instructions.
transponder
And the transponder on the small plane is turned off, which is equivalent to it covering its "eyes".
At the same time, it also makes other aircraft unable to "see" it. If the air traffic controller does not issue a warning and the crews of both sides rely too much on autonomous driving and do not have to look outside with the naked eye, it is really a life-threatening thing at high altitudes. Whether they can live depends entirely on the will of heaven.
Regarding how the transponder is turned off, it was found through multiple investigations that the transponder on the small aircraft was initially installed on another aircraft.
was removed because it could not work properly and was installed on this small plane after repair. Although it was " second-hand ", no problems were found during the accident.
The small plane was fine when it took off, but according to the voice record of the cockpit, the co-pilot found that the transponder was turned off after the collision. The captain
took a look and confirmed that the transponder was turned off. About 3 minutes after the collision, the transponder was turned on and entered a normal working state.
investigation team speculated that the transponder might have been mistakenly shut down by the pilot.
There is such a guess because there is a foot pedal on the edge of the transponder for the pilot to rest. If you are not careful, the pilot's soles may indeed touch the switch of the transponder.
transponder is next to the foot pedal
There is also a guess that the two pilots accidentally turned it off when they were familiar with the flight system, but there is no actual evidence for these speculations.
This aircraft has defects in the system that controls the transponder. When the transponder is turned off, the system will not issue an obvious alarm, and will only show text prompts on the monitor.
Both pilots are newbies on the road and are familiar with the operating system. Their attention is attracted by other things, so the transponder is turned off for about an hour and they don't notice it.
Where to get along
Coincidentally, the air control officer on duty in charge of the Brasilia control area is also a novice, and he started to work for one year.
From his business level of " not asking or saying ", " taking for granted " and " not seeing " that he still lacks professional skills, command experience, communication and equipment familiarity, and does not have the qualification to be on duty independently.
However, due to the shortage of manpower and heavy tasks, he was assigned to work alone.
From this we can also see how chaotic the air traffic control is in Brazil.
Based on the above clues, the accident investigation team seems to have found the cause of the air crash.
Investigation Report
In December 2008, more than two years after the accident, two " leader " announced the final accident investigation reports respectively. Although the two companies of
reached an agreement on most facts and investigation results, they had differences of opinions on the conclusion of the accident.
Brazil believes that the main cause of the accident was the air traffic controller and pilots.
First, the air traffic controller issued an inappropriate flight permit to the small plane, which caused the pilot of the small plane to misunderstand.
Brazilian
During the process of the small plane being handed over to the Brasilian Control Center, or afterwards, the air controller did not find or correct the error, which led to the air crash.
But at the same time, the pilot also had errors in dealing with the loss of radio contact and transponder in the small aircraft.
The two pilots have not noticed that the transponder was turned off. This is related to factors such as their short training time on this model, insufficient preliminary preparation work, and lack of strict training results.
and the U.S. National Transportation Safety Commission (NTSB) focuses on the cause of the accident on Brazilian air controllers and air traffic control systems.
U.S. National Transportation Safety Commission
The pilot's mistake on a small aircraft is just a trigger. The transponder is shut down, causing the air collision prevention system to fail. The pilot has certain responsibility, but Brazil's air controllers and air traffic control systems have great problems.
Because the pilots on both aircraft were flying accurately on the approved route, they comply with all the instructions of the air controller, but they were still arranged to fly relatively on the same road and lost effective air traffic control.
The problem of air traffic control is not the result of a single error, it is the result of the combined effect of many people and various factors.
For example:
Brasilia Control Center is not equipped with sufficient control personnel, which leads to high work intensity of air control personnel and often overload work, which increases the chance of making mistakes in busyness;
For new controllers, the necessary training and training plans are not formulated based on actual conditions;
Due to limited funds, many equipment in the Brasilia Control Center has been outdated and has not been updated, and the radar display equipment has defects and encounters high inconsistency;
When the transponder is closed, the prompt information is not obvious, which is not easy to attract the attention of the controller, etc.
In short, this air crash was caused by a series of man-made accidents.
Afterwards
With the exposure of the causes of the air crash, the Brazilian civil aviation system encountered an unprecedented crisis.
Brazil's air traffic control system is managed by the Brazilian Air Force. The entire system management is very chaotic, and air controllers on the front line have long complained about it.
System management is very chaotic
What is more work, less money, long time, and a lot of pressure. I am worried about selling white powder and the money for selling cabbage.
Moreover, the company's training is not enough, and many on-the-job air traffic controllers have poor English, which makes them poor communication with foreign pilots and other problems.
When we learned that the government would attribute the responsibility or part of the responsibility to the air control officers, air control officers in various parts of Brazil began to use strikes, hunger strikes and other methods to demand reduced working hours and act in accordance with regulations.
strike, hunger strike
This wave of operations has forced nearly 70 airports across Brazil to be temporarily closed, a large number of flights were cancelled, delayed, and passengers were stranded.
But when this problem has not been completely solved, it has been less than a year since this air crash.
When Brazilian Tianma Airlines Flight 3054 landed in heavy rain, the plane rushed out of the runway and crashed due to a pilot's mistake.
Brazilian Tianma Airlines flight 3054 crash
killed 199 people, becoming the air crash with the largest number of deaths in Embraer's history.
Two huge air crashes, one in front and one behind, stimulated the nerves of the people. For this reason, the president directly fired the Minister of Defense, who was responsible for aviation basics and safety, and made up his mind to improve Brazil's air traffic control system.
In May 2011, during the trial of in an military court, only the five air control officers who were prosecuted, who said the wrong height and misrepresented information, were sentenced to three years and four months in prison, and the others were acquitted.
The two American pilots flying the small plane, due to mistakenly turning off the transponder, resulting in the failure of the air collision prevention system. The person returned to the United States shortly afterwards, reduced his original four-year and four-month sentence to serving in the American community.
Two American pilots of the small plane
However, the two pilots on the small plane have never admitted it.
This is an avoidable tragedy, but it happened under the superposition of a series of fatal mistakes. Sometimes luck and negligence are more terrible than accidents.
OK, the above is all about today's accident. I am Changfeng, see you next time!
Author: Qiwen Observation Room
The views in the article only represent personal
Text copyright belongs to Qiwen Observation Room
reprint/citation please contact us
reprint/citation
