Aeroflot puts AIR TR/ANSPORT

A330-200
into service
AIRTRANSPORT PlO

JOHNCROFTWASHINGTONDC
INVESTIGATION

Air traflic Gontrol

factorscited in
fatal Golcollision
lnadvertent of Legacy
inactivation likely
transponder

Followins the publication of "The evidencecollectedduring

l' tn. nrr"iti* final report into
the 2006fatalmid-air collisionbe-
hveen an Embraer Legacy 600
businessjet and a Gol Transportes
Aéreos Boeing 737-BOO over the
Amazon, investigationparlicipant
the US National Transportation
SafetyBoardsaysthe accidentwas
the result of "numerous individu-
al and institutional AIC factors".
Crucially,it hasnotbeen estab-
Iished how the Legacy's trans-
ponder had been inadvertently
deactivated, preventing the air-
borne collision avoidancesystem
fromworking.
all rs+ passengem and crew on
board C,olflight 1907 died in the
29 September2006collision after
the damaged aiflraft plunged to
the forest fl.oor from 37.000ft
(11,29sm). The Legacy(N6ooXL),
being flor,rmon a delivery flightby
US air taxi operator Excelaire,
made an emergencylanding with
damageto its left winglet and left
horizontal stabiliser.Brazil's in-
vestigationagencyCenipa,which
headed the investigation, pub-
lished its final report last week.
SAFETYDAVID KAMINSKI-MORROWLONDON
this investigation sbongly sup-
ports the conclusion that this ac-
cidentwascausedbyN600)G and
Gol 1907following ATC clearanc-
es,which directedthemtooperate
in oppositedirections on the same
airway at the samealtifude, result-
ing in a midair collision," saysthe
NTSB in commentsappendedto
the Cenipareport.
"The loss of effective air haffc
conhol was not the result of a sin-
gle error,but a combination of nu-
merousindividual and institution-
al ATC factors that reflected
systemicshortcomingsin empha-
sison positiveATC concepts."
As for the transponderissueon
the Legacy, the NTSB says that
"contributing to the accident was
the undetectedloss of flrnctionali-
ty of the airbome collision
avoidancesystemtechnologyasa
result of the inadvertent inactva-
tion of the hansponderon board
N600XL. Further conhibuting to
the accidentwasinadequatecom-
munication between ATC and
the N600XL flightcrew."
In May 2OO7the NTSB raised
concemsover inadvertentdeacti- guard, along with other possibili-
vation ofcollision avoidancesys- ties discussedin the report, sewe
tems, asking the US Federal as important reminders of human
Aviation Administration to recom- ergonomic considerations at pre-
mend that an audio warning and venting inadvertentcontactsin ac-
enhanced visual alert be inho- tual flying situations."
duced. This was followed by a The NTSB says the investiga-
wamingto EmbraerERJand Lega- tion "has identified many safety
cy operatorsthat they could acci- issues for ATC operations, but
dentally deactivatethe hanspond- these issues need to be further
er by placing their feet on the highlighted. Eventhough the body
foohestsdirectly below the instru- of the [Cenipa] report acknowl-
mentpanel. edges safety deficiencies with
The NTSB says in its report ATC, these deficiencies are not
comments that although the foot- sufficiently supportedwith analy-
rest guardis "designedto prevent sis or reflectedin the conclusions
unintended interactions" with or causeof the accident."
controls, in flightdeck obsewa- The board adds: "These defi-
tions with the FAA it was ob- cienciesinclude a lack of timely
servedthat pilots "might misuse ATC action after the loss of
the foohests",adding: "The cap- N600XI-s transponder and two-
tain'sright foot...couldmakeunin- way radio communication, and
tended contact lwith the trans- featuresof the ATC softwarethat
ponder controlsl" (seegraphic). may haveaggravateddeficiencies
It adds: "It cannot be deter- in altitude clearanceawareness
mined exactly how the accident forN600XL."l
crew commandedthe hansponder ffi
"* Keeoabreastof allthe latestair
to standby,but the possibility of
r.rnexpecteduse of the footrest {;ffi;ffiH"#îSm/saftty

ffiraeilinyestigatmrmfumf;*mwæ
ffrueil
dm*msæffitr#h toss
trfiffiærædtrmmsrmtssilmm
BraziIianinvestigationagency theunit'sscreen -twice in 20s. arecontained on separate display fuelpage,didnotnoticehehad
CENIPA believesthecruciallossof TheLegacy's copilothadbeen pagesinthe unit. pusheda buttonthatwouldchange
the Embraer Legacy'stransponder calculating takeoff parameters from "Whilethe[commander] wasaF thetransponder statusto 'standby'."
transmission - andwithit thecolli- Manaus, thejet'sdestination,using parentlytryingto clari! the issueof CENIPA dismisses intentional de
sion-warning system-took placeas a laptopcomputer inthe minutes theairplane fuelstatus...his radio activation as unlikelyandextensive
thecommander soughtfueldata leadingupto thelransponder loss. management unitwasusedina way testjngturnedup noevidence of avi-
throughtheavionics. CENIPA hasruledoutaccidental thatchanged the...transponder...to onicsfailure.Cockpitrecorder evi-
CENIPA saysthisisthe "mostlike contactbetweenthe laptopandthe 'standby',"it says,andsuggests this dencerulesoutinadvertent contact
ly"scenarioafterit drewupfivehypo radiomanagement unit. happened justasthecopilotin- between commander's footandthe
theticalcircumstances to explain the Butit claimsflight+ecorder evi- formedthecommandeL afterape radiomanagement unit,viathein-
suddendisappearance ofthetrans- dencesuggests thecommander riodof silence, thathehadsome strumentoanelfootrest.CENIPA cal-
mission. Access to thetransponder wasassistinS thecepilotwithfuel important Manausdeparture data. culatesthe probability oftransponder
isthrough theradiomanagement considerations andlookingat fuel "Themostlikelyexplanation...is deactivation thiswayat oncein 192
unit.Switchingthetransponder to dataonthe radiomanagement unit thatthe[commander], whileinatten- trillionflighthours:"Thiskindof con-
"standby" requiresthepilottopress display. Fuelinformation andthe tivelytryingto returnhisradioman- ditioncanbeconsidered virtuallyim-
a soecificbutton- onthe leftsideof collision-avoidancesystem's status agement unit...after
consulting the oossible inthefleet'slifetime."I

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