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COLISÃO em VÔO Cel. Rufino/CENIPA Flight 1907 Manuf. USA Regist. and crew BRA N600XL Manuf. BRA Regist. And crew USA SEPt.29,2006 16:56h (Mid-Air collision)

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Presentation on theme: "COLISÃO em VÔO Cel. Rufino/CENIPA Flight 1907 Manuf. USA Regist. and crew BRA N600XL Manuf. BRA Regist. And crew USA SEPt.29,2006 16:56h (Mid-Air collision)"— Presentation transcript:

1 COLISÃO em VÔO Cel. Rufino/CENIPA Flight 1907 Manuf. USA Regist. and crew BRA N600XL Manuf. BRA Regist. And crew USA SEPt.29, :56h (Mid-Air collision) TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

2 COLISÃO em VÔO Cel. Rufino/CENIPA INQUIRY OBJECTIVES: Identify the factors related to the crash with an exclusive prevention target. “The only objective for a crash or an incident inquiry is prevention. In no case it will intend to determine culpability or civil responsibilities.” Ref. Item 3.1, Annex 13 of the ICAO. RECOMMENDATIONS RELATED TO FLIGHT SAFETY will be elaborated in order to avoid further occurences of such crashes, incidents or dangerous situations. TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

3 COLISÃO em VÔO Cel. Rufino/CENIPA INVESTIGATION AREAS:  HUMAN FACTOR:  Biological complex of the human being  Physiological and psychological aspects.  MATERIAL FACTOR:  The aircrafts and their systems. (design and manufacturing)  OPERATIONAL FACTOR:  The human being;  Operational environment;  The airplanes;  Operational systems.. TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

4 COLISÃO em VÔO Cel. Rufino/CENIPA Autres:  Nominated members.  Operators.  Aircrafts and equipments manufacturers.  Air trafic control and airports infrastructure organisms.  Observers (?). PRESIDENT COORDINATOR HUMAN FACTOR PHYSIOLOGICAL ASPECTS PSYCHOLOGICAL ASPECTS MATERIAL FACTOR OPERATIONAL FACTOR TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

5 COLISÃO em VÔO Cel. Rufino/CENIPA INVESTIGATION EXPECTED DURATION: (10 mth)  Phase 1: Data collection. (45d)  Phase 2: Analysis. (90d)  Phase 3: Preliminary conclusions. (120d)  Phase 4: Final Conclusions and Recommendations. (30d)  Phase 5: Final Report (30d) TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

6 COLISÃO em VÔO Cel. Rufino/CENIPA THE FACTS: 1. Flight N600XL  The N600XL plan for a flight from São José dos Campos to Manaus, was to fly FL370, until overhead Brasília. From Brasília to intersection TERES, FL360 was selected. From TERES to Manaus, FL380 was expected.  N600XL took off at 14:51 (HB) and by 15:33 (HB) it reached FL370 as planned for the first leg to Brasilia.  That flight level was maintained until the planes collided. COLISÃO em VÔO TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

7 COLISÃO em VÔO Cel. Rufino/CENIPA LES THE FACTS: 2. Flt 1907  The flight 1907 leaving Manaus requested FL370  It took off at 15:35h (HB) and reached FL370 at 15:58 (HB), on the jetway UZ6 track, those conditions were maintained until the planes collided.  There were no communication problems between Flt 1907 and the ATC at any time.  There was no radar contact loss of Flt 1907on the Amazon Center monitors until its transfer to Brasilia Center. TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

8 COLISÃO em VÔO Cel. Rufino/CENIPA THE FACTS: : 3. Air Trafic Control  At 15:51 (HB), ultimate two ways contact bilatéral between N600XL and Brasília Center. (Freq MHz)  At 15:55, N600XL flies over Brasília VOR, and engages on jetway UZ6 maintening FL370 without contacting or receiving any instruction from Brasília Center.  At 16:02, N600XL identification data have disappered from the secondary radar monitor which includes the exact aircraft flight level.. COLISÃO em VÔO TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

9 COLISÃO em VÔO Cel. Rufino/CENIPA THE FACTS: 3. Air Trafic Control  Between 15:51 (HB) and 16:26 (HB), there was no radio call neither from N600XL nor from Brasilia Center.  At 16:30 (HB) the primary radar which indicates the plane geographical position lost track of N600XL for 2 min.  From 16:26 (HB), the BR Center emits 7 calls : 16:26h (16:30:56h) (16:53:39h) 16:27h (16:32h) (16:30:40h) 16:34h TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

10 COLISÃO em VÔO Cel. Rufino/CENIPA THE FACTS: 3. Air Trafic Control  At 16:38:00 (HB) Brasília primary radar definitely looses N600XL track, until it reaches Amazon Center.  At 16:53:39 (HB), Brasília Center ultimately calls N600XL to notify the transfer to Amazon Center on Mhz or, alternatively on Mhz. TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

11 COLISÃO em VÔO Cel. Rufino/CENIPA THE FACTS: 4. Flt N600XL  A 16:48:16 (HB), starts a serie of 12 calls to Centro Brasília: 16:48:16h 16:51:08h 16:48:40h 16:51:24h 16:49:33h 16:51:41h 16:50:08h 16:52:10h 16:50:28h 16:52:42h 16:50:48h 16:52:59h  At 16:53:39 (HB), the N600XL receives the ultimate message from Centro Brasília, notifying to call Centro Amazon, but do not copy the frequencies. TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

12 COLISÃO em VÔO Cel. Rufino/CENIPA THE FACTS: 4. N600XL  At 16:53:57 (HB), N600XL answers Centro Brasília and asks to repeat the decimals of the first frequency, but the Center never received that message..  From that moment, N600XL will call Centro Brasília 7 times: 16:54:16h 16:55:43h 16:54:40h 16:56:41h 16:55:00h 16:56:53h 16:55:16h  At 16:56:54h(HB), the planes collide. TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

13 COLISÃO em VÔO Cel. Rufino/CENIPA THE FACTS: 5. General considerations.  The Centro Amazone never lost contact with flight Gol1907 until it was transfered to Centro Brasilia  There are no recordings of a flight level change request from N600XL after it reached FL370. Il n’y a aucun enregistrement indiquant que le N600XL ait demandé un changement d’altitude après qu’il ait atteint le niveau 370.  There are no recordings of an ATC controller informing N600XL to go to a different flight level aftyer the last two ways contact with Centro Brasilia (Ndt: 15h51)  The two airplanes collided as they were flying opposite direction at FL370 along the UZ6 jetway TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

14 COLISÃO em VÔO Cel. Rufino/CENIPA Coordonnées Geográfiques 10º 44’ S / 053º 31’ W 16:56:54h (19:56:54 Z) Approximativement à 20km au nord-ouest du point NABOL. NIVEAU DE VOL: 370 TRADUCTION LIBRE PAR MERMOZ01 © 10º 44’ S / 053º 31’ W 16:56:54 (19:56:54 Z) Approximatively 11Nm NW from intersection point NABOL. FLIGHT LEVEL: 370 TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

15 COLISÃO em VÔO Cel. Rufino/CENIPA THE FACTS:  The TCAS (Anti collision system) installed on both planes did not alert for incoming trafic nor delivered any elusion maneuver instruction to any of the crews.  There is no indication that any of the 4 crew members has a visual contact with the opposite approaching aircraft.  The flight recorders (Ndt: black boxes) show no sign of elusion maneuver on any of the 2 planes. TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

16 COLISÃO em VÔO Cel. Rufino/CENIPA THE FACTS:  At 16:56:54 (HB) A collision occured, the left wings of both planes probably hitting each other.  After the collision, the Flt 1907 is out of control and dives immediately towards the ground.  The Flt 1907 flight recorders (CVR et DFDR) stopped recording at 7887 ft  From that moment, the N600XL made 9 calls to Centro Brasília: 16:57:47h 17:02:40h 17:04:03h 16:58:09h 17:03:11h 16:58:47h 17:03:41h 17:01:45h 17:03:50h TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

17 COLISÃO em VÔO Cel. Rufino/CENIPA

18 COLISÃO em VÔO Cel. Rufino/CENIPA UZ6 Hdg 155° Flt 1907 disappears from radar FL ,210m) Wreck area Route to the ground impact area Hdg 130° / 3,48 NM (6,2 Km) TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

19 COLISÃO em VÔO Cel. Rufino/CENIPA Wings and body central part Cockpit RH wing tip LH stabilizer Vert. Stabilizer Motor 2 Body rear top part Body LH part Motor 1 RH stabilizer Last heading recorded on the radar 130 ° 459 m 535 m Rescuers base camps TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

20 COLISÃO em VÔO Cel. Rufino/CENIPA THE FACTS:  At 16:59:50 (HB), about 3 minutes adter impact, the Centro Amazônico receives the ID code and altitude reading for N600XL on the secondary radar screen.  At 17:00:30 (HB), Centro Amazônico calls N600XL getting no answer.  At 17:01:22 (HB) N600XL tries to contact Centro Amazônico, through the Polar 71 flight, to obtain a landing clearance on the Campo de Provas Brig. Veloso military airfied (Cachimbo)  At 17:02:10 (HB), Centro Amazônico starts receiving the secondary radar N600XL informations with Emergency code TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

21 COLISÃO em VÔO Cel. Rufino/CENIPA THE FACTS:  At 17:03:11 (HB) the N600XL declares an emergency situation but gets no answer from Centro Brasília, and begins an emergency landing procedure.  Centro Amazônico emits 4 new blind calls to N600XL: 17:10:41h 17:11:00h 17:10:50h 17:12:44h  At 17:13:16h(HB) Polar 71 establsh a communication with Centro Amazônico announcing the N600XL emergency situation. TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

22 COLISÃO em VÔO Cel. Rufino/CENIPA 6. ACTIONS TAKEN:  Collect N600XL and Flt 1907 data from the flight recorders.  Interviews and medical exams of N600XL crew members. (02/10)  Seizure of all the ATC data records related to the crash.. (02/10) TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

23 COLISÃO em VÔO Cel. Rufino/CENIPA ACTIONS TAKEN (CONT.) :  Preliminary check of the Legacy Navigation equipments. (07/10/06).  Examination of the wrecks on the crash site.  Read and process the flight recorders data, except for the 1907 voice recorder (VCR) by the TSB in OTTAWA Canada.  Preliminary analysis of the written notes and communications transcripts between the aircrafts and the control agencies. TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

24 COLISÃO em VÔO Cel. Rufino/CENIPA ACTIONS TAKEN (CONT.) :  Examination and checks of the 1907 equipments salvaged from the wreck.  1907 voice recorder sent to TSB in OTTAWA.  Examination of the survey radar data recorded by the control agencies in the “Cindacta 1” in Brasilia and “Cindacta 4” in Manaus. TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

25 COLISÃO em VÔO Cel. Rufino/CENIPA 7.NEXT ACTIONS  Laboratory analysis of the radio, navigation, transponder et TCAS equipments from both aircrafts.  Intreview the ATC controllers.  Discuss with FAA officials (in USA) to analyze the requirements for US pilots flying in foreign countries.  Discussions and interviews with air operators. TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

26 COLISÃO em VÔO Cel. Rufino/CENIPA SUMMARY OF THE CURRENT SITUATION. The data collection is not complete yet and the analysis emphasize some key points related to :  The N600XL transponder and radio equipment operation.  The competence and training of the N600XL crew for that flight in the Brazilian airspace.  The aspects related to the ATC specifications and procedures currently in use in Brazil and over the world.  The ATC communication and survey systems and equipments. TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

27 COLISÃO em VÔO Cel. Rufino/CENIPA SUMMARY OF THE CURRENT SITUATION (CONT.)  AT THIS STAGE, ANY TENTATIVE TO DRAW CONCLUSIONS IS PREMATURE.  RECOMMENDATIONS MIGHT BE MADE BEFORE THE FINAL CONCLUSIONS OF THE INQUIRY. L’ENQUETE.  ALL FACTUAL DATA AND RECOMMENDATIONS RELATED TO FLIGHT SAFETY WILL BE PUBLICLY RELEASED. TRADUCTION LIBRE PAR MERMOZ01 TRADUCTION LIBRE PAR MERMOZ01 ©

28 COLISÃO em VÔO Cel. Rufino/CENIPA Welcome page gol1907.pfiquet.be


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