A Pilot’s View on the Brazilian Gol/ExcelAire Accident (Guest Post)

We got into an off-topic discussion in the comments section of a previous post recently about the latest in the Gol/ExcelAire midair collision in Brazil, and I thought it was worth a closer look. Fortunately, I was able to turn to a pilot friend of mine for an excellent piece about the accident. I know it’s lengthy, but I highly recommend reading the whole way through.



With the release of investigative reports by the Brazilian Air Force and U.S. NTSB, as well as the publication of an article in January’s Vanity Fair magazine by William Langewiesche, there has been renewed interest in the September 2006 collision of a GOL Airlines 737 and an ExcelAire Legacy business jet. The tragic accident claimed the lives of all 154 passengers and crew aboard the 737; the Legacy jet landed safely at a military airport in the Amazon. The on-line version of the Vanity Fair article provides links to the entire recordings of the both aircraft’s cockpit voice recorders (CVRs), which Langewiesche, himself a private pilot, uses to analyze the accident.

As an airline pilot whose every word is recorded at work, I am deeply troubled by Vanity Fair’s decision to publish the entire actual audio recordings of both CVRs. The sole purpose of the CVR is to aid in the investigation of an accident, not to serve as entertainment or to help sell magazines. The audio recordings are protected from release by U.S. and international laws, with only the portions relevant to the accident transcribed in official NTSB reports. It is therefore unconscionable that the entire 30 minutes of the Gol recording and all 2 hours of the Legacy recording now appear on Vanity Fair’s website. What possible value other than entertainment is provided by having subscribers listen to the 737 pilots chat about their friends and family for 30 minutes before their deaths? It is within this context that pilot opposition to cockpit video cameras must be understood.

Releasing the CVR recordings to Langewiesche also allows him to investigate and dramatize the accident, despite the fact that his private pilot certificate is completely inadequate to qualify him as an accident investigator. He makes a number of small technical errors, including a statement that autopilot use at 37,000’ is required by law (autopilots should be used in Reduced Vertical Separation Minimum (RVSM) airspace but may be disengaged any time), and that transponder failures are routine (failures are common in Cessnas but not in modern aircraft operating above 30,000’). But more troubling is his dramatization of the events in the Legacy cockpit and his portrayal of the thoughts and character of the Legacy pilots, none of which is warranted by the recordings themselves. This is important in light of the fact that far more people will read the Vanity Fair article than will ever come in contact with the official NTSB or Brazilian Air Force Reports.

I therefore hesitated to provide my own thoughts based on the recordings and article, but ultimately thought that the perspective of someone who has flown often in South America could fill in some of the holes in the article and answer some of the questions it raises. For example, the article correctly concludes that this accident could have only happened with the extremely accurate navigation in use on modern aircraft, and is an example of the unintended and unexpected consequences of improvements in technology. But the article didn’t mention the procedural changes that had already begun before this accident to address the problem and are now in wide spread use – namely SLOP (strategic lateral offset procedure).

SLOP is now in use by airlines in all oceanic and non-radar environments, and also by many crews over South America, where radar coverage can be spotty. Essentially, SLOP is a 1-mile offset to the right. The Legacy pilots seemed largely clueless about international procedures, so it’s unlikely they would have been SLOP-ing, but if the GOL airplane had been doing it they would have missed the Legacy by a mile. Unfortunately, no one was using SLOP over South America in 2006.

Still, the majority of the responsibility for the accident clearly rests with air traffic control (ATC). The interactions between the Legacy aircraft and ATC are very representative of my experience dealing with controllers in South America, an experience that is far inferior to the service provided by ATC in the rest of the developed world. It’s not just a language problem, although that certainly plays a factor. But Chinese and Russian controllers are often just as difficult to understand and provide far better service. Language issues did not prevent the Brazilian controller from issuing a clearance to 36,000’ at Brasilia, from realizing that the Legacy’s transponder had stopped working, or for allowing a system to be in use that showed a filed altitude on a radar display instead of the actual altitude. Regardless of language, the controller should have realized that the two airplanes were in conflict, and could have at least moved the GOL airplane.

Flying over Brazil is much like flying over an ocean, although in many ways it’s more dangerous. Communication is difficult, as shown by the inability of the Legacy crew to be able to communicate with an ATC facility on the emergency frequency (121.5) following the collision. Radar coverage is inconsistent, and in fact the Legacy flew out of radar contact for 50 minutes without having the benefit of non-radar separation standards or procedures. At least over the ocean, altitude separation for the entire oceanic portion would have been provided prior to entering the airspace.

Much has been made of the fact that the Legacy pilots should have known that they were at the wrong altitude; Langewiesche equates it to “drive-on-the-right highway rules”. The reality in international flying is unfortunately a little more complex. While there are direction-of-flight altitude rules under radar contact, these rules largely don’t exist over oceanic airspace. There are flights everyday flying eastbound to Europe at 36,000’ and 37,000’, as well as westbound to Asia at 38,000’ and 39,000’. I’m almost embarrassed to admit that I have to stop and think which altitude is appropriate for an eastbound flight across the United States; it is not instinctive. I seriously doubt that I would have noticed the aircraft was at the wrong altitude following a slight left turn at Brasilia and a course somewhat to the west of north. Without a new clearance from ATC, we would have likely stayed at 37,000’ as well.

Assuming the transponder was turned off (as opposed to failing) the level of warning for the Traffic Alert and Collisions Avoidance System (TCAS) being off is fairly typical across aircraft. Turning the transponder off is normal system function and is done on every flight after landing. Warnings are generally not given for normal system functions – i.e, turning a Pack off will also generally give a white status message without an aural warning. On the 777, turning the transponder off would result in a white TCAS-Off message on the upper Engine Indicating and Crew Alerting System (EICAS) screen. It seems the Legacy warnings were even less apparent – a message on the Flight Management System (FMS) and on the Primary Flight Display (PFD) are really easy to overlook.

Having said that, it’s probably very appropriate to upgrade the TCAS-Off message in flight to a higher-level warning. On a Boeing, it should most likely be at the Master Caution level, resulting in an aural warning and illumination of lights in front of both pilots if the TCAS fails or is turned off. Had this occurred on the Legacy aircraft, it is extremely unlikely the accident ever would have happened.

Despite the majority of the responsibility lying with Brazilian ATC, the Legacy crew cannot escape without criticism. It’s very apparent that they were in over their heads on a flight from Brazil to the United States. Not to be too condescending, but this was a regional jet crew who really had no business operating in this environment. The problem is that they didn’t even realize it. I have a lot of sympathy for the feelings of confusion over language and procedures internationally – I’ve felt it myself a lot in South America and Asia. The difference is that at my airline the other 2 or 3 crewmembers are usually very experienced in the area, or we at least compensate by paying a lot more attention. These guys were treating this like a flight from Chicago to Dallas, and weren’t doing any of the things we normally do internationally (plotting, monitoring position, etc.). After the impact, it’s apparent they really didn’t even know where they were.

Their cockpit resource management after the impact is poor. That’s another area where I see major differences between an airline crew and a couple of corporate pilots. They didn’t do any of the things we would normally do following an emergency – one pilot will normally fly and handle all of the radio communications with ATC, while the other pilot will work on the problem and utilize any other resources.

The captain was essentially useless. The copilot rightly took over to a certain extent, but then he tried to do everything and didn’t manage the cockpit well. They also spent far too much time trying to establish communication with ATC and not nearly enough time flying the aircraft or utilizing any of the other resources available to them.

If I had been the captain (in the perfect world of hindsight and sitting at a computer), I would have had the First Officer fly and talk to ATC/relay via Polar on 121.5. I would have first evaluated the condition of the airplane and solicited help from the back. With the airplane intact and still flying, it may not have been necessary to initiate an emergency descent until a plan was in place. I would have used the SATCOM (they had a satellite phone they apparently never even used) to get Dispatch on the line to assist with determining the nearest suitable airport and with frequencies for ATC. They wouldn’t have had our Dispatch capabilities, but their Operations should have been at least able to help.

With all of that more efficiently accomplished, they should have had time for a bit more of an investigation into how the aircraft was flying. I would have incrementally extended the flaps and attempted to gauge some controllability; they would have been better served by slowing for landing. Langewiesche incorrectly states that they couldn’t slow down; the truth is that they never attempted to. They seemed to really have had no idea what they were doing or why they were doing it, and I can’t say I’m very impressed with how they handled the situation following the impact.

None of that performance changes the fact that Brazilian ATC put them on a collision course with another aircraft, or failed to realize their error despite numerous opportunities. The Legacy pilots’ performance also doesn’t rise to the level of criminal negligence; the fact that these pilots face trial in Brazil is deplorable. With the reliability of TCAS and the introduction of SLOP, it’s not an accident likely to ever be repeated, but then neither is any airline accident that occurs in the modern era. I can only hope that the accident will spur some much needed improvements in Brazilian Air Traffic Control, and that next time the CVR recordings will stay where they belong – in the hands of the investigators.


15 Responses to A Pilot’s View on the Brazilian Gol/ExcelAire Accident (Guest Post)

  1. Aviatrix says:

    So maybe I’m a ghoul. I listened to the whole Legacy transcript in my hotel room while doing paperwork.

    It’s so cringeworthily normal in terms of pilots trying to figure out unfamiliar equipment, second guessing what went wrong, and spouting profanity-laced relief when it all works out. I agree with your anonymous contributor that the performance doesn’t exemplify CRM, but in the earlier discussion of their CofG computer it’s pointed out that the BOW includes one crewmember. Is it possible that this company normally operates single-crew, and that the two-crew procedures are somewhat ad hoc, hacked together for this international flight?

    The other thing that stands out is the radio language. They know they are having communications difficulties with ATC that speaks another language. Why then do they not revert to formal ICAO terminology? For example, I hear “Say that one more time?” instead of “say again”. “six hundred x-ray lima” instead of “six zero zero x-ray lima” and “Emergency, Emergency” instead of “Mayday, Mayday, Mayday.” Is “Emergency” a standard ICAO difference in the US, or did they just feel way too much like someone in a WWII movie to bring themselves to say it? There don’t appear to be specific misunderstandings associated with those, but “Say runway length” might have helped.

    Glad it wasn’t me.

  2. axelsarki says:

    im glad you cleared up the TCAS thing, when i read about tha accident i wondered what happened to TCAS

  3. Pingback: An Interesting (And Technical) Look at the Gol-ExcelAire Crash | Online Travel Review

  4. A says:

    I took listened to both CVR’s. My sympathy goes out to the passengers on the GOL flight. As an aircrash junkie this is one that I’m not very familiar with and enjoyed the read. Hopefully those 154 gave their lives so that this will never happen again. Unfortunately those that died were innocent, as is all too often when a plane crash occurs.

    When spending some time growing up in Houston a good friend’s father was a pilot of private aircarft (oil company I believe). This man was 100% professional, even when I saw him when he was relaxed at home. I would in no way believe that he would act like the pilots of Legacy did. The CVR recording clearly makes the many professional private pilots look bad.

    I’m no pilot but I don’t even pull a rental car out of the parking lot without knowing how to run the thing. Clearly no commerical airline will let anyone pilot a plane without some flight training. There is no excuse that neither of these two weren’t fully familiar with all the “options” on this aircraft. The TCAS being off is inexcusable. You do that over the US and a fighter jet will be on you in no time. Pilots with this much experience should not have allowed that to happen.

    That said, I don’t intend to single out the pilots. A friend is an ATC that has worked in the regional centers and now is a tower controller. He has said on numerous occasions that S. America is the most unsafe place to fly in the world because of very very lax ATC. He personally will not fly there and would rather take a boat. This accident does nothing to make me feel differently about his strong concerns.

  5. Gumpfs says:

    These guys were definitely trained on the aircraft, it’s the international experience that they lacked. But don’t let that confuse you into thinking that they weren’t familiar with TCAS or any of the other “options” on the aircraft. The NTSB rightly pointed out that it’s very easy on the Legacy to inadvertently turn off the TCAS with your foot, and the indications that it is off are minimal. I really don’t think you can fault the Legacy pilots for turning off the TCAS.
    Also, I guarantee you won’t get a fighter in the U.S. very quickly for turning off the TCAS. Heck, my airline had a flight that didn’t answer ATC for over an hour and still didn’t get an intercept. It’s not quite as easy as you might expect.

  6. Flight Surgeon says:

    I found the avalilability of the CVR recordings pretty disgusting, particularly in the case of the Gol Boeing. It’s horrendous to have people listening to the agonizing crew screaming and dying. I didn’t listen to the Gol CVR, in respect for the dead. I think it shoudn’t be available at all. I consider the matter less serious in the case of the Legacy crew, since they survived.

    Congrats to Cranky and his guest writer, for criticizing Vanity Fair for its absurd behavior. I suggest all Cranky readers and fans should go there ans protest:

    http://www.vanityfair.com/contact/emailLetters

    regards,
    Carlos Valle
    Curitiba, Brazil

  7. Bystander says:

    On 19 Dec Gumpfs said “and the indications that it is off are minimal. I really don’t think you can fault the Legacy pilots for turning off the TCAS.”

    Actually, the cockpit indication of TCAS OFF exceeds the existing international requirements, and you would expect that the Excelaire pilots would be very familiar with these indications for that particular loss of function as they have been trained on it since beginning to fly TCAS equipped airplanes. If changes are needed to the warning then the issue should go to the world regulatory agencies for review and action. Adding new aural warnings to a cockpit is not a small undertaking and demands that appropriate study & engineering be completed.

    Accepting that it was OK for the Excelaire pilots to mistakenly turn off the TCAS function is ludicrous. Would it be OK for them to run out fuel? Land with the gear up? Fly past a waypoint and not contact ATC for almost an hour?

  8. Gumpfs says:

    Bystander wrote “Actually, the cockpit indication of TCAS OFF exceeds the existing international requirements”

    Which is why the NTSB recommended that the TCAS off indications be upgraded to a higher warning level.

    Then, Bystander wrote “you would expect that the Excelaire pilots would be very familiar with these indications for that particular loss of function as they have been trained on it since beginning to fly TCAS equipped airplanes.”

    Why do you have an expectation that these pilots had been flying Legacy aircraft since they were trained to fly TCAS airplanes? Regardless, if you think pilots are specifically trained in “TCAS off” identification, then you haven’t been a part of any serious pilot training.

    Bystander wrote, “If changes are needed to the warning then the issue should go to the world regulatory agencies for review and action”

    Again, that’s exactly what the NTSB recommended. Just because it hadn’t been recommended before doesn’t mean it wasn’t relevant – a better warning would have prevented the accident, period.

    Bystander wrote, “Adding new aural warnings to a cockpit is not a small undertaking and demands that appropriate study & engineering be completed.”

    Small compared to the engineering work for EGPWS, takeoff configuration warnings, etc. A better warning would have prevented the accident, and the work is definitely worthwhile.

    Your next comments are non-starters – they aren’t in the same league as missing a small TCAS OFF flag at the bottom of the PFD. Let’s look at them:

    “Would it be OK for them to run out fuel?”

    That would be a failure of planning, plus the blatant disregard of many warnings (including aural) onboard.

    “Land with the gear up?”

    It’s pretty hard to inadvertently raise the gear by putting your foot in the wrong place. Plus, then you’d have to land despite the EGPWS saying “Too Low, gear”, and the gear warning horn.

    “Fly past a waypoint and not contact ATC for almost an hour?”

    That happens all the time – I did it a couple of days ago over the ocean. But if you’re referring to what happened on the accident flight, it was only about 30 minutes before they actively started calling ATC, and they had answered every call previously.

    I guess what I’m saying is that yes, it should be like the examples you stated. It should be just as hard to fly around with the TCAS off as it is to run out of fuel or land with the gear up. But it’s many orders of magnitude easier to accidently turn off the TCAS and not notice. That’s definitely a problem.

  9. Stephan Wilkinson says:

    William Langeweische is hardly a “private pilot.” It’s been years since I flew, worked–and partied–with William, but as far as I know, he has an ATP (Airline Transport Pilot rating). He has worked as a commercial pilot (not airline but a variety of other for-hire purposes) for years, many of which jobs have been far more challenging than flying an automatic airliner between point A and B and back again, then do it again tomorrow….

    And, incidentally, his father Wolfgang Langeweische wrote “Stick and Rudder,” perhaps the single most admired book ever published on the techniques of flying. Not that it matters, but I hate to see some aerial busdriver refer to William as “a private pilot” when Langeweische has been seriously and professionally involved with aviation since our “expert” was in kindergarten. Or, if you count his family, since decades before the guy was born.

    Stephan Wilkinson

  10. Gumpfs says:

    Honestly, it’s irrelevant whether Langeweische is a private pilot or whether he has worked as a commercial pilot, he is missing some fundamental understanding of airline flying (or corporate jet flying) over South America. I find it interesting that you chose only to attack my characterization of him as a “private pilot”, not any of the factual errors or misunderstandings I pointed out in his article. I would be much more interested in discussing the facts surrounding the accident, rather than trying to post resumes.

    But for what it’s worth, I’ve been involved in quite a bit more than flying “an automatic airliner between point A and B”, but even that is exactly the relevant experience if we’re talking about an airline accident (GOL) and at least one of those two points are in South America. I’ve flown many general aviation aircraft, many light corporate aircraft, the F/A-18, SA-227, EMB-120, 737, 757, 767, A319, A320 and 777. I’ve been an accident investigator, air safety representative, and have testified before Congress on air safety. I’ve flown aircraft in North America, Central America, South America, Europe, Hawaii and Asia. I have well over 10,000 hours and will put my qualifications up against anyone, be they an airline pilot, private pilot, or a “commercial pilot who has flown a variety of for-hire operations”. I can’t churn out 8 pages of magazine prose for publication, but then neither do I claim to be able to.

    But that’s really not what’s important. If you take issue with any of the facts in my guest post, please let me know. Otherwise, you can tell William that I was wrong – he is not a private pilot, he is a commercial pilot without sufficient understanding to properly analyze the accident.

  11. Stephan Wilkinson says:

    Didn’t even read the rest of your piece. My comment was simply in reaction to your condescension in calling Langeweische “a private pilot,” which is a very specific put-down in the eyes of nonpilot readers (and even many ticket-holders). If you’d said William was “a pilot,” I wouldn’t have bothered.

    I see that you’ve left the “private pilot” put-down in place, so I still won’t read the rest of your piece.

    Oh, and you’ve added the information that Langeweische can “churn out” something you refer to as “magazine prose,” assumedly a lesser form of creativity that I must admit I too “churn out.” Thanks for that.

  12. FAA test says:

    The federal police of Brazil ended the case.
    Two guilted : the air control, and legacy pilots.
    I suppose that both of them would not face their responsabilities, this is not the country of justice.
    What would happen if brazillian pilots have been charged at US?

  13. CF says:

    FAA test wrote:

    What would happen if brazillian pilots have been charged at US?

    That wouldn’t happen, because we don’t criminalize air accidents in the US.

  14. Pilot says:

    I.D.I.O.T

  15. Paulo says:

    two wrongs dont make right.
    The controllers of Brazil was wrong and the Legacy Pilots as well.
    Before you go to other countrys, did you make a litle research???
    The pilots even dont known how or where was the instruments…
    R.I.P the people of boing.
    Let’s learn with ours mistakes and seiz the License of that Pilots. If you dont like…. Just
    Imagine the pilots was Brazilians… and the people dead was Americans.

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