Brazil's Black Eye: Criminalizing Pilots

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In this week's verdict on the collision between a GOL 737 and an Embraer Legacy, the Brazilian government proved that its justice system couldn't untangle itself from its internal politics after all. As we reported this week, the court convicted Joseph Lepore and Jan Paul Paladino of negligence, claiming the two turned off or failed to notice a failure in their transponder that led to the collision. The court also found the military controllers who put the two airplanes together to be culpable.

The two American pilots were tried and testified in absentia through a remote connection to a courtroom in the U.S. For as mistaken as proceeding with a criminal trial in the first place was, the verdict itself was an even bigger joke. The judge sentenced the pilots to four years, then suspended that in lieu of an equal amount of public service work. There's no extradition possibility here and I doubt if the court has any standing to enforce the sentence.

As this case progressed, I really thought the Brazilians would come to their senses, realize that criminalizing this accident serves no one and would just quietly make it go away. For reasons known only to people who understand Brazilian politics and culture, they didn't do that. In all this time—five years—they couldn't untangle this mess and work in their own (global) interest.

It makes me wonder what airlines and pilots who fly into Brazil must think. They have unique criminal liability for what most countries in the developed would consider an accident. I also wonder what they think in the halls of Embraer. They can't possibly like this verdict, can they? I wonder if we will hear them speak out about it. They should step up to the plate.

In the U.S., we routinely get excoriated for our money grubbing civil tort climate, perhaps deservedly. But I'll take that system any day over one biased to treat pilots as criminals in accidents for which they were at fault. Even in the U.S., criminal actions can result in cases of willful negligence. But what sane person turns off a transponder to willfully cause an accident?

The answer to that fundamentally erodes this verdict, one that Brazil should never have let seen the light of day.

Click here for an earlier blog on this accident.

Comments (76)

I doubt you will hear a peep out of Embraer. They get too much money from the Brazilian government to want to rock that boat.

Posted by: Adam Hunt | May 19, 2011 6:42 AM    Report this comment

I wonder how much of this verdict was due to families of the victims aboard the 737 making a public fuss? It reminds me of Congress passing the Colgan law because the families of those aboard made a fuss. Granted, the law has some good provisions in regards to crew fatigue but I still feel it will cause more harm than good.

I realize it's hard to lose loved ones, but in the end it doesn't accomplish much other than making the families feel a little better with the loss thinking it meant something.

Posted by: EJ Gonzalez | May 19, 2011 7:26 AM    Report this comment

Look at it from a non-pilot point of view. There was equipment on the brand new aircraft, which if it was working, would probably have prevented the accident, even though the controllers were negligent. The pilots did not check the equipment was working, or turned it off, accidently. Hence the guilty verdict. Same as a driver who does not notice their tyre treads are worn and then causes a fatal accident in a rain storm.

Posted by: Brian McCulloch | May 19, 2011 8:17 AM    Report this comment

We Americans are very naive about what constitutes justice in other "free" countries. One only has to look at the Amanda Knox debacle that was, and still is, taking place in Italy. When we travel abroad we must be aware that if we somehow find ourselves at odds with the authorities, we might be judged in the press or the political arena.

Posted by: Steve Tobias | May 19, 2011 8:52 AM    Report this comment

Checking the transponder interrogation light isn't something included in my instrument scan. New aircraft, new avionics, one shouldn't have to expect failure. Ever forget to turn the transponder on during departure? I guess in Brazil now, should that happen, one is now a criminal. Perhaps another item added to the master caution annunciator panel could warn of no transponder output...

Posted by: RAY GIBOULEAU | May 19, 2011 9:17 AM    Report this comment

Politics aside, these two pilots failed to turn on their transponder or failed to notice that their aircraft was not in a state for safe flight operations. If this happened in the USA, I'm sure, Mr. Bertorelli, you'd have a different take on it. Fact remains, these two pilots were negligent, and that has yet to be proven otherwise. Having the transponder on would have permitted the TCAS to provide alerting to both airplanes regardless of controller error. If the Brazilian court just dusted this under the rug, it would serve no one as well. Pilots must realize their responsibility when flying ANY aircraft. I for one am glad that these two got convicted, albeit, will likely hold zero weight. But it is a guilty verdict, and it was well deserved. I only hope the same applied to the controller for their equal share of this tragedy that never should have happened had the pilots turned on their transponders and actually did their jobs correctly.

Posted by: William Wang | May 19, 2011 10:24 AM    Report this comment

Quote: New aircraft, new avionics, one shouldn't have to expect failure.

As a mechanic, I think the opposite. New machines often have undiscovered squawks. I think the crew of a new airplane should DEFINITELY expect failures, just as does any pilot operating a first flight after heavy maintenance.

Still that doesn't mean that I think they (nor I) would or should have thought to check that the transponder was still replying every minute of the flight. That's just crazy.

Posted by: David Bunin | May 19, 2011 10:25 AM    Report this comment

>>>As a mechanic, I think the opposite. New machines often have undiscovered squawks. I think the crew of a new airplane should DEFINITELY expect failures, just as does any pilot operating a first flight after heavy maintenance.

I second that. It's a false sense of security to think otherwise. The first number of hours in service should be considered shake-down flights.

Posted by: LARRY ANGLISANO | May 19, 2011 10:32 AM    Report this comment

In the US, (particularly in the state of Nevada)where I live, there are many people serving years in prison for vehicular manslaughter. Many of these sentences are questionable. Look up Jessica Williams for example. Lets not pretend that we (the US) have such a superior system , we clearly do not.
Just for the record I do not agree with the Brazilian government in this case. Or the American government in many cases where accidents have led to long jail sentences...

Posted by: Steve M | May 19, 2011 11:18 AM    Report this comment

Brian McCulloch demonstrates what is wrong with the legal system. The truth doesn't matter. A pilot's view IS important, as non-pilots don't understand how things work in aviation. Transponder not working? ATC will tell you right away. It's not a criminal act to be human and forget something, or not realize something isn't working when you have a high workload. Read Deep Survival if you want to understand. Lawyers care about money, not the truth. This verdict is clearly Brazil covering up their clueless controllers, even if they did find them culpable. Does it really make sense to ruin a pilots career because of a faulty transponder? What purpose does that serve? Justice? No. Prevention? No. Specious retribution? Yep. People suck.

Posted by: Unknown | May 19, 2011 11:39 AM    Report this comment

Wm Wang is simply wrong. Reading the entire report issued by Brazilian and US NTSB confirms that the primary cause of this accident was Brazilian ATC. "The evidence collected during this investigation strongly supports the conclusion that this accident was caused by N600XL and GLO1907 following ATC clearances which directed them to
operate in opposite directions on the same airway at the same altitude resulting in a midair collision.
The loss of effective air traffic control was not the result of a single error, but of a combination
of numerous individual and institutional ATC factors, which reflected systemic shortcomings in
emphasis on positive air traffic control concepts."
The overwhelming EGREGIOUS error in my view was Brazilan ATC continuing to follow RVSM procedures to aircraft NOT in communication and WITHOUT valid radar txdr returns!
As a pilot I refuse to operate in Brazilian airspace and will BOYCOTT all Brazilian airplanes until Brazil corrects their corruption of justice and investigation. I will not ride in one as a passenger either! Let them try to sell their airplanes and policies somewhere ELSE other than the world's largest aircraft consumers in the U.S.!

Posted by: George Horn | May 19, 2011 11:54 AM    Report this comment

Mr. Bertorelli, why do you stick your neck out to protect these two pilots? I sure as heck don't want their careless / incompetently flown aircraft in MY airspace in the U.S. either! Mr. Bertorelli sounds like a typical ethnocentric who assumes Brazil must be wrong and the US pilots must be right. We are all aviators, and must take responsibility for our screwups. Mr. Bertorelli should be praising Brazil for going so light on these two pilots, who IN PART caused the deaths of all aboard the 737.

Posted by: Jeff Mirsepasy | May 19, 2011 1:45 PM    Report this comment

Actually George Horn, I'm not wrong. The NTSB report supports my position. The crew was noted to be unfamiliar with the aircraft and its avionics, was identified to be fraternizing with the passengers, not paying attention to their duties as pilots. It was also noted that their training in international flight operations was insufficient. Their professionalism break down and inattention to their flight operation was well defined in this report. Yes, the pilots were not the only party at fault, and I stated that I would like to see the ATC controller get a slap on the wrist for this as well. But back to the transponder...the aircraft's EFIS annunciated that the transponder was in the "standby" mode for hundreds of miles. Are you telling me that the pilots didn't see this annunciator for almost an hour? Where was their instrument and systems scan? Right. I rest my case. Google for this report. Read it for yourself. Oh, and apology accepted.

Posted by: William Wang | May 19, 2011 2:42 PM    Report this comment

Sorry Paul I don't buy it. The pilots were partially responsible in this case, there was negligence on their part. Pilots in the US are sued under Civil Statues for negligence all the time, the penalties are usually monetary, but there are examples of pilots here who went to jail for killing a passenger. I'm certainly no fan of the smelly tort side of our legal system, but we can't avoid our responsibilies just because someone else screwed up too. I'm frankly amazed the FAA and NTSB didn't weigh in more actively in this case, they certainly would have had it occured in US airspace.

Posted by: Barton Robinett | May 19, 2011 3:19 PM    Report this comment

Anyone know how the transponder is displayed in the subject plane? There are interfaces, and there are damn poor interfaces. I've struggled with some of Garmin's interface and we accept it as the gold standard for navigation, but it is till prone to misinterpretation.

Remember Three Mile Island? I took a human factors class from an accident investigator who reviewed the control room of that facility and she described it as 'Atrocious." All systems have an input-process-output-feedback control methodology, and at TMI the feedback for the critical cooling pumps was a gage on the opposite side of a control panel where the input was made. Furthermore, identical gages sat side by side displaying opposite readings for volume, pressure and reserve, and employees had written in china marker 'left is good' on one and 'right is good' on the other. When people are confused, designed-in confusion is as criminal as the crew's failure to note an anomaly or management's scheduling inexperienced crew in a new plane.

Posted by: THOMAS M CONNOR | May 19, 2011 3:29 PM    Report this comment

You can read the NTSB report for yourself. But I will quote it here:

"The evidence strongly supports the conclusion that this accident was caused by Legacy N600XL and GOL Flight 1907 following ATC clearances which directed them to operate in opposite directions on the same airway at the same altitude resulting in a midair collision.

"The loss of effective air traffic control was not the result of a single error, but of a combination of numerous individual and institutional ATC factors, which reflected systemic shortcomings in Brazilian air traffic control concepts. Contributing to this accident was the undetected loss of functionality of the airborne collision avoidance system technology as a result of inadvertent deactivation of the transponder on board N600XL and inadequate communication between ATC and the N600XL flight crew."

Culpability, yes. But rising to the level of criminal negligence? No. If that's the test, then I can name U.S. accidents that had a similar pattern.

Bottom line: Does criminalizing serve a positive purpose? I say no. And my neck isn't out there. I think it's wrong and I'm saying as much.

Posted by: Paul Bertorelli | May 19, 2011 3:46 PM    Report this comment

Mr. Bertorelli, 14 CFR 91.3(a) states:

"The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft."

And I emphasize "directly responsible for" above. If a pilot doesn't want the liability and responsibility, don't fly. It's that simple. If the pilot choose to fly, then that pilot has taken responsibility for the aircraft, cargo, and passengers.

Violating the law is a criminal act whether by intent, omission, or otherwise. I think if anything positive that could come out of this, would be a firm reminder to all pilots that flying an aircraft is serious business, and should be taken as such. Yes, flying an airplane is fun, but that fun comes at a cost. And that cost, is clearly defined by 14 CFR 91.3(a) for starters.

Posted by: William Wang | May 19, 2011 4:10 PM    Report this comment

Violating 91.3 is in no way a criminal act. These are civil/adminstrative not criminal penalties. There's a difference.

Following your reasoning, the maintenance workers who used modified engine removal procedures on American Flight 191 should have been jailed, along with their managers and the entire airline management. Similarly, Colgan's management should be jailed because they let a poorly trained pilot of questionable competence fly one of their airplanes. They were responsible for that.

Or how about FAA management? Their own red teams told them repeatedly that it was trivial to slip weapons through security and they did nothing, resulting directly in the deaths of thousands during the 911 attacks. Aren't they just as directly responsible? Should they he held criminally liable?

And on and on. When you begin jailing people for oversights and bad judgement, you'll degrade safety, not improve it.

Posted by: Paul Bertorelli | May 19, 2011 5:00 PM    Report this comment

Personally, jail is a pretty damn big motivating force for me to stay on top of my game. Even bigger is my ethics, morals, and conscience about killing someone else with my airplane. If it takes jail to keep the weak/unprofessional pilots out of the air, so be it. Aviation already suffer enough from these people. I rather see them out than continue to defecate on aviation's reputation.

Posted by: William Wang | May 19, 2011 7:48 PM    Report this comment

Willie: You must be the perfect pilot, error free and not of this Earth. Like a fighter pilot, only arrogant.

Posted by: THOMAS M CONNOR | May 19, 2011 8:20 PM    Report this comment

I have not read the report but would have a number of pretty basic questions re the facts. Assuming it was an IFR flight, was the code given, acknowledged with clearance, and identified on departure? If so, at some point it sounds as though it got lost. Who noticed and when? If not, why not? Surely a "not identified" call would have been made pretty smartly once a primary paint with no mode C became apparent on the ground. Do we actually know that the transponder was in "standby", either intentionally or otherwise? Was the flight in constant VHF coverage and contact along the route? Whatever, the legal result does seem a bit specious despite the tragic outcome.

Posted by: MICHAEL ALLSOP | May 19, 2011 9:49 PM    Report this comment

Tom Connor, how are you translating my opinion on this matter into my skill as a pilot? I'm pretty sure I never stated my piloting skills or indicated my competency as one. My desire to see weak pilots out of the air does not make me arrogant.

Mike Allsop, read the NTSB report. It answers all your questions.

Posted by: William Wang | May 19, 2011 11:16 PM    Report this comment

Let me see if I have this right - both aircraft were on an airway - on a collision course - as per their clearance. If in VMC, pilots of both aircraft would br required to see and avoid, so I would think they would be guilty of that, but otherwise it looks like the ATC is the one at fault here. I find the "guilt because the transponder is off" argument weak because ATC is still to provide separatiom to IFR aircraft in the event of avionics failure. At least here in the US. Must be the "wild west" down in Brazil if ATC cant even cope with an inop transponder!

Posted by: Josh Johnson | May 20, 2011 6:39 AM    Report this comment

Josh Johnson, you'd be right about see and avoid, but with two airplanes traveling at above 500 MPH with almost a 1000 MPH closure rate, you'd be hard pressed to see a plane and react to it. Hence, one of the major benefits to TCAS (which depends on both aircraft having their transponders on). As a matter of fact, the 737 crew did see the Embraer and took evasive action, but it was insufficient...or should I say, sufficiently enough that we don't have two airplanes downed and a higher body count in the Amazon. The question is, what were the pilots on the Embraer doing that they didn't take any evasive action? They were both heads down playing with the avionics and reading the operating manuals (which is documented in the report).

ATC is definitely at fault here as well. NTSB doesn't just point a finger at the pilots, but all parties involved, including technology.

Posted by: William Wang | May 20, 2011 8:31 AM    Report this comment

There is no question both the pilots and controllers share responsibility in this case. The question of which bears a greater responsibility, while perhaps an interesting academic question, is not really relevant. The real question is should a mistake be a criminal penalty.

Operating technically-advanced modern aircraft is a complicated affair, rife with the possibility of making mistakes. Pilots train and use procedures to mitigate the possibility, but eliminating mistakes entirely is a goal that so far eludes us.

In America, criminal negligence most often involves the operation of a motor vehicle while impaired (drugs or alcohol) in a manner which causes injury or death to others. This kind of behavior is clearly and unequivocally negligent--anyone who operates a motor vehicle impaired surely knows the behavior places others in harms way.

To my knowledge, no pilot has been accused of criminal negligence for making a mistake in the course of their duties. To do so would be to equate making a mistake, such as overlooking a checklist step and missing an annunciated warning, with the kind of intentional endangerment a drunk driver engages in -- to me they are not comparable. (cont)

Posted by: Mark Sletten | May 20, 2011 10:17 AM    Report this comment

(cont) The FAA and the military services instituted safety programs based on the premise that punishing the technical errors of pilots will serve to shut down the communications process that has provide the data which driving the many safety improvement ideas and recommendations of the NTSB. Granted, not all of these recommendations are implemented, but those that have serve to make America's aviation industry the world's safest.

I cannot speak intelligently about the intricacies of the Brazilian legal system, perhaps there is no corollary to our civil court system and the outcome of this case is the only way the families and loved ones of the victims can get satisfaction. But based on America's success in this area, it seems clear criminalizing technical mistakes is the best approach to avoiding them in the future -- which is really the point of Mr. Bertorelli's blog.

Posted by: Mark Sletten | May 20, 2011 10:21 AM    Report this comment

Will said "how are you translating my opinion on this matter into my skill as a pilot?" It's easy: Your words. I've donated hundreds of hours to flight students so they could finish their training when other instructors gave up on them, claiming they had no business in the cockpit. In reality the instructors had no business instructing, ready to give up on those who didn't get it the first time. Some of us are not so quick on the uptake, and I'm sympathetic to others with similar skill sets and not interested in throwing them in administrative jail. Sadly I have had WWII war heroes who I wouldn't sign off on BFRs because they could no longer hear radio calls, seemed to be sundowning when stressed or had physical problems that made it difficult to get in and out of the aircraft. That broke my heart, and punishment for getting old was not in my thoughts.

Posted by: THOMAS M CONNOR | May 20, 2011 10:23 AM    Report this comment

Correction: Last sentence should read, "...criminalizing mistakes is *NOT* the best approach to avoiding them in the future..."

Posted by: Mark Sletten | May 20, 2011 10:24 AM    Report this comment

Tom Connors, there's a huge difference between a student pilot who don't quite get it and is working towards proficiency with an instructor versus a couple of professional pilots conducting a flight operation where they were clearly negligent of their responsibilities. Examples are aplenty in aviation history of this behavior. It may be harsh of me to hold my opinion and position, but so is 154 deaths attributed to a completely avoidable situation had these two pilots paid more attention to their flight operations than tinkering with the toys and fraternizing with the passengers.

I just found an article that some readers might be interested in reading. Search for "Terror at 37,000 Feet Threat Level Wired" and the article is from Wired.

Posted by: William Wang | May 20, 2011 11:09 AM    Report this comment

I've stumbled thru most of the 282 page FINAL REPORT
A-00X/CENIPA/2008 and must say the authors dug deep and were redundant to a fault. Find it here if the security software doesn't strip it out: ntsb*gov/Aviation/Brazil-CENIPA/Midair_Collision_Final_Report_1907_English_version*pdf (I've replaced periods with asterisks to try to fool the security software and save others the trouble of finding it). Or look at the NTSB database for 26 sept 2006.
The report was educational in on aspect: I did not know that setting the transponder to standby also sets the TCAS to standby, effectively disabling TCAS in both aircraft. That design seems somehow unhelpful.

Posted by: THOMAS M CONNOR | May 20, 2011 1:53 PM    Report this comment

Another section indicates that the crew were under pressure from upper management - the pax - to leave immediately after a ceremonial transfer of the new plane to the customer. The plane had to be fueled, flight plan filed and weight and balance completed. That put a lot of pressure on the crew to complete mission planning, and they instead relied on others for both flight planning and weight and balance in an area they had never flown before and a plane they had little time in. To expedite things the SIC had the weight and balance software loaded on his laptop by factory personnel as he was simultaneously trying to finalize the flight plan. Amid all this he missed a notam that the runway at their destination was shorter than planned due to maintenance. Catching the error after takeoff, they both focused on the laptop and landing weight and other mysteries of the new plane.

Posted by: THOMAS M CONNOR | May 20, 2011 1:54 PM    Report this comment

The preamble to the final report also has this: "Moreover, one must stress the importance of protecting the individuals responsible
for providing information relative to the occurrence of an aeronautical accident. The utilization
of this Report for punitive purposes against such people maculates the principle of non-selfincrimination
deduced from the right to remain silent, sheltered by the Federal Constitution.
Consequently, the use of this Report for any purpose other than that of preventing
future accidents, may induce to erroneous interpretations and conclusions"
Probably not a great translation from Portuguese, I suspect the authors are saying they want immunity for those who cooperated with the investigation so we can prevent it from happening again.

Posted by: THOMAS M CONNOR | May 20, 2011 1:55 PM    Report this comment

Of special note is Paul Bertorelli's comment that they managed to have a bullet hit a bullet. One of the recommendations is to fly airway offsets - I assume to the right - so those deadly accurate flight systems cannot find each other horizontally.

Posted by: THOMAS M CONNOR | May 20, 2011 2:03 PM    Report this comment

A tip of the hat for slogging through all that, which I did when it first appeared and which shapes my view of the outcome. Further, two airline friends--both retired now--flew international into Sao Paulo from Miami and from Los Angeles and hated Brazil's ATC for its cavalier regard to ICAO standards, poor communication practices and cowboy routing methods in non-radar.

Basically, what Brazil is saying is that its government put the two airplanes together, then proposes to charge the surviving pilots as criminals for not avoiding the collision.

When you look at the drawing of the collision juxtaposed, it's amazing that the Legacy's winglet sawed through a structure as robust as a 737 spar. If someone in the cabin had walked forward four feet, it might have changed the altitude just enough to for that winglet to be six inches or a foot lower. Could have made all the difference.

Of such stuff is survival made.

Posted by: Paul Bertorelli | May 20, 2011 3:41 PM    Report this comment

The NTSB report seems to disagree with the Brazilian findings in a few key areas. The NTSB finds no evidence to suggest that the crew of the Embraer was inadequetly trained in intl operations, that the Brazilian controllers failed to change the Embraer's altitude to an odd flt lvl, and when being handed off, this change in clearance altitude was assumed to have been handled previously. The NTSB also found that the transponder being in standby was inadvertant...clearly not a deliberate act, and that the Brazilian controllers were applying RVSM separation standards, even though the criteria was not met. The main cause of this accident was that controllers cleared both aircraft to maintain tracks and altitudes that brought them into conflict. As with many accidents, there were secondary actions that could have either furthered a poor situation or mitigated it. Did any secondary action (or lack, thereof) on the part of the crew rise to a criminal level? Clearly not in the U.S. Many cultures, however, define criminality differently.

Posted by: Steve Tobias | May 20, 2011 3:52 PM    Report this comment

Mr. Bertorelli, since you read the NTSB report, can you speak to the professionalism of the two pilots and how they conducted their flight so that we can understand your position on them as aviators?

Posted by: William Wang | May 20, 2011 3:54 PM    Report this comment

Steve Tobias: Just to be clear, is the report you read the English translation from Portuguese written by Brazil, or is there yet another version? The report I read states that USA based players refused to talk to the investigators, but agreed to talk to the NTSB, hence my confusion.

An interesting point is the number of times the report states that the controllers manually input FL36 on the flight strip without a known effort to talk to and clear them down from FL37 and without mode-C verification (the TCAS standby problem). The SIC was heads down looking at a frequency chart and cycling thru the freqs looking for a controller when the collision occurred.

Posted by: THOMAS M CONNOR | May 20, 2011 7:09 PM    Report this comment

My position on the pilots as aviators is irrelevant. I can judge their actions based on the detailed CENIPA report, but that's about it.

I did that in a 2008 blog on the accident. I placed the link above, at the end of the main text. Bottom line: There were shortcomings in the crew's knowledge and performance. They could and should have known more and done better. But the same can be said of all of us. Their performance did not rise to the level of criminality, in my view.

Posted by: Paul Bertorelli | May 21, 2011 4:57 AM    Report this comment

I find it rather ODD that we have Not heard from Mrs. Willie Wang. According to Mr. Wang he is Incapable of making a mistake, could he possibly be divorced and that is why we haven't heard testimony from his spouse! Surely he didn't pick the wrong girl! This whole Attitude of Casting Stones is taking our Society back to the Stone Age! Aviation has No Room for REVENGE!! Yes we all Make mistakes, except of course lawyers and Judges!! Ha Ha! This continued escalation of pursuing pilots will only Mandate an END to Aviation! The FAR/AIM was approximately 200 pages in 1970, now it's over 1,400 pages and in Addition to knowing all of the associated regemines of weather, avionics, propulsion and FAR's pilots are being Overwhelmed! There is only so much a person can keep up with, at the current rate of growth in FAR's every pilot will Need a Lawyer for a Co-Pilot. Then we will see the Accident Rate Skyrocket for lack of Deciciveness!!

Posted by: Buz Allen | May 21, 2011 5:46 PM    Report this comment

In general, in our system discussion of whether something is "criminal" or not can't be divorced from analysis of the statute that was allegedly violated. If you review statutes regarding various types of "criminal negligence" in the U.S., what you'll find is that they (typically) require something like recklessness - knowledge of a substantial risk of harm followed by continued action. Firing a gun into the air at a party, for example, is itself criminal as reckless endangerment under one statute; if the bullet lands on someone and kills them, you have "negligent homicide" or manslaughter or the like. What offends US sensibilities about this incident is that these bizjet pilots were not, in most people's views, sufficiently "reckless" to warrant criminal prosecution. They didn't know their transponder wasn't working. Sufficient negligence for tort liability, perhaps, but insufficient recklessness for criminal liability. Other criminal justice systems (apparently including Brazil's) draw this line differently. Choose your flying destinations accordingly.

Posted by: DOUGLAS GARROU | May 23, 2011 6:45 AM    Report this comment

With the caveat that I am only a private VFR pilot and thus perhaps not fit to engage in this debate with experienced professionals, I'd just like to say: I don't understand why the only mistake that these pilots are supposed to be culpable for is the turning off of the txpndr (or failing to notice it had gone into standby mode). It seems pretty clear that they launched with a very poor understanding of the avionics. Isn't that significant?

Posted by: BOB GILCHRIST | May 23, 2011 7:55 AM    Report this comment

"It seems pretty clear that they launched with a very poor understanding of the avionics. Isn't that significant?"

It's significant only if you think it's below below the minimum, normal standard, whatever the minimal normal standard is. It's significant only if you believe that every pilot who trains on a new type knows the automation cold, to include all the human factors glitches built into the things and all the oddball abnormals.

I suspect many, if not most, pilots have had the experience of being in a modern cockpit where both pilots are puzzled by something to do with the automation because they are new to it. Fake it till you make it is alive and well and the reality of modern flight.

There are those who might say, "well, that would never happen to me," and they very well may be right. Or maybe that this shouldn't be allowed to happen. Maybe that's right, too. But the reality is very different and it's not clear to me that jailing pilots would help,

Posted by: Paul Bertorelli | May 23, 2011 9:05 AM    Report this comment

Mr. Bertorelli, thank you. I can appreciate your view better with your last comment.

Buz Allen, thank you for contributing to this discussion at the 5 year old level. If you have something meaningful to add, please do. But keep your libel to a minimum. Thank you. Being a pilot requires a lot of dedication. From my student pilot days to today, I continuously hear "not everyone can be a pilot" from one circle to another. And they are 100% correct. The day that I can no longer keep up with the changes and knowledge requirements to maintain a safe, competent, and proficient pilot in myself, is the day I will hang up my hat. I only hope others will have the will and wisdom to do the same when their time comes, instead of putting the airspace users and people at risk.

Bob Gilchrist, you are correct. It is significant. These two pilots failed to maintain a professional flight deck, and certainly, their instrument scan techniques were insufficient. The transponder was annunciated as STANDBY in yellow but they failed to see this for a very long time. To me, that's negligence and poor piloting. Anything annunciated in yellow or red on a flight deck requires attention. It's really that simple.

Posted by: William Wang | May 23, 2011 9:17 AM    Report this comment

I think everyone has missed the real reason this accident happened...the antiquated Brazilian Air Traffic Control system. The Brazilian system still operates by rules from the 60's. They are not equipped to handle the amount of air traffic that Brazil has experienced that last ten years. The equipment that the ATC system is operating with are decades old and do not cover all of Brazil, especially over the Amazon. Further, the military is running the ATC system. The military should get out of the ATC business and a civil system should be put in place.

Every time I fly into Sao Paulo, the busiest airport in South America, we ar delayed because military aircraft are practicing approaches. We have been held at 10,000 for up to 30 minutes until the military is finished. This, of course wouldn't happen in the US for several reasons; the military wouldn't have priority to shut down other traffic, we operate on a "first come, first" basis and we have the rules and equipment to allow more than one aircraft to operate in the same airspace at a time.

In September of 2008, President Lula announced that the system would be moved to a civil department and taken out of the military's control; it was a very short-lived idea, the military wouldn't give up control, sighting National Security.

Posted by: John Mueller | May 23, 2011 11:13 AM    Report this comment

Mr Bertorelli (I address you thus out of genuine respect - I find your writing both interesting and illuminating). I know a couple of airline pilots and I have been in the jump seat of their widebody simulator at EGKK when they've been prepping for a check ride. They certainly seemed completely and impressively knowledgeable about their avionics. I had expected all commercial flight crews to be similarly on top of their game. Perhaps your comment about "fake it till.." was aimed more at the crew of biz-jets? Becaue it is a frightening thought that there are such a/c rocketing through the skies with pilots fumbling around trying to work out how to do something as basic as enter a radio frequency (as these guys did!). I do *entirely* accept your main thrust about criminalising mistakes and ATC errors. But at the same time, I do not think it acceptable for people to be at the controls of high-performance a/c with only a rudimentary understanding of how to tune the radios. You are an instructor. Would you have signed these guys off? Bob

Posted by: BOB GILCHRIST | May 23, 2011 11:38 AM    Report this comment

Years ago AOPA did a study asking accident-free airline captains how they managed to do it. The consensus was to not let the schedule force you to do things you normally wouldn't. The Legacy crew had originally intended to depart on the 30th, but management told them to depart on the 29th immediately after the transfer ceremony. Maybe there is a lesson to be learned from that.

Posted by: THOMAS M CONNOR | May 23, 2011 12:27 PM    Report this comment

"You are an instructor. Would you have signed these guys off?"

I am sooooo unqualified to answer that. We can only judge them from the cockpit transcript and little else. I am quite certain I have signed people off who were far from perfect or the best airmen on the planet. One can only make a reasonable judgment on competence and risk awareness. Perfection is unachievable and we couldn't afford it if it was.

I know a lot about non-radar operations (taught a clinic about it) and by dint of friends in the business, I even know a little bit about Brazilian ATC. But I can't say this scenario would have activated my exceptional risk antenna.

I acknowledge that it's very easy for some people to say that *after the fact.*

Posted by: Paul Bertorelli | May 23, 2011 12:56 PM    Report this comment

Colors: The TCAS standby condition is displayed in yellow on the Legacy's radio management unit, and in white on both PFDs. Under the lighting example shown in illustration 40 of the report it seems possible for the setting sun to wash out the yellow, especially with the yellow sunshades drawn or the wrong color of sun glasses. Something to consider.

The report dwelled on accidentally setting the TCAS to standby with the laptop or a foot on the footrest etc. If the Legacy system uses a main-bus architecture for I/O functions then all I/Os were possibly recorded by the main CPU. If available, that data can then be played back in a simulator so one could pinpoint where and when the switch action was taken, yet this was never addressed. Since there was an AD for the TCAS setting itself to standby on previous Primus systems with no crew input one has to wonder if the oversight was intentional.

Posted by: THOMAS M CONNOR | May 23, 2011 1:22 PM    Report this comment

'What's it doing now!' was a frequent comment overheard on Airbus cockpit recorders in the '80s and 90's. It seems that the software designers had no clue regarding the info a pilot needs and at times turned them into dogs watching TV: The pretty colors and action were fun to watch but not very meaningful. It also resulted in some interesting accidents, some of which involved factory crews with quals up the ying yang.

Posted by: THOMAS M CONNOR | May 23, 2011 2:22 PM    Report this comment

I was a mission crew member on the E-3 AWACS from '79 to '91 and have first-hand knowledge on how crude and frustrating some software can be. We hammered Boeing Software specialists for fixes and solutions. They frequently didn't have answers, claiming the customer had given them modules to integrate into the E3 software to save money. Modules came from SAGE, NORAD and ground TACCS systems developed in the 70s and performed significant functions such as radar and IFF tracking, track ID, data correlation and comm management. Boeing didn't know how they worked so there was no way to modify them, only that the modules did what they were supposed to and 'didn't degrade other systems under the testing they had done.' They were rightfully proud that they were making it work on a platform skipping along at about Mach .75. Operators were less impressed because we had first hand knowledge of combinations that made the creaky old IBM-360 mainframe freeze. Fun times when weapons was in the midst of an intercept. Our salvation was that the mainframe recorded everything to tape, so we could play the mission back, figure out who did what just before the system freeze and see if we could repeat it. Then we derived workarounds. The problems were eventually fixed, and the fixes often introduced a new set of problems. Such is life in a software intensive system.

Posted by: THOMAS M CONNOR | May 23, 2011 2:24 PM    Report this comment

For internal political reasons the Brazilian court had absolutely no choice but to find the crew "guilty", and the light sentencing was probably the best compromise that could be expected. You can bet they are taking a lot of heat for it.

More interesting to me is the division in attitudes expressed by the various responses in this thread.

Far too many (IMHO) appear to be of the same mindset as the only boss in my entire career that I had serious issues with. Although a nice enough fellow, he was totally blind to the realities of human imperfection. Whenever any error was made his only concern was to assign guilt and demand punishment, and I was constantly obliged to shield my "troops" from his excesses.

There are two common sayings that I recommend to all those whose view is that "anyone who makes a mistake resulting in a bad happening is by definition a criminal". The first is "poo happens", meaning it is the normal condition of the universe for things to break and humans to make errors. The second is "there but for the grace of God go I", meaning that you too have made mistakes that could have resulted in serious problems, but got away with it.

Life is not black and white, and judgement must be exercised in deciding whether some error or other rises to the level of criminal negligence.

Posted by: John Wilson | May 23, 2011 2:58 PM    Report this comment

"It seems pretty clear that they launched with a very poor understanding of the avionics." To which I say, Some admire a 'can-do' attitude. Others apparently, not so much.

According to the report, the crew went thru Flight Safety International training on this system and I assume they demonstrated some level of proficiency with the Primus system. If not that sheds a dim light on FSI. The time between the training and the incident flight is unclear to me, and we all know that time is not your friend when learning new stuff. The PIC recognized this and sat in the cockpit inputting flight data rather than attend the aircraft transfer and dinner, so I give him points for recognizing the problem and trying to solve it. The customer moved departure up a day, which may have messed with the crew's plans for factory refresher training, we don't know. The time compression had them divvy up tasks rather than do them together, which seems like a wise use of resources considering the circumstances. They missed a notam until after departure, which resulted in using a laptop to resolve landing weight concerns. There was some concern in the report that the laptop may have obstructed view of the TCAS status or touched a button that set it to standby.

Posted by: THOMAS M CONNOR | May 23, 2011 3:28 PM    Report this comment

So here we sit with some criticizing a crew with a 'can do' attitude while ignoring that ATC failed to do their primary job of traffic separation. ATC left them at the wrong altitude, failed to make contact with the plane and manually set the flight strip to the correct altitude without clearing the plane to that altitude or verifying altitude.

The investigators spent an inordinate amount of time evaluating the crew, the plane and the interface, and lip service to the ATC system. the recommendations were heavy with fixes to the ATC system however. But one must read carefully to figure that out.

Dave Gwinn once wrote that when you have that uneasy feeling about a flight and pax clamoring that you deliver then sabotage the plane so you cannot depart. Probably not a successful strategy at the factory. Ernest Gann wrote in 'Fate is the hunter' to 'just say no.' But he filled his book with first-hand experiences and the death of many friends that lead him to that position.

For the critics I ask: Where would you have stepped in and 'broken' the accident chain?

Posted by: THOMAS M CONNOR | May 23, 2011 3:28 PM    Report this comment

Tom Connors, just curious, who, ultimately, is the final authority, and is responsible for, this flight?

The accident chain could have easily been broken had there been a proper flight deck scan, and a proper delegation of task responsibilities. It is obvious that both pilots were not flying the airplane. The autopilot was flying it. Piloting 101: aviate, navigate, communicate.

In any case, it's obvious that people will believe what they want to believe. Criminal or not, these two pilots got off easy. I'd have a hard time sleeping at night knowing that my lack of skills resulted in so many dead.

Posted by: William Wang | May 23, 2011 3:40 PM    Report this comment

Tom - I am not qualified to respond - you are a working professional and I am an amateur. So forgive me. With respect, I have not said these guys are criminal. I am just amazed that we can't all agree that it is shocking to read that the crew did not even know how to squawk ident without clearing the active comms frequency. Is it really credible that the certificated Honeywell Primus gear is buggy to that extent? We can all be experts after the fact, especially rank amateurs like me. But what bothers me is the attitude that these guys are gung-ho, can-do types who are utterly blameless and "their only crime is saving the lives of their pax". We need to learn from our mistakes (and the mistakes of others)and surely this crew should or could ask itself: "what could we have done differently"? To which, as a software engineer, I'd have to suggest: RTFM!

Posted by: BOB GILCHRIST | May 23, 2011 4:09 PM    Report this comment

Mr. Wang, you're ignoring the points I've made about the lighting, the interface and the distracted crew trying to solve the very problem that resulted in staying at the wrong altitude. The only thing left is gazing out the window for traffic which you said yourself was probably not useful activity at a thousand kt closure.

I assume you mean that neither pilot was flying the plane, not both. Regardless, how could hand-flying have helped in this situation?

I also think you have a sometimes desired but incorrect view of the FARs as law. Many speak of them as such, but that is incorrect. Congress gives bureaus rule-making powers to make their job easier. In so doing congress recognized that the rules may not pass a test for constitutionality and hence have administrative, not legal penalties. A good example is democracy vs communism. Where one has a few 'thou shalt nots' prohibiting a few behaviors, communism and bureaucracy have thousands of thou shalt' rules proscribing behavior. By it's very nature perfect 'rule following' is difficult because there are so many.

Posted by: THOMAS M CONNOR | May 23, 2011 5:02 PM    Report this comment

RTFM: Isn't that what the crew was doing?

"Is it really credible that the certificated Honeywell Primus gear is buggy to that extent?"

Absolutely. If my experience has taught me anything, 'certified' and 'airworthiness' are highly overrated.

Posted by: THOMAS M CONNOR | May 23, 2011 5:14 PM    Report this comment

"I'd have a hard time sleeping at night knowing that my lack of skills resulted in so many dead."

And what possible flight of imagination leads you to believe that these two pilots don't? Judgementalism can lead to assumptions neither evident in fact nor record.

Posted by: Paul Bertorelli | May 23, 2011 5:23 PM    Report this comment

Mr. Connor,

How many pilots does it take to read a manual? At any time, someone has to be paying attention to the aircraft, it's navigation, and communication. Piloting 101. It's okay to have the AP fly, but one pilot better be looking at everything, including all displays and instrumentation, and make damn sure the AP is doing what it is commanded. These two were clearly staring at a laptop, and flipping switches to see what will happen. Hardly the time and place. My point is, no one was flying the plane.

By the way, the event happened one minute after the captain returned from a 16 minute poopfest.

Posted by: William Wang | May 23, 2011 5:27 PM    Report this comment

Mr. Wang, I am truly puzzled over your high and mighty opinion of yourself, which you MUST have in order to be so condemning of other pilots. I said it before..and I'll reiterate it because you seem so obtuse about this are WRONG, WANG!
At the MOST BASIC LEVEL this accident occured because two airplanes were at the same place at the same time.
If you will ask yourself how that happened you will arrive at the correct conclusion. The Brazilian ATC controller who handed them off and erroneously stated the Legacy to be at FL360 when in fact it was at FL370... Tell me Wang, ...would you consider THAT negligent? (as you so willingly leap to blame the Legacy pilots?)
I the most BASIC level... wouldn't you think that a pilot should be able to LOSE ALL AVIONICS and be COMPLETELY NORDO... and this accident STILL SHOULD NEVER HAVE HAPPENED!
Except, apparently... in BRAZIL!
Wang...if you can't see the simplicity of that...then, sorry Pal... it is YOU who needs to hang it up.

Posted by: George Horn | May 23, 2011 5:31 PM    Report this comment

Excellent point about being NORDO. The rules are designed to allow for human or mechanical mistakes of losing radio communications. After all that is what a transponder is -- a form of radio communications. Being NORDO in Class A airspace, or partially NORDO, isn't criminal or negligent.

Posted by: Timothy Holloway | May 23, 2011 7:00 PM    Report this comment

FYI Mr.Wang after flying over 160 combat missions as a KC-135 pilot I can assure you it is very possible to visually See other aircraft converging nose to nose at greater than Mach 1. That is the only way that fighters could be air-refueled on Post-strike missions,generally 8 to 16 fighters at a rejoin. So in your defense, yes one of the pilots should have been heads-up, if they were in VFR conditions. That would have given them time to Miss! But once again I reiterate, if you have flown over a thousand hours there have been many instances you have missed something you should have seen!! TCAS has proven that to many very experienced eagle eye pilots. As far as those pilots killing 154 people, what about the pilots of the Airliner, they should have seen the Embreair, they are the ones to Blame if so desperately Need someone to Blame! The Legacy Pilots should be given a Medal for Superior Airmanship after Safely landing an aircraft with structural damage that they had very minimal time in, lets see Mr. Wang tell us all about the aircraft you have landed safely with Major Structural Damage!! You are out of your element Willie and it's Very Obvious to all experienced pilots!! I wonder how many of the passengers on the Legacy think their pilots are Criminals!

Posted by: Buz Allen | May 23, 2011 7:26 PM    Report this comment

George Horn, whatever helps you sleep at night, guy.

Buz Allen, the 737 did execute an evasive action. It's in the report. I have to disagree with you on "if they were in VFR conditions". It doesn't matter if they were in VMC or IMC conditions. One of the pilots should have been flying the airplane, and by that, I mean running their instrument scan, and looking out the window. If they did that, it would have been apparent that the transponder was in standby mode. As for the rest of your statements, I won't be drawn into any other hypothetical situation discussions with you as it serves no purpose. Nor will I entertain your opinion of me, as I really don't care what you (or anyone else) think of me.

In any case, this discussion has deteriorated beyond my desire to participate further. It's clear to me that there's only one view here, and I'm more than happy to bow out. Enjoy the camp fire.

Posted by: William Wang | May 23, 2011 10:37 PM    Report this comment

I don't think you people get it...Brazil still operates under ICAO rules...if you change direction of flight, you change altitudes...even when NORDO; in the US you maintain your last assigned altitude. Brazil's ATC system is still in the 60's. Most commercial pilots have rated it as one of the worst ATC systems in the world. It's terrible. This wasn't the pilot's fault...this was a system which isn't equipped for this amount of traffic. And the worst part is that it still hasn't changed. Much of the airway system is still operating with NDBs.

Posted by: John Mueller | May 24, 2011 12:36 AM    Report this comment

Dear Mr. Wang. According to the report, the Boeing crew did not initiate evasive action. The GOL crew were doing exactly what the 'criminal' Legacy crew were doing. I cut and pasted from the report for all to see, including the paragraph number so you can look it up:

4.10.4. Onboard the PR-GTD
In the cockpit of the Boeing, moments before the collision, there was absolute tranquility.

The pilots were talking, and the collision took them by surprise. The airplane started an
abrupt descending roll to the left.
The two aircraft approached each other at a speed of about one thousand six hundred
kilometers per hour. The Boeing was a little left of the Legacy and slightly above.
According to the data obtained from the CVR and DFDR of both aircraft, their TCAS
systems did not emit any traffic alert or instruction for an evasive action to the respective
crews, so that the collision could have been prevented.
There were not any indications on the part of the crews relative to a previous visual
perception of the approach between the two aircraft.
No attempt of an evasive action or maneuver was made, according to the existing data
of the flight recorders.
After the collision, the PR-GTD lost 6.96 m (direction winglet – fuselage) of its 17.89 m wing . . .

This has been an interesting experience conversing with someone who can be so wrong yet never in doubt. I wish Mr. Wang well. And don't let the screen door hit ya where the good lord split ya.

Posted by: THOMAS M CONNOR | May 24, 2011 1:25 AM    Report this comment

Dear Mr. Connor,

Looks like I confused that part with the evasive action on the part of GOL with another subjective report. So I'll own that error. My point from the beginning of this discussion that has deteriorated to a pissing match has always been about the Legacy crew's professionalism in running their flight deck. The report alluded to this a couple of times. See section 4.7.1, section 4.9.2. What is also interesting is section vs.

So yes, these two guys managed to land a structurally damaged aircraft. Lucky them. It's the lack of professionalism that bothers me. Curious that few can see this as part of the accident chain. It's amusing to me because the FAA constantly push this "professionalism" word at their WINGS seminars yet it's clear to me now that few understand its true meaning and application thereof.

And yes, it certainly has been an interesting experience conversing with someone who is so determined to believe that the U.S. pilots can do no wrong yet never entertain the possibility. And I sure enjoyed the juvenile name calling and derogatory comments. This sure is a quality blog! Very enjoyable! Good day, sir.

Posted by: William Wang | May 24, 2011 9:50 AM    Report this comment

As the captain of a highly automated bizjet, I can't see any behavior on the part of the Embraer crew that is non-professional. From what I have read it seems that they were doing exactly what I would have been doing: digging in and trying to solve their communication problem with ATC. If the transponder was inadvertently switched off or worse, automagically put in standby with no input from the crew, then that would certainly go unobserved by the most seasoned crew for a great length of time when not alerted by ATC. Frankly, looking for an "ALT" or "STBY" indication on a busy PFD does not rank high in the scan of a crew that is trying to compute landing data and re-establish communication with ATC, ie: flying the plane.

Most of the posts condemning the crew of this flight sound like those of the 500-ish hour CFII, Captain of the right seat in his 172, gunning for anyone who's job he should have since he would do it so much better.

Posted by: Tyler West | May 24, 2011 11:58 AM    Report this comment

Will: Thanks for the references, they were enlightening. Of interest to me is the halo the report put on the GOL crew and horns on the Legacy crew: It brings to mind the 'tool' used by the military to 'get someone's attention' by failing them on a no-notice flight check, which gave the ops officer a chance to rail against him or her and their instructor as appropriate. It is easy to fail any person on a checkride: Wait long enough and they'll hand you an error. Dig and you can create your own. The easiest was a last minute substitution on a crew where someone else did the planning and then bowed out, got sick or it was done by a planning crew. There are similarities to that and how the Legacy crew was selected and pressured into departing a day early. So from afar the easiest and the hardest way to break the accident chain was to refuse to fly the sortie for incomplete information in a jet that allegedly can do it all for you. And then find your own way home from Brazil to clear out your desk. Tough call.

Posted by: THOMAS M CONNOR | May 24, 2011 3:37 PM    Report this comment

Talk about piling on. I'm glad Mr. Wang is here to uphold the concept of pilot professionalism. Judging by the comments of some of the "professionals" here that quality seems to be in short supply.

Whenever someone decides to go personal in these debates, it tells me all I need to know. Good work Mr. Wang. I don't know how I could have kept up a civil tongue here.

Posted by: Gordon Arnaut | May 26, 2011 10:29 AM    Report this comment

And Mr. Bertorelli, please spare us these cryfests in future.

Is the Brazilian ATC horrible? Maybe. All the more reason to exercise utmost airmanship while flying in that airspace.

Was the court ruling unfair? Maybe. But I was taught that even if someone is treating you unfairly to conduct yourself with honor. This crew promised to appear in court, then reneged on their word. That is not honorable.

Bottom line is 150 plus souls went down. The honorable thing to do would have been to stand in that courtroom and take your lumps.

Posted by: Gordon Arnaut | May 26, 2011 10:39 AM    Report this comment

"And Mr. Bertorelli, please spare us these cryfests in future."

Sorry, not my style to cry, bub. You might stand still while someone knocks your teeth out with a ballpeen hammer, but I wouldn't.

The larger point is what does Brazil gain on the international aviation stage by having its substandard ATC system put two airplanes together, kill a bunch a people and then try to jail the surviving pilots who everyone else seems to think acted reasonably professionally albeit not perfectly. The world of aviation at large sees this for what it is, a BS, politically motivated charge. They were right to stiff the court.

As I said, Brazil doesn't do itself any favors by pursuing this as a criminal case. I say work it out civilly.

Posted by: Paul Bertorelli | May 26, 2011 11:36 AM    Report this comment

You don't understand the Brazilian people or how Brazil or how Brazil operates. There always has to be a scapegoat in Brazil; nothing "just happens"...they have to blame someone. Also, anytime anything negative happens that involves foreigners, it's always the foreigner's fault. Brazil has a very sactimonious approach to everything; it's never their fault. To blame the ATC system would mean that Brazil would have to admit to a fault...something that Brazil will never do.

This accident should be put directly on the shoulders of the military, the government and the ATC people are arguing about "pilot responsiblility", etc. Brazil is the fifth largest country in the world, the fifth largest population with the eighth largest GNP in the world; yet it's ATC system is sixty years behind in every way.

Politically, if the government can place the blame of this "accident" on the pilots of the Legacy, then they don't have to look at their own ATC system with unbiased eyes.

If you remember, in 1958 a United DC6 and a TWA Super Connie came together over the Grand Canyon. This caused such an uproar, that the FAA (Federal Aviation Agency) and Congress worked together to create a much better, more sophisticated ATC system. Brazil was given the same opportunity to look at their system; instead of spending the time, money and efforts to change it they have elected to place blame on someone and continue to operate under the "Business as Usual" concept.

Posted by: John Mueller | May 26, 2011 12:00 PM    Report this comment

Paul, do you remember the cable car incident of 1998, when Marine crew flying a Prowler snapped a cable car line at a ski resort in Italy, killing 20 people?

The crew was acquitted in US military court, despite flying too fast and too low.

Result? Huge black eye for the US in international opinion. So let's not go pointing fingers too much.

Posted by: Gordon Arnaut | May 26, 2011 1:34 PM    Report this comment

And what about flight 587? Here the pilot was blamed for alternating rudder inputs, despite the fact that this is what you supposed to do and this is what is done in flight testing, as I can attest from personal experience. It's called rudder doublet.

There is no way a fin should break at Va. I looked at those photos of the broken tail and the metal fittings are intact but the plastic parts broke.

But rather than blame insufficient industry understanding and experience with composite airframe structures, not to mention spooking millions of airline passengers who would have to continue flying on plastic planes, the easiest thing to do was to blame the pilot.

Stinks. Far more than this Brazil thing in fact. So let's keep things in perspective.

And here 150 souls went down and this crew is still around. They were the closest to the scene and they get blamed, fair or not. That's how the system works here too.

Lots of bad politics to go around if you really want to go there.

And as for Brazil fixing its ATC, well let's give them a chance. This does not happen overnight. I think they will modernize and improve and you can be sure heads have rolled due to this screw-up.

Posted by: Gordon Arnaut | May 26, 2011 1:49 PM    Report this comment

Oh dear. That ridiculous comment about the rudder failure incident has me clicking on unsubscribe. Bye...

Posted by: BOB GILCHRIST | May 26, 2011 2:33 PM    Report this comment

And let's not forget the 2002 midair over Germany involving a Russian airliner full of schoolkids and a DHL 737 cargo plane.

Swiss ATC handling the two jets was found negligent by the German investigation, with systemic problems. A number of people in the privately owned ATC company were convicted in criminal court. As well they deserved.

Posted by: Gordon Arnaut | May 26, 2011 6:13 PM    Report this comment

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