Gol Transportes Aéreos Flight 1907
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On 29 September 2006, Gol Transportes Aéreos Flight 1907, a
Boeing 737-800 The Boeing 737 Next Generation, commonly abbreviated as 737NG, or 737 Next Gen, is a twinjet, twin-engine narrow-body aircraft produced by Boeing Commercial Airplanes. Launched in 1993 as the third-generation derivative of the Boeing 737, it ha ...
on a scheduled domestic passenger flight from
Manaus Manaus () is the List of capitals of subdivisions of Brazil, capital and largest city of the States of Brazil, Brazilian state of Amazonas (Brazilian state), Amazonas. It is the List of largest cities in Brazil, seventh-largest city in Brazil, w ...
, Brazil, to
Brasília Brasília ( ; ) is the capital city, capital of Brazil and Federal District (Brazil), Federal District. Located in the Brazilian highlands in the country's Central-West Region, Brazil, Central-West region, it was founded by President Juscelino ...
and
Rio de Janeiro Rio de Janeiro, or simply Rio, is the capital of the Rio de Janeiro (state), state of Rio de Janeiro. It is the List of cities in Brazil by population, second-most-populous city in Brazil (after São Paulo) and the Largest cities in the America ...
, collided mid-air with an Embraer Legacy 600 business jet flying on an opposite heading over the Brazilian state of
Mato Grosso Mato Grosso ( – ) is one of the states of Brazil, the List of Brazilian states by area, third largest by area, located in the Central-West Region, Brazil, Central-West region. The state has 1.66% of the Brazilian population and is responsible ...
. The
winglet Wingtip devices are intended to improve the efficiency of fixed-wing aircraft by reducing drag. Although there are several types of wing tip devices which function in different manners, their intended effect is always to reduce an aircraft' ...
of the Legacy sliced off about half of the 737's left wing causing the 737 to break up and crash into an area of dense jungle, killing all 154 passengers and crew on board. Despite sustaining serious damage to its left wing and tail, the Legacy landed with its seven occupants uninjured. The accident was investigated by the Brazilian
Aeronautical Accidents Investigation and Prevention Center The Aeronautical Accidents Investigation and Prevention Center (, CENIPA) is a unit of the Brazilian Air Force that investigates aviation accidents and incidents in Brazil. It is headquartered in Brasília. See also * Gol Transportes Aéreos Fl ...
( – CENIPA) and the U.S.
National Transportation Safety Board The National Transportation Safety Board (NTSB) is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and inci ...
(NTSB), and a final report was issued in 2008. CENIPA concluded that the accident was caused by
air traffic control Air traffic control (ATC) is a service provided by ground-based air traffic controllers who direct aircraft on the ground and through a given section of controlled airspace, and can provide advisory services to aircraft in non-controlled air ...
(ATC) errors, combined with mistakes made by the American pilots on the Legacy, including a failure to recognize that their
traffic collision avoidance system A traffic alert and collision avoidance system (TCAS), pronounced ), also known as an Airborne Collision Avoidance System (ACAS), is an aircraft collision avoidance system designed to reduce the incidence of mid-air collision (MAC) between aircraf ...
(TCAS) was not activated, while the NTSB determined that both flight crews acted properly and were placed on a collision course by ATC, deeming the Legacy pilots' disabling of their TCAS system to be only a contributing factor rather than a direct cause. The accident, which triggered a crisis in Brazilian civil aviation, was the deadliest in Brazil's aviation history at the time. It remains the second-worst plane crash in Brazil, after TAM Airlines Flight 3054 in 2007. This accident was also the first hull loss of a
Boeing 737 Next Generation The Boeing 737 Next Generation, commonly abbreviated as 737NG, or 737 Next Gen, is a twinjet, twin-engine narrow-body aircraft produced by Boeing Commercial Airplanes. Launched in 1993 as the third-generation derivative of the Boeing 737, it ha ...
aircraft and the first fatal accident of a
Boeing 737-800 The Boeing 737 Next Generation, commonly abbreviated as 737NG, or 737 Next Gen, is a twinjet, twin-engine narrow-body aircraft produced by Boeing Commercial Airplanes. Launched in 1993 as the third-generation derivative of the Boeing 737, it ha ...
.


Background


Boeing aircraft and crew

The Gol Transportes Aéreos twin
turbofan A turbofan or fanjet is a type of airbreathing jet engine that is widely used in aircraft engine, aircraft propulsion. The word "turbofan" is a combination of references to the preceding generation engine technology of the turbojet and the add ...
Boeing 737-800 aircraft, registered as PR-GTD, was a new Short Field Performance variant, with 186 seats (36 Economy Plus and 150 Economy seats). It only logged 202 hours and 18 minutes of flight time in 162 takeoff and landing cycles before the collision. Six crew members and 148 passengers were on board the Boeing 737. The six crew members and 105 of the passengers were Brazilian; the remaining passengers were of various other nationalities. The crew consisted of
Captain Captain is a title, an appellative for the commanding officer of a military unit; the supreme leader or highest rank officer of a navy ship, merchant ship, aeroplane, spacecraft, or other vessel; or the commander of a port, fire or police depa ...
Decio Chaves Jr., 44, First Officer Thiago Jordão Cruso, 29, and four flight attendants. The captain, who had also been serving as a Boeing 737 flight instructor for Gol, had 15,498 total flight hours, with 13,521 in Boeing 737 aircraft. The first officer had 3,981 total flight hours, with 3,081 in Boeing 737 aircraft. Gol Flight 1907 departed
Eduardo Gomes International Airport Manaus–Eduardo Gomes International Airport is an international airport serving Manaus, Brazil. On 11 December 1973, while still under construction, the name of the facility was changed from ''Supersonic Airport of Manaus'' (owing to its desig ...
in Manaus on 29 September 2006, at 15:35  Brazilian standard time (BRT) (18:35 
UTC Coordinated Universal Time (UTC) is the primary time standard globally used to regulate clocks and time. It establishes a reference for the current time, forming the basis for civil time and time zones. UTC facilitates international communica ...
), en route to Rio de Janeiro–Galeão International Airport, with a planned intermediate stop at
Brasília International Airport Brasília–President Juscelino Kubitschek International Airport () , also known as the Brasília International Airport, is the international airport serving Brasília, located in the Administrative regions of the Federal District (Brazil), admin ...
.


Embraer aircraft and crew

The twin turbofan Embraer Legacy 600 business jet, serial number 965 and registration N600XL, newly built by Embraer and purchased by ExcelAire Service Inc. of
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, was on a delivery flight by ExcelAire from the Embraer factory to the United States. It departed from São José dos Campos-Professor Urbano Ernesto Stumpf Airport (SJK), near
São Paulo São Paulo (; ; Portuguese for 'Paul the Apostle, Saint Paul') is the capital of the São Paulo (state), state of São Paulo, as well as the List of cities in Brazil by population, most populous city in Brazil, the List of largest cities in the ...
, at 14:51 BRT (17:51 UTC), and was en route to Eduardo Gomes International Airport (MAO) in Manaus as a planned intermediate stop. The ExcelAire flight crew consisted of Captain Joseph Lepore, 42, and First Officer Jan Paul Paladino, 34, both U.S. citizens. Lepore had been a commercial pilot for more than 20 years and had logged 9,388 total flight hours, with 5.5 hours in the Legacy 600. Paladino had been a commercial pilot for a decade and had accumulated more than 6,400 flight hours, including 3.5 hours in the Legacy 600, as well as 317 hours flying as captain of Embraer ERJ-145 and ERJ-135 jet aircraft for American Eagle Airlines. (The ERJ-145 and ERJ-135 aircraft are
regional jet A regional jet (RJ) is a jet airliner, jet-powered regional airliner usually defined by having fewer than 100 seats. The first aircraft considered part of this category was the Sud-Aviation Caravelle in 1959, followed by Douglas DC-9, BAC O ...
s of the same family as the Legacy.) Paladino had also served as first officer for
American Airlines American Airlines, Inc. is a major airlines of the United States, major airline in the United States headquartered in Fort Worth, Texas, within the Dallas–Fort Worth metroplex, and is the Largest airlines in the world, largest airline in the ...
, flying MD-82, MD-83, and Boeing 737-800 aircraft between the U.S. and Canada. Both pilots were legally qualified to fly the Embraer Legacy as captain. Two of the five passengers were Embraer employees, two were ExcelAire executives, and the fifth passenger was ''
The New York Times ''The New York Times'' (''NYT'') is an American daily newspaper based in New York City. ''The New York Times'' covers domestic, national, and international news, and publishes opinion pieces, investigative reports, and reviews. As one of ...
'' business travel columnist Joe Sharkey, who was writing a special report for ''Business Jet Traveler''.


Accident

At 16:56:54 BRT (19:56:54
UTC Coordinated Universal Time (UTC) is the primary time standard globally used to regulate clocks and time. It establishes a reference for the current time, forming the basis for civil time and time zones. UTC facilitates international communica ...
), the Boeing 737 and the Embraer Legacy jet collided almost head-on at , approximately midway between
Brasília Brasília ( ; ) is the capital city, capital of Brazil and Federal District (Brazil), Federal District. Located in the Brazilian highlands in the country's Central-West Region, Brazil, Central-West region, it was founded by President Juscelino ...
and
Manaus Manaus () is the List of capitals of subdivisions of Brazil, capital and largest city of the States of Brazil, Brazilian state of Amazonas (Brazilian state), Amazonas. It is the List of largest cities in Brazil, seventh-largest city in Brazil, w ...
, near the town of Matupá, southeast of Manaus. The left
winglet Wingtip devices are intended to improve the efficiency of fixed-wing aircraft by reducing drag. Although there are several types of wing tip devices which function in different manners, their intended effect is always to reduce an aircraft' ...
of the Embraer sheared off about half of the 737's left wing (the 737's left engine was unaffected, remaining attached to the wing part that stayed attached to the aircraft), causing the 737 to nosedive and enter an uncontrollable spin, which quickly led to an in-flight breakup. The
cockpit voice recorder A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. The device may often be referred to colloquially as a "black box", an outdated nam ...
(CVR) cut off at 16:57:46, less than a minute after the collision. The Boeing 737 eventually crashed into an area of dense rainforest, east of the municipality of Peixoto de Azevedo. All 154 passengers and crew died and the aircraft was destroyed, with the wreckage scattered in pieces around the crash site. The Embraer jet was able to continue flying, despite serious damage to the left
horizontal stabilizer A tailplane, also known as a horizontal stabilizer, is a small lifting surface located on the tail ( empennage) behind the main lifting surfaces of a fixed-wing aircraft as well as other non-fixed-wing aircraft such as helicopters and gyroplan ...
and left winglet, though its
autopilot An autopilot is a system used to control the path of a vehicle without requiring constant manual control by a human operator. Autopilots do not replace human operators. Instead, the autopilot assists the operator's control of the vehicle, allow ...
disengaged and it required an unusual amount of force on the
yoke A yoke is a wooden beam used between a pair of oxen or other animals to enable them to pull together on a load when working in pairs, as oxen usually do; some yokes are fitted to individual animals. There are several types of yoke, used in dif ...
to keep the wings level. With radio relay assistance from Polar Air Cargo Flight 71, a Boeing 747 cargo aircraft flying in the area at the time, the Embraer's crew successfully landed the crippled jet at Cachimbo Airport, part of the large military complex Campo de Provas Brigadeiro Velloso, at about from the collision point. Passenger and journalist Joe Sharkey described his experience on board the Embraer in an article for ''The New York Times'', titled "Colliding With Death at 37,000 Feet, and Living", filed on 1 October 2006:


Detention and charging of Embraer crew

Immediately after the Embraer's emergency landing at the Cachimbo air base,
Brazilian Air Force The Brazilian Air Force (, FAB) is the air branch of the Brazilian Armed Forces and one of the three national uniformed services. The FAB was formed when the Brazilian Brazilian Army Aviation (1919–1941), Army and Brazilian Naval Aviation, Nav ...
and Agência Nacional de Aviação Civil (ANAC) officials detained and interviewed the flight crew. The two " black boxes"—the
cockpit voice recorder A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. The device may often be referred to colloquially as a "black box", an outdated nam ...
(CVR) and the
flight data recorder A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. The device may often be referred to colloquially as a "black box", an outdated nam ...
(FDR)—were removed from the Embraer, and sent to
São José dos Campos São José dos Campos (, meaning Saint Joseph of the Fields) is a major city and the seat of the Municipalities of Brazil, municipality of the same name in the state of São Paulo (state), São Paulo, Brazil. One of the leading industrial and res ...
, São Paulo, and from there to
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, Canada, at the Transportation Safety Board (TSB) laboratories, for analysis. In an initial deposition, the Embraer flight crew testified that they were cleared to
flight level In aviation, a flight level (FL) is an aircraft's altitude as determined by a pressure altimeter using the International Standard Atmosphere. It is expressed in hundreds of feet or metres. The altimeter setting used is the ISA sea level pressur ...
370, about
above mean sea level Height above mean sea level is a measure of a location's vertical distance (height, elevation or altitude) in reference to a vertical datum based on a historic mean sea level. In geodesy, it is formalized as orthometric height. The zero level ...
, by Brasília ATC, and were level at that assigned altitude when the collision occurred. They also asserted that they had lost contact with Brasília ATC at the time of the collision, and their anticollision system did not alert them to any oncoming traffic. On 2 October 2006, the Embraer's captain and first officer were ordered by the Mato Grosso Justice Tribunal to surrender their passports pending further investigation. The request, made by the Peixoto de Azevedo prosecutor, was granted by Judge Tiago Sousa Nogueira e Abreu, who stated that the possibility of pilot error on the part of the Embraer crew could not be ruled out. The Embraer crew was forced to remain in Brazil until their passports were released to them more than two months after the accident, after a federal judge ruled that no legal grounds existed for "restricting the freedom of motion of the foreigners." Prior to their scheduled departure to the United States, the crew was formally charged by Brazilian Federal Police with "endangering an aircraft", which carries a penalty up to 12 years in prison. The two pilots had to explain why they had not switched on the transponder. They were allowed to leave the country after signing a document promising to return to Brazil for their trials or when required by Brazilian authorities. They picked up their passports and flew back to the U.S.


Search and recovery operation

The
Brazilian Air Force The Brazilian Air Force (, FAB) is the air branch of the Brazilian Armed Forces and one of the three national uniformed services. The FAB was formed when the Brazilian Brazilian Army Aviation (1919–1941), Army and Brazilian Naval Aviation, Nav ...
(the Força Aérea Brasileira or "FAB") sent five fixed-wing aircraft and three helicopters to the region for an extensive
search and rescue Search and rescue (SAR) is the search for and provision of aid to people who are in distress or imminent danger. The general field of search and rescue includes many specialty sub-fields, typically determined by the type of terrain the search ...
(SAR) operation. As many as 200 personnel were reported to be involved in the operation, among them a group of
Kayapo The Kayapo (Portuguese language, Portuguese: Caiapó ) people are an indigenous people in Brazil, living over a vast area across the states of Pará and Mato Grosso, south of the Amazon River and along the Xingu River and its tributaries. This l ...
people familiar with the forest. The crash site of Gol Flight 1907 was spotted on 30 September by the air force, at coordinates, east of Peixoto de Azevedo, near Fazenda Jarinã, a cattle ranch. Rescue personnel reportedly were having difficulty reaching the crash site due to the dense forest. The Brazilian airport operating company,
Infraero Empresa Brasileira de Infraestrutura Aeroportuária (abr. Infraero) is a Brazilian government corporation founded in 1973, authorized by Law 5,862, that is responsible for operating the main List of the busiest airports in Brazil, Brazilian com ...
, at first indicated the possibility of five survivors, but a later statement from the Brazilian Air Force, based on data collected by their personnel, who rappelled to the crash site, and local police who assisted in the SAR effort, confirmed no survivors. Brazilian President
Luiz Inácio Lula da Silva Luiz Inácio Lula da Silva (; born Luiz Inácio da Silva; 27 October 1945), known Mononym, mononymously as Lula, is a Brazilian politician, trade unionist and former metalworker who has served as the 39th president of Brazil since 2023. A mem ...
declared three days of national mourning. The FDR and a nondata part of the cockpit voice recorder (CVR) from the Boeing 737 were found on 2 October 2006 and handed over to the investigators, who sent them to the TSB for analysis. On 25 October 2006, after nearly four weeks of intensive searching in the jungle by about 200 Brazilian Army troops equipped with metal detectors, the memory module of the Boeing's cockpit voice recorder was found. The module was discovered intact, separated from other wreckage pieces, embedded in about of soil, and was also sent for analysis by the TSB in Canada. On 4 October, the recovery crews began moving the bodies to the temporary base established at the nearby Jarinã ranch. The
FAB Fab or FAB may refer to: Commerce * Fab (brand), a frozen confectionery * Fab (website), an e-commerce design web site * Fab, a digital asset marketplace by Epic Games * The FAB Awards, a food and beverage award * FAB Link, a European electricity ...
deployed a C-115 Buffalo aircraft to transport the bodies to Brasília for identification. The recovery teams worked intensively for nearly seven weeks in a dense jungle environment, searching for and identifying the victims' remains. All the victims had been recovered and identified by DNA testing by 22 November 2006.


Investigation

The accident was investigated by the
Brazilian Air Force The Brazilian Air Force (, FAB) is the air branch of the Brazilian Armed Forces and one of the three national uniformed services. The FAB was formed when the Brazilian Brazilian Army Aviation (1919–1941), Army and Brazilian Naval Aviation, Nav ...
's Aeronautical Accidents Investigation and Prevention Center (CENIPA) and the U.S. National Transportation Safety Board (NTSB). In accordance with the provisions of ICAO Annex 13, the NTSB participated in the investigation as representative for the state (country) of manufacture of the Boeing, state of registry and operator of the Embraer, and state of manufacture of the
Honeywell Honeywell International Inc. is an American publicly traded, multinational conglomerate corporation headquartered in Charlotte, North Carolina. It primarily operates in four areas of business: aerospace, building automation, industrial automa ...
avionics equipment installed in both planes. Once the black boxes and communication transcripts were obtained, the investigators interviewed the Legacy jet's flight crew and the air traffic controllers, trying to piece together the scenario that allowed two modern jet aircraft, equipped with the latest anticollision gear, to collide with each other while on instrument flights in positive control airspace. The Embraer's flight plan consisted of flying at FL370 to Brasília, on
airway The respiratory tract is the subdivision of the respiratory system involved with the process of conducting air to the alveoli for the purposes of gas exchange in mammals. The respiratory tract is lined with respiratory epithelium as respiratory ...
UW2, followed by a planned descent at Brasília to FL360 (about ), proceeding outbound from Brasília northwest-bound along airway UZ6 to the Teres fix, an aeronautical
waypoint A waypoint is a point or place on a route or line of travel, a stopping point, an intermediate point, or point at which course is changed, the first use of the term tracing to 1880. In modern terms, it most often refers to coordinates which spe ...
located northwest of Brasília, where a climb to FL380 (about ) was planned. According to the filed flight plan, the Embraer was scheduled to have been level at FL380, proceeding towards Manaus, while passing the eventual collision point, which was about northwest of Teres. The Embraer's crew asserted in their depositions and subsequent interviews that they were cleared by ATC to FL370 for the entire trip, all the way to Manaus. The actual transcript of the clearance given to the Embraer's crew prior to takeoff at São José dos Campos at 14:41:57, as later released by CENIPA, was:
November Six Zero Zero Xray Lima, ATC clearance to Eduardo Gomes, flight level three seven zero direct Poços de Caldas, squawk transponder code four five seven four, after take-off perform Oren departure.
The Embraer's crew's altitude clearance to FL370 was further confirmed after their handoff to Brasília, during which they had the following radio exchange with ATC at 15:51. (last ATC two-way comm at 17:55 on MP3 clip) This was the last two-way radio communication between the Embraer's crew and ATC prior to the collision.


Embraer flight and communication sequence

The Embraer took off from São José dos Campos at 14:51, reaching FL370 at 15:33, 42 minutes later, where it remained until the collision. ATC maintained normal two-way radio contact with the Embraer until 15:51, when the last successful radio exchange with the Embraer was made on VHF frequency 125.05 
MHz The hertz (symbol: Hz) is the unit of frequency in the International System of Units (SI), often described as being equivalent to one event (or cycle) per second. The hertz is an SI derived unit whose formal expression in terms of SI base u ...
with Brasília Center. At that point, the Embraer was just approaching the Brasília VOR. The Embraer overflew the Brasília VOR at 15:55, four minutes later, and proceeded northwest-bound along UZ6. At 16:02, seven minutes after crossing the Brasília VOR, secondary radar contact was lost with the Embraer, thus stopping the display of the Embraer's reported altitude ( mode C) on the controller's radar screen. No attempt was made by either the Embraer or Brasília Center to contact each other from 15:51 until 16:26, when, 24 minutes after the loss of secondary radar contact, Brasília Center called the Embraer and received no reply. Brasília Center then unsuccessfully attempted to contact the Embraer six more times, between 16:30 and 16:34. At 16:30, the Embraer's primary radar target became intermittent, and disappeared completely from the radar screen by 16:38. Brasília Center unsuccessfully attempted to effect a handoff of the Embraer to Amazonic Center at 16:53, by calling the Embraer in the blind. The Embraer, though, started calling Brasília Center, also unsuccessfully, from 16:48 and continued with 12 more unsuccessful attempts until 16:53. Some limited contact was made at that point, but the Embraer was unable to copy the Amazonic Center frequencies. The Embraer then continued its attempts to reach Brasília Center, seven more times until the collision. The collision occurred at 16:56:54 BRT (19:56:54
UTC Coordinated Universal Time (UTC) is the primary time standard globally used to regulate clocks and time. It establishes a reference for the current time, forming the basis for civil time and time zones. UTC facilitates international communica ...
) at FL370, (collision at 1:23:50 on MP3 clip) and neither TCAS had activated or alerted its respective crew, nor did any crew see the oncoming traffic visually or initiate any evasive action prior to the collision. While both planes were equipped with TCAS, the Embraer's
transponder In telecommunications, a transponder is a device that, upon receiving a signal, emits a different signal in response. The term is a blend of ''transmitter'' and ''responder''. In air navigation or radio frequency identification, a flight trans ...
was later determined to have ceased operating almost an hour earlier, at 16:02, rendering both planes unable to automatically detect each other. At 16:59:50, about three minutes after the collision, Amazonic Center started to receive the Embraer's secondary radar reply, with its correct altitude and last assigned code. At 17:00:30 Amazonic Center unsuccessfully attempted to contact the Embraer by radio. The Embraer started calling on the emergency frequency, 121.5 MHz, immediately after the collision, but as later determined in the CENIPA report, the emergency transceivers in the area were not operational, thus the crew was unable to reach ATC on that frequency. At 17:01:06, the Embraer established contact on the emergency frequency with a Boeing 747 cargo aircraft, Polar 71, which attempted to relay to ATC their request for an emergency landing, and continued to provide relay and translation assistance to the Embraer until its eventual landing. At 17:18:03, the Embraer contacted the Cachimbo Airport control tower directly to coordinate its emergency landing there, and landed safely at Cachimbo at 17:23:00.


Gol 1907 flight and communication sequence

Gol 1907 took off from Manaus at 15:35, flying southeast-bound along UZ6 and reaching FL370 at 15:58, 23 minutes later, where it remained until the collision. There were no radio or radar contact problems with the flight until its handoff to Brasília Center. No known attempts were made by ATC to warn Flight 1907 of the conflicting traffic.


NTSB safety recommendation

On 2 May 2007, the NTSB issued a safety recommendation document that included an interim summary of the investigation to date, as well as some immediate safety recommendations that the NTSB believes should be implemented by the U.S.
Federal Aviation Administration The Federal Aviation Administration (FAA) is a Federal government of the United States, U.S. federal government agency within the United States Department of Transportation, U.S. Department of Transportation that regulates civil aviation in t ...
(FAA) to enhance flight safety. The NTSB reported that the Embraer apparently experienced a TCAS outage, unknown to its flight crew prior to the collision, according to the CVR:
Preliminary findings in the ongoing investigation indicate that for reasons yet to be determined, the collision avoidance system in the Legacy airplane was not functioning at the time of the accident, thereby disabling the system's ability to detect and be detected by conflicting traffic. In addition, CVR data indicate that the flight crew was unaware that the collision avoidance system was not functioning until after the accident.
The NTSB added that the design of the Embraer's avionics is such that the nonfunctioning of the TCAS that apparently occurred is shown by a small static white text message, which may not be noticeable by the flight crew. The NTSB noted:
Using only static text messages to indicate a loss of collision avoidance system functionality is not a reliable means to capture pilots' attention because these visual warnings can be easily overlooked if their attention is directed elsewhere in the flight environment.
Based on its observations, the NTSB recommended to the FAA that design changes be implemented to improve the noticeability of TCAS announcements, and that the FAA advise pilots of all aircraft types to familiarize themselves with the details of this accident, with the ways in which a pilot could inadvertently cause the loss of transponder and/or TCAS function, and how to recognize a loss of function.


Final reports


CENIPA report

On 10 December 2008, more than two years after the accident, CENIPA issued its final report, describing its investigation, findings, conclusions, and recommendations. The CENIPA report includes a "Conclusions" section that summarizes the known facts and lists a variety of contributing factors relating both to air traffic controllers and to the Legacy jet's flight crew. According to CENIPA, the air traffic controllers contributed to the accident by originally issuing an improper clearance to the Embraer, and not catching or correcting the mistake during the subsequent handoff to Brasília Center or later on. CENIPA also found errors in the way the controllers handled the loss of radar and radio contact with the Embraer. CENIPA concluded that the ExcelAire pilots also contributed to the accident with, among other things, their failure to recognize that their transponder was inadvertently switched off, thereby disabling the collision avoidance system on both aircraft, as well as their overall insufficient training and preparation.


NTSB report

The NTSB issued its own report on the accident, which was also appended to the CENIPA report with the following probable cause statement:
The evidence collected during this investigation strongly supports the conclusion that this accident was caused by N600XL and GOL1907 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 NTSB further added these contributing factors:
Contributing to this accident was the undetected loss of functionality of the airborne collision avoidance system technology as a result of the inadvertent inactivation of the transponder on board N600XL. Further contributing to the accident was inadequate communication between ATC and the N600XL flight crew.


Conflicting CENIPA and NTSB conclusions

CENIPA and the NTSB collaborated in the accident investigation, and while agreeing on most of the basic facts and findings, the two organizations arrived at conflicting interpretations and conclusions. The CENIPA report concluded that the accident was caused by mistakes made both by ATC and the ExcelAire pilots, whereas the NTSB report focused on the controllers and the ATC system, concluding that both flight crews acted properly, but were placed on a collision course by the ATC. According to ''
Aviation Week ''Aviation Week & Space Technology'', often abbreviated ''Aviation Week'' or ''AW&ST'', is the flagship magazine of the Aviation Week Network, a division of Informa. The weekly magazine is available in print and online, reporting on the aeros ...
'', "the U.S. National Transportation Safety Board (NTSB) strongly disagreed with the Brazilian conclusions regarding the Legacy pilots' actions as a causal factor, noting, 'The crew flew the route precisely as cleared and complied with all ATC instructions,' as did the GOL airlines crew." ''Aviation Week'' adds that "the Brazilian military operates that country's air traffic control system, conducted the investigation, and authored the report."


Aftermath


Aviation crisis

The crash of Flight 1907 precipitated a major crisis in
Brazil Brazil, officially the Federative Republic of Brazil, is the largest country in South America. It is the world's List of countries and dependencies by area, fifth-largest country by area and the List of countries and dependencies by population ...
's
civil aviation Civil aviation is one of two major categories of flying, representing all non-military and non-state aviation, which can be both private and commercial. Most countries in the world are members of the International Civil Aviation Organization and ...
system, which included lengthy flight delays and cancellations, ATC
work-to-rule Work-to-rule, also known as an Italian strike or a slowdown in United States usage, called in Italian a ''sciopero bianco'' meaning "white strike", is a job action in which employees do no more than the minimum required by the rules of their co ...
slowdowns and strikes, and public-safety concerns about Brazil's airport and air traffic infrastructure. Historically, Brazil was ruled by its armed forces from 1964 until 1985. Since then, a
civilian government Civil authority or civil government is the practical implementation of a state on behalf of its citizens, other than through military units (martial law), that enforces law and order and that is distinguished from religious authority (for exampl ...
has taken over, but the country's airways () continue to be controlled and operated by the
Brazilian Air Force The Brazilian Air Force (, FAB) is the air branch of the Brazilian Armed Forces and one of the three national uniformed services. The FAB was formed when the Brazilian Brazilian Army Aviation (1919–1941), Army and Brazilian Naval Aviation, Nav ...
(FAB) via their Department of Airspace Control ( (DECEA)), overseen by a civilian defense minister. Most of Brazil's air traffic controllers are military
non-commissioned officers A non-commissioned officer (NCO) is an enlisted rank, enlisted leader, petty officer, or in some cases warrant officer, who does not hold a Commission (document), commission. Non-commissioned officers usually earn their position of authority b ...
, and all
area control center In air traffic control, an area control center (ACC), also known as a center or en-route center, is a facility responsible for controlling aircraft flying in the airspace of a given flight information region (FIR) at high altitudes between ...
s are run by the FAB. In October 2006, as details surrounding the crash of Flight 1907 began to emerge, the investigation seemed to be at least partly focused on possible ATC errors. This led to increasing resentment by the controllers and exacerbated their already poor labor relations with their military superiors. The controllers complained about being overworked, underpaid, overstressed, and forced to work with outdated equipment. Many have poor English skills, limiting their ability to communicate with foreign pilots, which played a role in the crash of Flight 1907. In addition, the military's complete control of the country's aviation was criticized for its lack of public accountability. Amid rising tensions, the air traffic controllers began staging a series of work actions, including slowdowns, walkouts, and even a
hunger strike A hunger strike is a method of non-violent resistance where participants fasting, fast as an act of political protest, usually with the objective of achieving a specific goal, such as a policy change. Hunger strikers that do not take fluids are ...
. This led to chaos in Brazil's aviation industry – major delays and disruptions in domestic and international air service, stranded passengers, cancelled flights, and public demonstrations. Those who blamed various civilian and military officials for the growing crisis called for their resignations. On 26 July 2007, following an even deadlier crash on 17 July ( TAM Airlines Flight 3054) that killed 199 people, President
Luiz Inácio Lula da Silva Luiz Inácio Lula da Silva (; born Luiz Inácio da Silva; 27 October 1945), known Mononym, mononymously as Lula, is a Brazilian politician, trade unionist and former metalworker who has served as the 39th president of Brazil since 2023. A mem ...
fired his defense minister, Waldir Pires, who had been in charge of the country's aviation infrastructure and safety since March 2006, and was widely criticized for their failures. On the same day, Lula appointed former
Supreme Court In most legal jurisdictions, a supreme court, also known as a court of last resort, apex court, high (or final) court of appeal, and court of final appeal, is the highest court within the hierarchy of courts. Broadly speaking, the decisions of ...
president Nelson Jobim to replace Pires, and vowed to improve Brazil's ATC system.


Legal action


Civil litigation

On 6 November 2006, the families of 10 of the deceased filed a lawsuit for negligence against ExcelAire and
Honeywell Honeywell International Inc. is an American publicly traded, multinational conglomerate corporation headquartered in Charlotte, North Carolina. It primarily operates in four areas of business: aerospace, building automation, industrial automa ...
, alleging that the ExcelAire pilots were flying at an "incorrect altitude" and that the Honeywell transponder was not functioning at the time of the collision. Other suits were subsequently filed on behalf of other victims, with similar allegations against ExcelAire and Honeywell. The victims' families also filed suits against other U.S.-based defendants, including the two Embraer pilots, as well as
Raytheon Raytheon is a business unit of RTX Corporation and is a major U.S. defense contractor and industrial corporation with manufacturing concentrations in weapons and military and commercial electronics. Founded in 1922, it merged in 2020 with Unite ...
,
Lockheed Martin The Lockheed Martin Corporation is an American Arms industry, defense and aerospace manufacturer with worldwide interests. It was formed by the merger of Lockheed Corporation with Martin Marietta on March 15, 1995. It is headquartered in North ...
, and Amazon Tech (manufacturers of Brazil's ATC equipment), and ACSS (manufacturer of the Embraer's TCAS). The attorney representing the Embraer crew, Miami-based Robert Torricella, responded to the allegation that the crew was flying at an "incorrect altitude" by stating that according to international regulations, clearances and directives issued by ATC supersede a previously filed flight plan, and in this case:
... the flight plan cleared by air traffic control at the time of departure required the Embraer to fly all the way to Manaus at 37,000 feet, and absent contrary directives from air traffic control, the Embraer was obligated to follow its cleared flight plan. As the findings of the investigation are made public, we are confident that ExcelAire's pilots will be exonerated.
A Honeywell spokesperson stated, "Honeywell is not aware of any evidence that indicates that its transponder on the Embraer Legacy was not functioning as designed or that Honeywell was responsible for the accident." On 2 July 2008, U.S. District Court Judge Brian Cogan of the
Eastern District of New York The United States District Court for the Eastern District of New York (in case citations, E.D.N.Y.) is the federal district court whose territorial jurisdiction spans five counties in New York State: the four Long Island counties of Nassau, ...
dismissed the families' suits against all the U.S.-based defendants under the premise of ''
forum non-conveniens ''Forum non conveniens'' (; Latin for 'an inconvenient forum') is a mostly common law legal doctrine through which a court acknowledges that another forum or court where the case might have been brought is a more appropriate Venue (law), venue fo ...
''. Without ruling on the merits of the cases, and while allowing
discovery Discovery may refer to: * Discovery (observation), observing or finding something unknown * Discovery (fiction), a character's learning something unknown * Discovery (law), a process in courts of law relating to evidence Discovery, The Discovery ...
to continue, Cogan recommended the Brazilian court system as a more appropriate jurisdiction for the dispute.


Criminal proceedings

On 1 June 2007, Murilo Mendes, a Brazilian federal judge in the small city of Sinop, Mato Grosso, near the crash site of the Boeing, indicted the two Embraer pilots and four Brasília-based air traffic controllers for "exposing an aircraft to danger." On 8 December 2008, he dismissed charges of negligence against the pilots, but left in place a charge of "imprudence". He also dismissed all charges against two of the four Brasília-based controllers and reduced the charges against the other two, but supported bringing new charges against a fifth controller, based in
São José dos Campos São José dos Campos (, meaning Saint Joseph of the Fields) is a major city and the seat of the Municipalities of Brazil, municipality of the same name in the state of São Paulo (state), São Paulo, Brazil. One of the leading industrial and res ...
, the Embraer's departure point. On 12 January 2010, his ruling was overturned by Judge Candido Ribeiro in a federal court in Brasília, reinstating the negligence charges against the pilots. On 26 October 2010, a military court convicted air traffic controller Sgt. Jomarcelo Fernandes dos Santos, sentencing him to 14 months in jail for failing to take action when he saw that the Embraer's anticollision system had been turned off. Santos was to remain free pending the outcome of the appeal process. Four other controllers were acquitted for lack of proof. On 17 May 2011, Judge Mendes sentenced air traffic controller Lucivando Tiburcio de Alencar to a term of up to three years and four months, but ruled he is eligible to do community service in Brazil, instead, and acquitted Santos on charges of harming Brazil's air transport safety. On 16 May 2011, Judge Mendes sentenced the two pilots to four years and four months of prison in a "semi-open" facility for their role in the collision, but he commuted the sentences to community service to be served in the United States. Brazilian authorities accused the pilots of turning off the Legacy's transponder moments before the accident and turning it on again only after the crash, but this was denied by the crew in a deposition via videoconference. Mendes said in his sentence that pilots had failed to verify the functioning of equipment for more than an hour, a length of time he called "an eternity" in aviation. On 9 October 2012, Brazilian federal prosecutors announced that they had successfully appealed the sentence of the pilots, asking to increase their sentences by 17 months (a total of 5 years and 9 months). The new trial was scheduled for 15 October, with the pilots again facing trial ''in absentia''. On that date, the court upheld the prior convictions, but modified the sentences to 37 months for each, requiring that the pilots "report regularly to authorities and stay home at night." In October 2015 Brazil's Supreme Court rejected the pilots' appeal, ordering them to return to Brazil to serve out their sentences. In 2019, a Brazilian judge ruled that the pilots could serve their sentences in the United States. In March 2020, after exhausting their appeals, Brazil requested their extradition. In 2023, the United States rejected the request. On 6 June 2024, another Brazilian judge dismissed the entire case against the pilots because the
statute of limitations A statute of limitations, known in civil law systems as a prescriptive period, is a law passed by a legislative body to set the maximum time after an event within which legal proceedings may be initiated. ("Time for commencing proceedings") In ...
had expired.


Embraer jet

The Embraer jet was temporarily repaired on Cachimbo Airport, and on 19 November 2010, the jet was flown to Cleveland Hopkins International Airport.


In popular culture

In 2007,
Discovery Channel Discovery Channel, known as The Discovery Channel from 1985 to 1995, and often referred to as simply Discovery, is an American cable channel that is best known for its ongoing reality television shows and promotion of pseudoscience. It init ...
Brazil aired ''A Tragédia do Vôo 1907'' (''The Tragedy of Flight 1907''), a documentary about the disaster. The Mato Grosso midair collision was featured in the 2008 episode " Phantom Strike", of the Canadian-made, internationally distributed documentary series ''
Mayday Mayday is an emergency procedure word used internationally as a distress signal in voice-procedure radio communications. It is used to signal a life-threatening emergency primarily by aviators and mariners, but in some countries local organiz ...
'' The collision was also one of the incidents included in the 2009 episode " System Breakdown", of the ''Mayday'' special series '' Science of Disaster'', which examined the role of air traffic controllers in aviation disasters. In 2013, it was a featured flight in season 1, episode 5, of '' Why Planes Crash'', in an episode called "Collision Course". In 2018, it was also featured in season 3, episode 6, of the documentary ''Aircrash Confidential'', titled "Flying Blind".


See also

* List of notable civilian mid-air collisions


Notes


References


External links

*
Aeronautical Accidents Investigation and Prevention Center The Aeronautical Accidents Investigation and Prevention Center (, CENIPA) is a unit of the Brazilian Air Force that investigates aviation accidents and incidents in Brazil. It is headquartered in Brasília. See also * Gol Transportes Aéreos Fl ...

Full NTSB docketArchive of English report

Final report

Archive

Associação Familiares e Amigos Vôo 1907
(Family and friends of Flight 1907)
Archive


(includes to links of the U.S. government response) -
National Transportation Safety Board The National Transportation Safety Board (NTSB) is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and inci ...

Statement by the International Federation Of Air Traffic Controllers' Associations, issued 24 November 2006
(PDF)
Archive

Agencia Brasil slideshow of a memorial ceremony for the passengers on Gol 1907

Archive

ExcelAire N600XL Cockpit Voice Recorder (CVR) audio clip
72 MB MP3 file, contains entire 2-hour CVR recording; last two-way radio comm before collision at 00:17:55; last radio comm before collision at 1:12:30; collision at 01:23:50.
Gol Transportes Aéreos 1907 Cockpit Voice Recorder audio clip
collision at 29:22
List of passengers
at ''
Folha de S. Paulo ''Folha de S.Paulo'' (sometimes spelled ''Folha de São Paulo''), also known as simply ''Folha'' (, ''Sheet''), is a Brazilian daily newspaper founded in 1921 under the name ''Folha da Noite'' and published in São Paulo by the Folha da Manhã co ...
'' {{Portal bar, Aviation, Brazil, United States 2006 disasters in Brazil Aviation accidents and incidents caused by air traffic controller error Airliner accidents and incidents caused by pilot error Aviation accidents and incidents in 2006 Aviation accidents and incidents in Brazil Aviation accidents and incidents involving the Embraer ERJ family Mid-air collisions involving airliners Mid-air collisions involving general aviation aircraft Mid-air collisions in South America Accidents and incidents involving the Boeing 737 Next Generation
1907 Events January * January 14 – 1907 Kingston earthquake: A 6.5 Moment magnitude scale, Mw earthquake in Kingston, Jamaica, kills between 800 and 1,000. February * February 9 – The "Mud March (suffragists), Mud March", the ...
September 2006 in South America