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Midair Collision Final Report 1907

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COMMAND OF AERONAUTICS GENERAL STAFF OF THE AERONAUTICS AERONAUTICAL ACCIDENT INVESTIGATION AND PREVENTION CENTER FINAL REPORT A-00X/CENIPA/2008 OCCURRENCE: AERONAUTICAL ACCIDENT ACFT REGISTRATION : PR–GTD and N600XL MODELS : B-737 8EH and EMB-135 BJ LEGACY DATE : 29 September 2006 FR A-022/CENIPA/2008 PR-GTD and N600XL 29 SEPT 2006 NOTICE According to the Law nº 7565, dated 19 December 1986, the Aeronautical Accident Investigation and Prevention System – SIPAER – is responsible for the planning, guidance, coordination and execution of the activities of investigation and prevention of aeronautical accidents. The elaboration of this Final Report was conducted taking into account the contributing factors and hypotheses raised. The report is, therefore, a technical document which reflects the result obtained by SIPAER regarding the circumstances that contributed or may have contributed to trigger this occurrence. The document is not focused on quantifying the degree of contribution of the different factors, including the individual, psichosocial or organizational variables that conditioned the human performance, and interacted to create a scenario favorable to the accident. The exclusive objective of this work is to recommend the study and the adoption of provisions of a preventative nature, and the decision as to whether they should be applied belongs to the President, Director, Chief or the one corresponding to the highest level in the hierarchy of the organization to which they are being forwarded. This Report does not resort to any proof production procedure for the determination of civil or criminal liability, and is in accordance with item 3.1, Annex 13 of the 1944 Chicago Convention, which was incorporated in the Brazilian legal system by virtue of the Decree nº 21713, dated 27 August 1946. 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-self- incrimination 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. 2/266 FR A-022/CENIPA/2008 PR-GTD and N600XL 29 SEPT 2006 CONTENTS ABBREVIATIONS.....................................................................................................................................7 SYNOPSIS ................................................................................................................................................12 SAFETY RECOMENDATIONS - RSV...................................................................................................14 1. HISTORY OF THE ACCIDENT..........................................................................................................21 2. DAMAGE..............................................................................................................................................22 2.1. INJURIES TO PERSONS..................................................................................................................22 2.2. TO MATERIAL .................................................................................................................................22 3. ELEMENTS OF INVESTIGATION ....................................................................................................22 3.1. INFORMATION ON THE FLIGHT CREWS INVOLVED .............................................................22 3.2. INFORMATION ON THE AIRPLANES..........................................................................................23 3.3. EXAMS, TESTS AND RESEARCHES ............................................................................................24 3.3.1. Evaluations and tests conducted (SBCC, 30 September 2006).......................................................25 3.3.2. Geometry of the collision between N600XL and PR-GTD ............................................................27 3.3.3. Architecture of the Legacy -600 system of avionics (Transponder e TCAS) .................................28 3.3.4. Tests (SBCC, 7 October 2006)........................................................................................................29 3.3.5. Laboratory Tests ..............................................................................................................................31 3.3.5.1. Bench Tests (Phoenix-AZ, 28 November – 1 December 2006)...................................................31 3.3.5.2. Integration Tests (Phoenix-AZ, 5 – 9 February 2007) .................................................................32 3.3.6. Records of the technical history of the N600XL airplane ...............................................................34 3.3.7. Interface between the Transponder and FMS systems in the N600XL...........................................35 3.3.8. Summary of the results of the tests and evaluations conducted ......................................................35 3.4. METEOROLOGICAL INFORMATION ..........................................................................................35 3.5. NAVIGATION...................................................................................................................................37 3.5.1. ATC Simbology...............................................................................................................................41 3.5.2. Radar equipment..............................................................................................................................47 3.5.3. Radar integration and presentation applications..............................................................................47 3.6. COMMUNICATION .........................................................................................................................48 3.6.1. Aeronautical Mobile Service (SMA)...............................................................................................48 3.6.2. Aeronautical Fixed Service .............................................................................................................50 3.6.3. Analysis of the Communications.....................................................................................................51 3.7. INFORMATION ON THE AERODROME ......................................................................................61 3.8. INFORMATION ON THE IMPACT AND WRECKAGE ...............................................................61 3.9. INFORMATION ON FIRE................................................................................................................62 3.10. ASPECTS OF SURVIVAL AND/OR EVACUATION FROM THE ACFT..................................62 3.11. FLIGHT RECORDERS ...................................................................................................................62 3.11.1. Readout of the CVR/FDR recorders in Ottawa. ............................................................................62 3.12. Organizational Aspects.....................................................................................................................65 3.13. Operational Aspects… ……………………………………………………………........................66 3.13.1. General considerations ..................................................................................................................66 3.13.2. The Pilots.......................................................................................................................................67 3.13.2.1. Applicability of the Legislations to the Investigation ................................................................67 3.13.2.2. Pilots of the PR-GTD airplane....................................................................................................69 3.13.2.2.1. Qualifications...........................................................................................................................69 3.13.2.2.2. Pilot admission requirements at Gol Transportes Aéreos S/A. ...............................................72 3.13.2.2.3. Knowledge and preparedness required for the conduction of the flight..................................72 3.13.2.3. Pilots of the N600XL airplane....................................................................................................73 3.13.2.3.1. Qualifications...........................................................................................................................73 3/266 FR A-022/CENIPA/2008 PR-GTD and N600XL 29 SEPT 2006 3.13.2.3.2. Conditions for admission of pilots by Excelaire .....................................................................75 3.13.2.3.3.Training at Excelaire ................................................................................................................76 3.13.2.3.4. Knowledge and preparedness required for the conduction of the flight..................................78 3.13.3. THE AIRPLANES ........................................................................................................................86 3.13.3.1. The PR-GTD airplane.................................................................................................................86 3.13.3.2. The N600XL airplane.................................................................................................................86 3.13.3.2.1.
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