On September 29, 2006, Gol Transportes Aéreos Flight 1907, a Boeing 737-800 on a scheduled domestic passenger flight from Manaus, Amazonas, to Brasília and Rio de Janeiro, collided mid-air with an Embraer Legacy 600 business jet flying on an opposite heading over the Brazilian state of Mato Grosso. The winglet 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 7 occupants uninjured.
The accident was investigated by the Brazilian Aeronautical Accidents Investigation and Prevention Center (Portuguese: Centro de Investigação e Prevenção de Acidentes Aeronáuticos – CENIPA) and the US National Transportation Safety Board (NTSB), and a final report was issued in 2008. CENIPA concluded that the accident was caused by air traffic control (ATC) errors, combined with mistakes made by the American pilots on the Legacy, including a failure to recognize that their traffic collision avoidance system (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 triggered a crisis in Brazilian civil aviation. It remains the second-deadliest plane crash in Brazil, after TAM Airlines Flight 3054 in 2007.
Background
Boeing aircraft and crew
The Gol Transportes Aéreos twin turbofan 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 logged 202 hours and 18 minutes of flight time in 162 takeoff and landing cycles before the collision.
On board the Boeing 737 were 6 crew members and 148 passengers. The 6 crew members and 105 of the passengers were Brazilian; the remaining passengers were of various other nationalities. The crew consisted of Captain 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 the airline, had 15,498 total flight hours, with 13,521 on the Boeing 737. The first officer had 3,981 total flight hours, with 3,081 in the Boeing 737.
Gol Transportes Aéreos Flight 1907 departed Eduardo Gomes International Airport in Manaus on September 29, 2006, at 15:35 Brazilian standard time (BRT) (18:35 UTC), en route to Rio de Janeiro–Galeão International Airport, with a planned intermediate stop at Brasília International Airport.
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 Ronkonkoma, New York, 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, 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 US 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 the Embraer ERJ-145 and ERJ-135 jet aircraft for American Eagle Airlines. Paladino had also served as first officer for American Airlines, flying the McDonnell Douglas MD-82, MD-83, and Boeing 737-800 between the US 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 New York Times 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), the Boeing 737 and the Embraer Legacy jet collided almost head-on at 37,000 feet (11,000 m), approximately midway between Brasília and Manaus, near the town of Matupá, 750 kilometres (466 mi; 405 nmi) southeast of Manaus. The left winglet 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 (CVR) cut off at 16:57:47, less than a minute after the collision. The interruption was attributed to the loss of electrical power following the in-flight structural breakup of the aircraft at an altitude of approximately 8,000 feet (2,400 m).
The Boeing 737 crashed into an area of dense rainforest, 200 kilometres (124 mi; 108 nmi) east of the municipality of Peixoto de Azevedo. All 154 passengers and crew died and the aircraft was destroyed, with the wreckage scattered around the crash site.
The Embraer jet was able to continue flying, despite serious damage to the left horizontal stabilizer and left winglet, though its autopilot disengaged and it required an unusual amount of force on the yoke to keep the wings level. With radio relay assistance from Polar Air Cargo Flight 71, a Boeing 747 cargo aircraft flying in the area, the Embraer's crew successfully landed the crippled jet at Cachimbo Airport, part of the large military complex Campo de Provas Brigadeiro Velloso, about 160 kilometres (100 mi; 90 nmi) 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:
And it had been a nice ride. Minutes before we were hit, I had wandered up to the cockpit to chat with the pilots, who said the plane was flying beautifully. I saw the readout that showed our altitude: 37,000 feet. I returned to my seat. Minutes later came the strike (it sheared off part of the plane's tail, too, we later learned).
Detention and charging of Embraer crew
Immediately after the Embraer's emergency landing at the Cachimbo air base, Brazilian Air Force and Agência Nacional de Aviação Civil (ANAC) officials detained and interviewed the flight crew. The two "black boxes"—the cockpit voice recorder (CVR) and the flight data recorder (FDR)—were removed from the Embraer, and sent to São José dos Campos, São Paulo State, and from there to Ottawa, 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 370, about 37,000 feet (11,000 m) above mean sea 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 October 2, 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 US.
Search and recovery operation
The Brazilian Air Force (the Força Aérea Brasileira or "FAB") sent five fixed-wing aircraft and three helicopters to the region for an extensive search and rescue (SAR) operation. As many as 200 personnel were reported to be involved in the operation, among them a group of Kayapo people familiar with the forest. The crash site of Gol Flight 1907 was spotted on 30 September by the air force, at coordinates, 200 kilometres (120 mi; 110 nmi) 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, 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 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 and handed over to the investigators, who sent them to the TSB for analysis. On October 4, the recovery crews began moving the bodies to the temporary base established at the nearby Jarinã ranch. The FAB deployed a C-115 Buffalo aircraft to transport the bodies to Brasília for identification.
On October 25, 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 20 centimetres (8 in) of soil, and was also sent for analysis by the TSB in Canada. 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 November 22.
Investigation
The accident was investigated by the Brazilian Air Force's Aeronautical Accidents Investigation and Prevention Center (CENIPA) and the US 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 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 UW2, followed by a planned descent at Brasília to FL360 (about 36,000 feet [11,000 m]), proceeding outbound from Brasília northwest-bound along airway UZ6 to the Teres fix, an aeronautical waypoint located 282 nautical miles (325 mi; 522 km) northwest of Brasília, where a climb to FL380 (about 38,000 feet [12,000 m]) 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 307 kilometres (191 mi; 166 nmi) 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.
This was the last successful 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 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.