Report faults U.S. pilots, Brazilian controllers for midair collision

WASHINGTON — Brazilian investigators released a final report Wednesday that blamed two U.S. pilots and Brazilian air traffic controllers for causing a freak midair collision that killed 154 people over the Amazon rainforest two years ago.

The 282-page report from Brazil's Aeronautical Accident Investigation and Prevention Center promises to put to rest widespread speculation at first offered by Brazilian officials about the causes of the Sept. 29, 2006, accident, which at the time was Brazil's deadliest air tragedy.

The U.S. National Transportation Safety Board, which participated in the investigation, issued a response Wednesday criticizing the Brazilian report for not focusing enough on mistakes made by Brazilian air traffic controllers.

That afternoon, a Legacy corporate jet flown by New York-based pilots Joseph Lepore and Jan Paladino collided with a Boeing 737 passenger jet operated by the Brazilian airline Gol Aerolineas Inteligentes and carrying 154 people.

The Legacy aircraft, which had just been purchased by the U.S. company ExcelAire from Brazilian manufacturer Embraer, managed to land safely despite suffering damage to its left wing and tail, while the Boeing jet spiraled to the forest floor, killing everyone aboard.

The Brazilian report blamed the U.S. pilots for not being familiar with their flight plan or the aircraft, which resulted in them not flying at the altitude originally indicated and not noticing that their transponder was turned off during much of the flight.

The transponder alerts flight controllers of planes' altitudes and sets off collision avoidance systems in aircraft.

"The low situational awareness of the pilots was a relevant factor for the occurrence of the accident," the report concludes. "It began during the phase of preparation for the operation, which was considered by them as 'routine.' The attitude of the pilots about the mission permeated their behavior during the other phases."

However, the report found the pilots hadn't intentionally disabled the transponder so that they could stunt-fly, as Brazilian officials had speculated immediately after the accident.

According to the report, the Legacy's transponder was disabled for nearly an hour until the collision occurred. The U.S. pilots also were unable to make radio contact with flight controllers, a problem the report credited to the use of weak radio frequencies and other technical factors.

Brazilian authorities held Lepore and Paladino for more than two months after the accident while they conducted a criminal investigation into the incident. The two pilots ultimately completed their testimony to investigators about the crash after returning the U.S.

Joel Weiss, an attorney representing Lepore and Paladino, slammed the report Wednesday, saying in a statement "it hides the real and obvious cause of this tragic accident."

"(Brazilian air traffic control) placed these two competent flight crews on a collision course, traveling toward each other at the same altitude on the same airway," Weiss said. "It also buries the fact that this was not only a result of major errors by individual air traffic controllers, but of institutional errors built into Brazil's ATC system."

Wednesday's report also blamed Brazilian air traffic controllers for a series of errors, including not communicating with each other about the heading of the Legacy jet and the lack of transponder information. The report also slammed the controllers for not diverting the Gol flight as it approached the Legacy jet.

The controllers in charge at the time of the accident refused to talk to investigators, the report said. Shortly after the accident, Brazilian controllers staged work stoppages to protest what they said were poor working conditions in the country's military-controlled flight control system.

The stoppages sparked mass confusion in the country's air traffic system and only stopped about 10 months later when another Brazilian airliner overshot the runway in the country's busiest airport in Sao Paulo, killing 199 people.

The National Transportation Safety Board, in its comments, emphasized the mistakes of the controllers over the U.S. pilots.

"The evidence does not fully support the conclusion that the crew of (the Legacy's) flight planning, or amount of time spent planning, contributed directly to the accident," the safety board's comments read.


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