Rapport d'accident du GOL et du Legacy au Brésil

Le BEA brésilien vient de rendre son rapport ... le contrôle aérien est clairement mis en cause de façon principale même si les pilotes du Legacy ne sont pas exempts de tout reproche.

Le rapport intégral est disponible en anglais ici !

Pour un résumé rapide :

1. The Sector 5 controller initiated the handoff of N600XL to Sector 7 at an unusually early point, prior to a navigational fix at which a level change should have been assigned.
2. ATC did not issue a level change instruction to N600XL at or prior to crossing Brasilia.
3. The controllers at Sector 5 and Sector 7 were unaware of the status of N600XL’s altitude clearance, and did not take positive action to provide an amended clearance, confirmation, or appropriate coordination.
4. The automatic change of the datablock field from “cleared altitude” to “requested altitude” without any indication to, or action by, the ATCOs, led to the misunderstanding by the Sector 7 controller about what altitude clearance was issued to N600XL.
5. The collision avoidance technology aboard the aircraft did not function, likely due to inadvertant inactivation of the transponder on N600XL.
6. The flight crew of N600XL did not notice the inactive status of the transponder.
7. ATC did not take appropriate action in response to the loss of N600XL’s transponder.
8. The automatic display of an altitude value (“3D”) which is invalid for ATC use reinforced the incorrect assumptions that N600XL was descending.
9. ATC continued to apply RVSM separation standards despite a lack of mode C transponder altitude information.
10. Neither ATC nor the flight crew recognized the significance of the long time period without two-way communication to N600XL.
11. The flight crew of N600XL did not recognize the significance of the long time period spent at a non-standard cruise altitude for the flight direction.
12. ATC did not take adequate action to timely correct a known lost communication situation with N600XL.
13. Incorrect frequency utilization and ATC sector configuration within the CINDACTA contributed to the breakdown in communication with N600XL and the accident sequence of events.
14. The Sector 07 controller did not inform Amazonic ACC of the lost communication and non-transponder status of N600XL.
15. DECEA did not provide adequate training and supervision to develop effective skills for the ATCOs to appropriately handle this situation.
16. The evidence does not fully support the conclusion that the crew of N600XL’s flight planning, or amount of time spent planning, contributed directly to the accident.

PROBABLE CAUSE

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.
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.

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