On September 29, 2006, in an area of the Brazilian Amazon known as Mato Grosso, two planes – a private ExcelAire Legacy 600 business jet and a Boeing 737 passenger airplane flown by Gol Airlines carrying 154 people – collided. Only the two pilots and five passengers of the private jet survived. During episode 105 of Take to the Sky: the Air Disaster Podcast, we explored how the CENIPA and the NTSB investigators agreed that the air traffic controllers issued an improper clearance to the Legacy jet crew, which put the jet on a collision course with the Gol airplane, and they neither caught nor corrected the mistake. CENIPA also found errors in the way the controllers handled the loss of radar and radio contact with the Embraer. The agency also concluded that the Legacy jet pilots 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. However, CENIPA and the NTSB arrived at conflicting interpretations and conclusions about to what extent the pilots of the Legacy jet were to blame. The CENIPA attributed blame to both ATC and the ExcelAire pilots, whereas the NTSB report focused on the controllers and the ATC system at large, concluding that both flight crews acted properly, but were placed on a collision course by the ATC. From the NTSB perspective, it is the responsibility of air traffic control to do just that – control the airspace. Following the crash, both ExcelAire pilots and several air traffic controllers were sentenced in Brazilian courts for their roles in causing the disaster. The crash caused an aviation crisis in Brazil as air traffic controllers went on strike. Some changes were made to the air traffic control infrastructure after the crash, though many maintain that some of the same problems identified during the midair collision investigation still plague the system even today.
ExcelAire Celebrates Maiden Voyage of Brand New Legacy Jet Purchased in Brazil
Our story begins with a regional airline known as ExcelAire, which provides private passenger air travel services across the Eastern seaboard of the United States via a fleet of private jets. And the company has much reason to celebrate on September 29, 2006. It has just purchased a newly built aircraft directly from manufacturer Embraer in Brazil. The plane is a twin turbofan Embraer Legacy 600 business jet that can seat up to 30 people. Now that the purchase is finalized, ExcelAire only needs to bring it back to the United States to be put into service.
And this is exactly what Captain Joe Lepore, 42, and First Officer Jan Paul Paladino, 34, are about to do. Between the two pilots, they have an immense amount of experience. Captain Lepore has been a commercial pilot for more than 20 years and has logged almost 9,400 total flight hours, with just 5.5 hours in the Legacy 600. First Officer Paladino has been a commercial pilot for a decade and has accumulated more than 6,400 flight hours, including 3.5 hours in the Legacy 600, as well as 317 hours flying in other regional jets of the same family as the Legacy. Before coming to ExcelAire First Officer Paladino had also served as first officer for American Airlines before getting furloughed, flying MD-82, MD-83, and Boeing 737-800 aircraft between the U.S. and Canada.
The flight plan today will have the Legacy jet depart from São José dos Campos near São Paulo, traveling northwest to Manaus as a planned intermediate stop. And they are not alone. Onboard the Legacy jet are 5 passengers: two Embraer employees, two ExcelAire executives, and the fifth passenger is The New York Times business travel columnist Joe Sharkey, who is writing a special report for Business Jet Traveler.
And as this is the maiden voyage of this aircraft, the passengers and flight crew are excited to get going. In true celebratory fashion, after a delivery ceremony attended by top Embraer executives, the 5 passengers boarded the airplane, which had been buffed to a car-wash shine. Shortly before 3 PM local time, the Legacy jet takes off into a beautiful Brazilian early-spring sky, while below, the Embraer team lined up alongside the runway, waving goodbye.
One of tasks that Captain Lapore and First Officer Paladino must perform while in flight is to contact local air traffic control along their route to Manaus. Let’s take a moment to talk about Brazilian ATC at this time, which is run by the Brazilian Air Force.
ExcelAire Pilots and Brazilian ATC Encounter Difficulty Maintaining Communications
Along their route, the pilots of the Legacy jet will interact with three ATC groups: the first one was while they were preparing for departure from São José dos Campos; the next one will be with Brasília Center, which is about the midway point on their route and handles 85% of the air traffic across all of Brazil; and then, as they prepare for landing, with Manaus ATC.
First Officer Paladino is working the communications for their flight, so he is the one who contacts Brasília Center. But, over the next hour, Brasília Center and the Legacy jet crew have trouble contacting one another and keep losing contact. In fact, Brasilia Center tries contacting the jet six times without success, and then the Legacy crew tries 12 times to make contact. And when they do speak, the controller’s response is garbled and incomprehensible. First Officer Paladino tries again, and this time the controller’s transmission is only slightly clearer. Captain Lepore said, “I think he just said, ‘radar contact.’” First Officer Paladino took the captain on faith and radioed, “Roger, radar contact.” To Captain Lepore he added, “I have no idea what the hell he said.”
Winglet of ExcelAire Legacy Jet is Shorn Off, Requiring Emergency Landing
But this is soon to be the least of this flight crew’s worries. At just a few minutes before 5 PM local time, and only about two hours since the Legacy jet has been in the sky, the unthinkable happens. A sudden and enormous bang fills the cabin followed by a massive shudder that reverberates across the entire jet. Even though First Officer Paladino is just that, the First Officer, he has more total experience flying Embraer jets, so he takes over manual control of the aircraft from Captain Lapore, while the Captain desperately begins searching their navigation maps for any location where they may need to land. And they will need to land – and soon.
The passengers in the jet’s cabin are looking out the windows, staring incredulously at what they are seeing: about four and a half feet of the left winglet (or wingtip) has been shorn off. And the remaining wing looks fragile, like it could disintegrate at any moment. They have no idea what took the wingtip. What everyone onboard does know, especially the pilots, is that they must put this plane down as quickly as possible. Their only problem is, they are flying 37,000 feet (or 11,300 m) high above the Amazon jungle. This is a section of airspace covered by densely thick jungle forest and a section of earth that many pilots say there was only one way to fly through: warily.
Luckily, they have an opportunity to make this emergency landing. The pilot of a Polar Air cargo plane flying nearby heard the Legacy crew's "Mayday" call on his radio and helped them locate the jungle airstrip. And not only that, but the pilots can see it. Dead ahead was a huge gash in the otherwise unbroken jungle. This would turn out to be a once-secret but now obscure military air base near Cachimbo in the state of Para, Brazil.
ExcelAire Pilots Manage to Land Crippled Legacy Jet at Brazilian Military Base
Captain Lapore, now leading communications, receives permission for the Legacy jet to land. Now it is in the hands of these skilled pilots to bring this jet back down to earth safely. Because of the wing damage, the pilots know they cannot turn the jet too sharply, or this could cause the wing to become unstable and maybe even come apart. In fact, the shorn winglet was not the biggest problem. Other pieces of the wing are now coming off. Rivets had popped. Some fuel was leaking. The airplane continues to fly on steadily, but it is losing altitude and speed.
The pilots also cannot configure the wings like they would for a typical landing – because of the damage, they cannot put too much pressure on the wing. This means they must land faster than usual and won’t extend the flaps until the very last minute. To lessen wing stress, the pilots begin making large spirals—the kind pilots make going into an airport in war-stricken areas to avoid coming under attack by rockets. And thankfully, the runway is long.
The pilots bring the plane hard and hot, with a lot of the automatic controls gone. Twenty-five minutes after the winglet was shorn off, the pilots manage to physically wrestle the airplane down onto the runway and bring it to a screeching, skidding stop. The five passengers and two flight crew members, immensely relieved they have just survived this ordeal, erupt into cheers and pat one another’s backs in congratulations of their amazing fate.
But on the ground, the plane is immediately surrounded by military personnel, who then begin to board the plane and check everyone’s passports. The soldiers then escort the pilots and passengers into assigned to bunks inside the barracks. Shaken and stunned, the seven men who had just survived a potentially disastrous situation cannot help but speculate about what had occurred. Over beers and food, they theorize that perhaps an aircraft had exploded or broken up at a far higher altitude miles up from the Legacy jet, and they had flown into the falling debris field. But the truth is far, far worse than anyone could imagine.
Gol Flight 1907 Goes Missing Over Section of Amazon Where Legacy Jet Felt Impact
You see, the emergency landing of the Legacy jet is not the only emergency happening in the skies over the Brazilian Amazon that day. Back at Brasília Center, controllers are in a panic. They cannot find Gol Transportes Aereos (or Gol) Flight 1907. This Boeing 737 passenger plane, with 154 people onboard, had been traveling southbound from Manaus, and its check in with Brasília Center is now overdue. Controllers have no choice but to count Flight 1907 as missing and to request that Brazil’s Search and Rescue Squadron initiate a search for the missing plane.
And soon, the news of a missing passenger plane reaches the Legacy jet crew. While the pilots and passengers were having dinner, one of the passengers, the only one in the group who spoke Portuguese, left the table. In about 10 minutes he came back, ashen faced. Speaking so quietly that the others could barely hear him, he said that a 737 with 154 on board had gone down in the jungle right where the Legacy jet had felt the impact. This happened over an area known as Mato Grosso, which is a state within Brazil.
Captain Lapore and First Officer Paladino are anguished and struggle to fight back their tears at the news. Never for an instant did anyone onboard the Legacy jet believe that what had hit them was a passenger jet. And soon, the world will get confirmation of what the pilots have just heard. Approximately 62 miles (or 100 km) from the military base where the Legacy jet landed, searchers find the wreckage of Gol Flight 1907. All 154 people are dead. At the time, is the worst crash in Brazil’s history.
The Brazilian public is, understandably, outraged, but not just over the crash that took 154 lives, but that a private business jet flown by Americans seemingly survived unscathed and all seven people made it out alive. The public feels that this accident, referred to as the Mato Grosso midair collision, is a huge injustice, and they want to know what – and whom – is to blame for this tragedy.
CENIPA and NTSB Partner to Investigate ExcelAire Jet and Gol 737 Midair Collision
The Brazilian Aeronautical Accidents Investigation and Prevention Center (known as CENIPA for its title in Portuguese) leads the investigation in partnership with the American National Transportation Safety Board (or NTSB). Examination of the wreckage of the Gol flight, investigators can immediately tell, based on the wreckage pattern that the plane came apart in air and then hit the ground in pieces. And they also find that the right wing of the Gol airplane is sliced clean through. These agencies now know definitively they are dealing with damage to two separate aircraft on opposite side wings, which spells out that a midair collision happened. Eventually, both flight recorders are recovered from the Gol aircraft wreckage along with the recorders from the Legacy jet.
Pending the investigation, Captain Lapore and First Officer Paladino have their passports confiscated by the Brazilian military, and while they are moved into nearby hotels, they are instructed not to leave while being questioned. And they are questioned – intensely.
CENIPA Establishes ATC Put Both Planes on a Collision Course for Disaster
Investigators use data from ATC radar to establish the flight paths of both planes. Normally, planes are supposed to fly in assigned corridors, or highways in the sky. To simplify things, and to ensure planes flying in opposite directions aren’t flying at the same flight level, northbound traffic flies in even-numbered altitude levels and southbound traffic flies in odd-numbered flight levels. Investigators find that, upon departing from Manaus and heading southbound, Gol Flight 1907 was flying level at its assigned altitude of 37,000 feet. Meanwhile, the Legacy jet had been cleared to the same altitude as Gol 1907 – 37,000 feet – as they departed from São José dos Campos flying to the north. Essentially, controllers from two different points across Brazil had permitted the planes to fly at the same altitude. But this was never supposed to have happened.
As both planes made their way toward the Brasilia waypoint on their separate routes, the Legacy jet, according to its flight plan, should have descended to 36,000 feet (or 11,000 m), which would have placed them out of the path of the southbound Gol passenger plane. The pilots insist they were never instructed by ATC to change their altitude. In fact, they claim that when they took off, they were cleared by São José dos Campos air control center to fly at 37,000 feet all the way to their destination. And investigators confirm that once the Legacy jet reached Brasilia Center airspace, which is roughly the midpoint from where both planes took off from opposite directions, the controllers indeed never asked them to descend that critical 1,000 feet (or 305 m). This revelation becomes one of the main contributors of the crash, according to investigators.
But this revelation does not paint the full picture of what happened. The reason why Brasilia Center controllers never instructed the Legacy jet to descend, as their flight plan indicated they would, was because of the way that the actual versus assigned altitudes appeared on their radar screens. These numbers appeared side by side on the radar screen, and the controller simply confused the altitude value on one side for the altitude value on the other side. In doing so, the controller mistook the lower, assigned altitude value (as indicated on their filed flight plan) as their actual altitude. And it is procedure for pilots to obey ATC instructions about altitude, even if what they are instructed to do differs from the flight plan.
CENIPA Points to ExcelAire Pilots for Disabling Transponder, Not Maintaining Radio Contact with ATC
The investigation also found that neither the Legacy jet pilots, nor ATC, were as active as they should have been in trying to maintain contact with one another. While each did try many times to contact the other, there were also precious periods of time, especially on the parts of the Legacy pilots, where no communications were exchanged nor were attempts made.
Additionally, investigators uncover another problem. At a point in time leading up to the collision, Brasília Center lost the transponder coming from the Legacy jet. Transponder data is important as it tells ATC what a plane’s altitude and airspeed are, among other things. On ATC radar, the loss of the transponder data would have made the Legacy jet appear as if it were changing altitudes erratically, which it did appear to do on radar, and yet, Brasilia Center never made contact with the Legacy jet to tell them that their transponder was disabled and to turn it back on.
On a side note, during the investigation, neither pilot of the Legacy jet knew why their transponder had been turned off. One possibility was that the footrest pedal for the pilot’s seat was right next to the button for the transponder, and once it was turned off, no chime would sound, so the pilots would not have known unless they were paying attention to this. At the time of the collision, the transponder was working. However, the general thought on the part of investigators was that both pilots were probably very distracted by the new plane and running through the flight manual and did not notice that one of them accidentally shut the transponder off.
But why would that matter? Well, not only does a transponder communicate important data to ATC, but it also communicates with other planes – through its traffic collision and avoidance system, known as TCAS, and in the event of a potential collision, provides the pilot with specific instructions on how to avoid the conflict with traffic. The system may instruct each pilot to descend or climb in opposite directions or adjust vertical speed. This is the final reason why the collision was not prevented: though TCAS was equipped via the transponder on Gol 1907, it was not on the Legacy jet, and therefore, neither plane knew the other one was in its path.
CENIPA Issues Probable Cause Focusing on Both Pilot ATC Errors While NTSB Emphasizes Faults in Brazilian ATC System
In all, the CENIPA found that the air traffic controllers contributed to the accident by originally issuing an improper clearance to the Legacy jet crew, 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. The agency also concluded that the Legacy jet pilots 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.
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. This is because, from the NTSB perspective, it is the responsibility of air traffic control to do just that – control the airspace.
Following Midair Collision, Brazilian Controllers Go on Strike
Regardless, following the midair collision, Brazil’s air traffic control infrastructure spiraled into crisis. Over and over, controllers came forward to complain about being overworked and undertrained, especially in being able to speak the English language, which is the international aviation language. They also complained about the confusing and outdated equipment used to control air traffic. Soon, controllers go on strike, which created massive delays and cancellations across the country. Brazil did eventually make many improvements in its air traffic control infrastructure. However, nine months after the Amazon crash, there was another horrific airplane crash at the airport in Sao Paulo. In that one, 199 died.
There have been some training improvements made at Brazilian air traffic control, including at least some acknowledgment that air space over the central Amazon has radio and radar blind spots. On the other hand, some controllers say the system remains poorly run, with little real change since the Amazon crash.
ExcelAire Pilots, Brazilian Controllers Charged with Their Role in Causing Midair Collision
But the fallout from the midair collision continued in the form of criminal proceedings against the two Embraer pilots and four Brasília-based air traffic controllers. One controller was sentenced to 14 months in jail. Another air traffic controller received a term of up to three years and four months, but he was able to do community service in Brazil in lieu of prison time.
Captain Lapore and First Officer Paladino were allowed to return home to the United States two months after the crash though proceedings in Brazil continued without them being present. In 2011, a Brazilian judge sentenced Lapore and Paladino to four years and four months of prison in a "semi-open" facility requiring that the pilots "report regularly to authorities and stay home at night. Later on, during appeal, the court modified the sentences to 37 months for each pilot. Ultimately, after many appeals, in October 2015, Brazil's Supreme Court rejected the pilots' appeal of the conviction, upheld the sentences, and ordered them to return to Brazil to serve out their sentences. If they return to Brazil, they will most certainly be taken into custody.
Gol Flight 1907 Fought to the Very End to Try and Save Their Passengers
And, while certainly, it can be said that what happened to the controller and pilots following the investigation was tragic, I think we can all agree that the real tragedy is the loss of the 154 people onboard Gol 1907. This next part of the story is based on an article from Vanity Fair by William Langewiesche.
On that same late afternoon across the blue Brazilian sky, Gol Flight 1907 had two pilots in their own cockpit. The captain was one of Gol’s most seasoned pilots named Decio Chaves Jr., who at age 44 had logged 14,900 hours in flight, nearly a third of them in the latest 737s. His co-pilot was Thiago Jordao Cruso, aged 29, an advanced apprentice with 3,850 hours.
The flight south so far had been routine, with the airplane cruising on autopilot at 37,000 feet, at all times, exactly where it was supposed to be. Based on what is left of the CVR, the pilots spent much of the flight looking through photographs of their colleagues and friends. About 10 minutes before the end, a flight attendant entered the cockpit for a flirtatious chat. Her comments made the pilots laugh. Soon afterward, Manaus ATC instructed Flight 1907 to contact Brasilia Center once they reached the waypoint a few minutes ahead. The pilots switched to the new frequency as instructed, and did not know it and never would, but they were hearing a transmission from controllers to the pilots of the Legacy jet at this same moment. The Gol pilots had no reason to suspect that the Legacy jet was near. They continued to look at their pictures and reminisce.
And then the end came for them after all. The Legacy jet came charging at the Boeing about 30 feet to the left of the fuselage and 2 feet lower. The Legacy’s winglet acted like a vertically held knife, slicing through the Gol aircraft’s left wing about halfway out and severing the wing’s internal spar, which runs the entire length of the wing and acts as its skeleton. This was a catastrophic strike. The combined speed of both planes reached a window-shattering 995 mph (or 1600 kph). The outside edge of the wing whipped upward, then separated entirely, spiraling over the fuselage and demolishing much of the Boeing’s tail. In the plane’s cockpit, the sequence was audible and sounded like a car crash. Instantly the plane twisted out of control, corkscrewing violently to the left and pitching straight down into a rotating vertical dive. The cockpit filled with alarms—a robotic voice insistently warning, Bank angle! Bank angle! Bank angle!
Back in the cabin the passengers audibly screamed and shouted. Even still, the pilots fought desperately to regain control. They probably did not know what had gone wrong. But they were laser focused on their duties. No one swore. There were no extraneous exclamations of fear or terror. Instead, one pilot urged the other one to stay calm. As William Langewieche said, if pilots must die in an airplane, all would choose to finish so well.
Of course, both pilots would have known there was no way out, but they did what they could anyway, even extending the landing gear to slow the spiral dive. It was hopeless. Twenty-two seconds into the plunge, the airplane’s over-speed warning came on with a rattle that continued to the end.
The force of the dive then grew and grew until it exceeded four Gs—the gravity-load threshold beyond which some passengers must have begun to black out as the forces drained blood from their brains. In the cockpit the pilots kept trying in vain to regain control, fighting with the controls and exchanging a few words here and there which could not be heard over the massive sound of alarms and wind. Fifty-two seconds later and still diving, and at 7,000 feet (or 2100 m), Gol 1907 finally broke apart, first breaking into three sections while cartwheeling through the air before smashing into the forest below into more pieces.
A lot has been written about the experience of the pilots and passengers onboard the Legacy jet. Some say this is because, obviously, they survived. Others believe it is because they were
Legacy Jet Survivor and Journalist Comes to Terms with Gol 1907 Tragedy
Americans and that alone allotted them privileges within the international aviation community. Maybe it was because so many Brazilians felt the pilots shared more blame than investigators determined them to have. Perhaps this emphasis on one plane in this midair collision over the other one is also not lost on journalist Joe Sharkey, who survived the collision as a passenger of the Legacy jet but then reported on the investigation as a journalist.
When Joe returned home several days after the midair collision, a television reporter asked him, "Do you believe in miracles?" His answer was pointed. "No," he said. "I believe in luck. If what happened to me was a miracle, then what do you call what happened to those 154 people who died?"
In a separate piece, he wrote the following about his own complicated human experience at the center of this story, and the reckoning one must go through examining their own survival. He wrote:
“As I write this on what happens to be my 60th birthday, I am unceasingly aware that my astonishing luck to be alive today coincided with the horrible fate of 154 people who plunged to their deaths on September 29. I have tried not to be flippant about any aspect of this story. But I do think how very fortunate I am not to have been the subject of a 400-word obituary. A lot of people—myself included, until recently—would have a small problem with the idea of turning 60. Now I cherish it.”
And THAT is the heartbreaking and frustrating story of the Mato Grosso midair collision of an ExcelAire Legacy jet and Gol Flight 1907.