Accident discussion in Vanity fair

[CAflyer]

Imagination & curiosity is the worst combination. I just read a new article in my Vanity Fair about a crash caused by a small jet hitting a airliner at cruise! I know its a small chance but now that is in my head. It was a bunch of small events that all happen to lead up to it by chance. I just don't ever want to be in that situation. I know to stay away from that bad information but I always want to know more. My biggest challenge is to not think I am the one everything bad will happen to.

[Barb-SAN]

Imagination & curiosity is the worst combination. I just read a new article in my Vanity Fair about a crash caused by a small jet hitting a airliner at cruise!
O.K....now I'm curious :rolleyes:, and don't have that Vanity Fair. Where did that crash take place? Perhaps we have already discussed it here on TF. I can think of one case that happened in Brazil awhile ago.

Later...Ah yes, I found the Vanity Fair article online:
Note: WARNING: This is NOT recommended reading for anyone who feels that they get much more anxious after reading about airplane accidents.
http://www.vanityfair.com/magazine/2009/01/air_crash200901 (don't have time to read it right now..looks interesting though)...and it is that crash..."The Devil at 37,000 ft."...that headline will get your attention! It's been covered at length here (one thread in Hangar Talk, and another in General Discussion; links here: http://www.takingflight.us/forums/showthread.php?t=5886&highlight=joe+sharkey
http://www.takingflight.us/forums/showthread.php?t=8549&highlight=joe+sharkey

Um, moderators...this probably should be in its own thread...not to hijack Andria's...sorry...

[MathFox]

How should that "moving of posts" work :confused:

*click* *click* *click* *another careful click*
*tap* *tap* *tap* *tap* *tap* *tap* *tap* *tap* *tap* *tap* *tap* *tap*
*CLICK*

:magic::sunshine:

[Barb-SAN]

Thanks, MathFox. I'm reading the article now...it is VERY detailed and LONG...interesting for the detail-oriented among us...;)

I think there are lessons that we can all take away from this unfortunate accident too. It's so important to pay attention to what you are doing, for example, when driving your car, and not let distractions take your attention away from your primary job.

[CAflyer]

Hey I didn't start this thread but it says I did. I am confused. I thought I just responded to a post, how did this end up as it's own thread?? I didn't want to go into it for fear of scaring others.

ok I see.. it was moved. I hope I just didn't start a mad rush to read about the accident only to make people more scared!

[MathFox]

It is just your moderator trying to be friendly :cry:

*wonder what this button would do* :lol:

BTW, I think I prefer an NTSB writeup over Vanity Fair.

[Andria]

Um, moderators...this probably should be in its own thread...not to hijack Andria's...sorry...

Ohhhh...my thread?! Nope...not me! I don't know how this started (ghost in the machine perhaps?) but for sure, I never birthed this one!

For one I don't buy Vanity Fair...and even if I did, I'd struggle to read it because it would be in Portuguese...I can speak Portuguese, enough to live here etc (and even then, I usually murder the language) but not enough to read well :rolleyes: And finally, I'm not one for reading about air-disasters. I know they happen, in the same way that car accidents do but I don't go looking for such stories.

Anyway, I'm a believer that some knowledge is great...but too much can become a negative. A bit like when you have your first child. When you don't know what's going to happen, you're frightened of the unkown. When it comes to your second child (or third...fourth...etc...) then you're frightened because you know too much. The ladies on here will know exactly what I'm talking about :lol:

[Barb-SAN]

Ohhhh...my thread?! Nope...not me! I don't know how this started (ghost in the machine perhaps?) but for sure, I never birthed this one!


Well, if you lived on the forum 24 hrs. a day you would understand! CAFlyer posted her comment on your "Hey" thread, I posted my comment in reply to hers, then realized I was taking your thread in a whole new direction...and that the topic warranted its own thread, especially since we'd discussed that crash at length here already. So I asked a moderator to move it and start a new thread. They have magic editing powers the rest of us don't have. :) Guess it's confusing if you didn't see where it was before.

[Barb-SAN]

BTW, I think I prefer an NTSB writeup over Vanity Fair.
Do you have a link to one? (NTSB)?
I did sense some subtle (and not) biases in this article. Also found it interesting to learn about the accident from the perspective of the Caiapós Indians into whose lands the 737 crashed.

[MathFox]

The official report is made by the Brazil authorities... It has even more details than the vanity fair story (282 pages)
There is a link to the report on this page: http://www.ntsb.gov/Aviation/Brazil-CENIPA.htm

[Barb-SAN]

Thanks for posting those links, MathFox. I just read through the first two U.S. NTSB ones linked on that page. There's certainly a difference in "tone" between those reports and the Vanity Fair story...(the difference between "analytical" and "details + drama" (I didn't see any mention of the "Devil" in the official U.S. summary report...haven't tackled the Brazilian report yet....maybe someone else will read and comment on that one?)

[MathFox]

I am about half-way through; primary factor is ATC that allows two planes on one airway at identical altitude but in opposite directions. Contributing factor was the Embraer pilots occidentally switching off their transponder (and TCAS) which was not properly handled by the controllers.

The US pilots made an interesting combination:
PIC: Hours on type: 5:35
SIC: Hours on type: 3:30 (and 368 on the EMB-145 series of which 317 and PIC)
Neither of the pilots had flown in Brazil before. It was the first trip of the SIC for his new company. Both the PIC and SIC were qualified for the left and right seat.
The SIC showed his PIC capabilities by taking command after the collision and making a safe landing on an airforce base in the jungle.

BTW, the Brazilian SIC was receiving training for re-qualification on the Boeing 737-700/800

What strikes me about the ATC:
At the last General Specialized Test (TGE), the result of his evaluation of the English language was “non-satisfactory”.For four of the controllers involved.
Furthermore, there were communication problems over the Amazon due to a "less than optimal" configuration of the available transmitters and receivers by the controllers. No coverage of 121.5... (the emergency frequency) by ATC. A cargo plane relayed the mayday call and brought the Embraer in contact with the airport tower where they landed.

* MathFox continues reading *

I do think that this section on page 263 summarises the ATC issues pretty good:

The authorization to maintain flight level FL370 was given to the crew of the N600XL, as the result of a clearance transmitted in an incorrect manner. The vertical navigation conducted by the crew ended up being different from the one prescribed in the flight plan that was filed and activated, on account of the instruction incorrectly transmitted that led the N600XL crew to maintain flight level FL370.

The air traffic control units involved, although providing radar surveillance (radar monitoring) service, did not correct the flight level and did not perform the prescribed procedures for altitude verification when they stopped receiving essential information from the Transponder due to the loss of mode C. The controllers assumed that the traffic was at a different flight level, without even being in two-way radio contact with the N600XL for confirmation. They did not make a correct handoff of the traffic between sectors and between FIRs. They maintained RVSM separation when the necessary requirements no longer existed. As a final consequence, they did not provide the proper traffic separation as prescribed in the ICAO Doc. 4444, item 5.2 “Provisions for the Separation of Controlled Traffic”, thus allowing the in-flight collision between the two airplanes.


And the (NISB) probabjle cause on page 271
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.

[aerobat]

I have followed this accident for a couple of years myself. It conforms to the now widely-accepted "swiss cheese" model in describing error chains which lead to accidents (not just in aviation). :(


http://en.wikipedia.org/wiki/Swiss_Cheese_model (http://en.wikipedia.org/wiki/Swiss_Cheese_model)

http://www.coloradofirecamp.com/swiss-cheese/introduction.htm (http://www.coloradofirecamp.com/swiss-cheese/introduction.htm)

[MathFox]

I have followed this accident for a couple of years myself. It conforms to the now widely-accepted "swiss cheese" model in describing error chains which lead to accidents (not just in aviation). :(

What I know from software development and QA is that humans make mistakes, so any robust system should accommodate for human error.

Brasilia ATC procedures* were fragile... (the true causes remain unclear due to lack of information.) The report mentions four controllers that made serious mistakes, mostly in communication with their colleagues.

*To be clear, I'm talking about the actual procedures executed, not about the "dead tree" procedures that nobody follows.

[Barb-SAN]

What I know from software development and QA is that humans make mistakes, so any robust system should accommodate for human error.
It was stressed to us student pilots in ground school that ATC can make mistakes...and that we should remain vigilent, and not hesitate to question them or say "unable" if instructed to do something we feel in our judgement is unsafe. After all....the worst that can happen to them is that they lose their jobs. The pilot and passengers may pay for an ATC mistake with their lives. :(
I found Aerobat Barb's links interesting..."Swiss Cheese" makes a vivid visual.