What happened
On 29 September 2006, a mid-air collision occurred involving a Boeing 737-800 (registration PR-GTD) and an Embraer Legacy 600 (registration N600XL). The Boeing 737, operated by Gol Transportes Aéreos, was performing a scheduled commercial flight when it collided with the Legacy 600, a business jet. The impact resulted in a catastrophic event involving both aircraft.
The investigation
CENIPA's investigation focused on the technical and operational circumstances leading to the collision. Investigators examined the aircraft's avionics, specifically the interface between the transponder and the Flight Management System (FMS) on the N600XL. The investigation also reviewed air traffic control (ATC) radar data, communication logs, and the flight paths of both aircraft. A significant portion of the inquiry centered on the functionality of the Traffic Collision Avoidance System (TCAS) and the status of the transponder on the business jet during the flight. Furthermore, the investigation scrutinized the proficiency of the flight crews and the adequacy of international operations training.
Findings
- The investigation established that the N600XL proceeded for an extended period without established two-way communication with ATC.
- A critical factor was a transponder outage on the N600XL, which prevented the aircraft from being properly identified by secondary surveillance radar and TCAS.
- The crew of the N600XL failed to invoke standard lost communication procedures despite being able to hear transmissions from ATC and other aircraft.
- There were identified deficiencies in the proficiency of the pilot-in-command of the N600XL regarding the requirements for international operations.
- The investigation noted that the crew and ATC both failed to recognize and act upon the loss of two-way communication.