Terror at 37,000 Feet

Yesterday's Hudson River plane crash had a happy ending for all of the passengers and crew concerned, thanks to the spectacular skills of the pilot.

But it reminded me of another crash that didn't end so well that is featured in a story this month in Vanity Fair, which I thought might interest readers. The piece is long, but a worthwhile read.

The article, written by William Langewiesche, a pilot himself, is a compelling chronicle of what occurred when a $25 million small private jet, fresh from the manufacturer's factory in Brazil and on its maiden trans-oceanic voyage to its new owners in the United States, clipped the wing of a Boeing 737 passenger jet 37,000 feet above the Amazon and sent 154 people to their deaths. The article makes effective use of cockpit black box recordings recovered from the two planes, one of which survived the collision.

The tragedy, entirely avoidable, resulted from a combination of technology blunders, human error and cultural and language barriers.

The pilots of the private jet, unfamiliar with the new Embraer
Legacy 600 plane, were feeling their way through the instrument panel, flipping pages on the aircraft manual and pushing buttons like adolescent boys with a new Christmas toy. In the process, Langewiesche suggests, they may have inadvertently turned off the plane's transponder, which then disabled the collision-avoidance system, making their plane invisible to the collision-avoidance systems of other planes. Exacerbating the problem was the fact that when the transponder went off, no alarm sounded in the cockpit to warn the pilots.

At that moment, 4:02 p.m., the transponder quit. No chime sounded in the cockpit. Instead, a small warning silently appeared on each of the two Radio Management Units, showing an abbreviation for “Standby.” The understated warnings must have made good sense to Honeywell’s engineers, who inhabit offices in Arizona, but they were not helpful to the pilots far away in flight, who were drowning in their products. For the next 500 miles the “Standby”
warnings remained in view but unseen. The pilots were occupied with other things: their automated flight-performance calculations, fraternal visits from the passengers in the cabin, offers of water and soft drinks.

Radio communication between the private jet and traffic controllers on the ground was minimal as the plane left Sao Paulo airspace and quit altogether at crucial moments when the two sides should have been talking with one another. Additionally, there was confusion about the plane's altitude. According to the flight plan, the private jet was supposed to descend from 37,000 feet to 36,000 feet as it changed direction in the sky, but the pilots didn't follow the plan. An altitude-measuring instrument in the control tower gave conflicting readings, indicating that the plane was at both 37,000 feet and 36,000
feet, yet the air-traffic controller made no attempt to clarify the plane's position with the pilots. Had he done so and ordered the plane to descend 1,000 feet, the collision would have been averted.

The private jet's vertical wing tip (see photo above) sliced through the Boeing 737 like a knife. The pilots of the private jet felt the impact, but never saw what they'd hit. In the heat of the moment, as their plane careened, the pilot, Joseph Lepore, seemed to choke, and his co-pilot, Jan Paul Paladino, seized control of the aircraft.

Paladino said, “Did we hit somebody? Did you see that? Did you see something?”

Lepore was hesitant. “I thought I saw … I looked up … ” He made another
Mayday call, but remained behind the game. Struggling to look up information about the nearest airport, he said, “What is it … S?”

Paladino answered, “S-B-C-C. We’ll just go direct to it.”

“I don’t know if it’s big enough.”

Paladino said, “I know. We’ll just fly. We’ll find out. Trying to contact these fuckers. They won’t answer the radio.”

They managed to land the plane safely, but the Brazilian pilots of the Boeing passenger jet weren't as lucky.

The cockpit filled with alarms—an urgent klaxon and a robotic voice insistently warning, Bank angle! Bank angle! Bank angle!, as if the crew might need the advice. Back in the cabin the passengers screamed and shouted. The pilots reacted as one might expect, fighting desperately to regain control. They probably did not know what had gone wrong. They certainly never mentioned it. What is unusual is that they also did not swear. Ten seconds into the dive, one of them did cry
“Aye!,” but the other urged him to stay calm. “Calma!” he said, and seconds later he said it again. If pilots must die in an airplane, all would choose to finish so well. Of course these two knew they were gone, but they did what they could, even extending the landing gear to slow the dive. The gesture was hopeless. Twenty-two seconds into the plunge the airplane’s over-speed warning came on with a rattle that continued to the end.

UPDATE: A New York Times travel columnist who was onboard the Embraer plane to write about the aircraft for a business magazine, wrote about his experience of the collision. His piece includes a photo of the Embraer's sheared wing tip and tail.

For those who are interested in wading through the details, a Brazilian panel issued a 266-page report (.pdf), complete with radar imagery, reconstructing the collision and examining the evidence. The controversial report laid the blame for the crash largely on the American pilots of the Embraer plane, for which it was criticized by the International Federation of Air Traffic Control Associations.

A second 10-page report from the U.S. National Transportation Safety Board (.pdf) focused on the poor design of the Brazilian air-traffic control system, which gave the controllers conflicting information, and the poor response of two traffic controllers to the information displayed by the system and their failure to communicate with the American pilots and with each other.

Photo: Joe Roy, flickr