Accident
Last updated: 24 October 2014
Status:Final
Date:Friday 29 September 2006
Time:16:57
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different
Boeing 737-8EH
Operator:Gol Transportes Aéreos
Registration: PR-GTD
C/n / msn: 34653/2039
First flight: 2006
Total airframe hrs:202
Cycles:162
Engines: 2 CFMI CFM56-7B26
Crew:Fatalities: 6 / Occupants: 6
Passengers:Fatalities: 148 / Occupants: 148
Total:Fatalities: 154 / Occupants: 154
Airplane damage: Destroyed
Airplane fate: Written off (damaged beyond repair)
Location:30 km (18.8 mls) from Peixoto Azevedo, MT (   Brazil) show on map
Phase: En route (ENR)
Nature:Domestic Scheduled Passenger
Departure airport:Manaus-Eduardo Gomes International Airport, AM (MAO/SBEG), Brazil
Destination airport:Brasília-Presidente Juscelino Kubitschek International Airport, DF (BSB/SBBR), Brazil
Flightnumber:1907
Narrative:
On September 29, an Embraer Legacy 600 executive jet (N600XL) was scheduled to be delivered from the Embraer factory at São José dos Campos Airport (SJK) to the United States. An intermediate stop was planned at Manaus (MAO). The Legacy took off at about 14:51. The filed flight plan included a routing via the OREN departure procedure to Pocos beacon, then airway UW2 to Brasilia VOR (BRS), airway UZ6 to Manaus. The cruise altitude was filed as FL370, with a planned change to FL360 at BRS, and to FL380 at the TERES navigational fix, approximately 282 miles north of BRS.
Meanwhile, at 15:35, GOL Flight 1907, a Boeing 737-800, departed Manaus (MAO) on a scheduled flight to Brasilia (BSB) and Rio de Janeiro (GIG). The flight was also routed via UZ6 to BRS. Cruising altitude was FL370, which was reached at 15:58. At that time, Legacy N600XL had just passed BRS, level at FL370. There is no record of a request from N600XL to the control agencies to conduct a change of altitude after passing BRS. There is also no record of any instruction from air traffic controllers at Brasilia Center to the aircraft, directing a change of altitude. When the airplane was about 30 miles north-northwest of BRS, at 16:02, the transponder of N600XL was no longer being received by ATC radar. Between 15:51 and 16:26, there were no attempts to establish radio communications from either the crew of N600XL or ATC. At 16:26 the CINDACTA 1 controller made a "blind call" to N600XL. Subsequently until 16:53, the controller made an additional 6 radio calls attempting to establish contact. The 16:53 call instructed the crew to change to frequencies 123.32 or 126.45. No replies were received. Beginning at 16:48, the crew of N600XL made a series of 12 radio calls to ATC attempting to make contact. They heard the 16:48 call, but the pilot did not understand all of the digits, and requested a repeat. No reply from ATC was received. The pilot made 7 more attempts to establish contact.
Both the GOL Boeing 737 and the Legacy were now on a head on collision course on airway UZ6 at the same altitude. Because the transponder of N600XL was not functioning properly -for as of yet undetermined reasons- the TCAS equipment on both planes did not alert the crews. At FL370, over the remote Amazon jungle, both aircraft collided. The left winglet of the Legacy (which includes a metal spar) contacted the left wing leading edge of the Boeing 737. The impact resulted in damage to a major portion of the left wing structure and lower skin, ultimately rendering the 737 uncontrollable. The Boeing 737 was destroyed by in-flight break-up and impact forces.
The Embraer's winglet was sheared off and damage was sustained to the vertical stabilizer tip. The crew made numerous further calls to ATC declaring an emergency and their intent to make a landing at the Cachimbo air base. At 17:02, the transponder returns from N600XL were received by ATC. At 17:13, an uninvolved flight crew assisted in relaying communications between N600XL and ATC until the airplane established communication with Cachimbo tower.
A safe emergency landing was made.


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."

Classification:
Mid air collision
Loss of control

Sources:
» Court wants two pilots' passports seized (AP 3-10-2006)
» Crash site of Brazil jet found (Reuters, 30-9-2006)
» Gol divulga lista de passageiros do Boeing desaparecido (O Globo, 30-9-2006)
» GOL press releaes
» Update on Brazilian investigation into September midair collision over Amazon jungle (NTSB 22/11/2006)

Official accident investigation report
investigating agency: Centro de Investigação e Prevenção de Acidentes Aeronáuticos (CENIPA) - Brazil
report status: Final
report number: A-00X/CENIPA/2008
report released:11-DEC-2008
duration of investigation:804 days (2 years 2.5 months)
download report: Aeronautical accident PR–GTD and N600XL B-737 8EH and EMB-135 BJ LEGACY 29 September 2006 (A-00X/CENIPA/2008)

Photos

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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Manaus-Eduardo Gomes International Airport, AM to Brasília-Presidente Juscelino Kubitschek International Airport, DF as the crow flies is 1940 km (1212 miles).

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