Brazil - A Missed Opportunity

On 10 December 2008, the Brazilian aviation accident investigation bureau, Centro de Investigação e Prevenção de Acidentes Aeronáuticos (CENIPA), published the final accident report on the mid-air collision between flight GOL 1907 and N600XL which occurred in Brazil on 29 Sept 2006.
IFATCA notes that whereas the inquiries in regards to the events in the cockpit of the Legacy private jet received a lot of attention and were investigated with rather detailed care by CENIPA, the same cannot be said for investigations of the ATC system and operation. The well-evidenced failures and safety problems of the Brazilian ATC system, including its contributions to the chain of events of the fatal accident, have not received the required attention and detailed scrutiny from CENIPA. While the final accident report admittedly focuses on some events and problems on the ATC-side, these items do not lead to clear conclusions. The reports proposed safety recommendations with regard to ATC system deficiencies will neither satisfactorily nor safely address many of the areas identified as being part of the fatal chain of events. As a response IFATCA has published a detailed position statement on this report. IFATCA believes this is a missed opportunity for the Brazilian aviation authorities to restore trust and safety in the national aviation system. Using this report to openly note the problems and shortcomings of the Brazilian ATM system would have then served as a starting point for an extensive and desperately needed healing process amongst the entire Brazilian aviation industry. It could further have served as the trigger event to reorganize and restructure the national ATC system that has received a lot of criticism especially with regard to safety. This unfortunately has not occurred as the Brazilian Air Force, to which both CENIPA and the ATC service provider report, appears reluctant to expose the staff and departments within in its own organization to scrutiny. On 24 November 2006, just two months after the accident occurred, IFATCA stated in a Press Release: "IFATCA believes that operators in the air (the pilots), and on the ground (the controllers) fell victim to unacceptable systems traps brought on by 'non-error tolerant', and 'bad system design' of air traffic control and flight equipment in use." IFATCA notes that in Appendix 2 to the CENIPA report, which contains the National Transportation Safety Board comments on the accident, this respected North American safety organisation comes to very similar conclusions in regard to the inherent deficiencies of the Brazilian ATC system, and the problems and failures that played a critical role in the mid-air collision of September 2006. IFATCA agrees with the NTSB that these issues still exist, and that they mostly likely will not be addressed and fixed by the clean-up process initiated by the Brazilian authorities. Even after the CENIPA accident report, the deeply rooted structural and organizational problems of the Brazilian ATC system continue to exist. However much we see this as a missed opportunity, we do hope and trust that it is not a lost opportunity as the Brazilian authorities may yet implement the needed safety improvements without the guidance of a CENIPA recommendation!
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