SF357 ERAUDB Language in aviation: ICAO and Midair Collision Discussion

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1.Can States file a difference about ICAO language proficiency Standards? Why or why not? Explain.

2.What evidence indicates that language may have been a latent factor in the BZ midair collision: list the pieces of evidence that two AeroSafety World articles explain.

Introduction: Midair Collision BZ


Shortly after September 29, 2006, a team of aviation safety specialists travelled from the United States to Brazil to assist in the investigation of a midair collision that occurred in clear skies, during daylight hours, between two newer aircraft, both equipped with collision avoidance equipment. The smaller of the two aircraft involved in the collision, an Embraer with seven persons on board, although damaged, was able to land safely at a nearby military airport. The larger aircraft, a Boeing 737, crashed in the Amazon jungle; all one-hundred and fifty-four crew members and passengers perished in the accident.

The US group of aviation safety specialists included representation from the National Transportation Safety Board and experts in operations, systems, air traffic control, flight recorders, and aircraft performance, advisors from Boeing, N600XL, Honeywell, and the FAA. Brazil’s accident investigation service, CENIPA, led the investigation with their own team of experts and published the Final Report. The National Transportation Safety Board (NTSB) published Summary and Detailed Comments in response to the CENIPA report.

The CENIPA report is particularly lengthy and detailed, not unexpected for an investigation of an accident that was considered highly improbable, requiring an extraordinarily intricate chain of unlikely events to link up so precisely that a breach in the multilayered safety wall opened, through which both aircraft were able to fly with such tragic consequences.

On the other hand, interrupting the chain of events that led to the accident may have been as simple as, “N600XL, check your transponder.”

Unanswered questions

Accidents are almost never the result of one single error, and the CENIPA Report and NTSB Responses detail a complex host of factors which led the American, English-speaking pilots ferrying the new Embraer (N600XL) from Sao Paulo to the United States to fly a Northwesterly direction at 37,000 feet on a route at which northbound aircraft would normally fly 36,000 or 38,000 feet. At that altitude, the aircraft was on a direct collision course with the B737, operated as GOL 1907, en route to Brasilia from Manaus, Brazil.

A significant factor in the accident was the loss of the transponder signal from N600XL approximately fifty-four minutes before the collision. The cause of the loss of the transponder signal is unclear, and the investigation teams rigorously tested multiple theories searching for possible explanations. After discounting several possibilities, the investigators ultimately determined that the pilots had most likely shut off their transponder inadvertently.Additionally, CENIPA finds that distractions on the flight deck interfered with the crew’s responsibility to monitor their instruments and maintain an awareness of ATC communications.

One question left unanswered concerns the controllers’ response to the transponder failure. CENIPA notes that air traffic control “did not perform the procedures prescribed to contact the aircraft when the transponder signal transmission was interrupted, a contact which was mandatory for the maintenance of the aircraft under RVSM vertical separation parameters.”

What is not clear, however, is why air traffic controllers who noticed the loss of the N600XL transponder did not notify the pilots of the failure. In their Summary response to the CENIPA report, the NTSB cites a “lack of timely ATC action after the loss of N600XL’s transponder and two-way radio communication,” as a deficiency in the ATC system that is not “sufficiently supported with analysis or reflected in the conclusions or cause of the accident.” This question does not appear to be as rigorously investigated as was the cause of the loss of the transponder signal. In a report that otherwise systematically analyzes other aspects of the accident in extensive detail, that this question is so scantily addressed bears review.

A careful linguistic review of the information provided in the accident investigation report suggests that linguistic factors had a more significant impact on the chain of events leading to this accident than are represented in the conclusions of the report.


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