Cachimbo Airbase Airport
Aircraft Accident/Incident Report

Azevedo Brazil
Friday, September 29, 2006 15:00 UTC

NTSB Narrative Summary Released at Completion of Accident

On September 29, 2006, at approximately 4:57 pm, Brasilia standard time, a midair collision occurred over the Brazilian Amazon jungle, between a Boeing 737-800 (PR-GTD) operated by Gol Airlines of Brazil, and an Embraer Legacy 600 business jet (N600XL) owned and operated by Excelaire of Long Island, New York. The accident investigation is being conducted under the authority of the Brazilian Aeronautical Accident Prevention and Investigation Center (DIPAA). Under the provisions of ICAO Annex 13, the United States, as state of registry and operator of the Excelaire Legacy, and state of manufacture of the Boeing 737 and Honeywell avionics equipment in both airplanes, has provided an accredited representative and technical advisors for the investigation. The U.S. team included the accredited representative from the major aviation accident investigations division of the NTSB, as well as technical advisors in operations, systems, air traffic control, flight recorders, and aircraft performance. Additional technical advisors from Boeing, Excelaire, Honeywell, and FAA have also been included. The Boeing 737 was destroyed by in-flight breakup and impact forces; all 154 occupants were fatally injured. The wreckage of the 737 was located in remote jungle terrain with very difficult access. Brazilian military search and rescue personnel located the flight recorders and all significant portions of the wreckage except the outer portion of the left wing. The Legacy N600XL experienced damage to its left wing and left horizontal stabilizer and performed an emergency landing at the Cachimbo Air Base, approximately 100 miles northwest of the collision site. There was no further damage to the airplane, and the 2 crew members and 5 passengers were not injured. The airplane remained at the base and significant components have been tested and recovered from the aircraft. Visual meteorological conditions prevailed in the area of the accident. Both aircraft were operating under instrument flight rules, on instrument flight plans and clearances. The Boeing 737 was a scheduled domestic air carrier flight enroute from the Eduardo Gomes International Airport, Manaus, Brazil; to the Presidente Juscelino Kubitschek Airport, Brasilia. The Legacy N600XL was enroute from the Prof. Urbano Ernesto Stumpf airport, San Jose dos Campos, Brazil (SBSJ), to a stopover in Manaus, and eventually enroute back to the U.S. This was Excelaire's initial flight with this aircraft, taking delivery from the Embraer factory and a planned flight to Excelaire's home base in New York. The Legacy N600XL departed SBSJ at about 2:51 pm. 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. After takeoff, N600XL was issued a number of interim altitudes during climb, all of which were read back. The flight was cleared to proceed direct to Araxa VOR (on airway UW2), and at 3:11 pm was cleared to climb to FL370. At 3:33 pm, the airplane leveled at FL370. At 3:35 pm, the Boeing 737 departed Eduardo Gomes airport, requesting FL370 as a cruise altitude, and a routing via UZ6 to BRS. The airplane reached FL370 at 3:58 pm. There were no anomalies in communications with or radar surveillance of the Boeing 737 throughout the flight. At 3:51 pm, an air traffic controller in the Brasilia ACC (CINDACTA 1) instructed N600XL to change frequencies to the next controller's sector. The crew of N600XL reported in on the assigned frequency that the flight was level at FL370. ATC acknowledged and instructed the crew to "ident" (flash their transponder). Radar indicates that the ident was observed. This was the last two-way communication between N600XL and ATC. At this time the airplane was approximately 40 nautical miles south of BRS. At 3:56pm the Legacy N600XL 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 reaching flight level 370. The crew made calls, but there is no communication in which they requested a change of flight level. 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 4:02 pm, the transponder of N600XL was no longer being received by ATC radar. A transponder reports a unique code, aiding radar identification, and provides an accurate indication of the airplane's altitude. Additionally, the transponder is a required component for the operation of Traffic Collision Avoidance System equipment, commonly called the TCAS system. Between 3:51 pm and 4:26 pm, there were no attempts to establish radio communications from either the crew of N600XL or ATC. At 4:26 pm the CINDACTA 1 controller made a "blind call" to N600XL. Subsequently until 4:53 pm, the controller made an additional 6 radio calls attempting to establish contact. The 4:53 call instructed the crew to change to frequencies 123.32 or 126.45. No replies were received. There is no indication that the crew of N600XL performed any abnormal maneuvers during the flight. Flight Data Recorder information indicates that the airplane was level at FL370, on course along UZ6, and at a steady speed, until the collision. Primary (non-transponder) radar returns were received corresponding to the estimated position of N600XL until about 4:30 pm. For 2 minutes, no returns were received, then returns reappeared until 4:38 pm. After that time, radar returns were sporadic. Beginning at 4:48 pm, the crew of N600XL made a series of 12 radio calls to ATC attempting to make contact. At 4:53, the crew heard the call instructing them to change frequencies, 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. At 4:56:54 pm the collision occurred at FL370, at a point about 460 nautical miles north-northwest of BRS, on airway UZ6. There was no indication of any TCAS alert on board either airplane, no evidence of pre-collision visual acquisition by any flight crew member on either aircraft, and no evidence of evasive action by either crew. Wreckage and damage examination indicates that it is likely 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, causing the outer portion of the wing to fail in an upward direction, separating the outer portion of the wing and a significant portion of additional upper wing skin, ultimately rendering the 737 uncontrollable. Flight recorder information ceased at an approximate altitude of 7,887 feet. After the collision, the crew of N600XL made numerous further calls to ATC declaring an emergency and their intent to make a landing at the Cachimbo air base. At 5:02 pm, the transponder returns from N600XL were received by ATC. At 5:13 pm, an uninvolved flight crew assisted in relaying communications between N600XL and ATC until the airplane established communication with Cachimbo tower. Flight recorders from both airplanes were recovered and downloaded at the Transportation Safety Board of Canada (TSB) laboratories. Transcriptions of the cockpit voice recorders (CVRs) were prepared (the transcript of the Legacy's CVR was produced at the NTSB's laboratory in Washington, D.C.) and data from flight data recorders obtained. Initial interviews and medical examinations were conducted with the crew of the Legacy. Air Traffic Control data was gathered. Preliminary tests of the avionics equipment on the Legacy were performed. Wreckage of the 737 was examined. Additional investigative work will include laboratory tests of the avionics components removed from the Legacy, an examination of the operating procedures of the avionics, interviews with ATC personnel, examination of ATC practices and comparison between Brazilian and FAA procedures, a technical examination of ATC communication and surveillance systems, and further examination of the training provided to the operators. Brazilian Contact: Brazilian Aeronautical Accident Prevention& Investigation Center 55-61-3329-9160

NTSB Probable Cause Narrative

Not Yet Reported

Event Information

Type of Event Accident
Event Date 9/29/2006
Event Day of the Week Friday
Time of Event 1500
Event Time Zone Coordinated Universal Time? Same as GMT
Event City Azevedo
Event State --
Event Country BRAZIL
Zipcode of the event site --
Event Date Year 2006
Event Date Month 9
MidAir Collision Indicator Yes
On Ground Collision occurred ? No
Event Location Latitude --
Event Location Longitude --
Event Location Airport Cachimbo airbase
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 100
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Unknown
Time of the weather observation
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID --
Elevation of weather observation facility --
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation --
Lighting Conditions --
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions --
Sky Condition for Lowest Ceiling --
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) --
Air Temperature at event time (in degrees celsius) --
Dew Point at event time (in degress fahrenheit) --
Wind Direction (degrees magnetic) --
Variable Wind Indicator --
Wind Speed (knots) --
Wind Velocity Indicator --
Wind Gust Indicator Unknown
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) --
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 154
Injury Total Minor --
Injury Total None 7
Injury Total Serious --
Injury Total All 154
Investigating Agency Foreign
NTSB Docket Number (internal use) --
NTSB Notification Source Boeing
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Dec 13 2006 10:30AM
User who most recently changed record DELI
Basic weather conditions Instrument Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft #2

Aircraft Registration Number -- N600XL
NTSB Number DCA06RA076A DCA06RA076B
Missing Aircraft Indicator -- --
Federal Aviation Reg. Part Non-U.S., Commercial Part 91: General Aviation
Type of Flight Plan filed IFR IFR
Flight plan Was Activated? Yes Yes
Damage Destroyed Minor
Aircraft Fire -- None
Aircraft Explosion -- None
Aircraft Manufacturer's Full Name Boeing Embraer
Aircraft Model 737-800 E135 Legacy
Aircraft Series Identifier -- --
Aircraft Serial Number -- 145-965
Certified Max Gross Weight -- --
Aircraft Category Airplane Airplane
Aircraft Registration Class -- --
Aircraft is a homebuilt? No No
Flight Crew Seats -- --
Cabin Crew Seats -- --
Passenger Seats -- --
Total number of seats on the aircraft -- --
Number of Engines 2 2
Fixed gear or retractable gear Fixed Fixed
Aircraft, Type of Last Inspection -- --
Date of Last Inspection -- --
Airframe hours since last inspection -- --
Airframe Hours 235 12
ELT Installed -- Yes
ELT Activated -- No
ELT Aided Location of Event Site -- No
ELT Type -- --
Aircraft Owner Name Gol Air Excelaire
Aircraft Owner Street Address -- --
Aircraft Owner City Sao Paolo Ronkonkoma
Aircraft Owner State -- NY
Aircraft Owner Country BR USA
Aircraft Owner Zipcode -- --
Operator is an individual? No No
Operator Name -- --
Operator Same as Owner? Yes Yes
Operator Is Doing Business As -- --
Operator Address Same as Owner? Yes No
Operator Street Address -- --
Operator City -- Islip
Operator State -- NY
Operator Country -- USA
Operator Zip code -- --
Operator Code -- --
Owner has at least one certificate None --
Other Operator of large aircraft? -- --
Certified for Part 133 or 137 Operation -- --
Operator Certificate Number -- --
Indicates whether an air carrier operation was scheduled or not Scheduled --
Indicates Domestic or International Flight Domestic --
Operator carrying Pax/Cargo/Mail Passenger Only --
Type of Flying (Per_Bus / Primary) -- Ferry
Second Pilot on Board Yes Yes
Departure Point Same as Event No No
Departure Airport Code -- --
Departure City Manaus San Jose
Departure State -- --
Departure Country BR BR
Departure Time -- --
Departure Time Zone -- --
Destination Same as Local Flt -- --
Destination Airport Code -- --
Destination City Brasilia Manaus
Destination State -- --
Destination Country BR BR
Specific Phase of Flight Cruise Cruise
Report sent to ICAO? -- --
Evacuation occurred -- --
Date of most recent change to record Dec 13 2006 10:30AM Apr 2 2010 10:18AM
User who most recently changed record DELI broda
Since inspection or accident -- Time of Accident
Event Location Runway Number and Location N/A N/A
Runway Length -- --
Runway Width -- --
Sight Seeing flight No No
Air Medical Flight No No
Medical Flight -- --