Mayday (2013) s05e10 Episode Script

NARRATOR: September 29, 2006, in Sao Jose dos Campos, Brazil - Three, two, one! - (POP!) .
.
it's a big day at Embraer headquarters.
The Brazilian aviation firm has just sold a brand-new private jet to ExcelAire, a US charter company.
The price tag - 25 million.
It's a beautiful airplane, and it was a beautiful little ceremony that Embraer had in the hangar just before we got on the plane.
And the guys from ExcelAire were particularly proud.
The Legacy is a modified regional jet.
The cabin, redesigned for comfort.
It can seat up to 13 people, and in its first four years of service, Embraer has delivered almost 100 of these sleek business jets.
ExcelAire will use the jet to fly customers around the world.
But first the company has to get the plane up to the United States.
Joseph LePore and Jan Paladino will be at the controls for the jet's maiden voyage.
They've been down in Brazil for a couple of weeks, getting familiar with the new plane.
Joe Sharkey is a reporter for the 'The New York Times'.
He's been offered a free ride home.
We were delivering an airplane, basically, and my role was hitchhiker and they kindly invited me along.
The Legacy jet is heading to Manaus, in northern Brazil - a stopover on its way to New York.
Half an hour after take-off, the Legacy is flying over the heart of Brazil.
The countryside stretches out below.
The view out of the window is spectacular.
I glanced out and I was amazed.
Just to the horizon, nothing but treetops.
And I just remember how pretty it seemed.
At 10 minutes to 4:00 in the afternoon, the Legacy jet makes contact with controllers still nearly 100km away.
Flight level 370.
Good afternoon.
(PEOPLE SPEAK PORTUGUESE) 75% of the country's air traffic is handled by the controllers in this room.
TRANSLATOR: The traffic volume is larger than in any other control centre in the country.
One of the many planes they'll be dealing with today is the Legacy jet.
Every flight that's handled appears on computer screens as a small circle moving in the direction of the plane.
The computer also displays the plane's actual and planned altitudes.
November six-zero-zero X-ray Lima.
- Squawk ident.
- Roger.
Paladino sends out a signal.
Controllers use it to confirm that the data on their screen is coming from the plane they think it is.
(SPEAKS PORTUGUESE) An hour later, the flight has settled into a familiar routine.
We all sort of settled down.
Everybody was working, and it was just a very, very calm and peaceful time.
I was transcribing notes from one of the interviews from the Embraer tour.
But in the cockpit, Paladino is having trouble getting back in touch with air He can't raise controllers on the frequency he used almost an hour ago.
He tries other channels.
CONTROLLER: November 600 X-ray Lima.
After 12 attempts, Paladino finally This time with a different controller, who provides radio frequencies for future contact.
Contact one-two-three, decimal, three-two.
(DISTORTED SPEECH) I'm sorry, I didn't get the last two.
Sorry.
Say frequency one more time for November 600 X-ray Lima.
The Legacy loses radio contact again.
It's just minutes before five o'clock.
(BANG!) Suddenly, there was the loudest bang I've ever heard in my life.
The concussion itself seemed to affect every atom in my body.
What the hell was that? Just fly the airplane, dude.
Declare an emergency.
Sit down back there! No-one's sure what's happened to the jet.
But when Joe Sharkey looks out of the window, he's stunned by what he sees.
The end of the wing was chopped off and it was serrated.
It looked like it had been chewed off.
It became clear that we were in very, very big trouble.
ExcelAire Vice President Ralph Michielli rushes to the window for a look at the damage.
I said to Ralph, "How bad is it?" He looked at me and he said, "It's bad.
" With more experience flying this type of plane, copilot Paladino takes over control of the limping jet.
Just let me fly the thing, dude, alright? We're descending.
I want to get down.
OK.
It's yours.
It's yours.
The crew still can't make contact with controllers.
November 600 X-ray Lima, declaring an emergency.
- Do we have a wingtip? - No! Dammit.
The entire tip of the Legacy's wing is breaking up.
That affects airflow, and is making the plane hard to control.
Are you doing OK? As the plane begins to descend, passengers in the back are worried that the damaged wing is getting worse.
The Amazon is a bad place to have to land a plane.
It's a dense jungle for as far as the eye can see.
There's nothing down there but trees, and I thought, "Where are they going to put this airplane down?" Just hours into its maiden voyage, the badly damaged jet is going down.
Paladino and LePore's flying will soon be analysed and debated throughout Brazil.
The verdict against them will be harsh.
Please answer.
November 600 X-ray Lima.
The crew of the Legacy jet searches desperately for a place to land their crippled plane.
Captain Joseph LePore finds a small military base on his chart.
November 600 X-ray Lima.
We have an emergency.
MAN: State your emergency.
November 600 X-ray Lima, declaring emergency.
We need to land at Zero Bravo Charlie Charlie.
- Is that your airport? - Affirmative.
So you know how long your runway is? - 2,600m.
- Stand by.
2,600.
Let's get it right.
8,000 feet.
OK.
We're coming in.
We're declaring an emergency.
This is November 600 X-ray Lima.
- Did you see something? - Something hit us.
2,600 metres is more than long enough to land a Legacy, but the crew doesn't know how the plane will respond when it touches down.
SHARKEY: When you land under those sort of circumstances, you're landing faster than you normally would, and you get a real appreciation of just how fast an aeroplane is actually moving, because, you know, you're coming down like gang busters.
I see these trees now at ground level, just sort of It looked almost like a movie with one of those moving backgrounds.
And I'm thinking, "I hope this runway doesn't run out.
" MAN: Go.
Paladino hits the brakes hard.
PALADINO: Good.
Good.
We got it.
Hold it.
Then, finally, the plane begins to slow.
(SIGHS) Whoo! (LAUGHS) Oh, man.
Good job.
Oh, man! - Oh! - (COUGHING) SHARKEY: And then finally we just did come to a halt.
There is that beautiful silence that occurs when the engines are shut down, and everything was just quiet again.
The bizarre day takes another strange twist.
Because they've landed at a military base, soldiers confiscate the passports of everyone on board.
JOE SHARKEY: That's the point at which I realised we were in custody.
I don't think the others on the airplane had had the immediate sense that this was a custodial situation.
Along with the two pilots, the jet's passengers are taken to the nearby air base.
MAN: N-6-0-0-X-L, raise altitude to 3,200.
The emergency on board the Legacy jet but it's not the only problem controllers there are facing.
Another plane they're expecting to see hasn't shown up.
Gol flight 1907 The missing flight is a Boeing 737 with 154 people on board.
It's been in the air for two hours, But controllers there can't find any trace of that plane.
Manaus, there isn't any Gol.
There isn't any Gol with us here.
MAN: (ON PHONE) It's on its way.
They check its status with controllers in Manaus, who were last in contact with the plane.
Anxiety was high, and controllers were confused about what to say.
They didn't know what was happening.
Deep in the Amazon, those who were on the ExcelAire jet are also struggling to figure out what happened.
We hit something, man.
That's all I know.
As they're trying to piece together the day's strange events, the group gets some shocking news.
A Gol flight has crashed.
It's the plane that's been missing.
I just heard the 737 went down in the Amazon right where we were.
What? SHARKEY: It was like a thunderclap.
The world changed immediately.
And Jo and Jan were just stricken.
I don't think I've ever seen two more anguished men in my life.
The Gol flight crashed right where the Legacy lost a piece of its wing.
It can't be a coincidence.
Over the next several days, troops pore over the scene of the Gol crash.
The dense jungle slows their progress.
(SPEAKS PORTUGUESE) TRANSLATION: To walk about 1km in the forest took us about an hour.
A makeshift helicopter landing pad is carved out of the jungle.
It's becoming increasingly clear that no-one has survived.
154 people are killed.
At the time, it's the worst crash in the history of Brazilian aviation.
What had happened in the skies above the Amazon? Investigators face a mammoth job.
Colonel Rufino Ferreira is in charge of the investigation into the Gol crash.
(SPEAKS PORTUGUESE) TRANSLATION: An investigator always has to keep an open mind.
You can't start with any preconceived ideas.
When we arrived at the location of the accident the only thing we knew for sure was that we had found the plane that was missing.
The wreckage of the Gol jet is spread over more than 2km.
The widespread debris tells investigators that the plane ripped apart before crashing to the ground.
(SPEAKS PORTUGUESE) TRANSLATION: The aircraft disintegrated during the fall.
It hit the ground in pieces.
There was practically no damage caused by the impact with the ground.
The plane had already fallen apart.
On October 2, just three days after the crash, the plane's flight data recorder is found.
Most of the cockpit voice recorder is also recovered, except for one critical part.
(SPEAKS PORTUGUESE) TRANSLATION: In this accident, the impact was so strong that the module separated from the recorder.
Modern voice recorders don't use tape.
Conversations are recorded digitally onto a memory module.
But that part of the Gol's CVR has broken free.
Without it, the rest of the cockpit voice recorder is useless.
While the search for the module continues Ferreira looks at the information from the 737's flight data recorder.
He learns that the plane was flying at 37,000ft.
It was on course and flying level at its assigned altitude.
Then, without warning, the plane pitched over and plummeted toward the ground.
Whatever happened, it was sudden and catastrophic.
The data recorder tells Ferreira that the plane spun 11 times before it hit the ground.
Colonel Ferreira studies air traffic control data from the day of the accident.
There is no sign of the Gol flight.
But the readings from the smaller Legacy jet capture his attention.
It seems to be flying erratically.
Instead of keeping to a single altitude the radar shows it flying up and down dangerously.
Perhaps the private jet pilots were testing out their new plane by climbing and descending quickly.
They may have collided with the Gol jet as a result of their reckless flying.
When that information leaks out to the country's newspapers it makes front-page news.
Neither LePore nor Paladino are officially charged.
But they are confined to a hotel room in Brazil while the investigation continues.
Ferreira interviews the two pilots about what they did and what they saw.
Look, we were proceeding northwest on course to Manaus at 37,000ft.
OK? We attempted to contact Were you changing altitude? No.
When he reviews the information from the Legacy's flight data recorder, Ferreira confirms the pilots' story.
Although the ground radar shows the Legacy flying wildly, the data from the plane shows that it didn't change altitude at all.
But there is something shocking about the Legacy's path.
The business jet was flying north to Manaus.
The Gol flight, south, from Manaus.
Ferreira can see that both planes were flying at the same altitude, 37,000ft.
He makes a horrifying discovery.
For some reason, the two planes were on a collision course.
Air traffic is typically routed along specific corridors through the sky, essentially highways in the air.
But planes travelling in opposite directions are supposed to be separated by at least 1,000ft.
The airway system, for instance is very simple.
It makes aeroplanes flying northbound maintaining even levels and aeroplanes flying southbound maintaining odd levels.
But somehow, the Legacy jet and the Gol 737 were travelling down the same aerial highway in opposite directions.
For long minutes they were heading straight for each other.
It seems more and more likely that the two planes collided.
At the crash site, workers find support for this incredible theory.
The left wing of the Gol flight is recovered.
Investigators discover that about halfway along the wing it's sliced clean through.
None of the other wreckage is sliced this way.
The precise nature of the cut tells Ferreira that this is not damage that was caused by impact with the ground.
TRANSLATION: The damage on the left wing clearly shows that it was caused by a collision with another plane.
The badly damaged wing would have sent the 737 into a spiral dive.
The pilots would have had no way of controlling it.
The sudden spiral motion would have pulled the plane apart.
It's the reason the wreckage is spread over such a wide area.
Ferreira finds the most conclusive evidence of a collision on the Legacy's damaged wing.
(SPEAKS PORTUGUESE) TRANSLATION: On the Legacy we found very small traces of paint that came from the Gol wing.
Together the planes had a combined speed of 1,600km/h.
At that speed the wingtip of the small jet easily sliced through the 737.
Colonel Ferreira now understands what caused the Gol jet to crash, but he doesn't know why.
How had the two jets ended up in the exact same airspace without anybody noticing? Investigators in Brazil now realise that they are dealing with something very unusual.
A mid-air collision is a very rare event in aviation.
And it should not have happened with two very modern new aircrafts.
The situation becomes more complicated when investigators study a critical document, the Legacy's flight plan.
Flight plans are filed by using a standard form which is the same all over the world.
The form will contain the flight number as well as requested flight level or altitude.
According to this document, when it collided with the Gol flight, the executive jet wasn't expected to be at 37,000ft.
The Legacy's flight plan called for the jet to fly at 37,000ft then descend to 36,000.
But the collision took place well past the point where the Legacy was supposed to descend.
So why hadn't the Legacy followed its flight plan? The flight plan calls for you - Why didn't you? - We weren't told to.
Before we took off we were cleared for 370 all the way to Manaus.
That's what we did, sir.
I don't know where you're getting the information from.
- Yeah.
- We followed the rules.
We were not told to descend and we did not descend.
MAN: (ON RADIO) X-ray Lima ATC permission for Manaus, flight level 370.
The Legacy's last instruction was to fly all the way to Manaus at 37,000ft.
The pilots obeyed that instruction, even though it differed from their flight plan.
Ferreira turns his attention to conversations between controllers The cockpit voice recorder from the Legacy gives investigators a remarkably detailed look into what happened on the private jet.
The brand-new Legacy jet has a state-of-the-art recorder that captures two hours of conversation.
TRANSLATION: The CVR was probably the most important component in the investigation.
At 10 minutes to 4:00, the crew is told to change radio frequencies and get in touch with the controller monitoring their flight.
MAN: (ON RADIO) Change frequency to 125053.
Decimal 1.
I'm sorry, 12505, good day.
Good day.
At this point, the Legacy jet but the crew never receives any instructions regarding their altitude.
good afternoon.
N600XL.
at flight level 370, according to the flight plan it should have been descending to 360.
But air traffic controllers simply forgot to give the order to the Legacy to descend to 360.
The pilots would have assumed they were meant to stay at 370, 37,000ft.
(SPEAKS PORTUGUESE) TRANSLATION: No airplane should ever change altitudes without receiving instructions from air traffic control.
To discover why controllers didn't give that crucial instruction Colonel Ferreira takes a closer look at the technology used to monitor the traffic over Brazil.
So, can you call up the Legacy jet screen for me? (SPEAKS PORTUGUESE) TRANSLATION: On the radar screen we see the altitude, speed and the transponder information of each plane.
Each flight has an individual code assigned to it that helps controllers track it.
Underneath that there are two separate numbers.
On the left, the plane's actual altitude.
On the right, the altitude the plane is supposed to be at according to its flight plan.
So here the number changes to 360.
As the Legacy jet the number on the right - the planned altitude - changed.
The computerised system automatically updated it.
According to the flight plan, at this point the plane was supposed to descend to 36,000ft, 360.
To my knowledge, only Brazilian air traffic control system is using this kind of design.
In other parts of the world this update has to be done manually.
The computer changed a single number which led to a critical error.
Without much experience with the computerised system, the controller mistook the new planned altitude for the plane's actual altitude.
(SPEAKS PORTUGUESE) TRANSLATION: The system changed it automatically from the authorised altitude to the planned altitude, which made the controller believe the Legacy was flying at 360.
Police investigators talk with the controller who was on duty when the number changed on the screen.
It was shortly after that I went on break.
Lucivando relieved me.
He tells police about a critical mistake on his part.
You have five aircraft.
The Legacy is at 360.
Before leaving, he handed his flights off to another controller, telling him where he thought the Legacy was flying.
I believed it was at 360 and that's what I told him.
When the new controller took over, the one being relieved gave him the Legacy's altitude information according to the flight plan - 360.
But the jet was actually flying 1,000 feet higher, right in the path of the Gol flight.
Colonel Ferreira studies transcripts of conversations on board the Legacy and finds that the crew was having their own difficulties during the flight.
How much longer, guys? That's a good question, Ralph.
The crew seems unfamiliar with some of the jet's advanced systems.
Still working out the kinks on how to work this flight management system.
Where's the one that gives us total time? My impression is that the pilots were trying to learn their aircraft's systems during the flight.
Investigators also uncover a breakdown in communications.
Good afternoon.
N600XL.
Squawk ident.
After a brief conversation between Colonel Ferreira notices something extremely unusual.
For almost an hour the Legacy pilots don't talk to anyone on the ground.
(SPEAKS PORTUGUESE) TRANSLATION: They stayed 57 minutes without attempting any contact with Air Traffic Control, which seems like a lot of time.
After 57 minutes, they tried to call 12 times - without success.
November six-zero-zero X-ray Lima.
Paladino did try to get hold of ground control, but he couldn't get through.
X-ray Lima.
He then tried the backup frequencies listed on his navigation charts.
six-zero-zero X-ray Lima.
MAN: (ON RADIO) November six-zero-zero X-ray Lima.
His only contact - a single garbled message.
(STATIC) Six (STATIC) .
.
five.
Sorry.
Say frequency one more time for November six-zero-zero X-ray Lima.
Both pilots and air traffic controller should have been more concerned of maintaining two-way contact all the time.
This is their duty.
Controllers should have been able to see on their radar screens that these two airplanes were flying in a collision course.
Brazilian air traffic control is one of the last in the world to be run largely by the country's military.
Since they're run by the military they're run by Brazilian Air Force.
We did not have complete access to information except for what was released.
As fingers are pointed at controllers, many of them come forward with stories of overwork and poor training.
They complained that they weren't well-trained in English language, which is the international aviation language.
Also, they had complaints about their equipment.
In fact, the controller who incorrectly reported the Legacy's altitude had been on the job for only a year.
A valuable piece of the puzzle is still missing.
Investigators still don't know what happened during the final minutes of the Gol flight.
Soldiers have been scouring the Amazon jungle with metal detectors looking for the plane's missing memory module.
Almost a month after the crash, they find it.
Colonel Ferreira hopes to hear some reason why the Gol crew wasn't able to avoid colliding with an oncoming jet.
MAN: (ON RECORDING) Gol one niner zero seven.
Thanks very much, There are no alarms before the collision.
No warning that they were flying straight for another jet.
Earlier in the investigation, strange radar images suggested that the pilots were flying wildly over the Amazon.
Now those suspicions have vanished.
But Ferreira revisits the fluctuating radar data to understand why neither plane knew the other was coming.
See the altitude is varying significantly.
To try to understand this last piece of the puzzle, Colonel Ferreira returns to the radar display that air traffic controllers saw the day of the crash.
Instead of displaying just the expected altitude and the actual altitude, the letter 'Z' appears between them.
The 'Z' on the air traffic controller's screens indicates that the airplane he's looking at has lost its transponder.
Modern commercial aircraft are equipped with transponders.
Like small radio stations, they broadcast information on the plane's altitude and flight number.
This information is received by computers on the ground and instantly displayed on the screens of air traffic controllers.
if the transponder fails, so-called primary radar takes over automatically.
Signals are sent out from the ground that hit the target and return.
Those readings are wildly inaccurate.
The inaccuracy of the radar tracking the Legacy jet explains why its altitude appeared to be rising and falling.
Investigators discover that the transponder wasn't sending out signals for more than 50 minutes before the crash.
But controllers didn't notify the pilots.
But maybe because they didn't notice the subtle change.
(SPEAKS PORTUGUESE) TRANSLATION: The way in which the information is displayed to the controller does not visually alert him to the change.
There are no flashing lights that would tell the controller that the plane has lost its transponder.
There's an even more critical role played by the transponder.
It doesn't just beam information to controllers on the ground but to other planes as well.
All commercial aircraft are equipped with a warning system called TCAS - the Traffic Collision Avoidance System.
TCAS gives relative position of other airplanes within range of your own airplane.
TCAS picks up a signal from an oncoming plane's transponder and issues a warning if it's too close.
If either plane's transponder is off, the system won't work.
(BANG!) What the hell was that? Ferreira discovers that the Legacy's transponder was working early in the flight and after the collision.
But for more than 50 critical minutes, it was silent.
How had a state-of-the-art jet, just off the factory floor, developed problems with its transponder? (FERREIRA SPEAKS PORTUGUESE) TRANSLATION: The failure of the transponder certainly contributed to this accident.
And we had to find out what caused it to fail.
Investigators examine the Legacy jet's transponder unit.
They discover that the system which controls it has a troubled history.
It had been installed on a different plane, but removed because it wasn't working.
It was repaired and then placed on the jet that was sold to ExcelAire.
Investigators have the system tested.
But even with its suspicious past, after the crash they can find no obvious problems with the plane's transponder.
Now, this is the layout now of the standard one in the Legacy jet.
Colonel Ferreira does notice something potentially dangerous about the design of the Legacy's cockpit.
If a pilot uses the built-in footrest during flight, his toes can come in contact with the buttons on the transponder.
Show me what it looks like in standby mode.
And when the transponder does go into standby, it would be difficult for a pilot to notice.
There's no alarm? A small yellow warning light is the only indication that the transponder isn't on.
It was not easy for the pilots to detect that.
Because it's not hooked up with the central warning and alert system.
But the pilots of the Legacy jet do not remember using the plane's footrest.
Still working out the kinks on how to work this flight management system.
Investigators suspect that one of the pilots may have turned the transponder off by mistake.
(FERREIRA SPEAKS PORTUGUESE) TRANSLATION: The most probable scenario is that, by accident, one of the pilots temporarily turned off the equipment as he tried to familiarise himself with the technology on board.
However the transponder went off, at a critical moment the crew had no last-ditch safety system to warn them that they were flying right at a 737.
Even though the TCAS system on the Gol plane was working, there was no signal from the approaching jet for it to receive.
Closing in on each other at 1,600km/h, the pilots never saw each other coming.
(BANG!) Brazil's air traffic control system would undergo some radical changes as a result of the collision.
But those changes would not come without a fight.
The investigation into the crash of Gol flight 1907 has uncovered dangerous problems with Brazil's air traffic control system.
level 3-7-0.
Good afternoon.
Two planes were assigned to fly at the same altitude in the same airspace.
Overworked and inexperienced neglected to instruct the Legacy jet to descend to 36,000ft.
You have five aircraft.
The Legacy is at 360.
Then they mistook the Legacy's planned altitude for its actual altitude.
To make matters worse, the Legacy pilots - unfamiliar with Brazilian airspace - were unable to make contact with controllers on the ground.
And somehow the transponder, which broadcasts their location in the sky, went silent failed to notice.
(ALARM BEEPS) (PASSENGERS SCREAM) A month after the crash of the Gol passenger plane, controllers begin a work-to-rule campaign.
They want to draw attention to problems with the system.
LEILA SUWWAN: Once they did start working to the rules and not stretching them anymore, this triggered what we called the aviation crisis in Brazil.
At a certain point, maybe 40% of flights in all of Brazil had over-an-hour delays.
Following the crash and the work slowdown, changes start being made.
There has been a lot of changes in Brazilian aviation after the accident, specifically with regards to air traffic control.
The Air Force had to admit that they had a shortage of controllers.
And also there's a higher degree of accountability.
In the United States, the Federal Aviation Administration issues two recommendations as a result of the tragedy.
Pilots flying Legacy jets are warned of the possibility that putting their feet up in the cockpit could accidentally turn off the transponder.
And manufacturers are told that an alarm should sound if the TCAS system shuts off.
The controllers who were involved in the crash are charged with varying degrees of manslaughter.
But those criminal charges worry people who were closely involved with the disaster.
(FERREIRA SPEAKS PORTUGUESE) TRANSLATION: An investigation like ours, which focuses on prevention, suffers huge setbacks and there is pressure to lay charges.
By blaming people we might be creating a culture where people will not come forth and be honest about failures and mistakes.
And when we try to hide that, things get swept under the carpet.
And soon enough, they'll come out again.
(WELLINGTON SPEAKS PORTUGUESE) TRANSLATION: No controller leaves his home in the morning thinking he's going to crash a plane.
And so the criminalisation only interferes with investigations that can prevent further accidents.
More than two months after the crash, the crew of the Legacy jet is finally allowed to return to the United States.
SHARKEY: Jo and Jan barely got out of the country.
There was an attempt to hold them under what I thought was a cobbled-together initial criminal charge of, quote, "failing to ensure the safety of Brazilian skies".
While we are all grateful for the safe return of Jo and Jan and everyone aboard the Legacy, we are all saddened by the tragedy that took many innocent lives.
More than a year after the accident, the Legacy jet that survived a mid-air collision was still at the airfield in the Amazon, its maiden voyage cut short by a tragic series of technological and human errors.
Supertext Captions by Red Bee Media Australia