
Naturally enough
the report on the Airbus A320 fatal loss at Sao Paulo Congonhas in 2007 has sparked all kinds of debate about the design and human factor issues regarding thrust-reversers, spoilers, and warning systems. Natural - but overlooking the devastating critique of the Brazilian regulatory system and of TAM's operational management that the report contains.
I spend quite a bit of time trying to explain to the general media why the global safety record exhibits the well-documented two-speed phenomenon, with the developed world reaching previously unimaginable levels of safety and the rest still plagued by numerous
unavoidable avoidable disasters.
For anyone who wants to understand the difference between the two environments, the TAM 3054 report is perfect reading material. Not the technical discussion - important though it undoubtedly is - but pages 47-55, summed up on p72, and then 87-90. It's a horrible chronicle of safety being at first slowly, and then rapidly crushed under the twin burdens of commercial pressure and indolent regulation. Finally the accident that has been waiting to happen in those circumstances does happen.
The point is that the situation described there in shocking detail (by Brazilian investigators) could more or less be summarised as an absence of all the safety-management techniques that together have made the developed world record the extraordinary achievement that it is.
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