TAM 3054 at Congonhas – literally an accident waiting to happen

TAM jpgNaturally 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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13 Responses to TAM 3054 at Congonhas – literally an accident waiting to happen

  1. Layman April 9, 2010 at 11:11 am #

    … with the developed world reaching previously unimaginable levels of safety and the rest still plagued by numerous unavoidable disasters.

    Kieran, surely you mean avoidable disasters..

  2. Kieran Daly (blog owner) April 9, 2010 at 3:06 pm #

    Precisely so. Thanks.

  3. Vincent Rice April 9, 2010 at 3:48 pm #

    Maybe I missed it, but is there an address for the report? Is it in english?

  4. MSL April 9, 2010 at 9:24 pm #

    #1 Rule in Accident Prevention/SMS: Every accident is avoidable.

  5. Kieran Daly (blog owner) April 11, 2010 at 1:50 pm #

    Vincent, the link is in the first line of the post. But anyway the address is here: http://www.cenipa.aer.mil.br/cenipa/paginas/relatorios/pdf/3054ing.pdf

  6. Caio Nery April 16, 2010 at 5:41 pm #

    Thank s for sending the link to the report.

  7. Steve Brack April 29, 2010 at 2:18 pm #

    I think the way the autothrottle on the A320 operates is a strong contributing factor. In the A320, the autothrottle adjusts engine power, but the thrust levers do not move as engine power demand changes. Because of that, crews get no useful information from looking at the thrust levers, nor do the autothrottles reduce engine power or deploy reverse on three-point touchdown. The automation creates complacency, then lets the crew down at a critical point in the flight.

  8. Fernando Camargo May 10, 2010 at 3:48 am #

    Kieran, I like your blog a lot, don’t read often but sometimes do.
    Maybe you would like to correct this airport’s name to Congonhas.
    it also may be interesting that your readers are informed that this is not an international airport, no matter what whoever claims.

  9. Fernando Camargo May 10, 2010 at 3:55 am #

    Steve, I am interested in your comment.
    Do you think this was no pilot’s mistake?
    I would love to know that clearly because I have always suspect so but authorithies and particularly press, not to mention the airline company (the real guilty, probably, for insisting in flying with the reversed pinned/inactive), are blaming the co-pilot for misplacing the throttle lever.
    I struggle to believe it would be any possible to do such a basic mistake with your life (not to consider passenger’s) at stake.
    What’s more, the same incident had happened with other pilots elsewhere in the world.

  10. SKYDIVE 4EVER May 11, 2010 at 2:10 am #

    PEOPLE

    i skydive since 95…. as an aeronaut, same as pilots, i am aware and convinced that accidents are not only the responsability of the one that pulls the trigger, there are lots of people technically and morally responsible for aeronautical accident, it is never one act or sudden failure, its a chain of events that push accidents to happen…. it is always easy to blame to those who are dead, but this is not true…. even if they commitd a mistake, its only a matter of time for someone to take their places and do the same… with the same consecuences.

    remember the fokker that accidentally they activated the reverser on the right engine? on takeoff run?… they too finished dead, an killed lots of people….and the company could have prevented this…im so sorry for those who perrished … god have them in his glory

  11. Fernando Camargo May 11, 2010 at 5:20 pm #

    Same airline, same airport, by the way…

  12. Oliver August 12, 2010 at 3:43 pm #

    As always, accidents do not have a single cause. Besides the serious issues regarding Brazil’s air transport system (fast growth, no investment, faulty oversight), and TAM’s training program, Airbus also had an important role in the accident. The issue with the throttles was known due to three previous incidents/accidents

    - 18 October 2004 in Taipei (Taiwan)http://www.asc.gov.tw/acd_files/164-c1contupload.pdf
    - 28 August 2002 in Phoenix (USA) http://www.ntsb.gov/ntsb/GenPDF.asp?id=LAX02FA266&rpt=fa
    - 22 march 1998 in Bacolod (Indonesia) http://aviation-safety.net/database/record.php?id=19980322-0

    In response to a recommendation made by the Taiwanese ASC:

    “Runway Overrun During Landing On Taipei Sungshan Airport
    TRANSASIA AIRWAYS FLIGHT 536
    A320-232, B-22310
    October 18, 2004
    4.1.2 Safety Recommendations
    To Airbus Company
    1. Reviewing the design of stop mode of Retard warning sounds or accommodating other warning methods to ensure that the warning will continue before the thrust levers are pulled back to Idle notch after a touchdown has affirmed.
    (ASC-ASR-06-03 –006)”

    Airbus committed to proposing a solution on a service bulletin:

    “According to the Airbus Company
    1. In response to: Reviewing the design of stop mode of Retard warning sounds or accommodating other warning methods to ensure that the warning will continue before the thrust levers are pulled back to Idle notch after a touchdown has affirmed.

    Airbus Company Response:
    Airbus has developed a specific warning when one throttle is set to reverse while the other is above idle. This warning generates an ECAM warning “ENG x THR LEVER ABV IDLE”, a continuous repetitive chime (CRC), and lights the red master warning light. This new warning is implemented in the FWC standard “H2F3″. A Service bulletin will be issued very soon on this subject.”

    The CRC was not installed in the A-320 that crashed in Sao Paulo. Why? Was the service bulleting ever issued? And if it was, why it was not implemented by TAM?

    It seems to me that we are in front of another case of a serious safety issue being addressed very lightly and with no rush by the authorities and the manufacturer. The accident with AF 447 last year demonstrated that the authorities and Airbus knew about the problems with the pitot tubes but took too long to take an effective action. Again, it was another accident waiting for the alignment of the “right” chain of events…

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