Concluding a 16-month judicial inquiry into the disastrous July 2007 TAM Airbus A320 overrun accident at São Paulo's Congonhas airport, Brazil's criminal investigation unit (ICSP) submitted a 656-page report that has led to the indictment of 10 government and TAM officials.
Among the indicted are the president and director of Brazil's civil aviation agency (ANAC) at the time of the accident, along with the former president of the country's airport authority (Infraero), and the two heads of TAM's flight safety and flight operations divisions.
A further three ANAC officials that managed that agency's airport infrastructure and safety operations were also indicted, as well as two Infraero employees based at Congonhas airport. State prosecutors are expected to shortly file charges of involuntary manslaughter and breach of air transport safety against all 10, which could result in prison sentences of up to 12 years.
The TAM A320 landed at Congonhas from Porto Alegre at night in rain, and the aircraft overran the 1,940m (6,360ft) runway at high speed and slammed into a cargo compound and petrol station, resulting in the death of the 187 occupants and 12 people on the ground.
The report acknowledges that the flight crew played a role in the mishap - they failed to retard the starboard power lever on landing - yet its analysis and conclusions are focused upon administrative decisions made by key ANAC, Infraero and TAM personnel, allegedly compounded by failure to comply with existing regulations.
Among factors listed in the report is Infraero's failure to follow ICAO's Annex 14 regulations regarding operations on wet runways, further aggravated by lax runway inspection procedures.
In April 2007 ANAC issued orders regarding runway grooving at Congonhas - but is said to have ignored flight-safety considerations, and to have failed to set adequate procedures for Congonhas operations in bad weather.
Finally, the ICSP report alleges that TAM failed properly to supervise standardisation among its flight crews. Although unable to indict Airbus, the ICSP's report states that blame can be apportioned to the manufacturer for its failure to make mandatory the installation of an audio alert system to warn flight crews of anomalous power lever settings.
Brazil's aircraft accident investigation board - CENIPA - is expected to release its technical report in early 2009.