TAM A320 crash at Congonhas, Brazil
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Originally Posted by IcePack
Monarch did not have an over run at IBZ. That night I was parked on the ramp and it was an Air UK Leisure a/c.
I'm in one of those moods
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looks like the chatter marks in the tracks of the anti-skid brakes working.
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This out from Airbus today -
This, to me, is so relevant; happened to me when I was a brand new skipper, first flight after a month's vacation, new FO, dispatch with one reverser inop. First two sectors went without incident but on the third (FO's leg) I reminded him of the inop reverser. Retrospectively he removed his hand compeltely from that thrust lever, it was midnight, dark cockpit. At the flare & "Retard" call he only closed the "operative" TL. The aircraft squawked "Retard" at least five times and then after the two second latch the engine that still had it's TL in the Climb detent went to TOGA. Aircraft yawed significantly and came dangerously close to the edge of the runway (we were at about 5 feet AGL). I took control, whammed the other TL closed and got the aircraft back on the black stuff. Was a long runway, CAVOK & wind calm. Glad it wasn't on a short, wet strip.
I know the "wait until the investigation" but that's it for me.
4HP
The data which follow have been approved for release by the Brazilian investigation authorities.
Facts collection is continuing on accident site with all parties involved.
Work on the accident site is very difficult due to post-accident damages (fire, building partial collapse).
The two accident recorders have been retrieved (CVR and DFDR) and provide good quality data.
The DFDR decoding started on July 20th, the CVR decoding started on July 23rd, both in NTSB facilities under the responsibility of the Brasilian investigation authorities with the participation of the other involved investigation authorities and parties.
It is confirmed that the aircraft was dispatched with the reverser of Engine 2 inhibited according to MEL.
Based from the preliminary analysis of the DFDR, and in agreement with the Brazilian investigation authorities, Airbus remind all operators to strictly comply with the following procedures:
A- During the flare at thrust reduction select ALL thrust levers to IDLE.
B- For the use of the thrust reversers when landing with one Engine Reverser inhibited refer to :
- For A320 MMEL 02-78-30 Rev 30
- For A310/A300-600 MMEL 02-78 Rev 15
- For A330 MMEL 02-78-30 Rev 17
- For A340 200/300/500/600 MMEL 02-78-3O Rev 19
Facts collection is continuing on accident site with all parties involved.
Work on the accident site is very difficult due to post-accident damages (fire, building partial collapse).
The two accident recorders have been retrieved (CVR and DFDR) and provide good quality data.
The DFDR decoding started on July 20th, the CVR decoding started on July 23rd, both in NTSB facilities under the responsibility of the Brasilian investigation authorities with the participation of the other involved investigation authorities and parties.
It is confirmed that the aircraft was dispatched with the reverser of Engine 2 inhibited according to MEL.
Based from the preliminary analysis of the DFDR, and in agreement with the Brazilian investigation authorities, Airbus remind all operators to strictly comply with the following procedures:
A- During the flare at thrust reduction select ALL thrust levers to IDLE.
B- For the use of the thrust reversers when landing with one Engine Reverser inhibited refer to :
- For A320 MMEL 02-78-30 Rev 30
- For A310/A300-600 MMEL 02-78 Rev 15
- For A330 MMEL 02-78-30 Rev 17
- For A340 200/300/500/600 MMEL 02-78-3O Rev 19
I know the "wait until the investigation" but that's it for me.
4HP
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Following another morning of confusion due to pilots from TAM and GOL refusing to land at CGH during rain (not for the first time since the accident), the president of TAM has just announced that no aircraft from the company will land when it is raining. This restriction will stay in effect until the grooves are in place on the main runway, and will then be reviewed.
GOL will probably follow suit in the near future, as their pilots also have grave concerns and have also been refusing to land in wet weather.
All this (and the Manaus radar failure) and still the head of INFRAERO insists that Brazil does not need international assistance to evaluate the risks to air transport in this country.
ab
GOL will probably follow suit in the near future, as their pilots also have grave concerns and have also been refusing to land in wet weather.
All this (and the Manaus radar failure) and still the head of INFRAERO insists that Brazil does not need international assistance to evaluate the risks to air transport in this country.
ab
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Originally Posted by BOAC
armchairpilot - a quick skim through a long report there - is there anything relevant in it? I could not see any 'conclusions' on a quick look.
The report linked by amrchairpilot was a "Factual Data Report", so no conclusions there. The main causes to the Taipei accident are in the final report as follows:
Originally Posted by Aviation Safety Council of Taiwan
3.1 Findings Related to Probable Causes
1. When the aircraft was below 20 ft RA and Retard warnings were sounded,
the pilot flying didn’t pull thrust lever 2 to Idle detent which caused the
ground spoilers were not deployed after touchdown though they were at
Armed position, therefore the auto braking system was not triggered.
Moreover, when the auto thrust was changed to manual operation mode
automatically after touchdown, the thrust lever 2 was remained at 22.5
degrees which caused the Engine 2 still had an larger thrust output
(EPR1.08) than idle position’s. Thereupon, the aircraft was not able to
complete deceleration within the residual length of the runway, and
deviated from the runway before came to a full stop, even though the
manual braking was actuated by the pilot 13 seconds after touchdown.
（1.11.2、2.3.2、2.3.3、2.4）
2. The pilot monitoring announced “spoiler” automatically when the aircraft
touched down without checking the ECAM display first according to SOP
before made the announcement, as such the retraction of ground spoilers
was ignored. (2.3.3)
1. When the aircraft was below 20 ft RA and Retard warnings were sounded,
the pilot flying didn’t pull thrust lever 2 to Idle detent which caused the
ground spoilers were not deployed after touchdown though they were at
Armed position, therefore the auto braking system was not triggered.
Moreover, when the auto thrust was changed to manual operation mode
automatically after touchdown, the thrust lever 2 was remained at 22.5
degrees which caused the Engine 2 still had an larger thrust output
(EPR1.08) than idle position’s. Thereupon, the aircraft was not able to
complete deceleration within the residual length of the runway, and
deviated from the runway before came to a full stop, even though the
manual braking was actuated by the pilot 13 seconds after touchdown.
（1.11.2、2.3.2、2.3.3、2.4）
2. The pilot monitoring announced “spoiler” automatically when the aircraft
touched down without checking the ECAM display first according to SOP
before made the announcement, as such the retraction of ground spoilers
was ignored. (2.3.3)
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A320 over run in Taipei
The Transasia over run by an A320 was also on a wet runway and they also had one thrust reverser inoperative. The spoilers also did not activate due to pilot error on landing. The charts showed that with one thrust reverser inoperative and spoilers not deployed, the plane couldnt stop even on the 9000 plus foot runway. What chance did our people in Sao Paulo have to stop on a runway that is much much shorter?
TAm's A320 had one reverser inoperative and the spoilers seem not to have been deployed either. IT simply could not have stopped in time then, it would appear.
http://www.asc.gov.tw/acd_files/189-c1contupload.pdf
I havent read the report in its entirety . Perhaps some A320 drivers can gain more insight from the Taipei over run as applicable to the Congonhas accident?
TAm's A320 had one reverser inoperative and the spoilers seem not to have been deployed either. IT simply could not have stopped in time then, it would appear.
http://www.asc.gov.tw/acd_files/189-c1contupload.pdf
I havent read the report in its entirety . Perhaps some A320 drivers can gain more insight from the Taipei over run as applicable to the Congonhas accident?
The news continues digging; media today says there were at least six complaints from crew after landings on Mon/Tue. A timeline from those:
Monday 16th
07:30 Gol 1879 “runway’s not all that great – low adherence”
07:31 TAM 3020 “runway somewhat slippery”
12:25 runway inspected
12:42 Pantanal ATR-42 skids off on landing
13:48 Tam 3215, managed to stop at end of runway
??:?? TAM 3461
??:?? Gol 1203
Tuesday 17th
Morning, change of shift briefing at which concern expressed over runway conditions and the complaints from pilots. Meeting to discuss with ATC boss scheduled for 18th
17:05 Gol 1697 reports runway slippery
17:07 Runway inspection ordered, ops suspended for 13 minutes
17:20 Runway reopened
17:50 TAM 3054 leaves runway end
Eyewitnesses
There were five controllers in the tower at CGH at the time of the accident, plus two ANAC employees. Two controllers saw the TAM flight land and crash; one said the aircraft seemed to accelerate.
The runway was closed to operations after the crash, for inspection. It seems that, when the TAM aircraft ran across the grass, it damaged the drainage system. After heavy rain most of today the earthworks beneath the point where it went off have started to collapse.
Monday 16th
07:30 Gol 1879 “runway’s not all that great – low adherence”
07:31 TAM 3020 “runway somewhat slippery”
12:25 runway inspected
12:42 Pantanal ATR-42 skids off on landing
13:48 Tam 3215, managed to stop at end of runway
??:?? TAM 3461
??:?? Gol 1203
Tuesday 17th
Morning, change of shift briefing at which concern expressed over runway conditions and the complaints from pilots. Meeting to discuss with ATC boss scheduled for 18th
17:05 Gol 1697 reports runway slippery
17:07 Runway inspection ordered, ops suspended for 13 minutes
17:20 Runway reopened
17:50 TAM 3054 leaves runway end
Eyewitnesses
There were five controllers in the tower at CGH at the time of the accident, plus two ANAC employees. Two controllers saw the TAM flight land and crash; one said the aircraft seemed to accelerate.
The runway was closed to operations after the crash, for inspection. It seems that, when the TAM aircraft ran across the grass, it damaged the drainage system. After heavy rain most of today the earthworks beneath the point where it went off have started to collapse.
In my experience, the manufacturer's recommendations after first run DFDR are usually an accurate indication of where at least the relevant operating aspects will be found, and in this respect the reported Airbus statement above seems to have many echoes of the previously reported incidents on this thread. Usual caveat that Airbus has a vested interest in the direction of finger-pointing.
Rippa: In your reply #97 you mentioned that MLW was over 97% of allowable for a wet runway at CGH. Does the "wet runway" parameter distinguish between grooved and ungrooved? Do you know whether this flight ( & TAM procedures in general) included tankering fuel?
Rippa: In your reply #97 you mentioned that MLW was over 97% of allowable for a wet runway at CGH. Does the "wet runway" parameter distinguish between grooved and ungrooved? Do you know whether this flight ( & TAM procedures in general) included tankering fuel?
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Very interesting announcement from AB and has been said above coming so close after analysis of the FDR would make you take notice.
Also notice in the photo showing the wheel marks in the grass, the angle of them does not line up with the actual building it hit, therefore one could assume there was still a lot of thrust on the right hand side pushing the plane further to the left as it left the end of the runway ?
Also notice in the photo showing the wheel marks in the grass, the angle of them does not line up with the actual building it hit, therefore one could assume there was still a lot of thrust on the right hand side pushing the plane further to the left as it left the end of the runway ?
Also notice in the photo showing the wheel marks in the grass, the angle of them does not line up with the actual building it hit, therefore one could assume there was still a lot of thrust on the right hand side pushing the plane further to the left as it left the end of the runway ?
The tracks show that there was some weight on both mains.
Further examination of Google Maps shows the impact point is pretty much a straight line from the tracks. The photograph showing the tracks and impact point is taken from a point off the path; so, imparts a distortion to the perspective.
Last edited by RatherBeFlying; 24th Jul 2007 at 01:48.
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Max tow,
Max landing at CGH 35L / 17R is limited my MLW on both cases (wet and dry), acording to the specific landing analisys. I presume that engeneering uses grooving / no grooving for that (I persoly know TAM's director of engeneering and he is a very serious guy when safety is an issue). About tankering: Yes, TAM uses that policy, but not always (canot recall if POA is used for that). Can tell for sure that SDU, BEL, SLZ, MIA and GIG are used for tankering.
Max landing at CGH 35L / 17R is limited my MLW on both cases (wet and dry), acording to the specific landing analisys. I presume that engeneering uses grooving / no grooving for that (I persoly know TAM's director of engeneering and he is a very serious guy when safety is an issue). About tankering: Yes, TAM uses that policy, but not always (canot recall if POA is used for that). Can tell for sure that SDU, BEL, SLZ, MIA and GIG are used for tankering.
Rippa - thanks for the answer. On reflection, I guess that whether or not the landing weight limit or any tankering policy into CGH had been changed to reflect recent r/way issues is probably irrelevant given the apparent extreme runway excursion speed. The inclusions and omissions of the reported Airbus note would suggest (their view) that a non-mechanical event or series of events occurred sufficient to catastrophically degrade the stopping performance. If so, the gaping wide"cheese holes" of conditions of CGH were already lined up.
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Latest news says that the pilots did not try a go-around at any time after touchdown, and that the runway had a significant role in this accident (past news...). But, on the other hand, I was thinking about the latest communication from Airbus (#424)...kind of early to send a report about the accident, so I believe it is of big relevance. 
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This, to me, is so relevant; happened to me when I was a brand new skipper, first flight after a month's vacation, new FO, dispatch with one reverser inop. First two sectors went without incident but on the third (FO's leg) I reminded him of the inop reverser. Retrospectively he removed his hand compeltely from that thrust lever, it was midnight, dark cockpit. At the flare & "Retard" call he only closed the "operative" TL. The aircraft squawked "Retard" at least five times and then after the two second latch the engine that still had it's TL in the Climb detent went to TOGA. Aircraft yawed significantly and came dangerously close to the edge of the runway (we were at about 5 feet AGL). I took control, whammed the other TL closed and got the aircraft back on the black stuff. Was a long runway, CAVOK & wind calm. Glad it wasn't on a short, wet strip.
I know the "wait until the investigation" but that's it for me.
by 4HP
I know the "wait until the investigation" but that's it for me.
by 4HP
Last edited by Dream Land; 24th Jul 2007 at 08:42. Reason: sp
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For what it’s worth, I’d be focusing my attentions firmly on the spoiler issue. Those 5 spoilers on the 320 ensure that the wheel braking system is able to do its job regardless of the auto brake setting. A high speed landing on a contaminated runway without spoilers would certainly produce the lack of retardation witnessed here.
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Originally Posted by Max Tow
In my experience, the manufacturer's recommendations after first run DFDR are usually an accurate indication of where at least the relevant operating aspects will be found, and in this respect the reported Airbus statement above seems to have many echoes of the previously reported incidents on this thread. Usual caveat that Airbus has a vested interest in the direction of finger-pointing.
The telex normally contains information on the accident/incident, and more importantly manufacturer recommendations (if applicable) to prevent it from happening again.
The telex is not about finger pointing, it is providing the best available information possible to operators from the manufacturer to enhance flight safety to prevent a similar occurrence.
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Well, we seem to have a consistency here, sadly. Re 4HP's post, (#424) from AB,
Can any AB pilots explain what it is in the AB operating procedures that makes this warning necessary? Are pilots 'encouraged' to keep their hand off the throttle with the inop reverser?
As someone has said, the 'Swiss Cheese' was perfectly aligned for this one. What a tragedy. Just like the Helios crash.
A- During the flare at thrust reduction select ALL thrust levers to IDLE.
As someone has said, the 'Swiss Cheese' was perfectly aligned for this one. What a tragedy. Just like the Helios crash.
Zeke: since the Airbus note is the first public pronouncement to apparently benefit from DFDR evidence, I'm sure it is highly significant. The reason for my caveat is simply that in the short term aftermath of an accident and until an objective investigation by an independent party is complete, it is prudent to take notice not only of what is said but who is saying it. So far we have had the airport operator defending the runway condition, the government defending Brasilian safety standards and infrastrucure investment, and the airline defending its maintenance performance. Airbus has in the past been, shall we say, staunch in its defence of its product; one would not expect otherwise. However if there do prove to be similarities with the previous overrun incidents mentioned in this thread, the pilot community will no doubt be equally resolute in exploring the perspective of crews who have been involved in such incidents, including the two individuals who cannot argue their case.
Last edited by Max Tow; 24th Jul 2007 at 08:08.
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BOAC - I can't think of an Airbus procedure that would require that notice to be issued, but I do know that when working toward the limits of your capacity with the autothrust engaged it is possibile to forget to retard the non-moving thrust levers to idle in the flare, especialy if new to the aircraft.