TAM A320 crash at Congonhas, Brazil

[3Ten]

My last post was a bit rushed, now I have more time. I have to stress that I’m not discussing this *primary cause* issue just for the sake of argument, I think the categorization of these factors is important in the understanding of accidents, and thus for flight safety.

DingerX wrote:

Numerous A320s have attempted landings with the TLA in the wrong position
This one is one of the few that finished off the runway
A major distinguishing factor is the shortness of the field

Therefore, CGH is the "primary cause".

I realy cannot agree with this way of putting things. The simple fact that one can make a association between facts doesn’t make it valid *per se*. Landing on a short runway isn’t a wrong action, unless you are out of the parameters to accomplish it (as Lemurian said, it is possible that the a/c was at a weight that required more LDA than the available, and that, in fact is wrong). Failing to retard the throttle is a wrong action *in any runway*. So, in this light, maybe you can tell me wich of the facts is more relevant.

PBL wrote:

The thing is, 3Ten, if I may phrase it so, that you haven't thought about these things very hard yet. You're applying the Counterfactual Test selectively, but you haven't said what your selection criteria are, or justified these criteria.

Let me propose three simple resolutions to this discussion. Either
1. I promise not to tell you how to fly your large commercial aircraft if you promise not to tell me how to think about causality; or
2. I give you a rather long reading list in the logic of causality and its practical application in analysing accidents, and you read it all; or
3. You take our course in practical analysis of accidents using WBA.

Starting by the end, for number 3, maybe one day I’ll do it, it’s na area that really interests me, unfortunately not the time yet.

Maybe this discussion is being affected by a difference in point of view. I’m a pilot, and consequentely, my priorities in analising a pilot error related accident are as follows:

Human failure related with basic airmanship principles: Our profession requires that we mantain a great ammount of knowledge of various cathegories. The basic airmanship is as the name states, the base that we have to achieve the safe conduct of flight, and exactly the type of knowledge that we have in the most *ready to use* condition, is (or shoud be) already built in our mind, and isn’t all that vast. So, it is our best chance to break the accident chain. I understand that these factors, beeing very meaningfull for the pilots, are less meaningfull for other parties involved, because these other parties don’t have as much to learn from this erros.

Ohter causes relate do various levels of our knowlege, levels that are in different states of availability during flight operations. These causes are much more vast in their scope, and cannot be all recorded in *ready to use* condition by us, so we have to use them to build a general awareness state, to develop a more critical attidude during the decision process. However, this causes may be much more relevant to other parties, as they relate to these partie’s areas of action, say ATC procedures, airport and aircraft design, maintenance procedures, etc. Those parties may learn a lot more from these causes than from the former ones, but for the pilot, they may be less relevant.

Other factors, although relevant in their role in the accident, may be cathegorized by the pilot as *nice to know*, as they fall in areas totally out of the pilot’s scope and influence, but still be very important to other parties.

We all know that accident investigation doesn’t exist just because of pilots. But, when pilot error accidents are investigated, typically basic airmanship failures are appointed as primary cause, they don’t fall on other cathegories. I’m not na accident analist, and I’m sure PBL can correct many of my choice of words in this post, but I hope I could convey what I think about this. When I’m airborne, I cannot change an aircraft design, or a runway condition, but I can do my best to overcome this problems and try to avoid an accident. So, we have different priorities.