Ten to be indicted over TAM crash

[alemaobaiano]

The criminal investigation into the TAM accident at Congonhas was completed yesterday and will recommend indictments against 10 as yet unnamed individuals for crimes against air safety. The penalty upon conviction is from 1 to 3 years.

The investigation spreads the blame around, but regards the behaviour of ANAC (the regulatory authority) as the main reason for the tragedy, followed in order of "responsibility" by Infraero (airport operator), TAM, and Airbus. How many indictments will be levelled against each of these organisations isn't yet known.

This is only the criminal investigation, the full technical report from CENIPA has yet to be released (it's not finished yet AFAIK), so precisely how much of this is based on fact and how much on political posturing isn't clear.

The Ministério Público Estadual will decide in the next few days whether to accept the recommendations from the investigation and go ahead with the prosecutions.

AB

[Finn47]

2500 pages in the report, but not published yet:

Brazil crash 'blamed on pilots, airline' - Breaking News - World - Breaking News (http://news.theage.com.au/world/brazil-crash-blamed-on-pilots-airline-20081115-67kn.html)

[Zorst]

Glueball,

You've done no more than demonstrate that you're in the remedial class there.

And you're only just keeping your head above water as it is.

Run along and let the grown-ups have their conversation, eh?

Now, shall we have a proper 'Airbus pilots are de facto disconnected from the power controls by non-moving levers' discussion? and get somewhere worthwhile?

If some of the designers and certifying regulators are going to be in the box, then I shan't feel so bad about this particular post-accident prosecution.

[ATC Watcher]

for glueball :
*"sciolist"... Noun, archaic. "a person who pretends to be knowledgeable and well informed".

[rogerg]

I would have thought that if the aircraft is not slowing down you close the throttles and apply the brakes. I cant believe airbus pilots are so disconnected from the real world that they dont know this. For anyone interested I am not a "sciolists" tho I did learn that word on prune.

[RAD_ALT_ALIVE]

Zorst, I can't for one millisecond believe that you are for real... your comment to Glueball (and I fully support your sentiment regarding his/her level of intelligence) is not dissimilar to my reflection on your own level of understanding/ignorance regarding Airbus' philosophy and Airbus' pilots procedural competence.

Having flown FBW Airbus aircraft for over 10 years now, I'm at a complete loss to understand what this concept of '...defacto disconnected from the power controls...' is that you (and rogerg) have mentioned.

Airbus power levers have to move at all critical phases to achieve the critical power application. By critical phases, I refer to Take-off and Landing. And just to keep our interest level up, we even have to move them to taxy about the airport! Quite conventional really.

There would probably be some other physiological reason why two experienced pilots (as evidenced by the fact that they were both Captains) failed to notice that one power lever was still in the climb detent. Never having been into the airport concerned, I can only go by all the correspondence that has been published in the media and on this forum.

On the basis of that reading, my humble opinion is that these two guys were already at a heightened stress/awareness level because of the physical vagaries of the runway they were using, the weather and subsequent surface conditions, and the nagging awareness of the MEL that they were operating under that would just make their arrival all the more difficult than the runway would normally make it (even on a lovely day).

We (all of us) only have so much excess RAM to use on a day-to-day basis; when it begins to be used up by stressors that don't normally occur, our ability to process begins to break down, and we then revert to our individual ability to 'priority-shed'. By that I mean that we unconsciously begin to prioritise what we need to do, and shed what we believe we don't have to worry about.

I'd guess that the two pilots were so ensconced in collectively doing their level-best to tick all the 'unusual/abnormal (in the common sense of the word, not the industry sense) boxes that this arrival presented, that a perfectly routine (though critical) action was overlooked. They then had to deal with the completely confounding situation of the aircraft failing to slow down as it 'normally' would be expected to, and had previously always done.

It is a nightmare scenario that any one of us could find ourselves in, given the same circumstances (Z, G and R - have you ever heard of the 'Swiss Cheese' model of accident-producing circumstance development?).

Unless there is clear-cut evidence of culpubility in an aviation accident, police add no practical worth to the investigation, the outcome of, or, more importantly, to the enhancement of future aviation safety.

And as writers, readers, participants and observers of this once-enviable (and I'd like to think it still is enviable) profession and industry, I think we should all be a little more circumspect in our criticism-based comments following tragedies; after all, it is only because of the accidents that have befallen the few, that we many have enjoyed the benefits of ever-safer flight.

Honor them, those whom circumstance has conspired to take, and let us respect the memory of them forever.

[J.O.]

RAD ALT ALIVE

That is without a doubt one of the most sensible responses I have ever seen to that old and tired anti-Airbus fear mongering we see all too often here on PPRuNe. Now if only you could convince the "law" officials in Brazil that prosecuting anyone for this tragic accident will do nothing except allow them to make political hay.

[rogerg]

Rad Alt Alive.
Thats what I meant, but with less words!

[alemaobaiano]

J.O.

Much as I disagree with the criminalisation of accidents, in this case it may be a blessing in disguise. It may result in a shake up of ANAC and Infraero where we see industry professionals appointed to the higher positions instead of the political appointees that we currently have. That would be a very positive move which would only benefit everyone involved in aviation in Brazil, and those who operate in Brazilian airspace.

Given the nature of the legal system here that might seem a little naive but there are a lot of questions being asked about the administration and bringing these out into the open will only stimulate the move for real change.

AB

[J.O.]

alemaobaiano:

Here's my problem with the prosecutorial approach. The industry in general is willing to allow that most crew-related human error events are not criminal acts and that they are the consequence of a number of contributing factors. In other words, the people involved didn't intend to cause an accident. In most cases, how the events transpired "made sense to them at the time".

Is it not fair to assume that people within ANAC or Infraero were also well intended and were simply doing their best to work within the system they've been given? To me, the investigation and corrective actions should be focussed on fixing the entire system, including the political aspects of it. If officials go to jail, it is not a gaurantee that the system will be made better as a result. It's much more likely that you'll end up with an even more dysfunctional system with new rules written by administrators who don't understand the system in the first place. This is not a slight against Brazilian culture, but the system as it currently exists is the result of cultural norms. System safety improvements often require cultural change, and in this particular case, and the Gol mid-air collision case, culture change is needed to make the necessary improvements. Punishing people for living and acting within their cultural norms is something Al Queda does. It's not something we should do in aviation safety.

[al446]

That is possibly the most sensible post I have read on this site.

[Piltdown Man]

Nothing quite like blaming people and then prosecuting everybody that you can stick a charge on. Quite how this will advance the cause of safety I'll never know - it's a bit like screwing for virginity or imprisoning people in the cause of freedom! Don't you just love fair and just societies!

This sort of ridiculous action totally negates any form of accident investigation. This is because if (and I'm sure I'm preaching to the converted already) they are criminally liable, a different aircraft flown by a different crew from a different operator would have definitely produced a different outcome . Finally, who will now co-operate with the Brazillian authorities?

Brazil should be thrown out of ICAO.

Halfwits!

PM

[SPA83]

I think, we must make the difference between the errors and the deliberate faults.

-When the crew forgets to retract the TLs this is an error.
-When airport’s authorities stop the necessary renovation of the runway (grooving) and reopen it before the holidays this a deliberate fault
-When Airbus accepts the Taipei safety recommendation about a specific warning when one throttle is set to reverse while the other is above idle, but never send the service bulletin this is a fault
-etc
Justice must punish the faults

[ATC Watcher]

Brazil should be thrown out of ICAO.

That would not bring anything, other than to confort the Brazilian Air Force in their paranoia that the whole world is againt them , and this would probably re-inforce their powers.

Also we should be careful ,as many self proclaimed " advanced" Countries are not doing any better. My own , France , is a good example of a poor weak regulator, an Investigation Bureau following political orders, and a Justice department wanting to score points in front of he public opinion. . The recent trials held after the Mt St Odile crash ( 14 years afrer the accident !) or the Gonesse Concorde one , are not any better than Brazil.

Greece and Cyprus are also coming to my mind as poor examples.

An excellent recent book is explaining quite well this " procecution issue" , whether it is in medecine, police or aviation. ( Balancing Safety and Accountability, Sidney Dekker ISBN 978-0-7546-7267-8)

[leftseatview]

Rad Alt Alive
very well said,and we can honor them best by learning from what happened,and trying to better prepare oursleves.
While as pilots,we might somtimes like to see some 'ass kicking' action in order to get the airport operater/manufacturer/regulator to do the right thing,i am not sure this new trend towards prosecution is the right way forward.I would like to hope that there is still some pioneering zeal(and willingness to self rectify) left in all sections of the industry.
Meanwhile,experience and training continue to be the most useful tools of our trade.
Trying to develope and pass on optimal/correct "Priority-shed" skills is what i base my work on
Incidentally i find that Capts transitioning from other types with larger thrust levers(in the TAM case it was a 757 transition i think) sometimes take a while to get the "feel" of the 320 detents/gates.
I use the TAM example to highlight this aspect to them

[aguadalte]

GlueBall,
Hard words like yours, normally don’t fit in this forum.
Although I tend to agree with you - that retarding throttles is what one has learned in school to land an aircraft (an airplane, not an helicopter…) - I would like to add that I personally feel that Airbus concept of "non-moving throttles" (and non-feed-backing side-sticks) are wrong and a human factor nonsense.
I remember when, in the early 90's, I first flew a FBW aircraft, (A330 SN002(?) test bird), invited by Airbus Industrie, to promote communality and AI family concept, together with Capt Baldomero Monterde (Iberia) and Pier Paolo Rachetti (Alitalia) (who soon would be one of the seven fatalities of a crashed A330 flight testing at Toulouse Blagnac) we had a debriefing with the AI test pilots that flew with us. Questioned about the technology, when I had the opportunity, I told them that I thought that their FBW aircraft had two "concept errors": those non-moving throttles (in fact they act as thrust limiting levers)and lack of other pilot movement feed-back on the side-sticks...I was promptly interrupted by one of the test-pilots who told the "class": Sorry folks, but Airbus Aircraft don't have "concept errors", they have "characteristics". (That must be the reason why, it took AI more than a decade to add that "double input" alert, to inform PF, that the PNF is moving his stick...:ugh:)

Well, one of the "characteristics" of the A320 is that one comes to the Final with the levers on the Climb Detent while the engines are spooling up and down to cope with the Ground Speed Mini...
Despite of briefing the approach to Congonhas, and the DMI'd reverser, they failed to understand what was really going on during the landing flare and subsequent seconds...
Just imagine for a minute what were the conditions: an ex-Boeing Pilot Flying, being checked, DMI'd reverser, short and contaminated RWY, "tunnel vision" with the back-ground idea of imminent requirement to pull only one reverser and in the mean time: both levers in Climb Detent and both engines providing near Idle Thrust (that is why you get the auto call out "Retard, Retard, Retard!" to remind you to retard your levers!) When he pulled ATS Lever One to Idle, the number 1 went to Idle and the number 2 kept giving forward thrust...the rest of this sad story is well known.
Easy to blame the pilots. But, could it happen on an Auto-Throttled aircraft? What prompts a pilot to make the wrong move, against all off what he has learned, against the nature of flight, itself?

RAD ALT ALIVE,
I believe your words on this subject were one of the best contributions I’ve ever seen on PPrune.

I fly Airbuses for more than 17 years and although I feel comfortable flying them, I still think that the concept of “non-moving throttles” and the “non-feed backing side sticks” is a mistake.
Is it “natural” to fly an aircraft that (in some situations) doesn’t give you the feed-back of what’s going on?
Can you hear the auto call out of “Double Input” in the middle of a stressing cross wind and variable direction gusts short final to Funchal (Madeira), Horta or Pico (Azores) Runways? And if you hear it, during flare, will you have time to cope with a double input? I believe that most of us, in an uncomfortable situation, would tend to “avoid ground contact” and interfere with the controls…and if you have a yoke, you’ll find out sooner, (that the other guy is “also afraid to die”), but with a side-stick, there is a much more intellectual process, to understand the obvious…
And on the last seconds of our lives, .i.e., when facing a potential disastrous situation, we all tend to revert to basics…
Wasn’t much more user friendly the Auto-Throttle system, were one could “help” the AT, (when the system itself was a bit “lazy”) by overriding it with small inputs on the throttles to keep the speed on final?
You may feel quite comfortable with the Airbus ATS but, that doesn’t mean that one day you will not feel otherwise especially trying to land an A330 or a 340 in Madeira, on a rough rainy and windy night, after a 10 hour service from Caracas.:ouch:

Airbuses are fantastic aircraft, but they could be better!:ok:

[B Sousa]

Nothing quite like blaming people and then prosecuting everybody that you can stick a charge on. Quite how this will advance the cause of safety I'll never know - it's a bit like screwing for virginity or imprisoning people in the cause of freedom! Don't you just love fair and just societies!


Sort of a question I was going to ask. Seems to me this will hamper any "questioning" of anyone within a hundred miles of the accident. Why just ten, could they not go farther up the chain?
Always a big issue between criminal and civil liability in matters such as these. I have pretty much always understood that unless someone seriously went out of their way to kill others it was to be a civil matter.
Accidents are certainly a combination of things, but rarely intent to do harm is one of them.
Anybody??

[Richard_Brazil]

In hierarchy, they've gone all the way up - ex-heads of the Civil Aviation Commission and the government airport management company.

While there were noises about accusing someone from Airbus, there's only the government people and employees of the airline, TAM.

Wire service articles will shortly claim these people were "indicted". That's just a mis-translation. "Accused" or "named in the police inquiry" is correct.

The charge - placing aviation at risk - is the same used against the American pilots of the Legacy in the midair with Gol flight 1907 in September of 2006.


Ex-presidentes da Infraero e Anac são indiciados pelo vôo 3054 - Estadao.com.br (http://www.estadao.com.br/cidades/not_cid280243,0.htm)
Cities - São Paulo

Wednesday, November 19, 2008, 15:52 | Online

Ex-presidents of Infraero and Anac are accused for flight 3054

Brigadier José Carlos Pereira and Milton Zuanazzi are on list of people who will answer for tragedy

by Eduardo Reina, of O Estado de S. Paulo
SÃO PAULO - The ex-presidents of the National Civil Aviation Agency (Anac) and the Brazilian Airport Infrastructure Company (Infraero) are among the ten indicted for the accident with the TAM A320 Airbus on July 17, 2007 at Congonhas Airport. Milton Zuanazzi and brigadier José Carlos Pereira, respectively of Anac and Infraero, were accused in the Flight 3054 tragedy.

The list with the names of those accused was released this Wednesday, the 19th, by the precinct captain of the 15th Precinct, Antonio Carlos Menezes Barbosa. In a press conference, he presented the inquiry's conclusions, which accused those responsible for the accident under Article 261 of the Criminal Code, for an attack on the safety of air transport. Each defendant could be sentenced to up to 6 years of detention.

Besides Zuanazzi and Pereira, the list of those accused includes Luiz Kazumi Miyada, Anac superintendent; Marcos Tarcísio Marques dos Santos, the agency's superintendent of operations; Denise Abreu, ex-commissioner of Anac; Jorge Luiz Velozo, director of Safety Management, Investigation and Prevention of Aeronautic Accidents; Marco Aurélio dos Santos de Miranda e Costa; Agnaldo Esteves, Anac employee; Esdras Barros, of Infraero and Abdel Salam Abdel el Salam Rishk, ex-manager of engineering and operations of TAM.

[B Sousa]

Lots of sad people as a result of the accident, no question there.. But this sounds like even if we dont know who to blame, lets round up the usual suspects and have a trial. Somebody must pay and it also makes the government look as though they have solved the problem..

[CONF iture]

Airbuses are fantastic aircraft, but they could be better!
Agree.
That Airbus would have been even better by just keeping it humble.

[aguadalte]

CONF iture,
Did you know that the "all new" A350 is planned to fit non feed back side sticks?
Well it seems that I'm the only one concerned about that...
Fly safe.
V

[CONF iture]

Did you know that the "all new" A350 is planned to fit non feed back side sticks?
Well it seems that I'm the only one concerned about that...

My apology aguadalte, I have obviously not expressed myself correctly, but I'm with you 100%

Airbus has taken unnecessary steps.
By embracing a more humble attitude, they would have developed an even far better product, but now, by ignoring the very early critics, they are stuck in their technology options.

... not in a rush to experiment their coming automatic TCAS ...

[Clandestino]

But, could it happen on an Auto-Throttled aircraft?

Lemmmesee... does B747 have autothrust or autothrottles? Keywords are Quantas and Bangkok.

EDIT: I apologise for mixing-up a couple of jumbo-overruns; Quantas at Bangkok wasn't caused by not retarding throttle(s), however, Air China at HongKong and Air France at Faaa, were.

Don't blame Airbus philosophy - while it's different compared to "conventional" aircraft and takes a lot of re-learning, there's no empirical evidence that it's less safe. However I do agree that FWC that shouts "RETARD!" untill all the levers are near idle would most likely prevent the accident but pulling all the throttles back for landing must have seemed so natural to AB designers that they never considered the scenario that was played at Congohas.

[aguadalte]

Well, CONF iture an automatic TCAS, or any other device taking control of the aircraft, against previous consent of the pilots, seems dangerous and a huge step against pilot full authority on bord...

Clandestino,
Can you please elaborate on that Qantas Bangkok situation, as I recall it has nothing to do with the Auto-Throttle/Auto-Thrust concept. (And yes, I think 747's are Auto-throttled, not Auto-Thrusted).

Here's a summary of the accident, taken from a quick look on the internet and I call your attention on what is writen in bold letters (my bold):

It can be viewed in its entirety at http://www.basi.gov.au/acci/ojh/vh-ojh.pdf. A preliminary ATSB report of the accident cited the company's Oct. 1977 policy to use flaps 25 (as opposed to flaps 30) and idle reverse thrust under normal conditions. This policy obtained maximum life of the carbon brakes on the B747-400 and reduced costs associated with maintenance as well as noise levy charges (see ASW, Jan. 3, 2000). The Accident Flight
Had the crew used reverse thrust, they probably would have been able to bring the airplane to a safe stop. However, other aspects of cockpit procedures raise substantive issues of crew coordination. When the aircraft was about 3 meters (10 ft.) above the runway and floating farther down than the ideal touchdown point, the captain, who was the pilot not flying, advised the first officer to execute a go-around. The first officer pushed the thrust levers forward just as the main landing gear wheels touched the tarmac. The captain immediately cancelled the go-around, not by saying so, but by retarding the thrust levers. As the ATSB report said, "Those events resulted in confusion amongst the other pilots (first and second officer) and contributed to the crew not selecting (or noticing the absence of) reverse thrust during the landing roll."
According to the ATSB report, the jumbo jet actually accelerated for about a 1,000 ft. after touchdown (due to residual thrust) before beginning a slow decrease in speed, but not enough to avoid hurtling off the far end of the runway. Having decided to not get airborne, the crew was waterborne, aquaplaning down the rain-slicked runway.
The ATSB report is structured in such a way that it provides a brief description in each subject area, with an itemization of significant failures and significant inadequacies in defenses. The very brevity of this approach gives a hard edge and an attention-getting potency to its findings.
Regarding cockpit procedures, the ATSB said:
"During the examination of the performance of the aircraft on the runway, it became evident that the flaps 25/idle reverse thrust landing procedure used by the crew (and which was the 'preferred' company procedure) was not appropriate for operations on water-affected runways. The appropriate approach/landing procedure was flaps 30/full reverse thrust. This had the characteristics of a lower approach speed, of being easier to fly in terms of speed control and runway aim point (for most company pilots), and of providing maximum aerodynamic drag after touchdown when the effectiveness of the wheel brakes could be reduced because of aquaplaning. Had this configuration been used, the overrun would most probably have been avoided.
(quoted from an article on BNET)

Clandestino, You may not agree with my point of view but, your argumentation has missed the whole point.
When I asked if the Congonhas accident may have happened with an auto-throttled aircraft I meant that, when retarding only one of the throttles the other(s) tend to follow. In order to retard only one of the throttles you would have to disengage the Auto-Throttle and this means a positive and intentional action. In the Congonhas case, they commited a mistake, and were completely overriden by the system. The only thing in common in both cases was poor judgement.

V.

[CONF iture]

Clandestino, I would not pretend Airbus A/THR concept is "less safe" but less straight forward, certainly.

These thrust levers could remain in a frozen position 99% of the air time and still assure all the necessary thrust changes … no wonder time to time, under stress, a crew forget about them …
A/THR disconnection takes some additional thinking … why should it be that way ?
Full thrust can be produced with both thrust levers still in the unrelated idle detent …

I think Airbus forgot to keep it simple.

However I do agree that FWC that shouts "RETARD!" untill all the levers are near idle would most likely prevent the accident but pulling all the throttles back for landing must have seemed so natural to AB designers that they never considered the scenario that was played at Congohas.
I am not aware of the logic in terms of frequency, repetition, volume change, behind the RETARD auto call-outs, but in this manual thrust landing (http://fr.youtube.com/watch?v=TgquZ5_A5t0) the reminder never gave up.


Well, CONF iture an automatic TCAS, or any other device taking control of the aircraft, against previous consent of the pilots, seems dangerous and a huge step against pilot full authority on bord...
I know, I know, aguadalte … but !? (http://www.flightglobal.com/articles/2006/03/22/205580/airbus-studies-emergency-traffic-avoidance-system-to-act-without.html)

[aguadalte]

Since my early years in school, almost 30 years ago, in the Air Force, every Flight Instructor I had, emphasized the need for planning and judgment with the phrase: "fly ahead of your aircraft".

I think that what's at stake here, is the complexity of the FBW a/c A/THR System, as well as the Flight Control Laws and Side Stick input system logics.
As I view it: The problem with this systems is that, when you're in need of your full attention (for what's going awfully wrong), you have also to "intellectualize" in step of instinctively fly basic skills.

As you said earlier (CONF iture)
Airbus has taken unnecessary steps.
By embracing a more humble attitude, they would have developed an even far better product, but now, by ignoring the very early critics, they are stuck in their technology options.That's the hard truth and we, pilots, have now to deal with that.
Some of us, just accept it without mental reservations, others prefer to be more assertive, despite of knowing that AI will not take their argumentations into consideration.
What most embarrasses us all, is that those "lunatic ideas" come from pilots within AI and AI a/c operators.
We're only humans and the idea that human error may be "avoided" by imposing automatic responses by the aircraft, may also be considered a human error, since those systems were also designed by Man.
TCAS, EGPWS, FANS, ILS, GPS, Auto-Pilot, Auto-Throttle and a lot of other systems were a good help and are useful tools for a safer aviation, as long as they are kept under full authority of the pilots. Regarding Manual Flight, I would tend to ask for a more strait forward approach and keep it simple and with a much more "honnest input response".
Apart from intervening in this forums my only way to push for a safer use of those apparatus is to express my concerns over certain events to my company's Safety Board and to highlight those (personally) questionable issues to my co-pilots.
What I can not accept is the simplistic idea that the Congonhas Captain just "forgot" that, to land an aircraft, one has to retard the Thrust Levers. I'm not Brasilian, nor a TAM pilot, I'm just trying to be fair and responsible on my understanding of what has really gone wrong. There is always a much more complex reason for an accident, than one may expect. To learn with other pilots mistakes and to prevent future accidents. Is it not, what this is all about?:E

Fly Safe,
V.

[J.O.]

Sometimes we have to accept that something which in hindsight may seem completely impossible to us, is something that, to the individuals involved at the time, either makes perfect sense, or that they are simply overloaded to the point where they overlook what should be an obvious discrepancy. This is not limited to Airbus pilots either. The Helios B737 is another example of a crew missing something which "should" have been obvious.

[GlueBall]

". . . What I can not accept is the simplistic idea that the Congonhas Captain just "forgot" that, to land an aircraft, one has to retard the Thrust Levers."

Retarding the thrust levers upon touchdown, with or without reverser anomalies, requires no thought and no decision making, because it is an elementary, instinctive process applicable in all airplanes. Even during CAT-IIIB autoland, the pilot flying must keep his hand on all thrust levers, not only for the purpose of selecting reverse thrust, but to ensure that all thrust levers are in fact moved to idle detent upon touchdown.

This senseless loss of life is either a case of temporary crew insanity, or gross crew incompetence at best. The capt at the controls had retarded only the left thrust lever and applied reverse to the left engine while engine number 2 had continued to develop substantial forward thrust. The capt in the right seat lacked basic survival instinct in that he belatedly had failed to yank No.2 thrust lever to idle detent and stand on the brakes.

I wouldn't be surprised if the moderator who had deleted my previous post had done so in deference to TAM and its bullying insurers in their obvious media hyped efforts to shift blame to the airport operator, Infraero and ANAC.

The "criminal" investigation in Brasil, magnified by the media, [as is the debate in this thread] has engaged the usual hamster-wheel exercise in addressing: "Ambiguous Airbus logic," "non grooved runway", "short runway", "wet runway", "dangerous airport", "ATC," . . . anything but the obvious probable cause of "pilot error."

Yes, the pavement length is only 6365' . . . but it has been in service for many decades, wet and dry, for thousands of successful landings. The incident/accident rate for the amount of traffic is not extraordinary. Before the life of A320s, Trans-Brasil B727s had also operated at this airport. Remember?

[J.O.]

Yes, the pavement length is only 6365' . . . but it has been in service for many decades, wet and dry, for thousands of successful landings. The incident/accident rate for the amount of traffic is not extraordinary. Before the life of A320s, Trans-Brasil B727s had also operated at this airport. Remember?

How many people have said, "but we've always done it that way", as they gazed over the smoking hole. Just because they got away with it doesn't make it right or smart.

[manrow]

Too true J.O.!

[clark y]

Excellent thread despite drift off initial topic.

Glueball,

I dislike it when ever people like yourself say "what were they thinking?" or "how did they make a such simple stuff up?"
I don't think these guys were incompetent or insane. They got caught in a hole with too little time to recover. It was caused by what could be considered a flawed system.

Not sure if you're aware, but the simple act of not putting one lever into a set detent creates major problems. Think about this-
Not only does it mean reverse on one side, climb on the other but at a glance the engine indications would have initially appeared to be what they were looking for (i.e. REV1 green only), the other engine does go from close to idle to climb power at a steady pace without the other lever moving so your hands on the levers will not notice. You're busy looking out the window tracking the centre line, the other guy is looking for ground spoilers etc. Your ears will not notice ( you expect it to get noisy). Your reflexes will push the rudder in and keep the aircraft staight potentially without your knowledge. And the first sign of something wrong could be a call of "No spoiler- negative deccel". And don't try and put the ground spoilers up with the lever because, like the thrust levers, it does not neccessarily reflect the position of the actual spoilers and you can't do it anyway. Auto brake won't work without ground spoilers. You also can't go around because you have a reverser deployed. By this time your out of runway.

I only know the basics of the accident. What is written above is hypothetical as I have not read detailed reports but I have read the pilots manual for the A320 and flow this scenario in the sim. But that is as quick as it happens and anyone could have similar happen at anytime. Yourself included.

Having flown both moving and fixed throttles/thrust levers, moving are by far superior.
The aircraft in question was smart enough to know it was on the ground, but it was not smart enough to realise that one engine was reversed the other was at climb. Maybe Airbus could at least change the logic so that in ground mode, once reverse is selected on one, the other thrust lever position is ignored and fwd idle is maximum thrust.

Clark y

[GlueBall]

Captain clark y . . . I am not from another planet. I fly 74s and I have four (4) thrust levers in the palm of my hand upon flare and touchdown; whether CAT-IIIB autoland/AT or VMC flying manual. I'm not looking at instruments during the flare and touchdown phase; I'm looking outside, at the centerline or centerline lights, rain or shine.

Ensuring that the thrust levers are closed/retarded to idle detent is done instinctively, exclusively by feel.

I can also feel by the seat of my pants . . . the onset of even a subtle application of auto brakes, [brake pressure commensurate with reverse thrust], and I can feel the onset of decelaration . . . even with rain bouncing off the windscreen and wipers whacking back and forth . . . all that without any clues from instruments.

And if there is no immediate feel of decelaration, I get on the brakes manually; without first having to think, without first having to check any settings, switches or instruments. It's just common sense, basic survival "stay'n alive" instinct.

The two TAM captains, in opposite seats had successfully landed during their previous sector with the same reverser DMI'd. For reasons unknown and unexplainable, the operating captain of this sector obviously did not have both thrust levers in the palm of his hand because he had failed to retard No.2 thrust lever.

This bizarre, elementary breakdown of human performance could be due to lack of training, lack of work discipline, lack of common sense, lack of survival instinct, or temporary insanity.

[aguadalte]

Having flown both moving and fixed throttles/thrust levers, moving are by far superior.
The aircraft in question was smart enough to know it was on the ground, but it was not smart enough to realise that one engine was reversed the other was at climb. Maybe Airbus could at least change the logic so that in ground mode, once reverse is selected on one, the other thrust lever position is ignored and fwd idle is maximum thrust.

Clark Y,

Couldn't agree more. Auto-throttles are far superior, because you can feel the aircraft, through their movement. They just give you another clue of what is going on and ATS don't. AI has suppressed that clue of auto-throttle movement to the pilots, as it has done also with the side-sticks. You have to look at your instruments to see engine response.

[CONF iture]

Even during CAT-IIIB autoland, the pilot flying must keep his hand on all thrust levers, not only for the purpose of selecting reverse thrust, but to ensure that all thrust levers are in fact moved to idle detent upon touchdown.
Just another case scenario ... This time thrust is automatically reduced even if both thrust levers are inadvertently forgotten in the climb detent.
Too many combinations, different circumstances different logic … but digest all of them !

This bizarre, elementary breakdown of human performance could be due to lack of training, lack of work discipline, lack of common sense, lack of survival instinct, or temporary insanity.
It would be over simplistic to blame the TAM accident on Airbus shoulders, but still, how does it seem recurrent for Airbus pilots to leave one thrust lever in the climb detent when one thrust reverser is deactivated, when other types look pretty immune to that scenario ?

[clark y]

Glueball, it is easy to blame these pilots but you're lucky to have feel. It takes a fair amount of time to get used to the fact that 99% of the time the thrust levers are just "limit switches". An A320 was lost back in March 1998 for the same problem i.e. 1 reverser unserviceable. On landing one engine was left in idle detent the other in climb detent. The result was the aircraft ran off the runway. Hopefully we can all learn from this.

As for the witch hunt to find someone to blame and or pay, pilots are always an easy target.

[CONF iture]

I believe there is something really insidious in this auto thrust philosophy.

After spending hours forgetting about those frozen thrust levers, but still brilliantly managing any thrust variation between idle and climb thrust, we can tend to unconsciously obliterate their function and keep them out of the process.

Anytime there was an auto thrust adjustment on the 757, I can remember placing my hand on the levers, almost by reflex, just to feel them moving, and moving together, sometimes even to initiate that movement or also to delay it in other circumstances ...

There was a physical materialization of any thrust change, a kind of complete cycle :

Instruments
Brain
Arm Hand
Thrust levers
Instruments

Nothing like it on the Bus unless you decide to get rid of the automatic process.
The Arm Hand Thrust levers are useless elements of an automatic thrust adjustment.

But on three known occasions, crews forgot to fully reconstitute that physical link and failed to retard one of both thrust levers, which lead to very serious consequences.

Blaming the TAM accident on Airbus shoulders is over simplistic, but thinking that Airbus auto thrust conception has nothing to do with it is all that much.

[aguadalte]

All of the "mechanical touching & feeling" components of the interface between pilot and aircraft, have been obliterated in the case of AI FBW concept (pilot-yoke (and trim) vs pilot side-stick; pilot A-Throttle vs pilot ATS).
I remember, when I came back to the A310, after almost 7 years riding A320's that I had to "learn" how to fly a conventional aircraft again. As I fly privately SE (Pitts S2B) I never had a real hard time to do so, but I must tell you that, things that I used to do instinctively on the B737's , like Rudder or Engine Trimming, now had to be done (at the beginning), as a "procedure" that was part of our normal scan. Sometimes I even had to call the attention of my newer PF F/O's (coming from A320's), after they engaged the A/P, that they should fine trim the aircraft. Because, on the FBW family there is no need to do it, normally.
We were left free of this functions even when hand-flying FBW birds. With ATS, non-feed back Side-Sticks and GSmini, most pilots don't even remember what was the VApp they have just used for landing...(if you don't believe it, just go ahead and ask them, after landing...)
We were not completely left off the loop, but close: we have no feed-back (and no need to trim), on our stick, when changing speeds and thrust settings; we have no feed-back on other pilot's inputs on his stick; no feed-back from the ATS levers, and, on a normal flight, one has only three actions to do on the ATS levers: Setting Take-Off Thrust, setting Climb Thrust and Retarding the levers over threshold for landing...:sad:
This might be "fantastic" for "monkeys", not for pilots.
As I said before, Airbuses are great aircraft, but they could be better.
V.

[GlueBall]

So, during the landing, flare and touchdown of this Fly By Wire A320 [where thrust levers are just "switches"] would your right hand be resting on your knee, or on the thrust levers. . . ? Or is this procedure altogether more complex than just that on the A320...? :rolleyes:

[40&80]

Cannot wait for the day some management ace decides in the name of safety that pilots should...."Fly mixed fleet"...and fly an airbus on one sector and a Boeing on another... on the same dark night!

[aguadalte]

No GlueBall, (I'm currently flying A340/A330) and depending on weather, crew, flight time, airport experience and other conditions, when I decide to hand-fly the aircraft I also disengage the ATS.
Its not against SOPs, since my company leaves that decision (for trainning purposes) to the Captain, although AI philosopy is to make use of ATS and disconnect it only if ATS is not providing adequate response.
Let me tell you that, on the A310, I didn't feel the need for that "trainning" once, most of the time, one had to "accompany" the work of the Auto-Throttle, trim the aircraft for changing speeds and configurations, and feeling the reactions of the auto-throttle, receiving those clues from throttle movement.
V.

[aguadalte]

Just with the purpose of enlightening our discussion I'm quoting a couple of paragraphs of a CAA paper 2004/10 called Flight Crew Reliance on Automation,writen by Mr.Simon Wood of Cranfield University

2 Crews of Highly Automated Aircraft Lose Manual Flying Skills
2.1 Summary
There has been very little research published on the subject of the change in manual
flying skill experienced by crews of highly automated aircraft. However, it is reported
consistently that there is a discernible reduction in manual flying skills that is
correlated both with the use of automation and whether the operation is long haul or
short haul.
2.2 Conclusion
The term “manual flying skills” is not fully defined and the loss of manual flying skills
is not covered by previous research.
2.3 Recommendations
Further investigation is required to establish; which skills are degraded, how can the
change be quantified and which pilot groups are affected.
A range of possible mitigating actions should be considered, including increased
practice, increased system reliability, safety reclassification of imposed manual flying
(e.g. to alert ATC), and increased automation training to avoid the necessity for
reversion to manual flight.
3 Inappropriate Response to Failures
3.1 Summary
3.1.1 Abnormal malfunctions have less well defined procedures compared with emergency
situations and therefore crew revert to knowledge-based behaviour requiring more
understanding of the system, plus time and effort to properly assess and resolve the
situation. This refocusing of tasks results in reduced levels of procedural
accomplishment, communications and situational awareness, i.e. relatively minor
failures can absorb both crew members in a way that is disproportionate to the
significance of the problem. Published aircraft procedures specifically do not include
elements of 'airmanship'.
3.1.2 System design is not always appropriate to keep pilots in the loop. (Research has
shown that rather than design systems to work on thresholds or specific limits for
control there should be a continuous flow of information to the pilot to indicate the
difficulty or increasing effort needed to keep relevant parameters on target.)
3.2 Conclusions
3.2.1 The current level of training does not adequately prepare crews to recognise or deal
with all situations that might arise.
3.2.2 Crews may fail to recognise failures because a) they do not have sufficient
understanding of 'normal' automated operation to be able to detect what is abnormal
and b) they do not receive training in recognition of situations from the symptoms as
they appear to the pilot. Thus they may not realise there is a problem or may believe
the problem is different to the real situation. Further, even when they do correctly
recognise the situation, they may not have sufficient system knowledge to respond
appropriately.
3.2.3 As noted under Risk 1 current training does not include practice at recognizing a
situation from the flight deck symptoms, for example, a programming input error or a
navigation database error. Frequency of recognition errors in accidents suggests that
such training would be justified.
3.3 Recommendation
Research should investigate practical ways of incorporating the cognitive elements of
CRM into automation training such that failure recognition and recovery are improved.

V;)

[CONF iture]

So, during the landing, flare and touchdown of this Fly By Wire A320 [where thrust levers are just "switches"] would your right hand be resting on your knee, or on the thrust levers. . . ? Or is this procedure altogether more complex than just that on the A320...?
Funny enough, early Airbus thinking (as confirmed by one very early operator here (http://www.pprune.org/3968062-post427.html)) was to do without thrust levers and replace them by … Push-Buttons !

But when you look at the following events, there are very serious questions to be asked :

Philippines
1998 (http://aviation-safety.net/database/record.php?id=19980322-0)
One thrust reverser was deactivated before the flight.
Crew failed to retard one thrust lever upon landing.
The A320 continued past the runway end.

Taiwan
2004 (http://aviation-safety.net/database/record.php?id=20041018-0)
One thrust reverser was deactivated before the flight.
Crew failed to retard one thrust lever upon landing.
The A320 continued past the runway end.

Brazil
2007 (http://aviation-safety.net/database/record.php?id=20070717-0)
One thrust reverser was deactivated before the flight.
Crew failed to retard one thrust lever upon landing.
The A320 continued past the runway end.

Those are only the known cases that ended up with an accident.
Are there any other cases but with no bended aluminum at the end … I don’t know.


Does it mean other types don’t fly with a deactivated thrust reverser ?
Does it mean crews on other types are better trained for flying with a deactivated thrust reverser ?
Does it mean something in the A320 overall philosophy could insidiously facilitate that kind of situation ?


Pick up your own answer …
All I can say to Airbus FBW crews : Watch yourself, because Congonhas won’t be the last event of that specific type.

[GlueBall]

Then Airbus should modify the software to continue the voice generated callout "Retard, Retard. . . " until all thrust levers are physically retarded. :ooh:

[armchairpilot94116]

If you guys havent read it, the congonhas crash thread is very indepth.

http://www.pprune.org/rumours-news/284415-tam-a320-crash-congonhas-brazil.html

[aguadalte]

Thanks armchairpilot.
:ok:

[CONF iture]

Then Airbus should modify the software to continue the voice generated callout "Retard, Retard. . . " until all thrust levers are physically retarded
That’s the obvious for many … but not for the one concerned in the first place !?

That RETARD auto call out particularity was mentioned already in the 2000 official report following the first crash (http://aviation-safety.net/photos/displayphoto.php?id=19980322-0&vnr=2&kind=C), it was again part of the Safety Recommendations after Taipei (interesting reading here (http://www.pprune.org/3617288-post2589.html) and here (http://www.pprune.org/3617546-post2593.html)) but nothing was done before Congonhas ...
When Airbus accepts the Taipei safety recommendation about a specific warning when one throttle is set to reverse while the other is above idle, but never send the service bulletin this is a fault
and I haven't seen anything mentioning a change since ...


Glueball, you mentioned insanity a few times regarding this TAM crew, but to me insanity is keeping doing things over and over when knowing they are wrong and in that perspective Airbus is insane not to have adapted that RETARD auto call out logic.

BTW is there anything in FCOM detailing the RETARD call out logic … ?
I would rate it as a very nice to know for pilots.

[TyroPicard]

CONF iture..
My FCOM (TRG ONLY) 1.31.10 says..

warning signal RETARD
condition THRUST LEVER NOT IN IDLE POSITION FOR LANDING
duration PERMANENT
silencing THRUST LEVER

No mention of silencing by A/T disengage which happens when reverse selected on one engine. Which would be nice to know...

[CONF iture]

Thanks TP, your training manual gives here as "many" details than the most up to date FCOM …

If you guys havent read it, the congonhas crash thread is very indepth.
TAM A320 crash at Congonhas, Brazil (http://www.pprune.org/rumours-news/2...as-brazil.html)
Absolutely, very informative that huge thread of 130 pages.
All the contributors have produced a captivating reading and one year later there would still be a lot to say. I would like to comment on one of its posts #2295 on page 115 (http://www.pprune.org/3594930-post2295.html)

Before this accident, if someone has posited the scenario on PPRuNe, would you or anyone here have ever given creedance or even entertained the (wild) notion that thrust levers would/could possibly be left in any other position than idle, in any design, A or B, upon landing? I think not.
Sir, you are absolutely correct … but only as you fail to mention that Congonhas was already the third accident of the type. A trend developed already but 99% of the pilots around the world, including myself, and probably that implicated TAM crew, were kept ignorant of that once believed unconceivable mishap and its possible dire consequences … but Airbus knew and deliberately opted to ignore the very simple safety recommendation made after the second accident.


At that time Airbus faulted in two ways :

They failed to publish at minimum an FCOM BULLETIN as subject : Landing with one deactivated Thrust Reverser
They failed to implement the safety recommendation for a very simple alteration of the RETARD auto call out logic.

Strong of those two points, there was no Congonhas !

No chance the media will ever pick up on that. Far too serious for them and certainly not allowed to speak the truth anyway, but from the professionals on this forum, it is somehow disturbing not to feel more connivance and support in the name of safety.

[GlueBall]

I don't fly the bus, but can one of you A320 left seaters please answer this question:

1- Where is your right hand during the flare/touchdown phase? In the case of one DMI'd reverser, would your hand/palm or fingers be on top of only one (1) thrust lever prior to retarding thrust. . . ? :confused:

[J.O.]

No, it would be on both thrust levers, as it would on any other approach. And one doesn't have to be a "left-seater" to do the landing in that situation. In the end it's the skipper's decision, but it's not mandatory for him/her to do the landing.

[PJ2]

CONF iture;
Sir, you are absolutely correct … but only as you fail to mention that Congonhas was already the third accident of the type. A trend developed already but 99% of the pilots around the world, including myself, and probably that implicated TAM crew, were kept ignorant of that once believed unconceivable mishap and its possible dire consequences … but Airbus knew and deliberately opted to ignore the very simple safety recommendation made after the second accident.
Well, I didn't "fail" to mention it mainly because it wasn't then and isn't now a problem endemic to Airbus and non-moving throttles - the very same thing, leaving a throttle open, has happened on Boeing aircraft.

Thrust levers/throttles on airplanes are, without exception, simple, mainly because they can be a single-point of failure if mis-handled. Push them forward, more power, pull them all the way back, power to idle. Airbus is absolutely no different than any other airplane.

Perhaps it is a momentary helmet fire or perhaps it is a lack of understanding of the a/thr system through lack of training, practise or momentary confusion.

This isn't an Airbus problem - it is a training/SOP matter. Second-guessing what is perceived as a "complex or different" system is not the pilots' perview or job - never has been. Millions and millions of hours have been flown on Airbus 320/340 series airplanes without a hitch. Same with Boeing. Non-moving thrust levers are not an issue for almost all crews but there will always be crews on both types which will have "issues". For me, the 767 throttles "hunting for speed" on approach drove me up a wall and I always disconnected them to stabilize the "wolf-and-rabbit" population phenomena of throttles chasing speed and vice-versa. When teaching on the 320, I always got my students to practise disconnecting and re-connecting the a/thr system so they had confidence in it and their ability to do so and understand.

What I, (and many, I suspect) am presently finding far more disconcerting is stories of avionics/software issues including spike detection and voting. Those are issues which may possibly be beyond a crew's ability to assess and successfully counter and this again isnt' only an Airbus issue.

PJ2

[aguadalte]

For me, the 767 throttles "hunting for speed" on approach drove me up a wall and I always disconnected them to stabilize the "wolf-and-rabbit" population phenomena of throttles chasing speed and vice-versa.


Although I may understand your difficulty to "stabilize the wolf-and-rabbit population phenomena" I must tell you PJ2, that I never had to disconnect the Auto-Throttles on the A310 or B737 (except under moderate turbulence). When hand-flying, that "hunting for speed" momentum is normally reduced with good trimming technique. Unfortunately I can't say the same about all of the FBW aircraft I've flown: A320 family; A330 and A340...


When teaching on the 320, I always got my students to practise disconnecting and re-connecting the a/thr system so they had confidence in it and their ability to do so and understand.

So...they have to practice auto-thrust disconnection, hein? Did you have to "practice" auto-throttle "disconnection" on your 767, too? Or was it as easy as touching the instinctive disconnection push-button? Does this mean something about your aircraft? Or are we only "having issues" here too?:oh:

[TO MEMO]

aguadalte,:=

FBW airplanes are 4th generation airplanes and 737s, A310s and 767s are 3rd generation airplanes. One problem we pilots have (as with everyone) is being relunctant to accpet change. Aviation won`t return to the 3rd gen for sure, we are on our way to the 5th gen with so many stuff becoming available soon, like GPS technology, RNAV RNP, ADS-B, ethernet links allowing better use of automation, cockpit simplification, increased computer use and instead of 10 computers for 10 tasks, we`ll soon have 1 or 2 for 10 tasks. :hmm:

My point is more and more things will be taken out of pilot control (at least for normal operations) and we just have to adapt and... enjoy. Automation will bring other problems for us to solve since automation is used to simplify what has been complicated (procedures, minima decrease, etc).

Again my point is, the A320 thrust levers are good, but not good enough as demonstrated by the incidents and accident that have happend. Airbus has disapointed me for not having come up with a better solution than an aural warning that was provided in a FWC upgrade that was not mandatory (that also involves local regulators, they also have some blame) at least inicially. I believe that after the Congonhas accident it is now mandatory, but I`m not sure. Airbus recognizes this since the A330 thrust levers design and from there on are different. So its a question of TL design and not the way they work. They are good! :8

If you would leave one TL on the 737 forward during landing the same result would happen, but the TL desing is different making it indeed more dificult to happen.

One other thing. You said you never disconnected the ATHR on the 737... I believe you, what you used to do was to override it. Why? Because it couldn`t keep speed... so it didn`t work well. For me an airplane that you have to override an automation most of the time, like the 737 ATHR - and I also flew it - its better for that airplane not to have that feature at all.

Returning to the original thread, looks like that nolonger 10 people will be charged. Charges against some 2 or 3 people will be withrawn because there was not enough matter.

Fly safe!:cool:

[Baron737]

My company is operating the Busses since the first day. As I didn´t like that design, I kept on flying the old fashioned designs. But I talked to hundreds of colleagues and friends during that 18 years, who were flying the bus. Guess what answer you get, if you ask them about the non-moving-throttle design (...and the non-feed-back sidestick design) ??
In 99,9 % they will tell you: You get used to it !! You can be satisfied now, but you don´t have to. Just ask the second question: Was it a good decision to design it like that, or would you prefer a moving-throttle and feed-backing sidestick ?
You can surely easily guess the answer.
And why didn´t Airbus react ? Obviously we have to face the fact, that our oppinion
is the most irrelevant in the business.
I remember the words of one of the first EADS Chairmans: the most expensive passenger seats are the two in the cockpit.

[aguadalte]

TO MEMO,
Have you read all my contributions to this thread? I don't believe so, otherwise you wouldn't be paternalizing me with that story of being reluctant to accept change...that's the formal Airbus Industrie answer I've being hearing for almost two decades...
I fly Airbuses for more than 18 years. I (generally), like them. What I'm standing for is for moving throttles and side-stick feed-back! I know I'll never "win" this war. But do we have to accept it, just because "Change Happensnzzz"?

My company is operating the Busses since the first day. As I didn´t like that design, I kept on flying the old fashioned designs. But I talked to hundreds of colleagues and friends during that 18 years, who were flying the bus. Guess what answer you get, if you ask them about the non-moving-throttle design (...and the non-feed-back sidestick design) ??
In 99,9 % they will tell you: You get used to it !! You can be satisfied now, but you don´t have to. Just ask the second question: Was it a good decision to design it like that, or would you prefer a moving-throttle and feed-backing sidestick ?
You can surely easily guess the answer.
And why didn´t Airbus react ? Obviously we have to face the fact, that our oppinion
is the most irrelevant in the business.
I remember the words of one of the first EADS Chairmans: the most expensive passenger seats are the two in the cockpit.

Baron737,
Unfortunately my company is for a very long time an All Airbus Company, otherwise I would have done like you...
I do agree with your post, and, do you know why that EADS guy said that? Because most of us, are mere spectators in the cockpit! Accustomed spectators...:E

[TripleBravo]

They failed to publish at minimum an FCOM BULLETIN as subject : Landing with one deactivated Thrust Reverser

? Didn't understand. Simply pull BOTH levers to idle, then land.

[Northbeach]

Aquadalte please explain what you meant by this sentence: “do you know why that EADS guy said that? Because most of us, are mere spectators in the cockpit! Accustomed spectators...”
We are about the same age and I assume you are a Captain on an Airbus. I have 13K hours of flight time; I suspect you have just as much or more. I’ve worked in this industry for nearly 30 years you have probably done the same. During that time I have served as a mechanic, dispatcher, First Officer, Captain and instructor pilot at the airline level; I believe your resume is just as rich or even more experienced. As an ex-airline instructor pilot, and current airline (737 Classic & NG) Captain I have had the opportunity to evaluate and train hundreds of pilots. My observation is that the overwhelming vast majority of who are consummate professionals dedicated to the highest level of competency and safety. That holds true whether I am talking about the pilots I have had the privilege of serving with flying the remote bush in Africa or the last first officer I flew with executing the most recent RNP RNAV approach technology available in mountainous terrain right down to minimums during a snow storm last week.
For every one of us convicted of operating an aircraft under the influence of alcohol there are tens of thousands who would never jeopardize safety in any way. As a group we shoulder tremendous amounts of responsibility that most of the rest of the world takes out liability insurance to mitigate the exposure and/or hides under layers of bureaucracy to shield themselves from. Virtually no other work group is as scrutinized as closely professional pilots commanding airliners are; everything you say is recorded virtually everything you do is logged by one or more sources. We think in 3 dimensions at 7 to 10 nautical miles a minute. We have a working knowledge of hardware/software/electronics, electricity, hydraulics and pneumatic systems. We are responsible for executing without error a vast array of frequently modified procedures under normal, abnormal, and emergency circumstances. Many of us, such as yourself, are proficient in several languages and use them under extremely technical circumstances during the course of our work. Because as a group we are so very good at what we do we make it look easy, that is a good definition of a consummate professional. You are so very good at what you do that you make it look easy. What we often do not do well as a group is to communicate the tremendous complexity and responsibility that in reality is our job. Because we often we fail to accurately communicate the real demands of our job those individuals who are detached by several layers from the left front seat can form an erroneous impression. How dare some “guy” insinuate that most of us are mere spectators – what a foolish statement (his not yours).

[aguadalte]

My appologies, Northbeach, I may have expressed myself incorrectly.
I meant to say that we're often seen by the public as the "lucky guys who usually get all the girls, earn great salaries and go to work two or three times a month..."
The alleged EADS chairman phrase: "the most expensive passenger seats are the two in the cockpit" reflects that lack of respect for the "two guys in front", the industry seems to share. If he really said that, it means that they see us, as an expensive need, not as valuable assets. It would be totally different if the passenger word was taken out of the phrase.
And we really are "spectators", when we just accept what we get, without fighting for better human/machine interfaced equipment and when we just rest in this "we get used to it" way of handling this metters.

P.S.- I really don't understand some insensible positions like:
? Didn't understand. Simply pull BOTH levers to idle, then land.
This guys are either unexperienced or not humans, they never commited a mistake...
Errare humanum est:bored:
A.

[Northbeach]

No apology needed, I suspected the error was on my part understanding what you were saying. I am in complete agreement. Well said!

Respectfully,

Northbeach

[TO MEMO]

Aguadalte,

My dear TAP friend!

Yes I read all your posts! And that`s why I decided to reply to you, because instead of discussing the original thread you`re trying to explain everyone that you don`t like the FBW, and yes... I agree with you there are some design erros in the AI concept! As also Boeing has some design erros in some of their aircraft, like the 737 rudder, etc...

Lets face it... automation will be more and more present in aviation and that will only oblige us to be more and more carefull, professional, dedicated, etc

The original thread was discussing something very important about criminal prossecution on people known to be envolved in one of the many factors that lead to the accident.

Did you read the link to "Folha de S Pauulo" that the safety officer pilot and responsible for the SMS of TAM is one of the ones going to court? That is completely wrong! You`re a pilot, like me, do you agree that the safety management department to be indicted?

Cheers!

[aguadalte]

Dear Colleague,
As I said before:
Airbuses are fantastic aircraft, but they could be better!
I do like the FBW concept, I just do not agree with non-moving throttles and non-feed-back side-sticks.
And in this thread I'm trying to explain that it is a huge injustice to simplistically hold those pilots responsible for something that just goes beyond a simple process of retarding both levers to land an aircraft.
The same applies to the flight safety manager of TAM. I don't think the Flight Safety Department has anything to do with this accident, although I'm well aware that I'm in no possession of all the information.
I'm not trying to hold anyone legally responsible for this accident, including Airbus Industrie. I'm trying to bring some light into the possibility of an improvement to the Airbus Industrie FBW concept. I defend the idea that moving throttles would have prevented this accident to happen, because you're more "involved" with the process of managing power, and that because of the complexity of the ATS system one can commit mistakes under catastrophic stress. The simpler the concept, the easier to handle.
Let me give you an example:
Here in Europe, manual geared automobiles were the standard. I was driving automatic geared cars for more than a decade when it happened to me that I had once to break hard to avoid an accident. My left foot went immediately to the embrayage (clutch).The contrary happens a lot, to people used to drive automatic geared cars, when driving manual geared ones. They just simply forget to use the embrayage when stopping in a red light, and the engine goes off...
What I intend to say is that, all of us tend to go back to basics when facing disaster and one has more chances to survive if the machine really handles as expected.
Fly Safe.
Aguadalte.

[CONF iture]

Well, I didn't "fail" to mention it mainly because it wasn't then and isn't now a problem endemic to Airbus and non-moving throttles - the very same thing, leaving a throttle open, has happened on Boeing aircraft.
So, would you direct me to such a report from a non FBW airbus ?
Remember, the case involves the next 3 repetitive facts :

One deactivated thrust reverser
Same thrust / throttle lever left in an open position during landing
Overrun the runway, with catastrophic consequences for 2 out of 3


I do share your view that Airbus A/THR understanding and proficiency knowledge acquisition requires regular training. But as aquadalte mentioned, why such specific training has to become mandatory ?
Auto throttle doesn’t need much thinking thanks to its simplicity of operation, Airbus A/THR requires thinking + training … How is it any better ?

Manual operation of the Bus thrust levers is not a problem, it’s even a pleasure.
The transition between manual and automatic operation (and vice versa) lacks of simple simplicity … that’s where relies the culprit for "momentary confusion" as you call it yourself.

PJ2, (DC9, DC8, B727, L1011, B767, A320/319, A340/330 endorsed, past Airbus instructor, fully involved in flight safety and data work).
My next question is directed to a very experienced man obviously (and a good pilot also as you made it to your retirement !) but more particularly to someone who takes safety very seriously :
A simple modification of the RETARD auto call out could be implemented to make sure that the call out does not stop before ALL thrust levers are effectively retarded, which could help other crews not to inadvertently forget one of those thrust levers in the inappropriate CLB detent during landing.

Such a simple modification could help to prevent another Congonhas.

Why should we do without ?




What I, (and many, I suspect) am presently finding far more disconcerting is stories of avionics/software issues including spike detection and voting. Those are issues which may possibly be beyond a crew's ability to assess and successfully counter and this again isnt' only an Airbus issue.
For the spike detection and voting, I agree, but when the "protection" kicks in for no reason and overrides the pilot inputs, and sends the pax and crew in the roof, to this day, that is only an Airbus issue.

[Richard_Brazil]

Today's 'Folha de S.Paulo' updates the total to 11 to be accused, including two from the airline's pilot training area:

Prosecutors' Office suggests accusing 11 in TAM case
State Prosecutors' Office can only suggest, since case will go to Federal Prosecutors' Office
City Desk

The MPE (state Prosecutors' Office) yesterday concluded a brief on the 2007 TAM accident, suggesting the accusation of 11 people for the crime of an attack on the safety of air transport. The case should be passed on to the Federal Prosecutors' Office, which will return an indictment to the courts.

The Prosecutors' Office's list includes three more TAM employees whose names had not been indicated by the Civil Police: Orlando Bombini Júnior, Alex Frischmann and Alberto Fajerman - linked to crew training.

According to prosecutor Mário Luiz Sarrubbo, they were negligent because they did not explain to TAM's crews that they weren't landing in conformance with the manner indicated in the airplane's instruction manual, in relation to the throttle positions. Just the airplane that crashed had landed incorrectly 13 times.

The names of two Infraero employees - who okayed use of the runway on the day of the accident - were on the police's list, but were discarded by the Prosecutors' Office, under the argument that they were just following orders.

The Prosecutors' Office also suggests the following accusations: Marco Aurélio dos Santos de Miranda e Castro and Abd El Salam Kishk, of TAM, brigadier José Carlos Pereira, ex-president of Infraero, besides Milton Sérgio Silveira Zuanazi, Denise Abreu, Jorge Luis Brito Velozo, Marcos Tarcisio Marques dos Santos, Luiz Kazumi Miyada, all linked to Anac (the National Civil Aviation Agency) at the time of the accident.

[TOFFAIR]

Most threads here are so focussed on the old pro/anti airbus FBW philosophy, that you guys lost the complete picture! Im not sure how many of you know SBSP, but i can assure you any sim from MS to level D is much too decluttered to give you a feeling o approaching it. Doing training on a E190 (FBW) for a "special airport" certification, i learned that even though a landing might be practicable, given the many threats invloved prior to that mislanding a diversion and even a rejected landing should be considered. Consider the factors known to the captain at the approach: An ATR slipped off the RWY just one day earlier, Rwy contamination and heavy rain at the time, known poor rwy conditions, knowing rwy has no shoulders at both ends, knowing one reverse was inoperative, knowing they were at the high end of the weight limit (plus the last minute jumpseaters), inexperinced crew (at training) in an airport that requires special qualification, and for TAM policy does not allow FOs to land (not even on good wheater), still unfamiliar with aircraft (boeing offspring)... I think CRM wasnt unknoknw, why not practiced? What happened after touchdown, in my oppinion was so quick and all the discussion of what they did and what they could have done and what was wrong with the aircraft just weighs with bad luck... by the way, blaming the dead for the accident, neither brings anything back nor does it prevent similar situation...

[aguadalte]

You're right TOFFAIR, they had bad luck. Unfortunately, bad luck is not a scientific reason for an accident...

I think CRM wasnt unknoknw, why not practiced?

Further, can you please enlighten me on that subject?

Regards,
aguadalte

[dvv]

aguadalte, moving throttle levers didn't prevent the F-OGYP crash.

[GlueBall]

Consider the factors known to the captain at the approach: An ATR slipped off the RWY just one day earlier, Rwy contamination and heavy rain at the time, known poor rwy conditions, knowing rwy has no shoulders at both ends, knowing one reverse was inoperative, knowing they were at the high end of the weight limit (plus the last minute jumpseaters), inexperinced crew (at training) in an airport that requires special qualification, and for TAM policy does not allow FOs to land (not even on good wheater), still unfamiliar with aircraft (boeing offspring)...

You are digressing from the fact that the airplane easily could have been stopped and would have stopped within the confines of the 6,365' wet pavement [as had numerous other A320s immediately prior to this accident] if only the operating captain in the left seat would have closed/retarded both thrust levers during flare or touchdown. This "instinctive" elementary function of moving the levers to the idle detent position even applies to the fly-by-wire A320s where the thrust levers are "switches" . . . irrespective of whether one reverser is DMI'd, irrespective of whether it's raining or snowing, or whether the runway is short and wet.

The pilots screwed up perhaps due to lack of training, lack of experience, absent mindedness, incompetence. . . .

[aguadalte]

aguadalte, moving throttle levers didn't prevent the F-OGYP crash.
dvv, you're right (I must concede), but there is a slight difference that is very important for this case: in the F-OGYP accident, the pilot was hand flying with Auto-Throttle OFF. The behavior of the levers is the same on both systems, when disconnected. I'm comparing the behavior of Auto-Throttle vs ATS, when connected. And as far as I know (the last a/c I flew with Auto-Trottle was the A310-300) when the Auto-Throttle is ON, if you retard one of the levers, the other tend to follow the retarded one. You have to positively (in the sense that this is an intentional decision) disconnect the Auto-Throttle to bring only one lever to the retard position. And that makes all of the difference between both systems...
Regards,
aguadalte