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TAM A320 crash at Congonhas, Brazil

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TAM A320 crash at Congonhas, Brazil

Old 24th Sep 2007, 21:59
  #2421 (permalink)  
 
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Lemurian,
Despite the differences on Brazilian Portuguese to Portuguese from Portugal, you are correct on stating that "não necessário" could not mean "not mandatory". We have "mandatório" in Portuguese. It is clearer on the original "não necessário" for you to read "not necessary". What you are missing here is the first part of Mr. Malinge's phrase: "...o software FW3 era recomendável, mas não necessário". If it was "recomendável" (recommendable), "mas não necessário" (but not necessary) you don't need to understand Portuguese to see if it is recommendable, it can be NOT anything else. Recommendable but not reliable, recommendable but not cheep, recommendable but not existent. So the "necessário" part of his statment really doesn't make any difference after saying that the software FW3 was recommendable.

For me, this even shows that this Aibus representative was not very successfull on choosing his words. How can you recommend a NOT necessary upgrade?

I believe WE are not having a communication problem here. Airbus is...

Last edited by Rob21; 24th Sep 2007 at 22:09. Reason: another typo
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Old 24th Sep 2007, 23:00
  #2422 (permalink)  
 
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A software change appears to have originated from the recommendations in the final report of the Transasia Overrun.
The Aviation Safety Council of Taiwan recommended that Airbus review the ‘stop mode of the Retard warning’. Note that the level of importance was ‘review’ as opposed to ‘action’, which was used for other findings.
In such recommendations, the manufacturer is not obliged to take any action, just review. In this instance, Airbus responded that a software modification to the Fault Warning Computer (FWC, standard H2F3) would be available via a service bulletin (SB); I do not know the SB number.
Unless mandated by the national authority, SBs are not mandatory changes. Note that in the event of a mandate most are initiated by the manufacturer, with which the authority agrees – a good working relationship.
In addition, the Airbus action, presumably as a result of their review, appears to have decided that the continuation of the audio ‘Retard’ warning was not sufficiently urgent in the abnormal (erroneous) situation, and thus elevated the warning to include an ECAM message and audio/visual alert. This too can be seen as responsible action, particularly where the Retard call might be judged as a 'weak' cue due to its presence in normal operation; the failure to retard the thrust lever is erroneous operation which requires an appropriate level of alerting.
It is not clear from the report if the software change was already in progress before the Taiwan event or as a result of it. I suspect the latter, which implies a thoughtful and measured response by a manufacturer to an issue, which was identified during the course of an investigation.
One interpretation of this could be that the optional SB would be selected by those operators who presumably judged that their crew’s operational skills could still be error prone even after the safe guards of improved training (as per earlier Taiwanese recommendations).
It is quite possible that TAM management (or the Brazilian authorities) were unaware of the SB, thus Airbus were reminding them of its existence. No doubt Airbus had notified all operators via their normal communication channels, but then not everybody reads everything, and those SBs associated with cost are often rejected.
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Old 24th Sep 2007, 23:24
  #2423 (permalink)  
 
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.....and those SBs associated with cost are often rejected.
Penny-wise and pound-foolish comes to mind.
113 deaths....
And a few minor details like a hull loss, and a store building destroyed?

Ah I forgot.... that's what insurance is for.
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Old 25th Sep 2007, 01:49
  #2424 (permalink)  
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Originally Posted by alf5071h
particularly where the Retard call might be judged as a 'weak' cue due to its presence in normal operation; the failure to retard the thrust lever is erroneous operation which requires an appropriate level of alerting.
alf, the principal point made by the (very competent) Taiwanese investigators back in 2004 was that the 'Retard' call cuts out after touchdown, whether or not the levers are in the correct position.

"After touchdown, when the thrust lever 2 was not pulled back to Idle position and the Retard warning sounds have ceased, there were no other ways to remind pilots to pull back the thrust lever."

That was a very logical point to make. Why have a warning system at all if it cuts out even though it has not been complied with?

Originally Posted by alf5071h
It is quite possible that TAM management (or the Brazilian authorities) were unaware of the SB, thus Airbus were reminding them of its existence. No doubt Airbus had notified all operators via their normal communication channels, but then not everybody reads everything, and those SBs associated with cost are often rejected.
Incorrect as far as anyone on here knows. There is no evidence that the promised SB was ever issued; indeed, given that contributors like PBL have excellent sources, and can find no trace of it, it is virtually certain that it was NOT issued.

Airbus will eventually have to explain ('in due course,' as they say, once court proceedings on behalf of relatives commence) why it was not issued; in the same way that the airport authority will have to explain their position regarding the runway works, the airline will have to explain all aspects of their training, manuals, MELs, and all other possible contributing parties will also have to 'assist the court.'

But one can't blame any of the parties for saying as little as they can at this stage - that's the first advice their respective lawyers will have offered.
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Old 25th Sep 2007, 03:01
  #2425 (permalink)  
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Thanks

Translating to suit your arguments, aren't you ?
Thanks Lemurian. I think we are making progress, kind of trusting each other. Nowadays I shy away from people who "are sure" of things... I prefer the ones who are searching. Perhaps we will never know what happened inside that cockpit that night. But, before a final report (that also may not know...) I believe it is up to us to speculate as to possible causes, without biases. Of course, even a very distant almost impossible possibility, there could have been a malfunction in the pilots, the computers or both. Let´s start from here?
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Old 25th Sep 2007, 08:00
  #2426 (permalink)  
 
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Bringing this thread back to pilots and operators, do my fellow aviators consider they would have planned to land there and then if the TAM MEL had a realistic addition to LDR for 1 reverser inop in those conditions rather than just '50m'?
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Old 25th Sep 2007, 08:08
  #2427 (permalink)  
 
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RWA:
Airbus will eventually have to explain ('in due course,' as they say, once court proceedings on behalf of relatives commence) why it was not issued
Probably because it wasn't ready yet. We're talking a significant amount of testing before they flight-test it, even more before it gets 'released into the wild'. This is not a Windows or MacOS Service Pack or patch we're talking about here!
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Old 25th Sep 2007, 10:02
  #2428 (permalink)  
 
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Lemurian,
I don't think is fair for you to say that Marciovp is "translating to suit his arguments".

I can only gess you are "playing stupid", because you know very well what the word "necessário" means. It's the same in English (necessary) and it is even the same in French (nécessaire?).

In aviation, if a software upgrade is necessary, it becomes mandatory. If it's "recommendable", its optional.

So maybe you are not understanding translations in order to suit your arguments.

If Marciovp hadn't translated the article, you wouldn't be aware of the "existence" of the FW3 (software?).
Regards,
Rob

Last edited by Rob21; 26th Sep 2007 at 20:11. Reason: typo
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Old 25th Sep 2007, 10:15
  #2429 (permalink)  
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Originally Posted by Rob21
If Marciovp hadn't translated the article, you wouldn't be aware of the "existence" of the FW3 (software?).
Oh, for heaven's sake, Rob21, everybody who has duties concerning an A320 fleet knows about H2F3 and A320-31-1267 and has done since at least 13 November 2006 when the first version came out.

Don't you guys know how upgrades to commercial kit are made? They are made through Service Bulletins, every single one of them, without exception.

And please (you and marciovp) start referring to the FWC upgrades by their proper designations, such as H2F3, and not acronymic kludges misinvented by goodness knows who.

PBL

Last edited by PBL; 25th Sep 2007 at 10:16. Reason: Typo
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Old 25th Sep 2007, 10:59
  #2430 (permalink)  
 
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Oh, for heaven's sake, Rob21, everybody who has duties concerning an A320 fleet knows about H2F3 and A320-31-1267 and has done since at least 13 November 2006 when the first version came out.
Anyone with access to AirbusWorld can look up this information retrospectively. Doesn't mean to say everyone involved with 320's was aware of it.
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Old 25th Sep 2007, 12:03
  #2431 (permalink)  
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Originally Posted by Fargoo
Doesn't mean to say everyone involved with 320's was aware of it.
Maybe not. But I find the suggestion that someone who deals on a daily basis with one of the world's largest A320 fleets, who has been actively involved in this discussion, and who has read and commented on many posts referring specifically to A320-31-1267 and the H2F3 FWC SW would only have heard of it because of someone in Brazil telling the thread what a newspaper (mis)reported about what the president of an airline said to a group of politicians just *a little silly*.

PBL
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Old 25th Sep 2007, 12:06
  #2432 (permalink)  

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stresses

Rob21
If Marciovp hadn't translated the article, you wouldn't be aware of the "existence" of the FW3 (software?).
and,
If it was "recomendável" (recommendable), "mas não necessário" (but not necessary) you don't need to understand Portuguese to see if it is recommendable, it can be NOT anything else. Recommendable but not reliable, recommendable but not cheep, recommendable but not existent. So the "necessário" part of his statment really doesn't make any difference after saying that the software FW3 was recommendable.
Problem is that the subject of the software has been covered at length several hundred posts ago.
A few people, me included, have said that the warning was not *desirable*, AI had to look elsewhere...

For people who are quite keen of taking everything to the letter, your interpretation (s) of Mr Malinge's words are a bit far-fetched. ( Semantics, oh semantics ! )

After every accident report, there are recommendations, to the airline OPS, to the manufacturer, to the certifying authorities...etc... Some of them come, IMHO, into the *cover your bu77* chapter, with have really no influence on the *prophylaxis* of an another incident : On this chapter, the recommendation that AI changed the HDG/TRK window after the Strasbourg accident is the best example, as the main difference between HDG/VS and TRK/FPA was a glaring change in the ADI presentation, which happens as soon as the pilot uses the switch...The court was satisfied, the DGCA did its job in the public eye...The pilots just had a shrug...Training had a greater emphasis on the ADI presentation differences...
There are a few holes in your reasoning :
  1. You insist that there were 3 instances of similar incidents. Fine and true. Then you insist that there could be a system fault. Good so far.
    But comparing the three instances and at the same time disregarding the first two, in which both crews survived and could testify and the analysis of the airplanes post incidents have resulted in placing the T/L mishandling as a causal factor.
  2. Moreover, if you want to try and put the blame on Airbus - for not issuing the software change and the new warning -, you first have to accept that there was a crew error.
You can't have it both ways :
  • Either there is a system faulty design and AI needs to go back to the drawing board, or
  • There is a possible mishandling of the throttles that the new warning would cure.
    Can't be both at the same time.
So far, I have tried to remain as factual as possible and everything I've written has been based on facts or factual interpretations. No gremlin, here. I have not allowed myself to interpret *look at this*, *No joy* or *Decelerate* just because I wasn't there and there are too many possibilities... That you'd choose just one of them is your priviledge but IMHO you are the last people here to be in a position to claim as truth what is only one in a million theories.
The best proof is that you or Marcio have never answered my technical questions . You both just change the angle of your argument.
In a court of law, that would be fine, possibly.
Not here.
PS : I still have not seen Marcio defend the Indonesian pilot of the Phuket accident.

Last edited by Lemurian; 25th Sep 2007 at 12:18.
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Old 25th Sep 2007, 12:42
  #2433 (permalink)  
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Bravo, Lemurian.
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Old 25th Sep 2007, 14:34
  #2434 (permalink)  
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Originally Posted by DozyWannabe
Probably because it wasn't ready yet. We're talking a significant amount of testing before they flight-test it, even more before it gets 'released into the wild'.
Airbus said in 2004 that they HAD developed it, Dozy, not that they WERE developing it.

In any case, for the reasons I explained, there isn't much point in speculating on why they didn't issue an SB. The legal facts are that they said in 2004, in response to a Safety Recommendation, that they were going to; and then didn't. It will eventually be up to the court to decide whether, in its opinion, if they had done so, it might have prevented, or reduced the severity of, the Congonhas accident.

The court proceedings that follow all and any air crashes take a completely different path to that of the initial investigation. But it's fair to say that they almost always end up determining a percentage split of the liability between the various parties - usually including (but not necessarily limited to) the airline, the manufacturer, and the airport operator.

They also take many years. As one example, relative claims from the 'American 587 Heavy' accident (the A300 that crashed in Queen's in 2001) are currently being settled on a 50/50 basis by Airbus and American Airlines. Once all the claims have been settled, Airbus and American will presumably negotiate (or go to court themselves) to settle which of them bears what percentage of the total compensation cost.

If I had to bet, right now, on the likely final determination of liability for the Congonhas accident, I'd say that it's virtually certain to be shared between the airport authority, the airline, and the manufacturer. Wouldn't care to bet on what percentage split the court determines between them, though.
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Old 25th Sep 2007, 14:44
  #2435 (permalink)  
 
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Questions for the experts:

At the point immediately after touchdown (both main landing gear compressed) is it the case that a crew has only two possible courses of action, namely:

1 continue landing roll-out to a full stop landing;

or,

2 convert the landing to a 'touch and go'?

If so, is there any way that Airbus' software could deduce which of these options a crew intends to take by analysing the combination of crew control selections in operation (TL positions, autothrust, reverse thrust, autobrakes, manual braking, flap/slats, etc) at this point in the landing? Alternatively, if just after touchdown, the aircraft software detects a combination of control selections which would preclude a safe 'go around', would it be safer, in this case, if the software made the decision for the crew and executed a full stop landing procedure (automatic selection of both engines to Max Reverse, deployment of GS, autobrake operation and activation of any other devices available for slowing the aircraft down)?

I suppose the main problem would be in determining the precise combination of control settings the software should use when deciding to execute a full stop landing procedure. Would the combination of 'Main Gear Compression' AND 'Max Reverse on at least one engine' AND 'Manual brake application by crew' AND 'Aircraft speed above 72kts' be a sufficiently strong indicator of the crew's intention to perform a full stop landing?

Of course, as others have already stated, implementing the sort of changes suggested above runs the risk of introducing new undesirable alignments of 'holes in the Swiss cheese'. One final thought, what about giving crews a simple 'Button of last resort' or 'Get out of jail free button' which, subject to certain criteria being satisfied (a/c on the ground, etc) would cause the aircraft systems to execute an automatic full stop landing procedure ? It might help tired and stressed crews when time is of the essence and they are unable to figure out quickly enough why their aircraft is failing to decelerate.
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Old 25th Sep 2007, 15:14
  #2436 (permalink)  
 
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PBL,
I think you are manifesting your frustrations to the wrong person. The guy who started this "FW3" thing was the V.P. of safety for Airbus, in the presence of the press and broadcasted nationwide.

Lemurian,
1. I only speak for myself. My focus is on this accident (TAM), not the other two or three often mentioned on this thread. Specially because the crew survived on those, they know what happened with the TLs.
2. I am NOT blaming Airbus for not issuing this "new" warning. IF they are working on this "warning" only now, how could I know about it? And if not even PBL knows about this "new software", how can you expect that a light twin sunday driver like me can answer any of your questions?
3. I don't claim anything here as truth, but yes, I can permit myself to be open to the possibility of mechanical failure. I am also open to the possibility of pilot error. You are the one claiming my theory is one to a million. I have no means of doing this complex calculation. Like you said, I am the last one here who can claim a theory as truth. Where are you in this "ranking"?

Finally, you claim I didn't answer any of your tecnical questions. This is not a contradiction? Why would someone like you want to know anything from the last one here who can know anything?

But you do have a good point. I shall remain "quiet" for now, reading the posts of you all.

One last thought: When the official report comes out, and the main cause is HF, I will say "oh well, let's hope pilots get better training", or something like it.
But, if the main cause of this accident was a mechanical failure, remember me thinking of you "mordendo as cuecas" (you understand Portuguese, you know this is a very common expression here, not offensive).

Take care and all the best

Last edited by Rob21; 25th Sep 2007 at 15:23. Reason: typo
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Old 25th Sep 2007, 15:23
  #2437 (permalink)  
 
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"The engine 2 throttle is recorded in the Climb position, and remained in this position to the end of the recording"

In AIRBUS ACCIDENT INFORMATION TELEX, my underlining.

I'm sorry to show up like this, but there's no way I can thread this subject to the begining. I've been following this subject in other sources, but I can see there's a lot more of expertise around here, so forgive me for putting in the following questions. (I fly the A310, and have no experience in FBW Airbus, so this may be just a FBW suspicious attitude, you tell me)

- Has it been established wether the eng 2 throttle was actually (phisically) in the Climb position? By wreckage evidence or any other mean? At the date of the Airbus telex, Agust 2nd, the wording "recorded" is relevant enough for me, it states the recorded data.

- Is it possible that a throtlle lever movement may not be accordingly transmited to the engine control, due to a failure of the transmiting components? This, of course, is FBW suspicion, but I can´t help it. And the contents of the CVR transcript make me wonder about this question.

Even if there is pilot error in leaving the throttle behind, I think there is material for deep reflection on the subject, if not for presently flying aircraft models, at least for future models: A throttle that doesn't feedback to the pilot with autothrust on, is leading the pilot to disregard one of the primary acft controls. I allways have my hand on the throttles because they move, even with autothrottle on. If they didn't move, I would let them be, for sure.

Probbably this questions have allready been answered here, if that's the case, just tell me to take a hike and I will.

Thanks
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Old 25th Sep 2007, 15:25
  #2438 (permalink)  
 
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RWA:
Airbus said in 2004 that they HAD developed it, Dozy, not that they WERE developing it.
Do you have a citation for that? Or that it's a legal fact that they said they were going to and then didn't?

Otherwise it's just speculation.

Lemurian said:
A few people, me included, have said that the warning was not *desirable*, AI had to look elsewhere...
So it may be that the change was tried and proven to not work. This will need clearing up.
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Old 25th Sep 2007, 15:58
  #2439 (permalink)  
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Originally Posted by DozyWannabe
Do you have a citation for that? Or that it's a legal fact that they said they were going to and then didn't?

Otherwise it's just speculation.
Of course I have, DW, otherwise I wouldn't say it.

To quote the October 2004 Taiwan Report for the third time:-

Originally Posted by RWA, Post 2198
"According to the Airbus Company

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

"Airbus Company Response:

"Airbus has developed a specific warning when one throttle is set to reverse while the other is above idle. This warning generates an ECAM warning "ENG x THR LEVER ABV IDLE", a continuous repetitive chime (CRC), and lights the red master warning light. This new warning is implemented in the FWC standard "H2F3".

"A Service bulletin will be issued very soon on this subject."

http://www.asc.gov.tw/acd_files/189-c1contupload.pdf
Download the whole Report and read it if you like.
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Old 25th Sep 2007, 16:36
  #2440 (permalink)  
 
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OK, fair enough - but that doesn't explain why Lemurian descibes that warning as having been deemend undesirable. In this case I think any insinuation of blame or culpability should be held in check until we know exactly what happened here.

3Ten, this thread has pretty much exhausted that argument. While it is possible that the software didn't pick up a movement of the levers, it is *extremely unlikely* due to the multiple redundancies inherent in the system.

Don't be afraid of FBW, it's the future.
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