TAM A320 crash at Congonhas, Brazil

[Rob21]

PBL,

You are right. It is something with our culture that you don't understand.

In our culture, when we want confirmation (or proof) of something someone saw on the press, we don't try to get answers from the people who saw the news. And we don't go to the TV station either. We go to whom gave the information.

If your contacts at Airbus can't (or won't) tell you what the hell is this "FW3", how do you expect that us, mere spectators, can?

If I can suggest, try to get in touch with someone at TAM. They operate 44 Airbuses and, with your academic tittles, I am sure that they will try to answer your question. You can say that you saw on the news and want to know more about this "FW3" software.

This is what I would do.

I believe when marciovp posts some news here, and even spend his time with translations, the idea is to inform.

As for me, you can get Brazilian newspapers in any big city around the World. Or try the Internet.

Oh, don't forget to call Lemurian to help you out with translations.

Regards,
Rob

[marciovp]

Well letīs talk...

Marcio (and Rob21, I suppose), there seems to be something about your culture that I do not yet understand. I ask a question. You can't answer it (neither can anybody else) except through what you have seen on television and in the newspapers. So I say: yes, but I want to know about the paperwork, which must exist if this story is to be real.

Maybe there is indeed a difference in culture. I am Brazilian, I lived 30 years in the USA and I used to fly Cherokees...Of course I am not close to your expertise on these matters and I think I understand your need to have the papers. But, on the other hand PBL I remain very interested in aviation for the pleasure of it: no agendas, and I believe I am entitled to have an opinion on a matter that for sure has not been settled. Yes much of my information come from interviews on life television and on the press. Live and in colors. Do you doubt PBL that after the Taipei episode there was an recommendation for a new software from AB to keep warning pilots (light and sound) that the TLs were opposed to each other? Do you doubt that AB did malke this software and offered it for airlines that fly AB? Do you doubt that TAM did not buy it and is buying it now? Do you doubt that TAM and the AB representative agreed to call it by W3?... What are you trying to say after all?...

Also worth bearing in mind that some of the Brazilian contributions on here have been from the legal community rather than aviation. I do wonder if there's a chance that some of them are hoping for bigger settlements from an Airbus-sized corporation than they would get from a TAM-sized one?

Insofar as I am concerned this doesnīt apply to me, and I donīt have such an agenda. I am not from the legal community. Although I used to fly Cherokees...I can say that I was a pilot (of course far from being the experts like the pro pilots I find here). Donīt you think that the same argument could be made from the opposite side? People connected to AB trying to prove that it was Human Error in order to avoid a law suit?... And I suspect that there are people from AB here.

Regards to all.

[RWA]

Originally Posted by DozyWannabe

I do wonder if there's a chance that some of them are hoping for bigger settlements from an Airbus-sized corporation than they would get from a TAM-sized one?

DW, is there any possibility that we could leave the crucifixions until Easter?

The lawyers won't even be getting their second wind on the task of settling this case until about two years from now. It will take that long for the investigation report to come out, the claims to be formulated, and all the documentation to be 'discovered.' I would be astonished if anyone contributing on here was seeking to build some sort of legal case. And, in any case, mere hearsay on here would be of no value at all in that field.

What counts here, now, is for all of us to tease out as many facts as we can - and also contribute ideas, theories, suppositions - as to how this accident happened. If nothing else, the things discussed on here may possibly help serving pilots (who have to think all the time about their jobs, which, unlike the jobs most of us do, involve life and death decisions pretty well all day every day) to avoid similar problems in the future.

The discussion has nothing at all to do with future liabilities. And in any case, in my view (as expressed above) liability is likely to be shared in the end among the three main parties (manufacturer, airline, and airport authority, in no particular order). The only legal question that is ever likely to arise is what percentage of said liability each of those parties has respectively to bear.

The essential question is how vastly-experienced, over-10,000 hour pilots could have got themselves involved in such a horrible accident. And I for one still can't for the life of me work out how that could possibly have happened. For pilots like that, forgetting to retard the throttles in the flare would, on the face of it, be about as likely as them forgetting to put their trousers on before they left the hotel........

[Lemurian]

3ten,

The FDR recording and the general trend seems to indicate that the crew went all the way down to that building without ever doing nothing, and that, to me, is also unlikely.

As a matter of fact, the FDR graph shows that they *tried* a lot ;

• Full reverse
• Re-cycle the ground spoilers (We know that it would fail)
• Brake to max pedal input
• Transfer of control (s...?)
• Veer of runway (this, associated with the *Vira* plea shows even some monitoring of the aircraft progress ).

I dare say that was a pretty busy cockpit.

I travelled in a TAM A320 cockpit a couple of weeks before the accident, a instructon flight with 2 captains, and I observed perfectly good standards. I have to admit that I left that cockpit with a much better impression about aviation in Brasil. Of course, this is worth what it's worth.

That's interesting because we now have a first-hand testimony. But the cockpit procedures on a 320 are a lot stricter than on all my previous types (including some on different fleets of the same airlines...Nowadays, these SOPs have descended into the new FBW types, so I'd like to ask a few questions, if you could remember them, apart from the general impression of good standards :

• Were all the FMA changes, and generally all the messages (be they caution or change of configuration...) announced by the crew, and by whom ?
• Did they seem to have *triggers* for check-lists (like QNH = xxxx triggers the call for *Approach check*...) ?
• Did the handling pilot call for specific speed values or just *Speed S...Speed F+20...etc... or did he make his own speed setting ?
• Was the A/THR used during the approach or was it manual thrust ?
• Was the autobrake used ?
• If yes, was *Decel* called out, along with *Spoilers deployed*,* Reverse green*...?

These are the questions we could ask, on the accidented aircraft where while the general adherence to procedure is apparent, there are some calls that are missing (This crew, too was made of two instructors, one of them in training, so we must assume that adherence to SOPs were/should be the strictest ).

in my MEL, the asterisk means that the failure must be plackarded in the cockpit.

Yes, that's another presentation.
Thanks for your answer.

RWA,

The essential question is how vastly-experienced, over-10,000 hour pilots could have got themselves involved in such a horrible accident. And I for one still can't for the life of me work out how that could possibly have happened. For pilots like that, forgetting to retard the throttles in the flare would, on the face of it, be about as likely as them forgetting to put their trousers on before they left the hotel........

The two previous incidents are proof that it happened to their crews, and they were not less trained or experienced, so please leave that angle. You will never know.These crews cannot explain that mistake.

[BOAC]

I fully endorse RWA's post: before Danny or Rob come in with the 'red pencil' could I ask all of you to leave your personality spats, digs and arguments for PMs and emails etc and simply remember that a lot of people died in this crash.

Whether or not an AD/SD/SB or whatever was or was not issued and/or incorporated by the operator will become evident in due course and does not really need to be settled here.

Please can we confine ourselves to the main issues? As I see them they are discussion of the latest FACTS and professional opinion on how to avoid this sort of accident in the future.

[DozyWannabe]

RWA - Fully with you!

[3Ten]

bsieker

great update you gave me here, it'll take me some time to digest it. And also great job on the WBG. As you said, I haven't and won't read this thread from the begining, so this will help me a lot.

We will have to wait for the final report to have reliable answers, and I know that the wreckage examination will help to sort this either way (crew error and/or mechanical failure). I'm not standing up for any theory, merely reminding ourselves that several hipothesys are surely being raised by the investigators. I think this case is beeing so thoroughly discussed before the investigation conclusions, precisely because people are afraid of a technical failure, one that could take some more lives before the TAM final report (I'm not implying that it exists).

Just one more question, to know if you have an opinion:
In the video that shows the last stages of the landing run, there is what it seems to be an explosion in the #2 eng area, seems like a compressor stall, but could be anything else. For the little I've looked at the FDR graphs, there is no evidence of that event. I will take some time to back track from the moment of the final impact to try to plot that instant on the graphs. But is there any theory around this event?

Lemurian

Trying to answer your questions:

• Were all the FMA changes, and generally all the messages (be they caution or change of configuration...) announced by the crew, and by whom ? YES, BY PNF, IN THE CASE CM2, THE INSTRUCTOR
• Did they seem to have *triggers* for check-lists (like QNH = xxxx triggers the call for *Approach check*...) ? YES
• Did the handling pilot call for specific speed values or just *Speed S...Speed F+20...etc... or did he make his own speed setting ? SPECIFIC VALUES, AS I CAN RECALL IT
• Was the A/THR used during the approach or was it manual thrust ? I THINK IT WAS ON, I'M NOT SURE
• Was the autobrake used ? YES
• If yes, was *Decel* called out, along with *Spoilers deployed*,* Reverse green*...? YES, *DECEL* I DON'T REALY REMEMBER

I'm in the A310, but I've observed that the SOPīs and standard callouts are very much alike in the FBW generation. Although I probably was sometimes distracted with conversation with a coleague in the other jump seat, and thus cannot guarantee a 100% compliance, the overall impression was of compliance with SOP's. If there's one positive thing about the Airbus philosophy, is that it gives all the tools necessary to have a disciplined flight deck, so that's probably why the Airbus fleet is more strict than other fleets.

[IFixPlanes]

I first thought that the Warning mentioned by Airbus in the "GE 536 Occurrence Investigation Report" was not implemented in the new FWC Standard H2F3 because it was not listed in the "Standard improvements"- Section of SB A320-31-1267 (newest Revision 03 is dated Aug 31/07).
But i find the Message in the "ECAM System Logic Data" of H2F3:


You get this on EWD:
ENG X THR LEVER ABV IDLE (in Red)
-THR LEVER 1.......IDLE ( in Cyan)


But changing to the FWC Standard H2F3 is not only pulling out the old FWC and install the new one.
The Aircraft must have appropriate precondition (already performed SBs etc...) and this is an extreme cost factor.
So (IMHO) many Airlines did not do this improvement due to economical reasons.
I am not happy with that, but everyone who want to cry out loud should thing about the low prices everybody strongly request.
In Germany we have an advertisement "Geiz ist geil" (avarice is great).
And now you get what you payed for; all over the world and at every airline...
Think about it...

Ingo

[PK-KAR]

The crew of the previous flight (BH-CGH) was not the same. The PF worked during the previous years for Transbrasil and Passaredo, fliying on Boeing 737, and, if he really did a mistake, it is possible that this fact could in some way have contributed to it. But, in any case, it should be stressed that TAM's pilots did follow different procedures for the same kind of situation.

Confirm that the accident happened on the FIRST OR SECOND landing of the day for the crew? (And not 3rd or any higher number?)

If so, one must ask the previous crew landing in CGH, if they did retard both to idle and then reverse because the FDR did not read it as such, BUT did so in Porto Alegre. If the answer comes out as:
1. "Yes I brought both levers to idle and then reverse", Airbus has some answering to do...
2. "No, I brought both to reverse then #1 only into reverse," then TAM has some answering to do...

If not, then, the PF for both landings CGH is the same?
---

*RETARD ENGINE ONE *-or TWO- after the identification of one missing T/L in the *Idle* detent, along with a warning and caution chime.

Why not if both engines are on, weight on wheels, >72kts IRS speed, FLAPS 3(orFULL) and 1 is moved into reverse and the other is still in CLB, then "WARNING THRUST DISAGREE" on the voice... *just another lame PK-KAR idea*

---

I dare say that was a pretty busy cockpit.

Re-cycle as in moving the speedbrake lever?

It was busy... if I remember correctly it took them 7 seconds to notice something was wrong, and 11th second the braking started. If it happened with them, it could take us 7 seconds or more too! That's scary.

---

In the video that shows the last stages of the landing run, there is what it seems to be an explosion in the #2 eng area, seems like a compressor stall, but could be anything else. For the little I've looked at the FDR graphs, there is no evidence of that event. I will take some time to back track from the moment of the final impact to try to plot that instant on the graphs. But is there any theory around this event?

The exact location on where this happened is one of extreme curiousity for me, but after looking at the photos of the "excursion area" and the FDR, there's little to go on except some longitudinal accelerations did happen near the flash... While the lateral shows the airplane was skidding.

----
This is why I think it's always necessary to check for spoiler deployment before applying reversers... I think the crew deserves a go-around chance if no spoilers are deployed... But then, ask Airbus not me...

---

PK-KAR

[bsieker]

IFixPlanes,

Wow, thanks a lot for this inside information! So it exists after all.

You talk about the latest revision 03 of A320-31-1267, dated Aug 31/07. This is significantly after this accident.

Do you know if this warning was present in previous revisions? Can different revisions even have different features?

What are the updating procedures, i. e. if an airline has installed a previous revision, can/should/must they update to revision 03?

Thanks again, good to still have you around!


Bernd

[IFixPlanes]

...What are the updating procedures, i. e. if an airline has installed a previous revision, can/should/must they update to revision 03?...

Not necessarily.
Newer Revisions normally updates new aircraft effectivity and other minor circumstances.
Rev. No.3 has no conjunction to the accident.

[PBL]

Originally Posted by IFixPlanes

I first thought that the Warning mentioned by Airbus in the "GE 536 Occurrence Investigation Report" was not implemented in the new FWC Standard H2F3 because it was not listed in the "Standard improvements"- Section of SB A320-31-1267 (newest Revision 03 is dated Aug 31/07). But i find the Message in the "ECAM System Logic Data" of H2F3:

Thank you Ingo!

Revision 2 was what I had seen, dated the day before the Congonhas accident.

Now BOAC can relax, go back to his newspaper and let the dog continue chewing his slippers

PBL

[Rob21]

Ingo, thanks!

PBL was almost convincing me that I and millions of other Brazilians didn't see what we saw...

Good to "see" you back.

Rob

[PBL]

Rob21,

check the date on marciovp's reference to Portal Amazonia, and then check the date on H2F3 Rev 3.

PBL

[Rob21]

PBL,

No, YOU go and check the date you questioned the existence of this software modification and stated we believe in everything we see on TV (post #2381).

It was WAY after august 31st.

You don't need to apologize, but I won't play with you anymore...

[PBL]

Originally Posted by Rob21

YOU go and check the date you questioned the existence of this software modification..........
It was WAY after august 31st.

Actually, it was 17th August, and I had confirmation from my contact whose colleagues were at the deposition that the TAM president was talking about H2F3 Revision 2, which is why I got a little impatient with you and marciovp yesterday about using the wrong designation.

I think it is important to pay a lot less attention to slinging mud and a lot more attention to the exact course of events, otherwise we risk missing important information.

PBL

[Lemurian]

bsieker,

Do you know if this warning was present in previous revisions? Can different revisions even have different features?

Look at the bottom of the sheet :
Chapter 77 //Sheet Log 648 // ISSUE 2
ATA 77 is relevant to engine instruments. It seems that there was an ISSUE 1 in a previous revision, the one I referred to as having been found of dubious applicability.
On the other hand, this is a lot more than a warning and a little chime, it is a full fledged RED ECAM Procedure :

ENG X THR LEVER ABV IDLE (in Red)
-THR LEVER 1.......IDLE ( in Cyan)

We are no longer on the original league of essentialness !

Regards.

Oh ! Another funny item on the flow chart is this new value of TLA (TRA ?) of 6° for the initial conditions of the FWC warning.
See also that the cartouche indicating the inhibition phases reveals that it is only active on landing roll.

Sorry, have to work to-morrow. That's all I could find.
Ingo, thanks a lot !

[marciovp]

Things are working out...

PBL was almost convincing me that I and millions of other Brazilians didn't see what we saw...

I thought that maybe I was becoming delusional and needed to see a psychiatrist...

Actually, it was 17th August, and I had confirmation from my contact whose colleagues were at the deposition that the TAM president was talking about H2F3 Revision 2, which is why I got a little impatient with you and marciovp yesterday about using the wrong designation.

I understand PBL, actually I have a lot of respect for you. But, you know...different cultures...Germans love details and precision...

I may disappear from this great group for a while after 9/29 because I will be flying to the USA in vacation (Boeing 767-400 and Embraer 145...among others). But so that this is not constructed as a preference I have flown A320s with great satisfaction. Let me clarify, when I say I will be flying and I have flown I mean I will be there, in the back, squeezed in my chair without leg space...

Just as a news: The CPI of the House ended today with a report. It has the government party in the majority so they held fours controllers and the two US pilots responsible for the Lagacy X Boeing disaster and they
did not have any conclusion about the TAM one. Not a critical word about the government agencies, Ari Force, equipments, softwares and airports. And nothing about demilitarizing the Air Traffic Control.

Sometimes Brazil embarasses me...

Regards to all.

[RWA]

Many thanks, IFixPlanes.

Originally Posted by Lemurian

It seems that there was an ISSUE 1 in a previous revision, the one I referred to as having been found of dubious applicability.
On the other hand, this is a lot more than a warning and a little chime, it is a full fledged RED ECAM Procedure :

Quote:

ENG X THR LEVER ABV IDLE (in Red)
-THR LEVER 1.......IDLE ( in Cyan)

We are no longer on the original league of essentialness !

Must admit to being confused - was this mod always in the document, in that specific form, or was it inserted or amended later (i.e. in Rev. 2 virtually on the day of the accident, or in Rev. 3 after the accident)?

Additionally, what is its status - required, advisable, optional?

And does anyone know whether the warning is being built into new production aeroplanes? Is one entitled to assume that all such design revisions/improvements are automatically incorporated in new construction?

Originally Posted by Lemurian

Oh ! Another funny item on the flow chart is this new value of TLA (TRA ?) of 6° for the initial conditions of the FWC warning.

Lemurian, what is (or could be) the significance of that? Does it refer to the angle above 'idle'? What was the previous value?

[RWA]

Originally Posted by PK-KAR

If not, then, the PF for both landings CGH is the same?

As I understand it, this crew only did two landings. In the first, one lever was put to idle, the other to reverse; the second flight being the accident. One landing was made by a different crew, who put both levers into reverse.

I also believe that the accident landing was carried out not by the ex-737 pilot but by the senior TAM training captain?

Another complication is that the 'both levers to reverse' drill was (is?) incorporated in the European (EASA) MEL for one reverser inop,, but not in the US (FAA) one. So what TAM's procedure was presumably depends on whether the Brazilian authority conformed to the European or the US procedure; or developed one of their own?