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TAM A320 crash at Congonhas, Brazil

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TAM A320 crash at Congonhas, Brazil

Old 27th Sep 2007, 03:09
  #2481 (permalink)  
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The facts...

I also believe that the accident landing was carried out not by the ex-737 pilot but by the senior TAM training captain?
There was earlier a flight from Belo Horizonte to Congonhas and the crew landed with one TL in Reverse and the other on Idle.

Then the accident crew took over, went from São Paulo to Porto Alegre and back. They landed in Porto Alegre OK. The second pilot was the one who flew before for Transbrasil in 767-200 and 737s. He was with TAM for 6 months in training for A320s and was recently promoted to comandant. The other had been with TAM since 1987 and was getting ready to retire.
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Old 27th Sep 2007, 05:00
  #2482 (permalink)  
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Thanks, marciovp. But just to get it straight, were things as follows (according to the FDR, anyway)?

1. Porto Alegre landing - Pilot Flying ex-737, both levers put into reverse.

2. Congonhas (accident) landing - Pilot Flying senior-TAM, only one lever retarded/put into reverse.
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Old 27th Sep 2007, 06:41
  #2483 (permalink)  
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RWA,

At the previous landing but one, at Congonhas, with a different crew, both thrust levers were reduced to idle, then #1 was put into reverse.

At the previous landing, at Porto Alegre, both thrust levers were reduced to idle, then both were put into reverse.

At the accident landing, one thrust lever was put into idle, then reverse, and the #2 was left at CLB detent throughout the incident recording.

Source is the "standard" copy of the FDR transcript.
I don't remember what the sources are for which pilot flew which leg.

If you don't have the "standard" copy of the FDR transcript, the URL for it is on our WWW page on the accident.

One may conclude from the observations above that TAM crews did not use a SOP for handling thrust reduction on landing with one reverser locked out.

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Old 27th Sep 2007, 07:56
  #2484 (permalink)  
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Thanks, PBL. As you'll gather, I'm still puzzling over the 'human factor' angle, either one of two such experienced pilots making such a basic mistake.

According to this (AP) account, Captain di Sacco (much experienced in 737s, but a relative newcomer to A320s) was the "Pilot Flying', Captain Lima (the TAM veteran and training pilot) was co-pilot.

http://www.nctimes.com/articles/2007...2_118_1_07.txt

"Only one reverser. Spoiler nothing," says pilot Henrique Stephanini Di Sacco, 53, giving the first indication that something is wrong.

"Look at that. Slow down, slow down," says co-pilot Kleyber Lima, 54. Di Sacco replies: "I can't. I can't. Oh my God! Oh my God!"

Lima's last words are: "Go! Go! Turn! Turn! Turn!"


That makes more sense - in that a relative newcomer to the aeroplane would be more likely to get confused. It also possibly explains why the nominal 'co-pilot' seemed to be giving instructions in the last moments ('Decelerate!'....'Turn!') rather than offering advice.

Brings up a possibly-relevant new angle, though. From the CVR transcript, the words attributed to Captain di Sacco are shown as emanating from the 'HOT-2' microphone; which, as far as I know, records the occupant of the righthand seat. Don't know about anyone else, but I've up to now been visualising the PF in the lefthand seat.

"18:48:26.7 HOT-2 reverse number one only.
"18:48:29.5 HOT-2 spoilers nothing.
"18:48:30.8 HOT-1 aaiii. [sigh]"

As an amateur flyer, I'd have thought that if the 'Pilot Flying' was indeed flying the landing from the righthand seat (after all those years as a captain with his previous airline) it can't have made landing in such difficult conditions (or handling the throttles in a dark cockpit?) any easier? But I'm sure that the professional pilots on here can comment more authoritatively on that issue?
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Old 27th Sep 2007, 09:47
  #2485 (permalink)  

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About cockpit crew

Please stick to the known facts :
  • the aircraft was flown from the left-hand seat
  • the pilot on the right-hand seat was doing his job as assistant to the handling pilot, and as such, the annunciations came from his side. Forget CAM as it is *cockpit area microphone* and concentrate on the *hot mikes* which precisely record left or right-hand seat interphone/communications.
  • We know, from the CVR on technical communications only that TAM's SOPs are very much in-line with normal AI fleet practice. We even have on this forum a witness to this fact.
  • from the crew perspective, this was a training flight.
Now some interpretations on which we have no answer, yet :
  • What was the exact nature of this training flight ?
    The Brazilian press said that the co-pilot had been recently promoted as captain.
    If so, what was he doing in the right-hand seat ?
    The only explanation, from every airline I know and every DGCA -or equivalent- is that he was undergoing some line training in order to obtain right and left -hand seat approval to become a TRI. There is no other explanation.
    That situation aggravates the case for a *particular cockpit*
  • Who was the handling pilot on the previous sector ? I am not holding my breath for that answer.
  • Have the duties of both pilots being throughly briefed, because during the ground roll, there was an important breach of procedures. As a fact, it seems that the lesser type-experienced pilot took over. That did not help.
Be very careful in trying to use the CVR as on its own ; it is just about worthless. Needs to be aligned with all the other data available.
And I still wonder at the usefuness of *aiiii* and *look at this* or *O my God* in this forum. They belong to something very private and have to do with respecting the intimacy of deceased people.
Their publication is just too ghoulish for me, I presume.
Defending the dead pilots should start there, but it is just my opinion.

Last edited by Lemurian; 27th Sep 2007 at 10:03.
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Old 27th Sep 2007, 10:12
  #2486 (permalink)  
 
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To Lemurian, posts 2391 and 2394.

A couple of technical inaccuracies in your posts.

If a reverser is de-activated, the sleeve will indeed not move. If however the associated thrust lever is pulled into reverse range, the engine WILL spool up to the slightly higher idle setting that belongs to reverse! The correction of +55 meters to required landing distance on contaminated runways is the result of the fact that the (extra) forward thrust of the engine must be taken into account, while the retarding effect of the (serviceable) reverser may not be accounted for.

If a reverser is de-activated and the associated thrust lever is pulled into reverse range, the amber REV indication will appear on ECAM, because there is a disagreement between commanded position and actual position of the sleeve. Also, ECAM caution REVERSER FAULT will be displayed indicating a failure of the (locked) reverser to perform as commanded.
During normal reverse use, amber REV indication is not the result of the movement of the sleeve, but of the temporary disagreement between commanded and actual sleeve positions.


General information.

Some time ago, people have requested EPR and / or N1 figures for full reverse.

EPR indication about 1.05, which is a low figure for the amount of thrust. However, during reverse thrust, EPR value is not representative of thrust level as it is during forward thrust.
N1 is 72,5%, which will be a lot more representative of the thrust level that the engine is producing.

EMIT.
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Old 27th Sep 2007, 10:30
  #2487 (permalink)  

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Emit,
Thanks for your post.
If a reverser is de-activated, the sleeve will indeed not move. If however the associated thrust lever is pulled into reverse range, the engine WILL spool up to the slightly higher idle setting that belongs to reverse! The correction of +55 meters to required landing distance on contaminated runways is the result of the fact that the (extra) forward thrust of the engine must be taken into account, while the retarding effect of the (serviceable) reverser may not be accounted for.
I know that. Never said anything else.
If a reverser is de-activated and the associated thrust lever is pulled into reverse range, the amber REV indication will appear on ECAM, because there is a disagreement between commanded position and actual position of the sleeve. Also, ECAM caution REVERSER FAULT will be displayed indicating a failure of the (locked) reverser to perform as commanded.
I'll have to go back on that one. I flew recently with that inop T/r and I did not see the amber light, nor the ECAM fault.
On the CFM, the amber *REVERSE* indicates a transit/not locked condition and afaik not a disagreement with the command.
Following the quiet/dark cockpit philosophy, in that situation the warnings -unnecessary- are de-activared, aren't they ?
I'm going back to the manual again. Doesn't hurt.
Regards.
Ps : Are you operating V-2500 s ?

Last edited by Lemurian; 27th Sep 2007 at 10:39. Reason: PS
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Old 27th Sep 2007, 11:15
  #2488 (permalink)  
 
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To Lemurian

Yes, I fly the IAE engines.

In #2391 I read "With a locked reverser, the affected engine won't go beyond idle thrust."
I interpreted that as you meaning that the slight elevation of idle would not take place. I just wanted to make clear that it does.
I think that the concept, that not all "idles" are identical, is rather confusing to people, like ChristiaanJ, not actually flying jets (e.g. think of idle with engine anti-ice ON or OFF). That's probably why you see questions about it recurring rather often.

As far as the ECAM cautions are concerned, they are mentioned in the MEL. For myself, it has been to long ago that I had a reverser de-activated and moreover, that will have been in the time of the MEL procedure to not pull the de-activated one into reverse.

As to the "amber for disagreement point" I would have to search long and hard to find that - undoubtedly the descriptive text in FCOM will state that it indicates that the reverser sleeve is in transit. In general however, all travel of valves, etcetera, is indicated amber as a result of such temporary disagreement between commanded and actual position. An ECAM caution or advisory for faulty position would only occur after "enough time for normal travel" has timed out.

Regards, EMIT.
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Old 27th Sep 2007, 11:27
  #2489 (permalink)  
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Originally Posted by Lemurian
Forget CAM as it is *cockpit area microphone* and concentrate on the *hot mikes* which precisely record left or right-hand seat interphone/communications.
I do actually know that, Lemurian - that's why I mentioned 'HOT-2.'

I started off trying to discover which of the two pilots actually flew the landing. I still don't know; do you?

Captain di Sacco has been named in a number of press articles as the 'pilot flying.' But the CVR phrases attributed to him came from HOT-2. I agree that most of what he said is more likely to have been part of the 'back-up' co-pilot role rather than that of the pilot flying. But that would mean that the vastly-experienced A320 pilot, Captain Lima, was flying the landing; and that makes it even more unlikely that an oversight like failing to retard both throttles,and indeed then put them both into reverse, could have occurred.

So can you confirm that Captain Lima was in fact the PF?
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Old 27th Sep 2007, 11:56
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RWA,

Yes, it was capt. Lima the pilot flying the final landing at Congonhas.

You can google "Veja on line" or Comandante Lima pilotava...

I don't think there any doubts on who was flying (as long as I read).


sorry to intrude...

Rob
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Old 27th Sep 2007, 12:08
  #2491 (permalink)  

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RWA,
I do not have a reliable source as to who was on which seat
You'll have to wait until the final report on that subject.
I just pointed at the reasons why I reserve my judgement on that particular pairing.
What is sure - and even subject to caution, as we cannot dismiss the *instructor training* going on - is that the approach was flown from the left-hand seat : The FDR graphs show it. That 's all.
The published FDR graphs on the landing at POA don't show who was handling that approach, or from which seat.The flight control graphs are missing.And one cannot expand on *X used the T/L this way, Y did it differently*. The only thing we can say is that there are some differences in that handling, some of them not adhering to the published SOPs.
So there you are.
As to the *why such experienced, trained individuals could make such a basic mistake ?*, you are not qualified. NOBODY on this site is. Please refer to the Highest Authority, if you believed in one.
The only most complete study I know - but it even needs to be completed by some very good additions from this forum - comes from Bielefeld University. They, at least have the quality of thoroughness and factuality that is sorely missing from certain posters.
I, as a professional, awaits the outcome of the accident report for comparison with Bernd's WBG and Peter's comments as, having studied past comparisons between their work and the actual official report, theirs are -should be - the most useful for Flight Safety.

Regards.
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Old 27th Sep 2007, 12:17
  #2492 (permalink)  

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RWA,
As an addition to my latest post, and answering your
started off trying to discover which of the two pilots actually flew the landing. I still don't know; do you?
SOPs are quite stringent .
One pilot flies, the other monitors...that's the basics, but that's enough for this subject.
During the approach, the handling pilot asks for settings (Speeds, flaps, landing gear....) the non-handling pilot executes, then confirms the action.
The NHP also monitors and ammounces tyhe changes on the screen messages ( no need to be too specific here).
So, if you read *Reverse one only*.....it comes from the guy assisting the handling pilot.
Now make up your mind.
I certainly do not trust the newspapers to give me the identities.
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Old 27th Sep 2007, 15:11
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RWA,
Since many objects of the accident investigation came public because of a Congress Committee Inquiry, some information are reliable. Note that I said some. This "Inquiry Committee" was installed after the midair collision over the Amazon, and is investigating the crises of safety that that accident unveiled. And then came the accident with TAM # 3054.

Among other things, but related to you question, this Inquiry (CPI - Comissão Parlamentar de Inquérito) verified TAM's dispatch records and confirmed Capt. Lima was the PIC. Of course, they could've swapped seats. But it was his first assignment after vacations, I think he wanted to "drive"...

They also inquired the pilot who performed the previous landing at Congonhas before handing over the plane to the last crew. When asked why he chose to bring just one TL to reverse, leaving the other at idle, he said that given the slippery condition of the runway, by doing so he would not have the extra forward thrust caused by selecting the "locked" engine TL to reverse. He was also asked if this "extra forward thrust" he wanted to avoid when selecting TL to reverse on a "locked reverse" engine, is normal. His answer was yes, and he added stating that this "extra forward thrust" is not much, but it is more than leaving TL at idle.

Maybe this can explain why on "nice" runways (POA) is SOP (TAM) both TLs to reverse and also (maybe) there is another "SOP" selecting only one TL to reverse on the "good" engine when runway is slippery (CGH).

Again, I can understand why many contributors here on this thread get sceptical when we (Brazilians) post information we see on the press. If this CPI wasn't going on, info on aviation accidents could be pure speculation of the press, not only here, but anywhere. But because of this "Inquiry", we (normal public) are having access to live information (many of the sessions are broadcasted) and some (like me) have "senate TV" as one of the channel options on cable TV.

It is also important to note that this CPI is not doing the official accident investigation, but has the "authority" to subpoena anyone. And that was how many important info was "leaked" (FDR & CVR is an example).

regards

Rob

Last edited by Rob21; 27th Sep 2007 at 21:16. Reason: substituted PF for PIC (makes all the difference...)
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Old 27th Sep 2007, 15:38
  #2494 (permalink)  
 
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Lemurian
What was the exact nature of this training flight ? The Brazilian press said that the co-pilot had been recently promoted as captain.
If so, what was he doing in the right-hand seat ?
The only explanation, from every airline I know and every DGCA -or equivalent- is that he was undergoing some line training in order to obtain right and left -hand seat approval to become a TRI. There is no other explanation.
There is - one which appeared right at the start of the thread, where somebody (Dani??) said that TAM Captains flew together as normal line crews, swopping seats to fly as PF in LHS.
I raised the question of recency in the RHS for PNF, and got no response. Perhaps I will this time!

Tyro
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Old 27th Sep 2007, 18:19
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I started off trying to discover which of the two pilots actually flew the landing. I still don't know; do you?
Look at the stick displacement on the FDR and it'll tell you which was doing the landing, however, If I remember correctly, after touchdown the CVR got very confusing as to who was doing what, and some of the recordings did not match what one would expect from who was in LHS and who was in RHS...

What is sure - and even subject to caution, as we cannot dismiss the *instructor training* going on - is that the approach was flown from the left-hand seat : The FDR graphs show it. That 's all.
And...
that's why I mentioned 'HOT-2.'
Voila! I'll join you in the "wonder and ponder" group...

The published FDR graphs on the landing at POA don't show who was handling that approach, or from which seat.
This is the one we've all been asking...

The only thing we can say is that there are some differences in that handling, some of them not adhering to the published SOPs.
BINGO! I am asking the same questions.

As to the *why such experienced, trained individuals could make such a basic mistake ?*, you are not qualified. NOBODY on this site is.
We can only guess, not judge... that, for the moment, is reserved for the "Highest Authority" for He knows all and we can only wonder, argue, or keep guessing... *grin*

When asked why he chose to bring just one TL to reverse, leaving the other at idle, he said that given the slippery condition of the runway, by doing so he would not have the extra forward thrust caused by selecting the "locked" engine TL to reverse. He was also asked if this "extra forward thrust" he wanted to avoid when selecting TL to reverse on a "locked reverse" engine, is normal. His answer was yes, and he added stating that this "extra forward thrust" is not much, but it is more than leaving TL at idle.
Thanks for that, is it possible for the handling pilot to have been briefed on it by the previous crew or that he was caught out as it was "his first assignment after vacations" ?

PK-KAR
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Old 27th Sep 2007, 18:50
  #2496 (permalink)  
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I'd like to clear up some hanging points here. I chided marciovp and Rob21 for not using the proper AI designation for SW that they claimed to be talking about. The replies were
Originally Posted by Rob21
The guy who started this "FW3" thing was the V.P. of safety for Airbus, in the presence of the press and broadcasted nationwide
Originally Posted by marciovp
We did not do it PBL. We just listened from the TAM President and the Representative of Airbus. Now if Airbus says something to Brazilians and something else for the rest of the world, this is not our fault...
Both of these comments are wrong.

The AI rep to whom both are referring, Yannick Malinge, did not mention such SW by any name when he appeared before the CIP on 9th August, 2007. In fact, he said that AI considered whether they needed a supplementary warning about reducing thrust to idle and decided no, for two reasons: (1) they already have one (the "retard" message), and (2) reducing thrust to idle on flare is basic airmanship that one learns on day one of flying. He also backed this decision up by saying that it is necessary to get approval from regulatory authorities for any such modification and that the authorities always ask the question whether the mod is necessary or not; whether there is an "unsafe" condition of the airplane which such a mod would address. And there isn't such a condition which is not already addressed (by the "retard" warning).

The relevant comments by M. Malinge are to be found on pp107-8 of the official transcript, in answer to a question by Deputy Marco Maia, and on p123 in response to a question by Deputy Luciana Genro.

Now, whatever one thinks of that reply, that is what he said (modulo my translation and rephrasing).

For me, one major point follows. Namely, that this mod was not offered in A320-31-1297 Revision 2 on 16 July 2007, because if it had been M. Malinge would have found it necessary to say in his deposition on 9th August that AI had offered it; and instead he said that AI didn't.

I believe this answers to a high level of certainty our question about when this SW mod was first offered: namely, in Revision 3, on 31 August.

My hearty thanks to the late lamented flyingnewbie10, who sent me the official transcript of the session with M. Malinge's deposition.

PBL

Last edited by PBL; 27th Sep 2007 at 19:28. Reason: Changed a word
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Old 27th Sep 2007, 19:14
  #2497 (permalink)  
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This was Captain Henrique Stephanini Di Sacco who flew with Tansbrasil
since the 80´s flying all equipments including Boeing 737, 767-200, etc.
In 2001 Transbrasil went broke and he stopped flying. He took care of other businesses. In 2007 he came to TAM and trained for 6 months before being promoted to Captain. He was very well thought by all his colleagues at Transbrasil where he had no problems.
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Old 27th Sep 2007, 19:52
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PBL,

On August 14th, on the same "inquiry" (CPI), Mr. Marco Aurélio de Castro (Safety VP for TAM) announced that the software mod would be available from Airbus to TAM and they (TAM) are going to begin it's installation beginning October this year.

Rob
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Old 27th Sep 2007, 20:06
  #2499 (permalink)  

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TyroPicard.
The only explanation, from every airline I know and every DGCA -or equivalent- is that he was undergoing some line training in order to obtain right and left -hand seat approval to become a TRI. There is no other explanation.
There is - one which appeared right at the start of the thread, where somebody (Dani??) said that TAM Captains flew together as normal line crews, swopping seats to fly as PF in LHS.
Thanks, I found it : post #469 by Rippa who's no longer with us but seemed to have the most accurate info on TAM. But still,
That's against quite a few rostering rules elsewhere...

Rob21 writes :
They also inquired the pilot who performed the previous landing at Congonhas before handing over the plane to the last crew. When asked why he chose to bring just one TL to reverse, leaving the other at idle, he said that given the slippery condition of the runway, by doing so he would not have the extra forward thrust caused by selecting the "locked" engine TL to reverse.
Doesn't look very good about TAM SOPs, does it, if everybody could use his own personal procedures ? This lack of trust of one's hierarchy should be a concern in Brazil.
I know of someone else on another airline who lost his bars for six months for doing just that. He too had a seemingly valid reason.

Contrarily to the public perception, Flight Safety is not only about acting on an accident report, it mainly deals with what PBL calls *Prophylaxy*, i.e working ahead of trends, insuring strict crew adherence to SOPs, monitoring good standards of training...etc...
In the pilot community, the FCOM is called *The Bible* for no other reasons. Once good flight practices and discipline are allowed to slip, there's an incident waiting to happen.

Among other things, but related to you question, this Inquiry (CPI - Comissão Parlamentar de Inquérito) verified TAM's dispatch records and confirmed Capt. Lima was the PF.
That cannot be correct : the dispatch records would only show who the Flight Commander was.

Last edited by Lemurian; 27th Sep 2007 at 21:02.
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Old 27th Sep 2007, 20:20
  #2500 (permalink)  
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Originally Posted by Rob21
On August 14th, on the same "inquiry" (CPI), Mr. Marco Aurélio de Castro (Safety VP for TAM) announced that the software mod would be available from Airbus to TAM and they (TAM) are going to begin it's installation beginning October this year.
Thanks, Rob. The story is beginning to come together.

As I understand it, the Director of Safety of TAM, Sr. Marco Aurelio, gave a deposition on the morning of Tuesday 14th August (it was announced by the President of the CPI at the close of the meeting on 9th August).

I hope I can get the transcripts of that session, as also the session with the President of TAM, and then we can see what the story is on this SW.

PBL
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