TAM A320 crash at Congonhas, Brazil
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PBL:
Using my prior analogy and your summarization, Risk Control is keeping the gasoline away, IA is throwing the lighter in the pocket, beeing the 2nd easier to achieve.
The general knowledge of factors originating various accidents is a source for the pilot, to help him identify risks, which is what I think is more critical in Risk Control. Adherence to the SOP's is also a quite "passive" but very important way of contributing to RC, as it uses organizational knowledge systemathized to keep risk away. I also believe the Theory of Chaos is a good way of interpreting flight safety, and managing to mantain a low level of chaos is a good way of mantaining safe flight. Much of this has to do with RC, I think. This may be an old theory, but it seems to work allright to me.
Using my prior analogy and your summarization, Risk Control is keeping the gasoline away, IA is throwing the lighter in the pocket, beeing the 2nd easier to achieve.
The general knowledge of factors originating various accidents is a source for the pilot, to help him identify risks, which is what I think is more critical in Risk Control. Adherence to the SOP's is also a quite "passive" but very important way of contributing to RC, as it uses organizational knowledge systemathized to keep risk away. I also believe the Theory of Chaos is a good way of interpreting flight safety, and managing to mantain a low level of chaos is a good way of mantaining safe flight. Much of this has to do with RC, I think. This may be an old theory, but it seems to work allright to me.
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I'm trying to keep this in line with this site's reason for existence. It is primarily the Professional Pilots' Site, on which, of course, we welcome input from ALL involved in aviation.
I wish to view this from the PP standpoint. The theorists appear to be ignoring the fact that pilots regularly land on limiting and often 'difficult' runways and that this flight was TASKED to do so by the airline ops and scheduling department. Therefore the shortness of 35L at CGH, the wet, the ungrooved surface, the landing weight, the lack of over-run - even, looking at previous landings, the u/s T/R, are not primary causes to us. They are part of the 'routine' operation of that airframe expected on that day. Whether there should have been restrictions etc is for the enquiry - and I firmly believe there should.
At worst we should have seen a minor incident with an a/c in the grass. What turned what should have been a 'routine' landing' into a major accident was the thrust delivered by NO 2. The detailed analysis and categorisation of other factors is, of course, needed, and we also need to know whether the a/c system needs to be changed.
Sadly, it very much looks as if our old friend, the 'Swiss Cheese', had all the holes pretty well lined up except the last one.
I wish to view this from the PP standpoint. The theorists appear to be ignoring the fact that pilots regularly land on limiting and often 'difficult' runways and that this flight was TASKED to do so by the airline ops and scheduling department. Therefore the shortness of 35L at CGH, the wet, the ungrooved surface, the landing weight, the lack of over-run - even, looking at previous landings, the u/s T/R, are not primary causes to us. They are part of the 'routine' operation of that airframe expected on that day. Whether there should have been restrictions etc is for the enquiry - and I firmly believe there should.
At worst we should have seen a minor incident with an a/c in the grass. What turned what should have been a 'routine' landing' into a major accident was the thrust delivered by NO 2. The detailed analysis and categorisation of other factors is, of course, needed, and we also need to know whether the a/c system needs to be changed.
Sadly, it very much looks as if our old friend, the 'Swiss Cheese', had all the holes pretty well lined up except the last one.
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Hey, we're not forgetting that. And "my arguments" that are cited above are not for my position: they are arguments intended to show that the reasoning given for "primary causes" does not prove anything.
The point about causation is just as simple: you are (rightly) asking "what can we as PPs learn about this?" That's perfectly legitimate, as is "How may this affect our jobs or lives as professional pilots?"
My point is that you don't ask this question directly from unsorted data. Before you ask such questions, you need to get at "What happened?" And that can include routine conditions (Gruyere comes in various flavors) that played a causative role. When a robust system fails, you need to examine all the elements in the failure.
After you put the whole puzzle together, then you make a judgment about which factors need mitigation, and defend it against those who don't share your point of view. But that is a judgment, separate and posterior to the reconstruction.
In other words, it's what you're already doing, just formalized. And formalized, it's more persuasive.
The point about causation is just as simple: you are (rightly) asking "what can we as PPs learn about this?" That's perfectly legitimate, as is "How may this affect our jobs or lives as professional pilots?"
My point is that you don't ask this question directly from unsorted data. Before you ask such questions, you need to get at "What happened?" And that can include routine conditions (Gruyere comes in various flavors) that played a causative role. When a robust system fails, you need to examine all the elements in the failure.
After you put the whole puzzle together, then you make a judgment about which factors need mitigation, and defend it against those who don't share your point of view. But that is a judgment, separate and posterior to the reconstruction.
In other words, it's what you're already doing, just formalized. And formalized, it's more persuasive.
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Originally Posted by RWA
Further, the availability or otherwise of run-off areas would appear to be immaterial since none of the aircraft reached such areas before going out of control and veering off the runway altogether.
The Transasia incident landing stayed on the runway until after the runway threshold, and only veered off the stopway. Had this been an EMAS, it would possibly have stopped inside it. Look at the satellite image with superimposed track at pp.49,61 of the "Occurrence report".
Bernd
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Dingerx - all accepted and correct BUT in our cockpit world there is no time for the luxury of extended investigation, databases, statistics and judgements - they can come in the longer term and the most important message to get out right now (and heaven only knows it should have been out before) is CLOSE BOTH THROTTLES ON LANDING (in any twin) or you will most probably die at CGH and elsewhere too. My mind has certainly been 're-focussed'.
Next in urgency is to examine the A320 system to see if there could have been a fault and if there is a need for manual control of spoilers.
Removal of some of the holes has already taken place, but as we know, close one and the particular accident is avoided.
PBL - can you determine a primary cause for the 'events' at Taipei and Bacolod?
Next in urgency is to examine the A320 system to see if there could have been a fault and if there is a need for manual control of spoilers.
Removal of some of the holes has already taken place, but as we know, close one and the particular accident is avoided.
PBL - can you determine a primary cause for the 'events' at Taipei and Bacolod?
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To agree with the theorists here, I would have to agree that all landings at CGH performed under the same circumstances with A-320s were risky. But I can't.
Then I would have to admit that only pilots on their "good days" are capable to land an A-320 safely there (slippery, one Rev inop). And to admit that, I would have to admit that flying A-320s isn't safe.
IMHO, to give too much relevance to the runway on this case, is to compare landings on an aircraft carrier. No margin for error landing there. In CGH there is a margin (not much), and I have to believe that even a pilot having a "bad day" is able to land an A-320 there.
About "bad days" I understand flight computers are there to reduce workload on pilots. I believe also that a pilot having a bad day should be "helped" by computers, but not a partial help. This "I will only help you if you do everything right" mode, instead of helping the pilot overcome his bad day, can transform his and many other people's day on the worst of the worst.
Rob
Then I would have to admit that only pilots on their "good days" are capable to land an A-320 safely there (slippery, one Rev inop). And to admit that, I would have to admit that flying A-320s isn't safe.
IMHO, to give too much relevance to the runway on this case, is to compare landings on an aircraft carrier. No margin for error landing there. In CGH there is a margin (not much), and I have to believe that even a pilot having a "bad day" is able to land an A-320 there.
About "bad days" I understand flight computers are there to reduce workload on pilots. I believe also that a pilot having a bad day should be "helped" by computers, but not a partial help. This "I will only help you if you do everything right" mode, instead of helping the pilot overcome his bad day, can transform his and many other people's day on the worst of the worst.
Rob
Barit1
Well of course I do agree with your statement above.
Some of the layers of swiss cheese are simply environmental issues that are not normally controled, although assumed as normal operating conditions In this case, weather, runway length, pilot fatigue, etc. These types of layers may possibly be controled as potential solutions to prevent future accidents simply by assuming that wrong throttle may occur yet again and that by placing restrictions in the operating enevelop of the plane an accident can be prevented in the future (not terribly practical from a commercial standpoint).
On the other hand there may be some effective layers of swiss cheese preceding the wrong throttle command that if corrected may have prevented this accident, training and prior knowledge of manufacturer's recommendations comes to mind.
So in summary, it's not removing any layer of swiss cheese, but rather selecting the effective layers to remove that prevents the next accident
I don't have an exact list for this accident, nor (I suspect) does anyone else other than the parties to the official investigation.
And (as I used to tell my students) you cannot PROVE your case by analogy, but you can certainly use it as a powerful teaching tool.
The point to be made is that it's unlikely a single causative factor is the culprit.
And (as I used to tell my students) you cannot PROVE your case by analogy, but you can certainly use it as a powerful teaching tool.
The point to be made is that it's unlikely a single causative factor is the culprit.
Some of the layers of swiss cheese are simply environmental issues that are not normally controled, although assumed as normal operating conditions In this case, weather, runway length, pilot fatigue, etc. These types of layers may possibly be controled as potential solutions to prevent future accidents simply by assuming that wrong throttle may occur yet again and that by placing restrictions in the operating enevelop of the plane an accident can be prevented in the future (not terribly practical from a commercial standpoint).
On the other hand there may be some effective layers of swiss cheese preceding the wrong throttle command that if corrected may have prevented this accident, training and prior knowledge of manufacturer's recommendations comes to mind.
So in summary, it's not removing any layer of swiss cheese, but rather selecting the effective layers to remove that prevents the next accident
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wileydog3 makes this trilogy of points:
The trick of course is to properly manage all three, and of those layers of cheese, you must choose the one(s) which can be improved most efficiently. Unfortunately, trying to fix them all may put you out of business.
Every airline operates with an eye on three factors; safety, risks and economics.
If you want to be completely safe, you don't fly.
If you accept all risks, you are highly vulnerable to accidents/incidents.
If you don't acknowledge economics, you're out of business.
If you want to be completely safe, you don't fly.
If you accept all risks, you are highly vulnerable to accidents/incidents.
If you don't acknowledge economics, you're out of business.
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Originally Posted by bsieker
Sticking to the facts helps to make your argument more persuasive.
"The aircraft touch down at 1,750 feet on Runway 10, and rolling off 321 feet from the end of Runway 10. The aircraft stopped in the northern side of the stopway with heading 002 degrees."
The aeroplane left the runway before the end - its further progress was 'achieved' skidding sideways with the nose pointing at an angle of about 90 degrees to the runway direction, and it was finally stopped by the nosewheel falling into a drainage ditch.
Now that point's cleared up, do you have any OTHER comments on the points I made?
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Originally Posted by RWA
With all due respect, Bernd, I did. From the Report:-
"The aircraft touch down at 1,750 feet on Runway 10, and rolling off 321 feet from the end of Runway 10."
"The aircraft touch down at 1,750 feet on Runway 10, and rolling off 321 feet from the end of Runway 10."
The aeroplane left the runway before the end.
Bernd
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I don't have the A320 tables, but for the A310, Actual Landing Distance:
Weight 120 tons (MLW is 124 tons, Max takeoff W for the A320 must be around 70 tons)
No Reverser
Autobrakes off
DRY = 880m
WET = 1250M
COVERED W/ 6.3mm OF WATER = 1900m
For dispatch, this weights shall be divided by 0.6, and in flight they can be used as reference, although they require *test pilot* performance in the landing.
So, this should give a fair idea of how short CGH really is for the A320.
Weight 120 tons (MLW is 124 tons, Max takeoff W for the A320 must be around 70 tons)
No Reverser
Autobrakes off
DRY = 880m
WET = 1250M
COVERED W/ 6.3mm OF WATER = 1900m
For dispatch, this weights shall be divided by 0.6, and in flight they can be used as reference, although they require *test pilot* performance in the landing.
So, this should give a fair idea of how short CGH really is for the A320.
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RWA
Look at 1.18.1 of the Taipei report. Looks like EMAS there would certainly have had a chance to contain the aircraft. But you are not entirely wrong in that it didn't go to the very end of usable pavement, but did go past the threshold of 28.
p.s. Putting EMAS on stopways would make them cease to be stopways of course. In the sense that you couldn't then park any aircraft there. Better put them just off the existing pavement.
Look at 1.18.1 of the Taipei report. Looks like EMAS there would certainly have had a chance to contain the aircraft. But you are not entirely wrong in that it didn't go to the very end of usable pavement, but did go past the threshold of 28.
p.s. Putting EMAS on stopways would make them cease to be stopways of course. In the sense that you couldn't then park any aircraft there. Better put them just off the existing pavement.
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3Ten,
A320 at MLW 65tons...
# Required landing distance, Runway dry,at 2.600 ft : 1610 m
# Runway wet : 1849 m
# Runway with 3 to 6 mm standing water : 2379 m
# Runway with 13 mm standing water : 2266 m
The above are factored distances and assume no aquaplaning, no reversers and no autobrakes.
and...
PK-KAR
A320 at MLW 65tons...
# Required landing distance, Runway dry,at 2.600 ft : 1610 m
# Runway wet : 1849 m
# Runway with 3 to 6 mm standing water : 2379 m
# Runway with 13 mm standing water : 2266 m
The above are factored distances and assume no aquaplaning, no reversers and no autobrakes.
and...
PK-KAR
Sun worshipper
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PK-KAR,
Thanks for that sheet.
As I suspected, dispatch for *Runway Wet* was ok.
What I'd like to know is whether, instead of the straight "All Reversers inoperative", there's a crew performance limitation on the MELed T/R. So far, I've seen about everything on several companies'policies, from a NO-NO on contaminated runway to a "Takeoff only" approval.
With these figures in mind, though, there is absolutely no way they did consider looking into the "Contaminated Runway" pages, and neither did the Dispatch department...Surprising considering the multiple reports on the runway state and the ATR42 mishap.
Thanks for that sheet.
As I suspected, dispatch for *Runway Wet* was ok.
What I'd like to know is whether, instead of the straight "All Reversers inoperative", there's a crew performance limitation on the MELed T/R. So far, I've seen about everything on several companies'policies, from a NO-NO on contaminated runway to a "Takeoff only" approval.
With these figures in mind, though, there is absolutely no way they did consider looking into the "Contaminated Runway" pages, and neither did the Dispatch department...Surprising considering the multiple reports on the runway state and the ATR42 mishap.
I support PPRuNe
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Hi good people...I miss you...
I am here In Los Angeles. I flew a Embraer ERJ 145 from Newark to Baltimore and back ( as a passenger of course...). Great ride. II wished I could pilot it...
Then BWI to Los Angeles...
On the way I thought... is there an example of similar accidenrs with a reverser locked out on Boeings 737?...Or any other airplane? This came to my mind when we were landing at LAX...
Regards to all.
Then BWI to Los Angeles...
On the way I thought... is there an example of similar accidenrs with a reverser locked out on Boeings 737?...Or any other airplane? This came to my mind when we were landing at LAX...
Regards to all.
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PK-KAR, thanks for the info.
gpvictor:
WHAT?? Am I understanding it right? You're beeing argumentative, I would risk to say that you won't get many feedback form pilots here.
gpvictor:
The fact that a plane does a safe landing is without doubt an event.
I believe that that a clearer understanding of what is being debated may come from considering what we would do to prevent a similar, but not the same accident.
e.g. How would you ‘use’ EMAS. Would it be a risk management tool to compensate for a short runway without a standard overrun area; or would EMAS be there to mitigate your (or other’s) error during a landing?
e.g. How would you ‘use’ EMAS. Would it be a risk management tool to compensate for a short runway without a standard overrun area; or would EMAS be there to mitigate your (or other’s) error during a landing?
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Thanks for the responses, Bernd, armchairpilot94116.
Or an inaccuracy in the diagram of the aircraft's path? 
Bernd, perhaps I'd better recapitulate what I originally said:-
Happy to amend the last sentence to read just 'Further, the availability or otherwise of run-off areas would appear to be immaterial since none of the aircraft reached such areas before going out of control' if you wish.
I honestly cannot work out why this discussion KEEPS coming (or being 'steered') back to the Congonhas runway - given that the 'exact same' accident has occurred quite recently on much longer runways elsewhere.
In any case, the 'solution' usually proposed (EMAS) is not in fact a solution at all. It is at best a means of turning a completely uncontrolled arrival into a 'somewhat controlled' one. There's no doubt that EMAS might have reduced the severity of two out of the four accidents (the ones where the aeroplanes stayed more or less on the runway line until late on) but even in those two cases there would still have been a considerable risk of death or injury.
That's why I expressed the opinion, in the original post, that "neither its condition nor its limited overall length would appear to be in the same league as the wrong TL position, the inop. reverser, and the non-availability of both ground spoilers and autobrakes as 'causes'."
Mind you, Bernd - looking on the bright side - given that you only commented on the Taipei incident, and did not dispute the other cases, can I take it that you broadly agree with me on the limited relevance of runway length?
Tony
Originally Posted by bsieker
This is an inaccuracy of the (presumably) English translation of the narrative in the report.The aircraft passed the runway threshold while still almost aligned, although quite a bit to the left of the centerline
Bernd, perhaps I'd better recapitulate what I originally said:-
Originally Posted by RWA
Congonhas is the fourth recorded serious occurrence of this type - and the major points of similarity are:-
1. Aircraft was A320.
2. One reverser was inop.
3. One TL was wrongly-positioned.
4. ALL aircraft eventually swerved off the runway BEFORE the end.
There is no apparent correlation as to runway length. At Bacolod the length was 5,932' (i.e. shorter than at Congonhas); at Phoenix 11,500'; and at Taipei 9,200'. Further, the availability or otherwise of run-off areas would appear to be immaterial since none of the aircraft reached such areas before going out of control and veering off the runway altogether./
1. Aircraft was A320.
2. One reverser was inop.
3. One TL was wrongly-positioned.
4. ALL aircraft eventually swerved off the runway BEFORE the end.
There is no apparent correlation as to runway length. At Bacolod the length was 5,932' (i.e. shorter than at Congonhas); at Phoenix 11,500'; and at Taipei 9,200'. Further, the availability or otherwise of run-off areas would appear to be immaterial since none of the aircraft reached such areas before going out of control and veering off the runway altogether./
I honestly cannot work out why this discussion KEEPS coming (or being 'steered') back to the Congonhas runway - given that the 'exact same' accident has occurred quite recently on much longer runways elsewhere.
In any case, the 'solution' usually proposed (EMAS) is not in fact a solution at all. It is at best a means of turning a completely uncontrolled arrival into a 'somewhat controlled' one. There's no doubt that EMAS might have reduced the severity of two out of the four accidents (the ones where the aeroplanes stayed more or less on the runway line until late on) but even in those two cases there would still have been a considerable risk of death or injury.
That's why I expressed the opinion, in the original post, that "neither its condition nor its limited overall length would appear to be in the same league as the wrong TL position, the inop. reverser, and the non-availability of both ground spoilers and autobrakes as 'causes'."
Mind you, Bernd - looking on the bright side
- given that you only commented on the Taipei incident, and did not dispute the other cases, can I take it that you broadly agree with me on the limited relevance of runway length?Tony
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I guess Boeing pilots got spoiled knowing that on a short slick runway no matter what the airplane wanted to do you could always go manual ground spoilers, manual brakes, manual reverse and if a throttle stuck half way up you could shut the engine down and not have to worry about if the ground spoilers would retract or not deploy. I know this realy annoys some people but I always liked it that way. Just my opinion.