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TAM A320 crash at Congonhas, Brazil

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TAM A320 crash at Congonhas, Brazil

Old 24th Jul 2007, 15:47
  #461 (permalink)  
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I think it would be beneficial if you could manually extend the flight spoilers with the lever to transfer some weight and at least get the very complex deceleration sequence started. You may do that in config 3 but not in config Full but with short & slippery conditions the extra speed of config 3 is not acceptable
What are you talking about, do you fly an Airbus?
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Old 24th Jul 2007, 16:11
  #462 (permalink)  
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hetfield - it is an Airbus issued Accident Information Telex addressed to all Airbus Operators.
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Old 24th Jul 2007, 16:29
  #463 (permalink)  
 
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The Vice President of Flight Safety at Airbus normally issues an accident information telex to all either type specific (e.g. A318/A319/A320/A321) or all Airbus operators after every significant accident/incident. As far as I can remember back those telexes have always been factual when compared to the official report issued sometimes years later. E.g. they issued one after the Armavia A320 accident, soon after that data was recovered, it was factual, and corresponded to contents of the official report.

The telex normally contains information on the accident/incident, and more importantly manufacturer recommendations (if applicable) to prevent it from happening again.

The telex is not about finger pointing, it is providing the best available information possible to operators from the manufacturer to enhance flight safety to prevent a similar occurrence.
absolutely

Flight safety (offices) does not issue communications for political or face saving reasons.

I would hope that all operators of this equipment at their flight safety office understand and implement any necessary actions to ensure that this is addressed.

What the public believes as well as the general aviation community is less important as long as the respective flight safety departments at the airlines take heed of this communique.
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Old 24th Jul 2007, 16:44
  #464 (permalink)  
 
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I read once a long time ago in flight dispach wall:
"There is no dangerous place than a DC9 cockpit with two captains".
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Old 24th Jul 2007, 17:11
  #465 (permalink)  
 
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@Jose lourenco

Don't know DC9, but concerning 727, 300/310, 320 , 340, you are absolutely right.
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Old 24th Jul 2007, 17:27
  #466 (permalink)  
 
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Why no one (Gov) has explained the diference in RWY Lenght between Jeppsen and Brazilian charts, I mean, if the new hotel compromises the minima of the NPA for RWY 35, why everyone (airlines, INFRAZERO, DECEA,ANA(r)C) still use the bigger TORA?
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Old 24th Jul 2007, 17:29
  #467 (permalink)  
 
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http://www.smartcockpit.com/pdf/plan.../systems/0010/
This page shows the logic for ground spoiler operation
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Old 24th Jul 2007, 17:38
  #468 (permalink)  
 
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Flight Safety

Incidents or accidents are not just isolated incidents IMHO, unless of course it is a deliberate or willful act. That is certainly not the case here.

When an incident/accident happens the Flight Ops department should be looking at itself first and foremost. Flight Ops management have a duty and a responsibility to protect its employees and to give them all the help guidance and instruction within their control. Did they do enough to prevent such a situation from occurring?

What is an aircraft with an inop thrust reverser doing going to ‘marginal’ airfield, more so when wet – because it is legal – is that a good enough answer. Certainly not especially since it has had several incidents and near ‘misses’ in the past.

How many times in the simulator and for real has the thrust lever of an engine with a locked out thrust reverser been left in the climb detent on landing. I would imagine enough times and how many times has this been demonstrated in the simulator, probably not enough times.

The human brain is so complex that no one really understands it, only a thousand and one theories. I remember in the sim the instructor leaning forward and in a real western drawl said ‘Do you like that noise’. A warning horn was going off but both of us (pilots) had blanked it out during the emergency procedure. Of course it was driving the instructor nuts.

Here we have a situation where there are 2 Capts operating with one on a line check, the weather is not good, the runway is wet and by all accounts slippery, thrust reverser locked out, long duty day. These are some of the factors we know about. What about the human factors? Rosters and duty times plus a hundred and one other questions that need to be answered; all of which could have played a part in this tragic event.

I would not think for a minute that the pilots even heard the continuous retard retard – ASSUMING that the TL was above idle. Again getting back to the organizational responsibility – has this situation been demonstrated in the simulator, has a notice to aircrew been raised over this very possibility. The managers should be examining every aspect here and asking ‘did I do enough’ what more can be done.

Airbus have issued a 'Notice'. Had the airline issued such a notice in the past, I would hope they have done now.

The MEL states that ‘It is recommended not to select reverse thrust on the affected engine’ is it an SOP to brief for this. If not should there be one?

The report on ‘how good pilots make bad decisions’ mentioned earlier is worthy of mention again. This should not only be compulsory reading but also part of CRM training. How many times have pilots continued without being stabilized. Is there a stabilized Call? If not why not. On the airbus the call is – decel, spoilers, reverse green. Often just said and not monitored. But is a fault regularly practiced in the sim, not enough I would think.

Next in line is the Airport.
Enough has been said about the airport conditions which almost certainly played a factor in this accident.

As BOAC mentioned earlier the holes all matched up. Everything seemed to be against them.

What I am afraid of though is that this may go down as another pilot error, which would be grossly unfair on the pilots and aviation.

The flight ops management has a duty to protect and care for the pilots, I just hope that they have the resolve to do so here. They must stand up for their employees. It was not JUST their fault.

All factors should be considered and a thorough examination of every aspect of this accident. This should then be fully published so we can all learn from mistakes made.

Anyone can make a mistake and we all do. Sometimes we get away with them others are not so lucky. 4HP; would you have got away with it here, unlikely. What if the r/w was properly drained – possibly? We should give support to those involved and everyone can learn.

Flight Safety is for everyone and is not for those who want to castigate.

Jim
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Old 24th Jul 2007, 17:53
  #469 (permalink)  
 
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#443

That's what our MEL says:

One or both may be inoperative provided the inoperative reverser(s) is (are) deactivated and secured in the stowed position, and operation on contaminated runway is not expected.
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Old 24th Jul 2007, 19:19
  #470 (permalink)  
 
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I am not trying to speculate on the accident, but maybe shed some light on the Airbus comments, and some interesting further posts / links.
A- During the flare at thrust reduction select ALL thrust levers to IDLE.
What else can this mean but 1 TL was not retarded to idle...?
LEM's strange comment from an obvious non-pilot:
Landing an airplane with the thrust levers fully advanced is NOT natural.
I hate Airbus.
backs this up... I cannot think of any Airbus or Airbus procedure where you do not land with the TLs at idle

Subsequent posts seem to indicate a handling "issue" with 1 Rev Inop... in that the MEL states not to select "Rev Idle" on the Inop reverser - since the engine will accelerate to "Reverse Idle" thrust - somewhat higher than "Ground Idle" and therefore provides an element of forward thrust. The HP concentrates so hard on not selecting Reverse he also forgets to idle the TL with potentially disastorous consequences on thrust (ATHR disconnets so engine goes to CLB power), Spoilers (don't deploy - and if you call Gnd Spoilers without checking... ) and Autobrake (won't deploy)... (apparently from posts above).

In BA, due to our strange role swapping system, the NHP selects Reverse. Whilst most people knock the BA system, purely by coincidence in this case it helps - the HP doesn't have to remember anything strange, and will idle all TLs prior touchdown. It is the NHP that has to "remember" to only select Rev on one side (and usually forgets - or I do anyway - and selects both!).

IF the TAM suffered from this i.e. #2 at > idle thrust, potentially CLB Pwr, #1 in Reverse, potentially full Reverse, AND no spoilers and/or autobrake, then on that runway, and wet / ungrooved, the outcome is hardly surprising. The lessons would clearly be HF based, given the previous instances... and some training and/or systems change required to prevent something I find strange to be happening, but appears not to be a "one off"...
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Old 24th Jul 2007, 19:25
  #471 (permalink)  
 
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S7 Airlines flight 778

Causes of the accident

According to the preliminary results of the investigation[5], the accident was caused by the left engine thrust reverser's failure to deploy. The thrust reverser in question was known to malfunction prior to the accident. When the pilot attempted to slow down the plane by deploying the right engine thrust reverser, the left engine was inadvertently switched into takeoff mode, causing the plane to accelerate.


http://en.wikipedia.org/wiki/S7_Airlines_Flight_778
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Old 24th Jul 2007, 19:57
  #472 (permalink)  
 
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Although the relevance of the S7 accident to the TAM accident may be as yet tenuous, I find it hard to believe that the cause of the S7 accident was the failure of the left engine reverser. Surely the cause was the loss of control following forward thrust having been applied inadvertantly to the left engine?
As someone has already alluded to, the holes were 'inline' on the Swiss Cheese model. It is for the investigating authorities to determine the cause, which has had several notable factors mentioned, such as an MEL item, wet conditions on a newly surfaced, short runway and two Captains possibly on a tiring training day. Neither of the above factors should have caused such a tragedy on its' own, but when added to the landing weight and Vref and the possibility of a deeper and softer touchdown than desirable, they may all have contributed to this unfortunate overrun.
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Old 24th Jul 2007, 20:57
  #473 (permalink)  
 
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Originally Posted by NigelOnDraft
The lessons would clearly be HF based, given the previous instances... and some training and/or systems change required to prevent something I find strange to be happening, but appears not to be a "one off"...
One change that was also suggested in the Taipei accident investigation (section 2.5.4) is not to inhibit the RETARD warning on one engine reverse selection. In other words, if you forget one of the thrust levers to above idle during the ground run, the warning will not cease until you positively correct it (or failing that, have such a serious overrun that it removes power from the FWC).

I know it's not a fool proof method due to the sensory lockout problems associated with repeated warnings, but IMHO a warning of that sort should not automatically stop without being acknowledged. Selecting reverse on one engine with the other being higher than idle should be considered a very serious misconfiguration during the landing roll and be associated with a Master Caution annunciation (and this would be separate from the normal call at 20 ft RA). If you ever need to use reverse on one side and high thrust on the other while taxying, then it would be cancellable as a Master Caution or from the ECAM.
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Old 24th Jul 2007, 21:33
  #474 (permalink)  
 
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The Airbus note is for all fleets and covers the case of non fadec A300 family which have been known to have the occasional throttle jam/freeze.
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Old 24th Jul 2007, 21:42
  #475 (permalink)  
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I'm really sorry to ask this, all you AB folk, but as an 'old-fashioned' Boeing driver, how can you 'forget' to close the throttles on landing - or do you have no control over the engine speeds?
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Old 24th Jul 2007, 22:00
  #476 (permalink)  
 
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S7 778 Irkutsk A310.

hetfield,

I followed S7 778 discussion in Russian forum. Here what was talked about:

-1- full forward power was triggered at the moment reverser handle(s) was moving home AFTER working reverser was used. FDR reported expected slowdown from single reverser.

-2- Reverser handle movement (gradual on-to-off) was rather synchronous with forward power gain (gradual off-to-on) (from FDR).

-3- official report blames crew for unintentional pushing power handle(s) along with reverse handle(s). Sleeves or unfortunate finger was to blame. Official report was not published but was re-told by official media.

-4- Many discussion participants, included A310 pilots, disagreed with official findings. Claims were made that (by one-hand) moving handles together impossible by handles geometry.

-5- Leading alternative version of the event included some kind of mechanical/electrical/computer malfunction that caused forward power gain from reverse handle movement. Wrong INOP reverser locking procedure was suggested as a factor.

-6- No go-around attempt was seen in FDR data.

-7- Tragically, crew (and most of passengers) died. Official version (be it right or wrong) did not hit nor airline management, nor Airbus; so it stand for now.
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Old 24th Jul 2007, 22:05
  #477 (permalink)  
 
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I'm really sorry to ask this, all you AB folk, but as an 'old-fashioned' Boeing driver, how can you 'forget' to close the throttles on landing - or do you have no control over the engine speeds?
The TLs tend to sit in the "CLB detent" - this is you "setting" the max thrust the ATHR can use. Once nearing/in the flare you bring them back to idle - and if you don't it shouts "Retard" at you (and the front few Pax rows ) ... to remind you.

The "Retard" is to stop you forgetting... and the unintended consequences that may be a factor here. It further seems that once an engine goes into Rev, maybe the "Retard" stops?
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Old 24th Jul 2007, 23:53
  #478 (permalink)  
 
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From Aviation International News today

Brazilian Tragedy Sparks Int’l Ops Considerations
A week after the tragedy in Brazil that killed nearly 200 people when a TAM Linhas Aereas A320 went off the end of the runway at Congonhas airport in São Paulo, business aviation operators are reflecting on the safety of international operations, specifically in Brazil. Although the FAA has not issued any formal advisories for Brazil, David Solo, a trip planner at Universal Weather & Aviation, said that certain airports and runways are restricted and that the situation is still unsafe. “The unfortunate thing about the changes in Brazil is that there really haven’t been any,” he said. Although Universal is able to offer a range of services for international operators, Solo said that even with security and a proper airport assessment he still advises not traveling to Brazil unless it’s absolutely necessary. Meanwhile, the International Federation of Air Traffic Controllers’ Associations said last week that air safety is still compromised in Brazil.
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Old 25th Jul 2007, 00:44
  #479 (permalink)  
 
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Assuming the AB letter is based on the TL of the reverser locked out engine not being moved to idle:
  • Would the noise of the gear running through the water on the runway prevent the crew from hearing the "Retard" announcement?
  • Would the TL position inhibit the spoilers, autobrakes and perhaps even the "Retard" announcement?
In the Dover C-5 accident, the problem engine was shutdown and a good engine was left at idle.
The discussion of that accident produced the opinion that it was better to move all the TLs together as it would not prejudice the shutdown engine and would avoid the risk of not using all the remaining engines.

The same doctrine may apply here as it seems more important to ensure the TLs are both at idle than to avoid attempting reverse on a locked out engine.
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Old 25th Jul 2007, 01:01
  #480 (permalink)  
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2 Captains

... wonder if the PF (capt) was in the right seat?
.
... a somewhat different feel to the left i.e. throttles lefthand, stick righthand ... opposite their normal (left seat)!
.
Throttle retard may feel very different from that seat??
.
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