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TAM A320 crash at Congonhas, Brazil

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TAM A320 crash at Congonhas, Brazil

Old 1st Aug 2007, 22:51
  #881 (permalink)  
 
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it appears that with full configuration and no air/ground logic telling the spoilers the plane is on the ground, there is NO WAY to get spoilers.

I understand that in config 3, one can at least deploy speedbrakes (inflight spoilers if you will) and get the plane to be heavier on the wheels to trigger ground spoilers.

it has been mentioned that TAM requires CONFIG FULL for landing at this airport.

regarding ducking the glide slope. there is an old joke at midway...after a plane goes off the end, the rest of the pilots say...he followed the glide slope.

the fact that the pilot flying called for glide slope inhibit meant he knew he was going into a short field and wanted everything HE KNEW TO BE TRUE to be on his side.

while there may be a ton of data saying this is wrong, it is still done and it is not done as much at airports with very, very long runways.

regarding which do you want first, spoilers or reverse...spoilers should be out before you can get into reverse just as a matter of speed of the spoiler mechanism. also, many planes, not all, require the nose wheel to be on the ground prior to having pilot select reverse.
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Old 1st Aug 2007, 22:51
  #882 (permalink)  
 
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Well put, about the design holes, Kit d'Rection KG.
I think it's those holes that the report will have to focus on.
If human error stood at the beginning of the chain or not won't make a huge learning item for the future.
Question for the AB people: What is the SOP when you realise you have no spoilers?
I might sound cynical but I'm not sure there is such a SOP... simply because it's not supposed to happen...
and yet the deployment of ground spoilers is rigidly inhibited by the governing logic.
Before the Warsaw incident, it required both squat switches to deploy full spoilers.
They've fixed that.
But the thing I still don't understand:
why not use full manual braking as an override signal for the whole ground spoiler inhibition?
Why is this logic so rigid in the first place?
Were the engineers afraid the spoilers could deploy in flight?
They would surely have to be armed to do so, no matter if in flight or on the ground.
There are situations where you would love to be able to tell the system that you know better, and this clearly was such a situation.
Any automation system will only perform those tasks that the designers could envision.
pj
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Old 1st Aug 2007, 22:55
  #883 (permalink)  
 
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What is the SOP when you realise you have no spoilers?
No SOP, because there's no requirement for one, and it wouldn't work anyway...
Maybe we should rephrase this as "what is the SOP for a landing where the AB automation fails to recognize (for whatever reason) that the plane has landed and should be slowing down"... ?!
Again there was a big mistake in leaving the T/L above idle, but there might be other occurrence (such as a sensor malfunction) that will prevent spoiler / autobrake magic... what do you do then ??
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Old 1st Aug 2007, 22:58
  #884 (permalink)  
 
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@Rbonatta
My point is: "Look this" means something is weird ? What could the pilot be refering to ? And the answer, decelerate, decelerate. Decelerate is not break, right? Wouldn't decelerate mean pull back the throtle? And if that is the idea, why the answer I can't, I can't ?
The transcript says 'IT can't It can't' - Not I can't.

@Flyingnewbe:
This is my understanding and I may be wrong:-
If it was an airworthiness directive then this HAS to be implemented and there is a timeline when this has to be done.
If if was a service bulletin then this is optional or at least some are.

My first post here mentioned
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?
All the paperwork will be thoroughly examined and any anomolies will no doubt be uncovered.

The point you mentioned will be one of them along with the MEL updates.

Interesting that the 'Retard Retard' call stopped at 18:48:25.5. I would have thought it would be continuous untill both TL are at idle. - Maybe they were?

Jim
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Old 1st Aug 2007, 23:22
  #885 (permalink)  
 
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No, that would be ground spoilers. Just reassure me - you don't fly a big aeroplane, do you?
You usually arm the ground spoilers for their automatic extension upon touchdown yes. That means they should be the first braking system to be set in motion.

But what I wanted to stress is that the PF real preoccupation and first action on a short and slippery runway will be asap to set TLs to full reverse.

The PNF will immediately check and announce the spoilers deployment, the REV and the deceleration status if the autobrake is used.
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Old 1st Aug 2007, 23:29
  #886 (permalink)  
 
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Just an aside note: who would be the female voice reported in the CVR transcript ? I don't imagine a flight attendant entering the cockpit during landing roll...
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Old 1st Aug 2007, 23:39
  #887 (permalink)  
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My guess

Tam plane was carrying many TAM personnel and was totally crowded with 187 people inside. I guess perhaps an off duty airline hostess traveled inside the cockpit somewhere. By the way the plane was fueled in Porto Alegre with 9 ton of fuel and it needed 4 to 5 to arrive at Congonhas. Why? Because the taxes on fuel were less expensive there. The plane was weighting 62.7 ton and it was reported that the maximum landing weight would be 64.5 ton.
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Old 2nd Aug 2007, 00:08
  #888 (permalink)  
 
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people behave as they do because it makes sense to do so.
Repetition does not help to this becoming true.

There are many examples against, but one did stick in my head: An airplane (100+ Pax) landed, suffered exceptional deceleration, all wheels deflated - the pilots did have the parking brake on whilst touching down. As far as I know, nobody was seriously injured, but on a small wet runway things could have developed other than that.

Does this make any sense to do so for any pilot? For sure not and don't tell me it "made sense". (I looked it up, parking brake was no check item neither in the checklists of that particular aircraft nor in any other I am aware of. Maybe because you cannot foresee every(bad)thing human beings are able to do?)

People not always behave like they do simply because it "makes sense". Psychology is far more complex and obviously this applies also to professional pilots on duty. (Hopefully less than average, but....)


Disclaimer: This is no statement against the poor guys of JJ3054 and implies nothing particular with this flight, it is against wrong simplification.
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Old 2nd Aug 2007, 01:30
  #889 (permalink)  
 
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UPDATE 2-Throttle error likely key in Brazil crash - probe
Wed Aug 1, 2007 7:21PM EDT
(Changes sourcing to congressional committee, adds quotes)

BRASILIA, Aug 1 (Reuters) - An engine throttle in the wrong position was probably a major cause of Brazil's worst air accident last month, a congressional committee reported on Wednesday, citing flight recorder data.

Marco Maia, a senior member of the panel investigating the July 17 crash that killed 199 people as well as Brazil's long-running air traffic crisis said the throttle "was not in the correct position." But he added this did not necessarily mean human error, as some local media have suggested.

"It is irresponsible to say it was pilot error. ... All the standard landing procedures were carried out. It is premature to say the pilots were responsible," Maia was quoted as saying on the congressional Web site.

Maia said aircraft equipment failure had not been ruled out, and that it was possible the pilots had shifted the throttle lever correctly but that the plane's computer had failed to respond.

The report casts doubt on initial speculation that a slippery runway was the major cause of the accident. Aviation authorities were criticized for opening a recently repaved runway without the grooves that allow rainwater to drain more quickly and help avoid skidding.

"The runway had a smaller influence. It may have contributed, but was not the dominant factor," Maia said.

An Airbus A320 (EAD.PA: Quote, Profile, Research) operated by Brazilian carrier TAM Linhas Aereas (TAMM4.SA: Quote, Profile, Research)(TAM.N: Quote, Profile, Research) barreled off the wet runway while landing at Congonhas airport in Sao Paulo on July 17, crashed into a cargo terminal and burst into flames. All 187 people aboard and at least 12 more on the ground were killed.

Data from the flight recorder suggests that one of the thrust levers was in the "accelerate" position when it should have been switched to idle because one of the aircraft's thrust reversers was inoperative. TAM had acknowledged that it had a defective reverser, which is used to help brake.

Airbus issued a safety advisory to its customers last week stressing the need for pilots to follow proper landing procedures when a thrust reverser is not working.

The congressional probe read out loud on Wednesday the last 12 minutes of cockpit conversation, as horrified viewers followed the drama on national television.

The transcript showed the pilots were aware of the disabled thrust reverser but were unable to brake the plane.

"Reverse one only," "Slow down, slow down," and "I can't, I can't," the pilots shouted. The last statements recorded were "Oh my God!" and "Oh, no!"

The committee decided to make public the cockpit transcript, but it examined the remaining data from the flight recorder in a closed-door session.

Aviation authorities are also looking at other possible causes of the accident, including the runway condition and other mechanical problems.

Air travel in Brazil has been in chaos since 154 people were killed last September when a Boeing 737 (BA.N: Quote, Profile, Research) clipped wings in midair with a private jet and crashed in the Amazon.
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Old 2nd Aug 2007, 01:54
  #890 (permalink)  
 
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From the quote in the above post:
"It is irresponsible to say it was pilot error. ... All the standard landing procedures were carried out. It is premature to say the pilots were responsible," Maia was quoted as saying on the congressional Web site.
As far as I'm aware, no-one has yet shown that reverse was applied to both engines in accordance with TAM's revised MEL (IF that was what was on the aircraft).The transcript comment "Reverse number one only" can be interpreted in a number of ways, not all favourable. In which case, how on earth can this government spokesman say in the same breath that "all the standard landing procedures were carried out"?
What a way to conduct an investigation. Officials saying don't jump to conclusions, then doing just that.
Interesting report above re tankering fuel into CGH. Not an issue in isolation, just another hole in the cheese that night.

Last edited by Max Tow; 2nd Aug 2007 at 02:37.
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Old 2nd Aug 2007, 02:13
  #891 (permalink)  
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TV News

Just came from the TV. The black box with the voice of pilots is out...but guess what...the CENIPA Chief said that it was necessary a software that it is not founf in Brazil to listen to the whole recording...It had been done by NTSB in english. Then it was said that Airbus Industry offered to companies to place a warning voice and light to advise the pilots when the throtle lever of a locked down reverser was left in the forward position. Many companies did this. Apparently TAM did not do. In the recording, when one voice asked to decrease acceleration the other said " I can´t " (meaning I am unable to). There have been reports now - also in TV - that workers for the airlines have been pushed to work more than their shifts and at least one pilot has complained that he was forced to land in Congonhas against his better judgement. 131 flights were diverted from Congonhas to Guarulhos (Cumbica) but Guarulhos is close to capacity and its runway is now 4 years old and needs recapping. The Minister of Defense wants Congonhas not longer be a hub but only an airport for flights to Congonhas and from Congonhas to within certain limits. The air companies don´t seem to agree... The crises in Brazil is growing and the end is not near. It seems that investments were not made in the last few years when the demand for air traveling went up fast.
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Old 2nd Aug 2007, 03:53
  #892 (permalink)  
 
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Since started flying AB, I only belive the beast in under control and deccelerating when I arrive at home. Those brakes come direct from Wright bike shop.
It is amazing the CENIPA, a top ranking Brazilian Air Force official don`t know what GPWS means.
So, one more AB overrun. Again "pilot error". How much more until AB do some thing?
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Old 2nd Aug 2007, 04:24
  #893 (permalink)  
 
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(flyingnewbie10)

Interesting that the 'Retard Retard' call stopped at 18:48:25.5. I would have thought it would be continuous untill both TL are at idle. - Maybe they were?
I suspect (suspect) it was a TL fault.
Not pilot error...
I believe someone earlier stated that the "retard" call only occurred for 2 secs after WoW by design.

In fact, it was you!

Besides, one should notice that in the accident in Taiwan the only remainder of wrong positioning of the TL was the "retard" alarm for two seconds. This is pointed out as a risk that should be dealt with by Airbus in the accident report.
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Old 2nd Aug 2007, 05:27
  #894 (permalink)  
 
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let me ask this again:

ground spoiler deployment is totally under control of the airplane systems. No manual way for the pilot to do it manually.
Also, the logic equation behind that requires a number of parameters to become TRUE before it will allow spoilers to deploy.

Does anyone have an Idea why the system tries so hard not to deploy them? What would the opposite case be? Would a wing with all the panels up suffer structural overload apart from probably losing 80-90% lift?

I can perfectly understand that you don't want a wing with fully deployed spoilers while you're still in the air, but there are so many air-to-ground checks in the equation, it's amazing. What's the scenario that the engineers were afraid of?

pj
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Old 2nd Aug 2007, 06:29
  #895 (permalink)  
 
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Would a wing with all the panels up suffer structural overload apart from probably losing 80-90% lift?
On the A320 there are ground spoilers and flight spoilers. (In fact it is partly just a question of the maximum deflection, not of the control surfaces used).
Driving factor for not allowing several spoilers to operate (or to fully deflect) in flight is not the loss of lift. This is much lower than 80-90% anyway. Main problems are pitch trim changes and turbulence hitting the stabilizer, causing high dynamic loads there and causing some control difficulties, which you do not want to have close to the ground. Structural overload of the wing is no factor.

I have already witnessed landings with flight spoilers operated until close to touchdown, but I do not remember on which plane this was. Might have been a 737 as well.
Could anybody enlighten me, whether the flight spoilers are available during any phase of the flight, even close to the ground with the flight controls being in flare law, at all flap settings, with U/C down?
Will there be an auto spoiler function (armed spoilers, lever pulled) if one T/R is inop on the A320? (See the FedEd MD-11 Crash Report for comparison, the pilot was not aware that the ground spoiler auto deployment is not working, with the No.1 T/R inop)
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Old 2nd Aug 2007, 06:52
  #896 (permalink)  
 
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Design and Phylosophy

I agree with you, a TL fault could well explain it... but as you touch-down and you see NO ground spoilers deploying, in that case a go-around could be initiated because you've got eng-2 (rev pinned) ready to go and lots of speed (even if you got eng-1 retracting the shells you'll be up to flight speed in a second or two). At short runways like this one there is no time to think (or read and interpret ECAM or even do any stupid LOSS of BRAKES recall action) you have to be go-around minded and that is that... What is really to blame is the design and flight philosophy. If that TL moved as in the Auto-Throttle design or if he had simply disconnected the AUTO-THRUST the same-time as the AUTO-PILOT (as opposed to AIRBUS recomendation) this accident would not have happened! I think too much automation is not very good for split-second decision making. Think about that!
Regards,
A320 pilot
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Old 2nd Aug 2007, 07:18
  #897 (permalink)  
 
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Deployment of Ground Spoilers

let me ask this again:
ground spoiler deployment is totally under control of the airplane systems. No manual way for the pilot to do it manually.
Also, the logic equation behind that requires a number of parameters to become TRUE before it will allow spoilers to deploy.
Does anyone have an Idea why the system tries so hard not to deploy them?
Looking at the diagram quoted earlier, i don't agree with you. In fact the logic seems to be doing it's best to deploy the spoilers, never mind if the pilot wants them.
Just to recap - if the following conditions are met, the ground spoilers will deploy -
One of (both wheels speed > 72kt) or (RA<6ft and both MLG compressed)
plus
one of (ground spoilers armed and TL at or near idle) or (one TL in reverse and the other TL in reverse or at or near idle)
It seems to me that the first condition is designed to detect that the plane is on the ground, and the second condition is to detect that the pilot wants it to stay on the ground
As the pilot cannot do anything to influence the first condition the only thing that has to be done to achieve ground spoiler deployment is to ensure that both TLs are in idle, or reverse, or one idle and one in reverse. The logic takes that as a positive signal of intent to stay on the ground.
Of course, I cannot comment on how the logic actually detects the position of the TL or the possibility of a physical problem preventing TL movement.
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Old 2nd Aug 2007, 07:42
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The problem is: Did they know the right engine was pushing them forward ? Didn't they credit that situation to the slippery runway and that prevented them from simply shutting down the right engine ?
we will obviously never know for sure but I would say that they never fully understood what was going on. Otherwise I'm pretty sure that they would have tried to kill that engine, no matter the "apparent" T/L jam. I guess panic might have (understandably) hindered their judgment.

In any case their only viable option IMHO was an immediate go around. There was no way to stop that plane with very degraded braking due to no spoiler deployment on a wet (and short) runaway.
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Old 2nd Aug 2007, 08:10
  #899 (permalink)  
 
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bomarc
the fact that the pilot flying called for glide slope inhibit meant he knew he was going into a short field and wanted everything HE KNEW TO BE TRUE to be on his side.
As General Norman Schwartzkopf said, this is Bovine Scatology. Why inhibit a warning that is designed to help you out of a hole?

James7
Interesting that the 'Retard Retard' call stopped at 18:48:25.5. I would have thought it would be continuous untill both TL are at idle.
I have read somewhere that one T/L in reverse cancels the Retard warning - or both at idle.
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Old 2nd Aug 2007, 08:24
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The problem here is that Airbus design takes the pilot out of the picture. A connection between thrust-levers would make it difficult for a quick EGT ajustment on a hot-engine (for example). On an auto-throttle system that moves respectively with the power, this would not have happened because the pilot would know when the engine is accelerating with his hands. On the Airbus during normal flight the Thrust-Levers are fixed on the CLB detent until flair. As the pilot is flairing for touch-down he cannot know what the power is doing because he cannot look down to see, and a warning "retard, retard" triggers and so the pilot must reduce both levers to idle then reverse on touch-down - This is what did not happen. The pilot did not know the power was increasing. He did not realise that one Thust Lever was advanced or faulty, and thus could not know its power because he must be looking out to maintain center-line. On the other hand the co-pilot during roll-out must read ground-spoiler and engine reverser deployment and auto-brake action. The co-pilot at this point could not interpret whether the engine without the reverser deployed would have a abnormally high N1 (EPR) power because he cannot compare with the other engine (which is on reverse thrust). It is very dificult to know what is going on when flying the airbus just by feel. You always have to read everything on the FMA and ECAM!
Regards
A320 pilot
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