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TAM A320 crash at Congonhas, Brazil

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TAM A320 crash at Congonhas, Brazil

Old 2nd Aug 2007, 21:35
  #961 (permalink)  
 
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AlexL, Yes, you said it, the B757 would require you to put the L TR in full reverse and physically advance the R TL to do what seems to have happened with the A320.
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Old 2nd Aug 2007, 21:40
  #962 (permalink)  
 
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OK just re-checked my manauls, and no the 757 will not let you do that!
reverse levers can only be lifted if both thrust levers are closed
either thrust lever can only be opened if both reverse levers are down
.
so you are protected both ways - no reverse if one still in forward, no forward if one still in reverse.

So in order to try and replicate what happened I would have to close both, land, put one in reverse, and re-open the other one - but the aircraft will not let me do that. And thats a 25 year old design. And I'm pretty sure my spoilers would deploy anyway - i need to check the logic on those.
Boeing don't put too many interlocks in, but they obviously think this one is important. Surprising then that with all airbus's interlocks and overides that it lets you do this, and more to the point will actually do it itself.
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Old 2nd Aug 2007, 21:42
  #963 (permalink)  
 
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I've read practically all of this topic, can't instantly point back to the right post, but this sounds familiar, and has been mentioned before. Same scenario, but on a nice long and dry runway. Maybe somebody else remembers.

Rain, short, wet, slippery runway to set the scenario.
"Right TR inop."
Thinks ... what does the MEL and the SOPs say? Do not select the inop TR or select both? Move both TLs to idle then reverse, or leave the righthand TL in idle? Select both TRs anyway, or not select the inop one?
Only seconds, mind you, and something else can have happened to distract.
And somehow, somewhere, a mind link gets broken, and not only does the right TR not get selected (which would not have mattered) but the right TL lever does not get pulled back either, at all.

"No decel!", "no spoilers!"
Twenty seconds to think back to what you did, and to realise there might have been something you didn't do... too long.

No ground spoilers, no autobraking.... if you know the aircraft your thoughts go to the squat switches, or aquaplaning, not to a TL you left where it shouldn't have been - because your mind set at that moment was that it should be there.

Humans will always make mistakes.
They should have margins to correct for them.
There were none, this time.
Short runway, wet runway, no grooving. No overrun, no EMAS.

May their souls rest in peace.
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Old 2nd Aug 2007, 21:47
  #964 (permalink)  
 
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AIUI the airbus will retard thrust automatically regardless of lever position, land, and then disconnect the AT and spool the engine back up to the TL position if the TL is still forward.
Correct, provided thrust levers are between idle and climb detent.

If TL is left in climb detent you get thrust lock - fadec maintains last thrust commanded by the A/THR until TL is moved.
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Old 2nd Aug 2007, 21:48
  #965 (permalink)  
 
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On my 757 the thrust is NEVER anything other than the TL position.
On the 757s I flew, if the engine failed, the TL did not retard itself, so mine must have been different to yours
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Old 2nd Aug 2007, 21:54
  #966 (permalink)  
 
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I believe this is the key question. There is no logic which would support such a condition. AB should just fix it. They are going to get sued anyway, everybody does when something like this this happens. So just fix it.
AB should fix what is broke, no argument, but the last thing you want to dick arround with is a software change just because some lawyer or armchair investigator thinks it's broke.
However if you would like to add a one word qualifier if in front of your statement above then I'm open to listen.
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Old 2nd Aug 2007, 21:57
  #967 (permalink)  
 
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IF TL2 was stuck in the climb detent, the PF would have felt it around 20ft, when he was supposed to retard the thrust levers. So the "I can't" or "it can't" probably does not relate to TL 2. If at 20 ft you realize you can't reduce one TL there is plenty of time for a go around.
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Old 2nd Aug 2007, 22:20
  #968 (permalink)  
 
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1) Are they the same people who are saying that the computer should not allow the pilot to command reverse on one engine and above idle thrust on the other the same people who are appalled at the thought of the computer second-guessing the pilot?

2) I can't immediately see any reason why a Boeing-style interlock: [all TLs not at idle: no reverse allowed] shouldn't be implemented on Airbus types, given that reverse thrust has a secondary effect on stopping distance but may compromise go-around.

3) Should it be SOP not to select reverse (on one or both) until spoiler deployment is confirmed, given that reverse thrust has a secondary effect on stopping distance but may compromise go-around?

Last edited by SyEng; 2nd Aug 2007 at 22:23. Reason: multiple grammatical errors
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Old 2nd Aug 2007, 22:25
  #969 (permalink)  
 
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Im curious.....
Has Boeing fixed the non auto retraction of spoilers upon thrust levers advancement on the 757??? And have they fixed the non retardation of the thrust levers/thrust upon inflight deployment of thrust reverser on the 767???(AA 757 in Colombia and Lauda Air 767)
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Old 2nd Aug 2007, 23:09
  #970 (permalink)  
 
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boeing vs airbus

IF one maker has a better way to do something, its good for the sake of safety to use that method yes? Boeing is not perfect and neither is Airbus. But if AB has a methodology that has been proven to be suspect, then they should emulate some other maker's "tried and true" method.
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Old 2nd Aug 2007, 23:14
  #971 (permalink)  
 
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Training on the B757 now requires verification of speed brake position with GPWS warning go around. It is not automatic. Cali was an example of how this might have saved them, maybe not, it would have been close. The main problem there was navigation and too much raw data and not enough map data that would have showed their error of turning into the mountains. I flew into Cali a lot and it isn't that challengeing. They were just trying to land straight in and not do the ILS approach from the other side. Botota happened to have the same FAF designator as Cali, unfortunately when they headed for it it was on the other side of the mountain. Sorry, drifting away from this thread just trying to answer a question.
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Old 2nd Aug 2007, 23:43
  #972 (permalink)  
 
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IT can't

The voice on the CVR says - IT can't IT can't. NOT I can't. This was in answer to the voice - Decelerate. i.e 'IT CAN'T DECELERATE' Nothing to do with the TL No2.

Why does it not decelerate. - The runway is super slippery, like thin ice was mentioned earlier. The no2 engine would have been producing climb thrust at this stage. Either because the AT had disconnected or that it was trying to maintain Vref. The anti-skid system would be continuously engaging at this time. - just as it should.

There is a fix for having one TL forward on landing and was implemented by Airbus.

Flyingnewbe -
"Airbus has developed a specific warning when one throttle is set to reverse while the other is above idle. This warning generates an ECAM warning "ENG x THR LEVER ABV IDLE", a continuous repetitive chime (CRC), and lights the red master warning light. This new warning is implemented in the FWC standard "H2F3""
It just was not implemented on this aircraft. At least it is not on the CVR.

This warning would probably have saved the day.

According to the SOP into CGH the Wheel Brakes are manual. Hence no decel.
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Old 3rd Aug 2007, 00:22
  #973 (permalink)  
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P.S.: Is it true the envolved Airliner and Aircraft maker participate in the investigation, but Congressmen, by ICAO rules, can't. ?
Can't it make investigations suscetible to vested corporate interests ?
What really rules ICAO ? Is it just aircraft safety ?
Of course the manufacturer participates in the accident investigation, as do many of the specialist suppliers to the manufacturer, they provide detailed technical information to the accident investigation board.

However, why would Congressmen need to take part? What could they possibly contribute? Surely the involvement of politicians is what would make any investigation susceptible to vested interests?

You only have to look at the leaking of the CVR/FDR data, safe at the NTSB, safe in the hands of the Air Force, leaked seconds after being locked in the safe in Brasilia, despite a request from the Brazilian investigators to keep everything under wraps until they had concluded their technical investigation.

Investigations should be left in the hands of the specialists.
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Old 3rd Aug 2007, 01:00
  #974 (permalink)  
 
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And this warning was labeled as "desirable" by Airbus. Not mandatory.

P.S.: Is it true the envolved Airliner and Aircraft maker participate in the investigation, but Congressmen, by ICAO rules, can't. ?
Can't it make investigations suscetible to vested corporate interests ?
First off manufacturers do not make regulatory rules regarding the (re)fitting of parts or procedures. They are recommendations only and are submitted to the regulatory authorities for their juristiction. Thus unless mandated by the authorities the implementation of these recommendations are decided by the user. The manufacturer should of course provide the usefulness and reason for the recommendation. I'm not aware what the specifics are in this case.

Second, I'm quite wary of questions that presuppose the answer (lawyer type tricks0 like is it true?

As an example of who participates in an investigation, a formal investigating body and any qualified experts invited by such fomal investigating body(s). in addition, the FAA in the US has the right to participate at any time even though they are not oart of the formal investigating organization.

Yes the manufacturers do have a vested interest and that is under their certification they must provide to the regulatory body (not necsarily the investigating body) timely corrective actions, warnings etc, to prevent another crash Good one for AB who jumped on this without obfuscation within the first days.
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Old 3rd Aug 2007, 01:18
  #975 (permalink)  
 
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Second biggest hole in the cheese... (IMHO)

Well, first off let me say that I am not a pilot. But I have written quite a lot of software that interacts with humans.

After reading through all the posts in this thread, imho, for the last 500 posts or so the biggest hole in the cheese has been largely neglected.

I understand very well the thinking that changing the flight software to make decisions "for the pilots" is not necessarily a clever idea, that pilots should be kept "in the loop" instead.

I think the second biggest hole in the cheese was that the "Retard, retard, retard" warning ceased right after first TL was pulled to reverse. After viewing the video of another A320 landing posted here, it is quite obvious that it is NORMAL for a pilot to hear two or three "retard" shouts during flare. It is normal, and it is expected. Part of the "culture" of flying this plane. Now, during the accident flight the pilots heard "retard, retard, retard" shouts probably exactly as many times as they have ALWAYS heard. It provided absolutely no new information to them. It did NOT tell them that PF had forgot to pull back the TL2 lever. It basically told them that "you are supposed to pull the levers just about now", instead of "you have forgot the levers". Then PF pulled the lever (mistakenly only one) and the warning stopped. Perfectly normal, it seemed, business as usual.

Only after not feeling retardation and PNF callout "no spoilers, no deceleration" it became clear that something was very wrong. But by that time it was actually quite difficult for them to find out what was wrong:
1. the "retard, retard" call came and went as normal.
2. the PF remembered pulling the levers (by that time he certainly didn't know/remember that he pulled only one), as he should.
3. quick look at the throttles probably showed what he expected to see: one lever in the max reverse, the right lever substantially forward of the left one, hand holding the left lever. Given the shock of "no deceleration" a second or so before, I don't think it would be easy to notice that the right lever is a bit MORE forward from the left lever than it should be.
4. and for the PNF scanning the instruments it would be very difficult too because of the new software version not being installed and hence no warning about right lever being in the wrong position.

*IF* the plane had continuously shouted "retard, retard, retard" at them while they were frantically thinking about what the hell is wrong, why isn't it stopping, then I don't think it would have taken too many seconds for them to see the problem. I would bet the "retard, retard" calls would have actually reached their minds quicker than the written warning on displays, but either way, both would have eventually gotten to them.

As it was I think they went over the end blissfully unaware of the right lever being well forward of idle detent.

Frankly, I can't see ANY good reason for a "retard, retard" calls to stop after one engine pulled to reverse. From CVR it is perfectly clear that it did.

* * *

Besides that, as a secondary thought I think the interlock preventing forward thrust during at least one engine reverse (and ALLOWING spoilers) and/or vice versa: preventing reverse (and spoilers) during one engine forward thrust - makes perfect sense and should be introduced. First off, if even Boeing drivers who hail their planes as epitomes of manual flight consider such interlocking prudent, then it should have been incorporated on AB software even before the plane left the drawing boards. Because AB philosophy is to be MORE active at protecting the pilot from his own mistakes, not less.

And having forward thrust on one engine and reverse on the other IS a mistake, any way you cut it: when on a runway a plane should either be taking off (or going around, almost the same thing) OR stopping, braking. No inbetween, no hesitation. The current setup allows the plane to do neither of the two. Nor accelerate nor decelerate. That should NOT be possible, no matter what. Whenever the plane would do that (i.e. do nothing, no accel, no decel), the result is 100% certainly catastrophic - or at the very least
shockingly close to a nasty incident IF the pilot was quick to realise his/her mistake.

And from Airbus manuals and apparently from common knowledge: when engine(s) have gone into reverse then you ARE staying on the ground, no other choice - then this actually means that from the moment engine(s) have gone into reverse there remains no ambiguity whatsoever about the pilots intentions: he IS going to land. Full stop. When both squat switches are on, wheels are spinning and the reverser has deployed, there's no way to go around anyway (or at least it supposedly isn't), so
one throttle forward should NOT prevent activating the most important braking aid there is - spoilers.

* * *

Of course all this doesn't mean this logic caused the accident - the biggest hole in the cheese was of course a human mistake. But lack of "retard, retard" shouts *has* to be the second biggest, preventing them from diagnosing the nature of the problem quickly.


And no, I don't think AB human interface design philosophy (including the throttle design) is somehow flawed or worse than Boiengs. Implementation, yes, seems to have some flaws, which seem to even have already developed cures, albeit not installed on this particular aircraft because of various parties not respecting the gravity of those shortcomings - even in light of previous accidents.


And no, of course I don't have too many credentials to write about all that. A mere software developer (occasionally SLF) as I am. And a 5 year lurker on this great forum.
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Old 3rd Aug 2007, 02:19
  #976 (permalink)  
 
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Cool

Hello,

AFAIK ... NTSB -DGAC etc... are paid by the governements
So I think ..representatives of the peoples have right to keep a eye of what happend.....with the money of the tax payers.
Just checking ..no intervention.

Regards.
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Old 3rd Aug 2007, 03:07
  #977 (permalink)  
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Very interesting information being tossed around, some points.
.
This accident could have been prevented a few different ways, let's see:
.
1. Some system as AlexL points out that prevents REV being selected until thrust levers are retarded.
.
2. An auto thrust system similar to the Boeing's that retards thrust automatically at a certain height,
.
3. By Airbus modifying Maintenance procedures on one T/R inop; Simply lock both T/R's out.
.
4. Another idea by Tyro, whereby T/R deployment is dependent on spoilers being deployed, thereby giving you the go around option.
.
5. The crew following the current MEL operational procedures for T/R inop.
x
6. The Big Red Button.
.
D.L.
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Old 3rd Aug 2007, 03:58
  #978 (permalink)  
 
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Airbus has sent an email saying that reverser 2 was left in CLB (1.2EPR) until the end. No autbrk and no spoilers therefore. I would post the whole thing, but I am worried about copyright...
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Old 3rd Aug 2007, 06:34
  #979 (permalink)  
 
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"TAM President Marco Antonio Bologna testified before the commission yesterday and said thrust reversers are "the last redundancy" in braking an aircraft. He warned that "any kind of conjecture [on the accident's cause] would be premature before the investigation has been wrapped up." He noted that TAM's sales have been hurt badly by the accident, with ticket purchases down significantly." (ATW)

What a bunch of hypocrats. The brazilian authorities had no problems jumping to conclusions when they arrested two American pilots without a proper investigation. I know TAM had nothing to do with it, but it is pathetic to see what a change in attitude Brazil has had in general when it is one of their own.

I hope they learn something about propper investigation and implementing changes to prevent further accidents rather than just throwing out blame. Unfortunatey, judging by the way they are handling the whole ATC fiasco, I don't think they will.

I just wish exposing this outdated way of thinking hadn't cost so many people their lives.
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Old 3rd Aug 2007, 06:46
  #980 (permalink)  
 
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Originally Posted by nigel on draft
On my 757 the thrust is NEVER anything other than the TL position.
On the 757s I flew, if the engine failed, the TL did not retard itself, so mine must have been different to yours
yes of course you are quite correct. I was referring to 'normal' operations. obviously there are failure cases on both makes that change the ball game.
However I still make the point, that in normal ops the 757 (and all other boeings?) the thrust lever matches the actual thrust delivered at any point n time, whereas on the airbus it doesn't.
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