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TAM A320 crash at Congonhas, Brazil

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Old 5th Aug 2007, 23:19
  #1181 (permalink)  
 
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PLEASE - why is everybody asking that the aircraft should not allow different thrustlever settings?

There is no such thing as a foolproof airplane and surely nobody thought about every silly thing that one could do in the cockpit. There have been incidents that were caused by a set parking brake at touchdown. Should that also been prevented by some logic?

All the Boeing drivers are not getting at ease with the non moving throttles. I think, I can understand your point. But apparently the ones that actually fly Airbus have no problem with that.

So my critical point is what exactly happens with your mindset when you are transitioning from - say - B737 to A320? Is the current training sufficient? Is the different philosophy in operating an aircraft tought well enough and are the trainers / teachers aware of those aspects? It seems to me that it is a completely different thing to get an initial typerating at A320 than transition from B737. One of the pilots of JJ 3054 was just half a year flying A320.

As to the thrustlever positions: How should the aircraft tell which one is wrong and which states the pilot's intention? The reversed lever could have been the wrong one as well as they could have been desperately trying to go around with one malfunctioning lever. Again, the aircraft cannot tell and just lets them do. In general, a running engine is more safe than one that quits thrust for some "logic" reason. You could just cut off fuel if you want the engine to stop, but there would be no way out if the logic would shut down the engine on its own. Think about that, every rule you implement shall not lead to catastrophe in a different situation. If you cannot be sure: Leave all competency at the pilot's actions.

That's what Airbus did here: The engineering is not trying to second guess what the pilots are doing, this is the proof if you wish.

There are just a few rules you should strictly adhere to (or a few more) as with any other airplane.

Last edited by TripleBravo; 5th Aug 2007 at 23:22. Reason: typo(s)
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Old 5th Aug 2007, 23:21
  #1182 (permalink)  
 
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Hand Solo
I think AB310's point is that "idiot proofing" the aircraft is exactly what AB seem to be aiming at (that is not necessarily a criticism since we have long since passed the point when men understood all the workings of the machines which they operate) but that in the process the logic path is sometimes taken away from the comprehension of the pilot brain,which after all remains in the same mod state as at the time of the Wright Brothers.
Hence BOAC's comments about training and my point about the misleading Retard warning which perhaps explains your "how could they."
We can't keep writing off experienced professional pilots who crash Airbuses (or indeed any other aircraft) as "idiots" without this sort of debate. We owe it to our colleagues.

Last edited by Max Tow; 6th Aug 2007 at 00:17.
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Old 6th Aug 2007, 00:16
  #1183 (permalink)  
 
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Originally Posted by ELAC
It's a percentage. Per the MEL it would apply equally to distances calculated on wet or dry runways. In the TransAsia accident Airbus provided calculations for an exhaustive variety of combinations of thrust, braking, spoiler deployment and runway condition. All the numbers can be found in the accident report.

ELAC

PS - The specific value (e.g. 1.15) seems to vary a bit depending on mod status. For a previous carrier's A330's I found numbers of 1.15, 1.18 and 1.2 applying to different aircraft in the fleet.
ELAC,

FYI the TAM landing performance chart below for SBSP 35L/A320-233/V2527E-A5 engines WET CONF FULL shows no landing distance penalty for inoperative spoilers in nil wind or headwind.

Last wind given to the crew from the TWR was 330°/8kts, landing was on 35L, CONF FULL, Gear Down, MED Autobrake, autopilot disconnected at 370' RA, FD/ATR ON. The approach speed was 145 kt, CM1 was PF.

CM1, 54 years old, 14,744 hrs flight time, 2,236 hrs on the A320, last rating test May 19, 2007. CM2 52 years old, 14,486 hrs flight time, 258 hrs on the A320, last rating test June 5, 2007.

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Old 6th Aug 2007, 00:34
  #1184 (permalink)  
 
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Just a thought. If this has been discussed before, I appologise.
Does anybody think the actual design of the throttle quadrant, ie. the fact that you pull the Thrust Levers back rather than the A330/A340 version of pulling them up, had anything to do with his mindset, that at landing I am only going to pull the left Thrust lever back?
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Old 6th Aug 2007, 01:04
  #1185 (permalink)  
 
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so why didn't the crew pull both throttles back?

I'd like to hear the reasons why two type rated pilots DIDN'T pull back both thrust levers/throttles? (though this should not be taken as admitting that they didn't try)
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Old 6th Aug 2007, 01:10
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Bomarcs last ditch procedure would have worked better than what was done but what happens to the antiskid system when you lose all of your AC busses? Boeing systems don't put you in that predicament. Boeing systems are so much more pilot user friendly than Airbus. You always get what you ask for. You don't have to see if Airbus logic agrees. When have you seen a Boeing aircraft go off the end of a runway over 100 knots because the pilots could not control the thrust? No matter who is at fault.
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Old 6th Aug 2007, 01:37
  #1187 (permalink)  
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When have you seen a Boeing aircraft go off the end of a runway over 100 knots because the pilots could not control the thrust? No matter who is at fault.
I am only a pax who has read every post in this thread but what I have read (in more than one post) is that - if you land with asymmetric thrust in a Boeing it is going to be very tricky to have a good outcome. From what is currently known, this a/c landed with asymmetric thrust - for reasons that have yet to be learnt.

Over the years of reading A/B arguments here, I am continually mystified that those arguing do not want to try to understand anything other than what they know. Comments from those who have operated both a/c most usually say: "Each has it's own strengths and benefits, you must just fly the machine as it was built and designed." Whereas those who have only operated one type almost always state as certain that they have the better machine.

I am well aware of the issues at stake and have a not dispassionate interest in the final report of this incident. One of the things I have learnt in 27 years of working in IT is that - whilst you are busy looking for a complex fault and considering a technical solution to the perceived problem, the fault was usually so simple that it was overlooked by everyone and the solution equally simple.
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Old 6th Aug 2007, 01:42
  #1188 (permalink)  
 
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Bubbers44

BKK, B744. #1 thrust lever not at idle, after aborted rejected landing. No reverse as a consequence. No fatalities.

I'm not really sure what airbus logic has to do with closing thrust levers. If you are a pilot, you should know that.
Also the "you always get what you ask for" comment with regards to Boeing aircraft, is a little off base if you understand that that is what was asked for (in aircraft logic terms), a Boeing would do the same thing with one engine not at idle.

Just so you know, I've flown both Airbus and Boeing.
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Old 6th Aug 2007, 02:01
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Originally Posted by bubbers44
When have you seen a Boeing aircraft go off the end of a runway over 100 knots because the pilots could not control the thrust? No matter who is at fault.
"12 SEP 1993, Boeing 747-428, F-GITA operated Flight AF072, Paris-Los Angeles-Tahiti. Weather was good when the flight approached Tahiti at night. The aircraft positioned for a Runway 22 VOR-DME approach. At 21:05 the aircraft touched down at a speed of 168 knots. Two seconds later no. 1 engine power increased to 107% N1.

Because of this the spoilers did not deploy and the automatic brake disarmed. Reverse thrust was used on all remaining engines. Because of difficulties due to thrust asymmetry, the no. 4 engine thrust reverser was cancelled. The aircraft overran the runway and ended up in a lagoon."

Sound familiar ?
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Old 6th Aug 2007, 02:24
  #1190 (permalink)  
 
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This has to be the ultimate A vs B debate!
The facts are that something so simple as retarding thrust levers was tragically c0cked up. This is the classic swiss cheese accident. Take away just one of the main factors and it would just be an incident. Also fact is that the no2 engine kept the same power it had at touchdown. i.e it did not increase to CLB power .This suggests that if it had been a Boeing the end result would have been the same.
God rest all their souls, I hope we all learn something from this tragedy!
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Old 6th Aug 2007, 03:22
  #1191 (permalink)  

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Max Tow

You got it. Fully automate it and idiot proof it or let the pilot have full control of all surfaces/power plants without computer logic based inhibitions....not a mix of the two.
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Old 6th Aug 2007, 03:34
  #1192 (permalink)  
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Boeing 747 F-GITA operated Flight AF072, Paris-Los Angeles-Tahiti. Weather was good when the flight approached Tahiti at night. The aircraft positioned for a Runway 22 VOR-DME approach. At 21:05 the aircraft touched down at a speed of 168 knots. Two seconds later no. 1 engine power increased to 107% N1.
Because of this the spoilers did not deploy and the automatic brake disarmed. Reverse thrust was used on all remaining engines. Because of difficulties due to thrust asymmetry, the no. 4 engine thrust reverser was cancelled. The aircraft overran the runway and ended up in a lagoon.
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Old 6th Aug 2007, 04:47
  #1193 (permalink)  
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As a former Lear and Metro operator, (both REAL airplanes) I'll take the technology.
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Old 6th Aug 2007, 07:48
  #1194 (permalink)  
 
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Hi Zeke ...

Thanks for posting the landing performance chart. It's certainly instructive in terms of the level of analysis that TAM has put into their operations to CGH.

Regarding the effect of inoperative ground spoilers shown as a factor of influence on the chart: The scan is a bit hard to read but I think the two conditions stated on the left side of the chart are "1 pair of spoilers inop" and "2 pairs of spoilers inop". These would match permissible dispatch conditions allowed under MEL 27-64-01. These conditions are different than the case with MEL 27-92-02 where the entire Ground Spoiler Control System is declared inoperative and consequently there are no ground spoilers available at all.

The MEL I'm using for reference is an A330 one so there may be some differences with the A320 but for the A330 it shows no landing performance penalty applicable for 1 pair of spoilers inoperative and a penalty of either 5% or 10% applicable for 2 pairs inoperative (depends on the MSN, different PRIM standards?). As the chart you've provided shows, the actual runway specific performance penalty for 2 spoiler pairs inop for all stated wind conditions is less than the 5-10% conservative correction shown in my MEL (and I assume the A320 MEL). It is probable that the same would hold true for the 15% penalty applicable for the Ground Spoiler Control System inoperative case as well.

Having said that, these factors are intended to be applied to the RLD values used for dispatch, not the ALD values which represent the actual landing distance capability. Depending on how the effect of the actual performance decrement is considered when determining the MEL penalty (is it added before or after factoring?) the effect on ALD may be higher. Certainly the QRH factors for inoperative spoilers are higher, but these are probably inherently conservative and must take into account the various uncorrected system failures that may occur during flight as opposed to an aircraft with an inoperative system properly diagnosed on the ground and then dispatched in accordance with the required maintenance actions.

Taking another look at the Airbus data in the TransAsia report suggests that the performance decrement may well be added after calculating the factored distance (though I would have thought the reverse more likely) as the inferred ALD for all spoilers deployed versus retracted rises by approx. 25% in the one engine in reverse one in idle wet runway case. But again this is based on a specific set of factors (speed, weight, flap config, wheel braking effort, and etc.) which don't conform to the assumptions used to calculate an ALD.

ELAC
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Old 6th Aug 2007, 07:54
  #1195 (permalink)  
 
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FROM : AIRBUS FLIGHT SAFETY DEPARTMENT TOULOUSEACCIDENT INFORMATION TELEX - ACCIDENT INFORMATION TELEXTO : ALL AIRBUS OPERATORS / ATTN : FLIGHT SAFETY DEPARTMENTSUBJECT: TAM LINEAS AEREAS FLIGHT JJ3054 ACCIDENT IN SAO PAULO,BRAZIL
Our ref.: TAM JJ3054 AIT 4 dated August 02nd 2007Previous ref: TAM JJ3054 AIT 3 dated July 24th 2007This AIT is an update of previous AIT n°3 concerning the A320 Tam Lineas Aereas involved in an accident during landing phase at Sao Paulo Congonhas airport- Brazil on the 17th of July 2007 at 06:30 PM local time.
The data which follow have been approved for release by the Brazilian investigation authorities.
It is confirmed that the aircraft was dispatched with the Engine 2 thrust reverser inoperative as authorized by the MEL.It is confirmed that the associated operational procedure of TAM MEL was updated according to current MMEL page 02-78 p1 SEQ 001 REV 29 which reminds the crew to select both thrust levers toidle before touchdown and requires to select both reversers at touchdownThe following is the sequence of events according to the recorders:Final Approach phase:- The aircraft was approaching runway 35L.- The last wind information given to the crew by the ATC was 330°/8kts.- The runway condition given to the crew by the ATC was wet and slippery.- Landing configuration was established with Slats/Flaps fully extended, gear down, ground spoilers armed, autobrake selected to MED.- Approach speed was 145 kts- The final approach was performed with Autopilot OFF - disconnected at about 370 feet(radio-altitude), Flight Directors ON, Auto-Thrust (ATHR) ON. - The CM1 was the Pilot Flying.- The crew approach briefing included a reminder that only the left engine thrust reverser was available.Flare and touch-down:- During the flare, the "RETARD" call-out has been normally triggered - The "RETARD" call-out has been triggered 3 times, ending at the selection of the engine 1 reverser.- Before touchdown, the engine 1 throttle was retarded to idle.- The engine 2 throttle is recorded in the Climb position and remained in this position to the end of recording.- Preliminary trajectory computation indicates that the aircraft landed in the touch-down zone.Landing roll- Just after touch-down, idle reverse was selected on engine 1, followed within 2 seconds bythe selection of max reverse which was kept to the end of recording.- Following reverser 1 selection, the ATHR disconnected as per design and remained disconnected to the end of recording.
- With the engine 2 throttle being in the Climb position: 1/ the engine 2 EPR remained at a value of approximately 1.2 corresponding to the EPR at the time of ATHR disconnection; and 2/ the ground spoilers did not deploy and the autobrake was not activated.- Maximum manual braking actions began 11 seconds after touch-down.- Rudder inputs and differential braking have been applied during the landing roll.- The aircraft overran the runway at approximately 100 kts.DFDR and CVR data show no evidence of aircraft malfunction.At this stage of the investigation, and as already indicated in the previous AIT n°3, Airbus remind alloperators to strictly comply with the following procedures:A- During the flare at thrust reduction select ALL thrust levers to IDLE.B- For the use of the thrust reversers when landing with one Engine Reverser inhibited refer to MEL.When appropriate, additional information about this event will be provided through the normal Airbus to Operators communication channels

Yannick MALINGEVice President Flight SafetyAirbus
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Old 6th Aug 2007, 07:56
  #1196 (permalink)  
 
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ELAC,

I agree, and you can express your thoughts very well.

Originally Posted by ELAC
I don't have current access to an A320 FCOM but the alternative scenario would require something like the simultaneous failure of both TLA sensors [...]
What is more, both TLA sensors would have to continue to transmit valid "Thrust lever in CL detent"-signals for the fault to go unnoticed.


Originally Posted by bomarc
flaps-config 3

manually select speedbrakes extend
Keep two things in mind:
1/ it is doubtful that FLAPS 3 plus speedbrakes, which are only 6 of the 10 available spoiler surfaces at much lower deflection, would create more drag than FLAPS FULL without spoilers (although admittedly CONF3+speedbrakes would create considerably less lift)
2/ speedbrake extension takes 4 to 5 seconds, unlike ground spoilers, which takes only 2s.

Originally Posted by TyroPicard
Sorry bomarc - it's the signal to extend Ground Spoilers that activates the Autobrake. To pull the speedbrake lever back you push it down first - this disarms the ground spoilers. With your memory drill - no Autobrake.
Ground spoilers will extend anyway, even if not armed, if reverse is selected on one engine (and the other is "at or near idle"). I don't know what will happen if speedbrakes are extended, ground spoiler extension logic doesn't mention that, so it should not matter.

It seems that the remedy Airbus came up with after the TransAsia incident, a CRC with a reminder on the ECAM "THR LVR (ENG) not at IDLE" would be the most appropriate one. PM was monitoring the ECAM anyway (we know since he noticed "No Spoilers" and announced it as per SOP), and even if not, at the sound of a CRC you always look.

And in an A320 you always know where to look, which is the point of the C in ECAM ("centralized"). I guess it will be very similar in all modern glass-cockpit aircraft.
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Old 6th Aug 2007, 08:19
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hmmm

by the Airbus telex and what seems to be consensus among those ppl defending the AB system, can I assume that the outcome might be similar to:

Cause of accident: PF failed to retard the #2 thrust lever.
The aircraft performed as designed.

Or in other words: human error is intolerable.

Sorry if this is not very positive posting, but I can't help thinking that's the way it's heading.

I still can't help my personal feeling that, even though the aircraft did perform as designed, it was the design that turned this human error into a disaster.

pj
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Old 6th Aug 2007, 08:29
  #1198 (permalink)  
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hmmm

by the Airbus telex and what seems to be consensus among those ppl defending the AB system, can I assume that the outcome might be similar to:

Cause of accident: PF failed to retard the #2 thrust lever.
The aircraft performed as designed.

Or in other words: human error is intolerable.

Sorry if this is not very positive posting, but I can't help thinking that's the way it's heading.

I still can't help my personal feeling that, even though the aircraft did perform as designed, it was the design that turned this human error into a disaster.
I've been flying the Airbus for nine years now and flown with a few T/R's inop, I wonder how many successful landings have been made throughout the years with T/R's inop?
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Old 6th Aug 2007, 08:33
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@Dream Land

And how many incidents happened with one TR inop on 320 beside this tragically accident?
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Old 6th Aug 2007, 08:35
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hmmm

by the Airbus telex and what seems to be consensus among those ppl defending the AB system, can I assume that the outcome might be similar to:

Cause of accident: PF failed to retard the #2 thrust lever.
The aircraft performed as designed.

Or in other words: human error is intolerable.
Or more accurately put would be that you can't design for every eventuality. If people grossly misuse the system it's going to fail and no amount of clever design will fix that.
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