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TAM A320 crash at Congonhas, Brazil

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Old 6th Aug 2007, 15:14
  #1241 (permalink)  
 
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I'm inclined to agree with soaring also. Perhaps such focus on a non-standard landing config had simply confused the brain. That added to a mind set that they were going to experience a slippery runway. Emphasis on runway state at the expense of the actions required at touchdown?
Do we know if this was their first landing of the day?
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Old 6th Aug 2007, 15:30
  #1242 (permalink)  
 
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Ok, so let me complicate this logic a little.
Having in mind that Vref+something is not that far from V1 for a specific leg and usually a bit lower, why not INHIBIT that command above V1 (if this speed is entered on the FMGC as it normally should).
Simple. Bellow V1 uncommanded REV deployment would set the other engine to idle and the situation is treated as a RTO. OTOH on a situation of T/L left above idle on landing would let the plane do its magic. Either situation would trigger autobrakes and spoilers.
GD&L

Okay:

Below V1 uncommanded REV deployment would set the other engine to idle and the situation is treated as a RTO + DUAL LGCIU FAULT (Loss of A/G signal) = 1 ENG uncommanded reverse on approach at Vref + 1 ENG auto-commanded to idle = Dead Again!

Now to be fair, in this case I'm not sure that the default value for a loss of A/G signal from both LGCIUs is GROUND, but I think it is. It might be the last reported position or it might be different depending on the receiving system, I don't really know. Do you?

How about an incorrect V1 speed entered by crew? Optimized performance take-off where V1 is 20-30 knots above Vapp? Loss of FMGC V speed data to the autothrust? There are lots of cases to consider and if you get any one of them wrong you could leave the crew and airplane hanging like dead ducks without power when they really, really need it ... just ask anyone who's done a reverser deployed on takeoff scenario in the sim.

I know the thinking is well intended on your part (and by most if not all here), but I'm mystified by how we can have one part of the crowd carping that there's too much or too much wrong with the automation leading to a lack of crew awareness of the condition and another part of the same crowd mooting that an uncommanded automated reduction to something as vital as the thrust on a normally functioning engine in a critical flight regime might solve the apparent problem.

The way all the bits of automated logic fit together and the way they connect to human decision processes is a seriously complex subject; certainly way beyond my limited brain wattage. Suffice to say these inter-relationships are the product of an awful lot of pointy heads working together over a great number number of years to evaluate all the different ways these things can work or fail.

We are loathe (and rightly so too) to lay blame at the feet of the crew until there is concrete proof that their actions were unreasonable for the situation. Don't the folks who develop the logic of the systems deserve the same consideration? I don't know that the current system logic is perfect, but until we (i.e the investigators) get down to identifying a specific element of that logic that undeniably failed and actively worsened the situation (and pj and I are just going to have to agree to disagree here), I think that we are putting the amateur flight control system designer's cart before his horse.

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Old 6th Aug 2007, 15:39
  #1243 (permalink)  
 
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I asked a few dozen posts ago why two type rated experienced pilots wouldn't move the throttles to idle.

...

BUT, there are two pilots who can reach the throttles.

So why did both pilots not bring the throttles back?
I agree with you completely here, that is one of the two $50,000 questions. The other is why the long delay in braking, a factor that as you've noted is a repetitive part of runway over-runs on all types.

Perhaps there needs to be more emphasis on this in ALAR type training programs?

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Old 6th Aug 2007, 15:39
  #1244 (permalink)  
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BOAC,
of course an interesting if not the key question.
One thing I was wondering is this:
going from CLB to IDLE to REV is a series of state changes rather than true thrust commands.
Maybe, and this is wild speculation as I will admit, maybe they had briefed the final stage (CVR recorded "reverse only one") and they have mentally skipped the "IDLE" stage for whatever reason and went right into REV. Of course, they had REV only mentally linked with the #1 engine so they pulled that lever.
Very very very speculative, but the only way of tunnel vision I can think of at this point.
pj
Yes, I'm afraid you're right. What is an additional mind boggle to me, is the fact they didn't even come close to complying with the Ops. Procedures, was it preplanned?
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Old 6th Aug 2007, 15:50
  #1245 (permalink)  
 
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Dreamland,

See post 1281 above. FDR details released by AB and posted above state TL1 to idle before touchdown and TL1 to rev just after touchdown.
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Old 6th Aug 2007, 16:01
  #1246 (permalink)  
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bomarc;

so far no real answers.

. . .

I've seen excellent pilots, with more than 10,000 hours, some with 20,000 hours not bring throttles back in regular, non fly by wire airplanes.

. . .

Sometimes their hands were both on the control wheel in a very difficult x wind situation...and they asked for help with the throttles. Sometimes not.
Yes, it is interesting that there are no responses...

I think there are no "real" answers because the point you raise has yet to be acknowledged as a real possibility.

I've seen these very same occurrences, (and a host of other equally "illogical" responses), from very experienced pilots, (on Douglas/McDonnell-Douglas, Boeing, Lockheed and Airbus designs).

This is not a Boeing or Airbus issue. Flying the autothrust design of either type is a non-event providing both are flown and handled as designed and as-trained. PBL's treatment of this subject is a reference discussion in itself.

I think that plumbing the deeper subtleties and minutae of design differences in order to find cause in the design and man-machine interface may be trying too hard and missing other, (and perhaps for some), more disturbing causes. Many posts including those from professional aircrews with long experience have already acknowledged that regardless of design and despite behaviours based upon CRM and error-trapping principles, error can and does occur.

Whether there is a training and documentation issue is a matter for the investigation to resolve, as will be resolved the matters of fatigue, weather factors, performance issues (where this thread began), airport and ATC issues etc.

This accident may however, come down to what you have said in your post, bomarc. Although the dialogue regarding design differences and human factors is interesting and educational, I believe in this case, "why" will not be an easy question for us to answer because there are some cases where logic, design and even rationality may not assist in fully understanding what happened. Perhaps the cause is quite simple.
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Old 6th Aug 2007, 16:11
  #1247 (permalink)  
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Dreamland,

See post 1281 above. FDR details released by AB and posted above state TL1 to idle before touchdown and TL1 to rev just after touchdown. By SyEng
Not sure what is meant by your post, this is not in compliance with the Operational Procedures, outlined in the MEL.
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Old 6th Aug 2007, 16:27
  #1248 (permalink)  
 
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ELAC,

Point taken.

I hope AB (and other manufacturers) could use this thread as another tool to assess how their products are viewed / perceived by its users, and use this information to improve them.

Too much automation is dangerous if used all the time as the standard way of operating any kind of complex system, especially critical parts of the operation. At one point we will end up being killed by the medicine and not by the disease itself.

Aviate, Navigate, Communicate... One of these days the pilots will cease to talk to anyone; In the near future the plane will take over the last thing pilots still do unautomated. Then what? Even the proverbial dog would be of the electronic breed.

FBW used as a form of filtering/ enhancing/giving comfort to pilot actions is a good thing IMHO, and it should stop there. The only one allowed to be (although briefly) confused should be the pilot, not the system. Consider the situation that there were no auto brakes, no armed auto spoilers, no A/T, etc… the pilot mindsets is completely focused on energy management. Automation in this case is making pilots trust completely in the plane with this task.
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Old 6th Aug 2007, 16:44
  #1249 (permalink)  
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ELAC;

Superbly written posts, thank you for taking the time and adding to the discussion.

Re,
Perhaps there needs to be more emphasis on this in ALAR type training programs?
We might ask if this kind of training and even discussion for awareness really takes place at most carriers. My impression is that training budgets are under significant pressures and that training footprints are continuously shrinking. NTK, or "need-to-know" has been the mantra since the late-70's but as another poster has pointed out, our job as been re-defined by bean-counters looking over the shoulders of the operations people and we are now "energy-managers", not pilots. "Airmanship" is never discussed...it is assumed to be just "there".

Last edited by PJ2; 6th Aug 2007 at 18:01.
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Old 6th Aug 2007, 17:06
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folks

I few questions for the uneducated one

I believe there is a broad consensus that the FWC update designed by AB after the Taiwan incident to warn pilots about the very misconfiguration we are witnessing here might have saved the day... My question is what is involved in implementing such an FWC upgrade ? I guess it's more than just "patching" the software but how involved is this ? As an operator I would think that I'd like to keep my fleet as up to date and consistent as possible... so what are the considerations here for TAM not to install that upgrade ?

Regarding the INOP spoiler / auto break I do understand that they did not deploy because of the conflicting signal sent by the #2 T/L, and that there was no way to override the system logic. I am not clear about what would have happened if they had retarded the T/L to idle during the roll ? Would spoiler deploy and breaking kick in ?

I have not seen much discussion about the "turn turn" remarks / orders in the CVR. Would you think they had directional problems due to the asymmetrical thrust (I would presume so, especially as the FDR has some ruder inputs) ? If so that would have been yet another clue to check the T/Ls...
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Old 6th Aug 2007, 17:10
  #1251 (permalink)  
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If one found oneself with Config FULL on a slippery runway which was showing the signs of requiring all the stopping devices, a quick way to enable spoiler, autobrake and reverse systems was to move the flap lever from Config Full to Config 3 and back again
I think you are well meaning but let's hope that you aren't employed as a professional pilot.
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Old 6th Aug 2007, 17:14
  #1252 (permalink)  
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There are some polarising themes which have recurred in this discussion. I have a feeling that as well as having armchair pilots we also have a few armchair safety-critical system designers among us. Let me try to play the game of one-sentence repartee too. I don't know whether I will succeed.

Those suggesting that when one reverser is actuated, the logic should bring thrust on the other at least back to idle, are forgetting their history. Lauda Air had an electrical fault which commanded reverser deployment back in 1991 over Thailand. The pilots were heard discussing it on the CVR. There was a mechanical interlock on the reverser, which it is supposed malfunctioned, although no failure modes were known before the crash, so they and everyone died anyway. But imagine what they would have said had they seen that electrical fault and experienced at the same time thrust on the good engine reducing to idle! I doubt it would have been printable in 1991.

And we have squat switches on the gear to prevent things like that happening in the air, don't we. The result of that is people sometimes being unable to brake when they need to, for example at Warsaw.

People with experience in digital systems (SW or HW) know well this phenomenon of fix one "feature", introduce a few more. It doesn't go away when those systems are safety-related. That is why change is performed *extremely conservatively*.

Some correspondents here have suggested a "big red button" to push for when you don't get braking. Well, the A320 has it! It is called brake pedals. I refer to the FCOM 3.03.32 p11, Loss of Braking:
[begin quote]
IF AUTOBRAKE IS SELECTED:
- BRAKE PEDALS ................ PRESS
This will override the autobrake
[end quote]

This is a memory item. ELAC has pointed out that, as far as we can tell, with timely application it is likely that the airplane would have stopped. It is going to be a big question why this activity was delayed. (Note, there was a similar question in an incident to C-FTDF at Cardiff in the U.K. in 2003. There, it was decided that it was because the crew attempted to debug the system by recycling the Antiskid/Nosewheel Steering switch rather than just applying the brakes as they should have done. But they only lost less than 200m by so doing. See AAIB Bulletin 2/2005.)

(Now, at Warsaw this item didn't help, but there was an issue there about whether SOPs were adequate, which doesn't seem to have arisen in the Congonhas accident.)

There are other people here who have suggested changing the braking system logic because the SOPs weren't followed. Well, the usual response to cases in which SOPs aren't followed is to consider putting in reminders, not to change the system logic. And, indeed, this was done after the last thrust-discrepancy-on-landing incident.

Then there are those who query why this reminder-system was not made mandatory by Airbus. It might be that some correspondents here do not know that it is not manufacturers who make mods mandatory, but airworthiness authorities. To find out why the post-Taipei mod was not made an AD where you live, you can ask your local airworthiness authority. But be prepared for raised eyebrows, for the reaction of airworthiness authorities to cases in which pilots did not follow SOPs is not usually to issue an airframe AD because, well, it is usually felt more appropriate to concentrate on emphasising the SOPs.

Last, but by no means least, there is the extraordinary half-suggestion that overrun accidents don't happen to Boeing airframes! The beginnings of an answer pointed to B747 incidents (I think there have been more overrun incidents to B747 airframes than to A320s, if I remember rightly). I dug up an old paper by Marthinsen and Hagy of U.S. ALPA, presented at the ISASI forum in 1992, entitled "Boeing 737 Overruns - A Case History". I quote
[begin quote]
The inability to stop the aircraft was traced to a deficiency of the air/ground sensor which, (1) took away the pilots ability to use reverse thrust, (2) delayed or prevented the actuation of the ground spoilers and (3) degraded the braking capability of the anit-skid system.
[end quote]

Sounds familiar? We've been living with this air/ground logic stuff quite a while now. Marthinsen and Hagy dealt with a number of incidents in double figures in five years. Some people have been astonished at 2 (or 3 or 4, depending on how you count) in 19 years with the A320. How short our memories are!

So how did I do?

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Old 6th Aug 2007, 17:45
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Then there are those who query why this reminder-system was not made mandatory by Airbus. It might be that some correspondents here do not know that it is not manufacturers who make mods mandatory, but airworthiness authorities. To find out why the post-Taipei mod was not made an AD where you live, you can ask your local airworthiness authority.
Well I guess that most airworthiness authority (AA) will actually follow whatever recommendation the manufacturer issues. If AB had said "we think this is a very important and urgent mod" I'm pretty sure it would have been reflected verbatim to the operators... Short of a few countries I very much doubt that any AA would do a comprehensive assessment of every manufacturer AD...
But be prepared for raised eyebrows, for the reaction of airworthiness authorities to cases in which pilots did not follow SOPs is not usually to issue an airframe AD because, well, it is usually felt more appropriate to concentrate on emphasizing the SOPs
Well we are now faced with a statistically significant occurrence of a some obvious SOP not being followed by A320 crew. We also have an available warning system upgrade which might prevent that very problem. What would be the problem in "emphasizing the SOPs" AND recommending quick implementation of the software fix ? I guess if doing so avoids a few hundred more horrific deaths it's worth the seemingly simple effort.

Last edited by atakacs; 6th Aug 2007 at 17:49. Reason: Typo
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Old 6th Aug 2007, 17:53
  #1254 (permalink)  
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PBL, you're not a pilot either, very hard to discuss this with non pilots.
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Old 6th Aug 2007, 18:01
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atakacs,

Well we are now faced with a statistically significant occurrence of a some obvious SOP not being followed by A320 crew.
Please let us not misuse technical terms. Tell me your confidence level and your null hypothesis, and unless they are absurdly low, respectively, absurd, I will demonstrate to you (or you can demonstrate to yourself) that the incidents are not statistically significant.

Dealing with accidents involves noting facts (phenomena), determining causal relations amongst those phenomena, and seeing whether there are similarities that can be exploited for prophylaxis. In scheduled commercial air transport, thankfully, it does not involve any statistical significance.

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Old 6th Aug 2007, 18:07
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Dream Land,

PBL, you're not a pilot either, very hard to discuss this with non pilots.
I don't respond to ad hominem arguments (except like this).

PBL
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Old 6th Aug 2007, 18:14
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Please let us not misuse technical terms. Tell me your confidence level and your null hypothesis, and unless they are absurdly low, respectively, absurd, I will demonstrate to you (or you can demonstrate to yourself) that the incidents are not statistically significant.
Well, maybe I did not use the right terminology but those two accidents seem to have much in common. And having 3-4 hull loses out of 14(18?) due to very similar circumstances is significant IMHO...
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Old 6th Aug 2007, 18:14
  #1258 (permalink)  
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Dream Land;

You mistake information for advocacy and have lept to an unintended conclusion. The fact that such systems are available (and have always been so) in Config 3 is well-established. The post is edited lest others make the same error.

To clarify for others who may have similarly misapprehended, although the SOP is not unheard of on other types, (B727), it is not Airbus SOP to change configuration on the runway.
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Old 6th Aug 2007, 18:34
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PJ2 I am going to have to disagree with you slightly re:
Flying the autothrust design of either type is a non-event providing both are flown and handled as designed and as-trained.

I see many cases where "as-trained" is somewhat different from as-designed. We have to establish that the designer did not make a mistake or even the person writing the specification for the designer.
Then you have to ensure that the person writing the manual understood what the designer meant.
The person designing the training course...
The person writing the operational procedures ...
The person who trained the trainer
The person who transcribed the operational procedure from the manufacturer into the aircraft operator's procedures...
The person who decided that no simulator training was necessary for this scenario
The person who decided that a quick mention or not on the type conversion course...
The person who wrote the amendment for the manual
The person who translated it into the relevant language
The meaning that was understood by the end pilot who flew the aircraft.

So, as trained can be somewhat different from as designed. The list is not comprehensive, but just some of the places that I have found the source of a "pilot error" mistake.
[end of disagreement with PJ2]

For my 2 (not worth much on the Forex these days) cents worth: look for the mistake type category of error and not the slip error on this one, if you want to look for pilot error. If you want to look at equipment failure, then be very careful about the difference between actual position and recorded position data on the FDR. Do they have dual channel readouts? Was there a failure of one thrust lever sensor channel which was unrevealled but occurred earlier in the flight with a second (or logic elimination of its reading) later at RETARD?

Look at the failure of the recovery factors too: No procedure when there are "no spoilers", the lack of autobrake light coming on in many landings before the speed drops a bit, the expectation of aquaplaning with "slippery when wet" but still to make the landing distance ok, the banning of a baulked landing although it would have been possible, the lack of RESA and runway strip beyond the declared distance although the airport said it complied with all ICAO Annex 14 provisions.

I hope that the investigation will go into all of these areas, and many more.
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Old 6th Aug 2007, 18:40
  #1260 (permalink)  
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PJ2, ok fine, I am also of the opinion to do a bit of planning before I end up in the flare. For one thing, let's take into consideration that there is no room for error on a runway of this dimension, keeping that in mind, going through the no no brake memory items is NOT an option at this airport. I think it's safe to assume that all experienced flight crews realize that without spoilers, there is no braking. This crews number one mistake may be linked to the fact that they were so familiar with the airport that they didn't do some of the most basic survival procedures, that is, if no braking, you go around, there's a cliff at the end of the runway, what more can I say, basic airmanship 101.
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