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TAM A320 crash at Congonhas, Brazil

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Old 14th Aug 2007, 21:43
  #1661 (permalink)  
 
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According to Folha Online, TAM's Safety Director, Marco Castro, announced today that TAM is acquiring from AB the software that warns pilots of TLs out of position.

He also announced TAM's aircraft are prohibited to land in CGH with either reverse inop.
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Old 14th Aug 2007, 21:43
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Just being a dumb Airbus pilot, I am amazed at those who imply, that the system is to blame in this instance, if indeed the TL was never retarded.
The fact that the reverser were inop should not have been an issue, particular not with regards to were the TL should have been.

All the airplanes I have flown, when you want to land, you pull the power back, I would even go so far as to say, that this is a brilliantly simple concept, it works just as well in the J-3 Cub as it did in the Concorde, heck, a reduction of power even worked for the Wright Flyer.

As for the GS, they would have deployed, even without being armed, provided on TL is in reverse and the other at idle. The fact that one TL never was retarded, according to rumour, is quite odd.

The Airbus is an airplane, plane and simple, yes it has its own peculiar intricacies, but they all do.
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Old 14th Aug 2007, 23:13
  #1663 (permalink)  
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Rob21
Yes, but do we really know that engine #2 TL was not at idle? That was the computer reading, and he act accordingly. There is no doubt about that, and what we see on FDR's graphics is what the computer "saw"...
And at this point of the investigations, a "wrong" computer reading of TLA is not out of the question, I would imagine. I also believe it is one of the "probable causes" to be investigated.
This has been discussed in the thread in great detail. As you will recall, we have seen examples of the circuitry and redundancy built in to the monitoring of the TL position and several detailed explanations of it. Thus far, it is stated that the chances of both sets of monitoring failing at the same time in the same way, is remote in the extreme.

How could we 'see' if the #2 TL was not brought back when it should have been? Video camera on the flight deck. Many pilots do not want that and many pilots in here are unwilling to believe that a TL was left in the wrong place. We do not yet know and the report is a couple of years away.

The pilot concerned will undoubtedly have landed with one TR inop on many occasions and have understood the process well. The view that, having his concentration broken by the inop - whilst preparing for what was always going to be a difficult landing, proved too much on this occasion.

Some others in this thread have already asked about fatigue. One thing for sure, the carrier will state that he had worked correctly within the allowed hours and with the correct rest periods and that will be factually proven to be correct. Whether the work and rest periods should be changed will not be discussed.
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Old 14th Aug 2007, 23:13
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teropa,

In a case, where stopping the aircraft is the desired course of action, the automatics in the AB (no, it's not the computer who should be blamed) are not allowing for GS extension, IF a pilot makes a major operational mistake (like in the TAM case). Before anybody shouts that the computer cannot account for every possible scenario, I will respond that that is exactly why there should be a MANUAL way of assisting the aircraft to STOP.
This is ludicrous.

Notwithstanding the fact that if you don't comply with SOP, you're likely to get yourself into trouble somewhere, sometime (although I'm not suggesting this was intentional for a second), there was always a MANUAL method of stopping the aircraft available.

If you look at Pg 143 of the Transavia 536 flight final report, you will see the relative importance of the GS versus the brakes.

No autobrake is of far greater import than no GS.

The delay in the application of the brakes in this accident has already been discussed.

So now the critics will want the brakes applied automatically (Isn't that what "autobrakes" do?), just in case the machine (or the pilot for that matter) doesn't, and before you know it the whole construct has become ridiculous.

It seems to me that if you are not willing to accept that a team of pilots should, between them, always perform a certain number of basic functions correctly, you'd be better off designing the system assuming they weren't there in the first place!
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Old 14th Aug 2007, 23:41
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I havent read the Taipei report before now.One thing that stands out is that spoiler activation was called even though it hadnt actually occurred.I understand that deployment is shown by green arrows on the WHEEL ECAM page.Thats one sensory channel;optical.
On a Boeing,the deployment of the spoilers is transmitted to the pilot via 3 sensory channels;sight,sound,touch.And the pilot needs only peripheral vision to do this,enabling heads-up at the critical moment.They know pilots are stupid so they put this goddam big lever that looks like a flap and have it move back and forth.

The sequence in which you deploy retardation devices is absolutely critical when on a short wet runway.SPOILER(1),then BRAKES(2) then REV(3).Never go for (2) or (3) before (1) is successful.And that is why the way in which spoiler deployment is transmitted to the pilot is so crucial.
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Old 15th Aug 2007, 00:32
  #1666 (permalink)  

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I am really getting sick and tired of the B vs A war, as if the manufacturers the other side of the aAtlantic are absolutely perfect and their design flawless.
And, STS, if the Airbus jocks defend that airplane, maybe - just maybe - they know better than you and hadn't the *Not Boeing, not going *- brigade been so unashamedly vocal - and bring NOTHING to the discussion.
May I just remind you that -take the most modern one - landing a 777 on a wet runway, with one de-activated T/R and leaving the #2 throttle on the approach setting...yes, you would get a deployment of the ground spoilers, but you won't have autobrake and you won't have any "Retard" voice call either. You will also have the approach thrust left on engine #2, in other words, you'll be left in exactly the same situation as the TAM 3054. Will the spoilers extension alone save your skin, then ?
Remember also the AF 744 in Papeete. How could they have *forgotten* that #1 throttle was at Go Around thrust while the other three were in full reverse ? And funny enough, no warning either. (That time, they were lucky, the lagoon can be a very efficient means of braking ).
Do you know that the 777 is in fact a lot more difficult to handle in a windshear situation than a 737, because close to the envelope limits the control forces are increased (Boeing philosophy for avoiding the Airbus-type limits), so one would be muscling his way in and out of the stick shaker with some very heavy controls ?
Someone mentioned Cali. It was a 757. THey attempted a Go-around and forgot to retract the spoilers, Has the design changed on the 777 ? I'm not sure, looking at the spoiler logic under my eyes.
Could I go on , and on ?
So, please, leave off. And spare me the hypocritical attitude of defense of the pilot's memory. As a group, we know that mistakes are made and there is no blame -should be no blame -. We'll just study how it was made and try to find a cure. That's part of our trade.
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Old 15th Aug 2007, 01:34
  #1667 (permalink)  
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Well said Lemurian, I'm not biased in favour of either manufacturer's products although I have many thousands of hours on Boeings but the "Aint going if it's not Boeing" attitude is entirely juvenile IMHO. There have been more over runs in Boeing aircraft than Airbus for a start.
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Old 15th Aug 2007, 03:33
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Human Factors

Hello Everyone, I am not sure if this has been covered before but I believe there is a significant lack of understanding on how any major emergency affects the pilot in the few critical seconds that you have to correct the situation. Most pilots who have experienced it will understand what I am saying but as background I will tell you the effect it had on me.
I had an engine failure in a single seat single engine military aircraft at low level many years ago. The events lasted less than 25 seconds from start to ejecting.
Your brain tunnels, you only have the capacity to take in 3 significant pieces of information, the first sense your brain dumps is hearing and your time reference almost doubles.
During the debrief I could recall EGT, (JPT then) RPM and Airspeed, I never cancelled the aural warning because I never noticed it, my estimate of the total time from the very loud bang to ejecting was 45 seconds. I was able to do 3 relight attempts because they were drills etched into my brain and practiced monthly in the Sim, absolutely no thinking required to do them.
Subsequent to this experience I have always tried to make things very simple in the flight deck, almost any complicated procedure will be very difficult to use in an emergency. Mental capacity for use in emergencies can be increased by practice but the modern flight deck is designed to be fully automated and this dulls these capabilities.
Transfer this to the situation these two guys were in.
Their aircraft suddenly fails to do what they expect it to due to either an error by them or to a systems failure. The Throttle Control is not an item that is used often in the “fbw” Airbus, you never see it move in your peripheral vision hence, it being in the wrong position will not be one of the 3 things you are capable of taking in. They would probably take in the Reverse indication on the good engine, the EPR would be approximately as expected from the normal two engine application of Reverse but the aircraft would not slow. The lack of Spoilers was mentioned but the implications would be lost in the reduction of mental capacity. Each pilot may say things but it is unlikely that the other would fully understand the comment, their time reference would have extended and suddenly the end of the runway would be upon them….
Personally I believe they had little or no chance to avoid this accident once the initial mistake/failure had occurred and not been immediately corrected. There were not enough easily interpreted cues from the flight deck environment. This is not something that you can train for in the Simulator, it is a situation that should be Designed Out of the Flight Deck Environment.
Clever complicated solutions to Flight Deck Systems are never the correct answer.
Whatever is decided to be the main contributor to this accident, i.e. who gets the blame, will now be greatly influenced by lawyers who are thinking mainly of compensation claims and institutions who have vested interests. As pilots we only want to know the truth and to put in place procedures that will avoid this happening in the future. As passengers we all hope that the chances of accidents are reduced to a minimum.
There might be solutions but unfortunately lawyers and accountants will divert this accident investigation from the best answers. Pilots will continue to flag up potential problems in other areas but these will be ignored until there is a major accident, that is the way of the world.
The human brain is brilliant but it has limitations, strengths and weaknesses, these should be enhanced by better flight deck design and increased by allowing pilots to extend their mental capacity within normal day to day flying as opposed to the current management culture of automation only.
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Old 15th Aug 2007, 04:04
  #1669 (permalink)  
 
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Firstly, excellent post Woodvale. You said, what I have tried to say, so much better. Plus, you have first hand experience of this kind of thing, and are luckily there to tell about it.

SR71,

I think it's ludicrous to call it ludicrous that there should have been a way (other than correcting the TL position, that was obviously missed and then forgot) out of the impossible situation the TAM crew was faced with.

I am just amazed at people who are still telling here that a pilot error so massive as the one that happened with TAM.... that it's not going to happen. Well it DID. And it wasn't the first time.

I am sure every human is capable of making even the most elementary kinds of mistakes, given the proper circumstances. There are so many things even when considering just one pilot with his/her mental and physical abilities (that are affected by almost anything and everything the person is doing in the life at that point), that are playing a role inside the person. To say that it's human to err is correct, but even better would be to say that it is inhuman not to err. Everybody makes mistakes, even "ludicrous" mistakes.

I conclude that some of the contributors here are seeing nothing wrong with how the AB works in this instance. I wish you the best of luck. Just hope that you will never come accross anything surprising. After all, you never make mistakes.

I also think it is a bit different situation in leaving either TL at CLB during a normal 2 engines operating + 2 thrust reversers operating landing. Than it is to leave the TR-crippled TL at a wrong position. Everyone here who has talked against needing a protection for a pilot error, has brought up the situation where the pilot wouldn't retard thrust levers when he wants to stop (a little exaggerated comparison, I think!). But no one has taken into account that neither this or the previous similar accident was about not "knowing to retard thrust when you want to stop". It was about dealing with an inop TR and then making a mistake in that situation. Surely that's a bit different than not knowing to pull thrust to idle when you want to land. If you had the possibility to ask the TAM crew if they knew how to land an airplane, would you do it? Or would you consider that in that particular situation there was something that made them forget the TL2 in CLB ? And by doing that they were doomed. Which is utterly wrong.

Tero

Last edited by teropa; 15th Aug 2007 at 04:33. Reason: noticed Woodvale's posting
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Old 15th Aug 2007, 05:27
  #1670 (permalink)  
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Great discussion from all sides, as a pilot that operates this system, I think it works fine, some people advocate more automation, some want complete control. Great post by Diesel8, by the way, I think the worst thing one can do is to make a change to a system that works fine, for those of you that think I am mad, you're probably not pilots. The flying pilot received crucial data in a timely fashion "spoilers nada", at this point, a very important decision should have been made, why, because at this airport there was NO room for error, I feel that blaming it on the Airbus logic, is as silly as blaming it on the inadequate airport.
PAXboy nice post, #1728.
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Old 15th Aug 2007, 06:03
  #1671 (permalink)  
 
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DreamLand,

I don't think anyone is laying blame on just one single part of this accident.

Your take on this seems to be one of giving the pilot the ultimate responsibility on ensuring the safety. You are right in that the pilot ultimately is the one making the decisions during operation.

But you are forgetting that piloting aircraft from A to B is more than just making your routine work in a set of conditions that do not exacerbate any possible problem, mistake etc. In the TAM case there were other conditions that brought up a mistake, that lead to a problem, and in the other conditions prevalent it lead to the total destruction of the said Airbus. So one can say that there were other contributing factors to the end result, beside solely the pilot operation.

Accidents are nearly always results of many single events going the "wrong way". In the TAM case one can surely identify already many contributing factors:

1. Failure of the PF to operate the acft according to manuf. specs
2. Runway conditions (slippery, short)
3. Aircraft system operation, that did play its fair role
4. MEL and other operational restrictions for operating TR-inop acft to CGH
5. Crew training, pilot roles in the flight deck
... + more

To simplify these factors to just #1, the pilot's failure of operating the AB according to instructions is rather alarming. The safety of operating the aircraft continously, with living human beings as the cargo, comes naturally from ensuring the maximal safety from each small factor. The end result is a contribution of all of these. There's no way even a skilful pilot can save the day when all the other aspects are working against him. On the other hand, the other aspects might just save the day, if the pilot was not performing 100% at any point. Of course this is not to justify any massive operational errors of pilots, but to highlight that safety comes from many other places besides from the two guys at the pointy end.

With respect.

Tero
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Old 15th Aug 2007, 06:29
  #1672 (permalink)  
 
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Go-around?

I see from earlier posts that the situation has been recreated in the simulator, all with the same result as the real thing.

Has any attempt been made at trying a go-around in this situation? Would they have been able to avoid the accident?

For the Boeing defenders (I have no allegiance to either A or B) has anyone tried recreating a similar situation with a Boeing in the simulator - similar weight, runway length, 1 rev inop, 1 TL not fully retarded. - What results would be obtained in that scenario? Would a Boeing have been able to go around?
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Old 15th Aug 2007, 07:03
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I think most any airplane would go around but once reverse is selected there is no guarantee if a subsequent go around is attempted that the reversers will stow so even though it has been done many times, it is not recommended. I know one incident in Honduras where a B727 after reversing chose to go around and made it but actually descended off the cliff at the end before regaining flying speed.
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Old 15th Aug 2007, 07:08
  #1674 (permalink)  
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VC-10: it has already been explored and yes both a/c COULD have executed a g/a from the runway.

The problems are:

1) It is contrary to training and SOPs to do this once reverser/s has/have been deployed and there is the risk of a reverser 'sticking', plus here there would have been the added complication of a slower accelerating No1 on a slippery runway.

2) It would have required a rapid analysis of the situation to avoid a high risk of contact with obstructions after lift-off. It is apparent that a large number of 'clues' to the crew were missing here in those early few seconds. Unless this becomes a 'trained' SOP manoeuvre (and that is most unlikely) it would be a non -starter I feel.
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Old 15th Aug 2007, 12:14
  #1675 (permalink)  

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StS

Sorry,I typed too fast, Of course, the only part of my post that concerns you is this :
STS, if the Airbus jocks defend that airplane, maybe - just maybe - they know better than you and hadn't the *Not Boeing, not going *- brigade been so unashamedly vocal - and bring NOTHING to the discussion.
I've seen very little "It must somehow have been AB's fault".
In this case, please remove the "not wanted" filter you've certainly have put on this forum.
Boeing and Airbus have chosen very different approaches to system control.
Ask the brigade to give us the difference between the two philosophies in this accident instance. And, just as a matter of comparison, go to the tables that have been provided by the Chinese authorities on the effect of each braking device, applied to this accident.
That will just be a start.
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Old 15th Aug 2007, 12:44
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Lemurian,
Its not an AB/Boeing thing I can assure you although I do admit that I have deep-seated mistrust of the AB design.I quite understand though that as long as a pilot forgets everything hes been taught and learns the new concept,everything should be just fine....
May I just remind you that -take the most modern one - landing a 777 on a wet runway, with one de-activated T/R and leaving the #2 throttle on the approach setting...yes, you would get a deployment of the ground spoilers, but you won't have autobrake and you won't have any "Retard" voice call either. You will also have the approach thrust left on engine #2, in other words, you'll be left in exactly the same situation as the TAM 3054.
NO SIR.You wont get TR#1.Both TL's must be idle to get TR.They wont get GS either(gear not tilted,TL's idle).Crucially,this leaves the GA option.And theres your big difference.The plane wont dig a big hole for you and your 200 passengers.
Its been discussed before but..woodvale,in his good post,showed how pilots tunnel their vision when faced with adversity.Therefore,the decision to continue with a landing on a short wet rwy,based on spoiler activation,must be learnt as an automatic drill(just like the go/no go up to V1).If you get GS,your TL's are at idle and theres spinup so your good to continue..you might still elect to abort if you landed long or misjudged the effect of a tailwind(allowed on a wet rwy but NOT on a contaminated one).If you dont get GS and TL's are at idle,then you're probably looking at an abort(rwy report was inaccurate).If you dont get GS,the recall item is check the TL's but it must be quick.Each second is about 200/300' of rwy,depending on ref speed.This relates to B,not AB.

Last edited by Rananim; 18th Aug 2007 at 11:01.
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Old 15th Aug 2007, 13:01
  #1677 (permalink)  

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Perhaps the depth of sentiment on the part of those defending the system as is is, because, subconsciously, they know that, if you follow the train of thinking of those arguing for wider error catching routines, it isn't long before you've reached the position where a pilot is actually superfluous to the whole adventure.

For example (and I'm not a logician so my terminology is probably strictly incorrect), consider the action of stopping the aircraft.

The pilot is the agent who, presumably, provides the "Stop" demand. This input, combined with other system inputs determines the state vector. The output of the computational algorithm(s) in the FCS are the inputs to the various braking devices that assist with the "stopping" process.

Now if the algorithms have to consider the fallability of the agent and whether or not the "stop" demand is appropriate in the circumstances, or indeed, has even been initiated, it isn't long before some clever system designer says, "Why the hell do we need the agent anyway?"

It seems to me that the reason there still are pilots flying aircraft is because we still trust their decision making. Whether this means they are better at it, I don't know?

What this doesn't mean is that, pilots won't make (some) bad decisions, or, that there are some pilots who, frankly, ought to be replaced by a FBW FCS system.

In my mind, it means, that as a population, we generally make a lot more good decisions than bad ones. This, no doubt, applies to the TAM pilots on the day as well. Their previous landing was uneventful after all. My respects to them.

I have already recounted a number of anecdotes on this thread of my experiences (or lack thereof - I could indeed share more, were it not for the fact I'd rather not provide additional evidence for those seeking to discredit my conclusions as a critic based on my incompetence as a pilot!), so I'll be the first to state that I, as a pilot, make mistakes.

In fact, I included one where we did not get reverse as expected.

I would love to know how many incidents there have been in A320's where pilots have not retarded an INOP TL to idle, realised their error, and rectified it uneventfully?

I agree with woodvale, the capability of the mind shrinks under pressure. My own nasty experience of this comes, not from a single seat ejection scenario, but a scuba-diving incident in excess of 250ft on air where things almost came unstuck for me.

(NB: I'm impressed with how cool these guys are after their birdstrike and subsequent ejection in a F-16: http://www.youtube.com/watch?v=06RJJQFLhao)

From the comfort of my study, there are 3 things which are fundamental to consider when stopping an aircraft:

a) What the engines/reversers are doing?
b) What the brakes are doing?
c) What the spoilers are doing?

Whilst Rananim has indicated the sequence in which they ought to be applied, the first action, in reality, is to retard the thrust levers.

Someone else has already mentioned it, but, this loop ought to be going throughout the stopping process, inspite of whether or not there are any failure modes to consider!

Personally, I think that better training will address this issue.

I've always thought that lip-service is paid to training in our industry because of how expensive it is.

No doubt the recommendations of the report will lie somewhere between the extremists' positions, including both, better training, and perhaps, some overhaul of the involved systems.

It should.

I know what I have learned from this thread and therein lies the value for me.
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Old 15th Aug 2007, 15:52
  #1678 (permalink)  
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NO SIR.You wont get TR#1. Both TL's must be idle to get TR. They wont get GS either (gear not tilted, TL's idle). Crucially,this leaves the GA option. And theres your big difference.The plane wont dig a big hole for you and your 200 passengers.
But ... what you have just confirmed is that: if a TL is left advanced on a 777, you will not get TR or GS? That sounds to me (as an outsider) exactly the same as the Airbus under discussion?

If the crew left a TL forward and so denied themselves TR and GS, how would a 777 (in this case) bring them an advantage? OK, they could GA but, as they would be expecting to land, how much time would they use on the runway before deciding that they were not stopping? They might not have to stow a reverser but they would still not be in a happy situation.
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Old 15th Aug 2007, 17:05
  #1679 (permalink)  
 
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If the crew left a TL forward and so denied themselves TR and GS, how would a 777 (in this case) bring them an advantage? OK, they could GA but, as they would be expecting to land, how much time would they use on the runway before deciding that they were not stopping? They might not have to stow a reverser but they would still not be in a happy situation.
They would have TOGA from both engines in not very many seconds and still be close to Vref as no reverse yet selected -- a much better deal than attempting a single engine go-around with one engine hopefully staying out of reverse and a whole bunch less airspeed.
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Old 15th Aug 2007, 17:06
  #1680 (permalink)  
 
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PAXBoy,
I think that having the option to go around would have easily saved the day in this situation. If no TR were deployed, having travelled a significant distance down the runway, still having ~140 knots speed, the pilots would have made the call to go around simply because the alternative would be death, and they'd have recognized that at that point.
Having the TR deploy eliminated that option for them.
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