TAM A320 crash at Congonhas, Brazil
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Professor Ladkin
Part of a professor's role in academia, within their chosen field of expertise, is is to lead the learning and guide the thinking I believe ...
Are you comfortable leading us here ?
There has I think been some uncomfortable learning for some pilots reading the thread who as you know, routinely and constantly have to ask themselves "am I in control of and ahead of this machine and the scenarios I might encounter with it ?"
Perhaps, and maybe using something approaching Frank Plumpton Ramsey's ideas about ranking their beliefs (as introduced by you), most can confidently say "yes I am".
In the absence of conspicuous review by manufacturer's or operators since the accident, can you confirm that these pilots' own self-belief is well-placed today ? Alternatively can you summarise clearly the revision items you would concentrate on if you can think yourself into their position i.e. preparing to flying a machine like this again tomorrow ?
Part of a professor's role in academia, within their chosen field of expertise, is is to lead the learning and guide the thinking I believe ...
Are you comfortable leading us here ?
There has I think been some uncomfortable learning for some pilots reading the thread who as you know, routinely and constantly have to ask themselves "am I in control of and ahead of this machine and the scenarios I might encounter with it ?"
Perhaps, and maybe using something approaching Frank Plumpton Ramsey's ideas about ranking their beliefs (as introduced by you), most can confidently say "yes I am".
In the absence of conspicuous review by manufacturer's or operators since the accident, can you confirm that these pilots' own self-belief is well-placed today ? Alternatively can you summarise clearly the revision items you would concentrate on if you can think yourself into their position i.e. preparing to flying a machine like this again tomorrow ?
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What we might do better
To a great extent I think we are losing sight of what we all might learn from this accident. There is a debate about whether Boeing or Airbus have the best technology, this is rather irrelevant, we mostly either fly Boeing or Airbus and don’t have too much choice about it.
We must learn to recognise and cope with the weaknesses of our own aircraft.
Each aircraft design has good and bad points. In normal operation they mostly work perfectly well. When things go wrong it is normally due to a lack of understanding, a failure to apply SOPs or an unusual situation which was not handled correctly.
The first two of these should be dealt with by normal training events in the simulator but the third needs us all to think.
I have been flying both civil and military for40 years now, I have always looked at accident reports, both pilot error and technical defects and, wondered if I would have survived the particular incident, sometimes I believed my though processes would have avoided the accident but sometimes I could see no way that I would not have died as well. A very sobering though process.
What do you as an individual think of this accident, might it have caught you out?? For instance I will tell you what I have learnt. From now on I will brief differently for any take off or landing that involves non standard operation of the controls, I will ensure that the PNF specifically monitors my required actions in order to add his/her capacity to ensure they have been carried out. I intend to add a brief reminder of the non standard items shortly prior to their occurrence. When I am PNF I will do the same.
I don’t want to prejudge the accident investigators but if, in this instance the PF had briefed for the PNF to observe both thrust levers into reverse as per the MEL in addition to the normal landing call outs we might not be writing to each other now.
As another more simple example, if you operate a sector with the auto-throttle u/s do you brief that at every 1000ft to level off you call e.g. 6000ft for 5000ft “manual thrust”, it helps!
It is all very well to have the Operational Procedures section of the MEL but do you adjust you briefing to include how the PNF might check/confirm you actions as PF.
I hate the thought of being bid headed enough to think that “it would not have happened to me”, the biggest disservice we can pay to these poor people is to not learn from their misfortune, personally I have adjusted the way I will brief when there are similar critical items. I would like to do my best to ensure I don’t get put into a situation I can’t get out of.
Safe Flying.
We must learn to recognise and cope with the weaknesses of our own aircraft.
Each aircraft design has good and bad points. In normal operation they mostly work perfectly well. When things go wrong it is normally due to a lack of understanding, a failure to apply SOPs or an unusual situation which was not handled correctly.
The first two of these should be dealt with by normal training events in the simulator but the third needs us all to think.
I have been flying both civil and military for40 years now, I have always looked at accident reports, both pilot error and technical defects and, wondered if I would have survived the particular incident, sometimes I believed my though processes would have avoided the accident but sometimes I could see no way that I would not have died as well. A very sobering though process.
What do you as an individual think of this accident, might it have caught you out?? For instance I will tell you what I have learnt. From now on I will brief differently for any take off or landing that involves non standard operation of the controls, I will ensure that the PNF specifically monitors my required actions in order to add his/her capacity to ensure they have been carried out. I intend to add a brief reminder of the non standard items shortly prior to their occurrence. When I am PNF I will do the same.
I don’t want to prejudge the accident investigators but if, in this instance the PF had briefed for the PNF to observe both thrust levers into reverse as per the MEL in addition to the normal landing call outs we might not be writing to each other now.
As another more simple example, if you operate a sector with the auto-throttle u/s do you brief that at every 1000ft to level off you call e.g. 6000ft for 5000ft “manual thrust”, it helps!
It is all very well to have the Operational Procedures section of the MEL but do you adjust you briefing to include how the PNF might check/confirm you actions as PF.
I hate the thought of being bid headed enough to think that “it would not have happened to me”, the biggest disservice we can pay to these poor people is to not learn from their misfortune, personally I have adjusted the way I will brief when there are similar critical items. I would like to do my best to ensure I don’t get put into a situation I can’t get out of.
Safe Flying.
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s&t
I can only say what I am thinking about at the moment.
I'm thinking, for example, about the guidance concerning Loss of Braking. As in, how much extra runway might you need if you don't get the decel light (for whatever reason) and you follow the Loss of Braking SOP. Looking at data from this accident, it seems to me you could need 1950 m after TD (let's say at 250m beyond threshold), plus your procedural time for getting to stomping the pedals, which amounts to, say, 5 seconds (at 70 m/s) or 350 m. Total 2550m. You can reduce that to 2200 m if you choose to land with manual braking.
That's a lot of real estate, which not all airports have. But it seems to me those are the figures you play with if you want leeway to screw up a landing a bit and still roll out safely. And it looks somewhat different from the figures in the Ops Manual.
Now, people do screw up. And sometimes in the most incomprehensible ways. It would seem prudent to accommodate that. How could that be done? I'd like to hear some thoughts on the written guidance on landing distances, and how it could accommodate slip-ups, but it doesn't appear to be the theme du jour.
PBL
Originally Posted by slip and turn
can you summarise clearly the revision items you would concentrate on if you can think yourself into their position
I'm thinking, for example, about the guidance concerning Loss of Braking. As in, how much extra runway might you need if you don't get the decel light (for whatever reason) and you follow the Loss of Braking SOP. Looking at data from this accident, it seems to me you could need 1950 m after TD (let's say at 250m beyond threshold), plus your procedural time for getting to stomping the pedals, which amounts to, say, 5 seconds (at 70 m/s) or 350 m. Total 2550m. You can reduce that to 2200 m if you choose to land with manual braking.
That's a lot of real estate, which not all airports have. But it seems to me those are the figures you play with if you want leeway to screw up a landing a bit and still roll out safely. And it looks somewhat different from the figures in the Ops Manual.
Now, people do screw up. And sometimes in the most incomprehensible ways. It would seem prudent to accommodate that. How could that be done? I'd like to hear some thoughts on the written guidance on landing distances, and how it could accommodate slip-ups, but it doesn't appear to be the theme du jour.
PBL
Last edited by PBL; 17th Aug 2007 at 18:16.
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http://www.smartcockpit.com/pdf/plan.../systems/0022/
I googled this for us Boeing guys that don't have access to A320 systems manuals to understand the thrust control system. While doing so found another site where an A320 returned to the gate because the TL would not control the engine. I know, that could never happen.
I googled this for us Boeing guys that don't have access to A320 systems manuals to understand the thrust control system. While doing so found another site where an A320 returned to the gate because the TL would not control the engine. I know, that could never happen.
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PBL on braking and contamination
PBL,
Would you please compare these figures with this little study I did somewhere else : ( I was off by 700 kg on the *official LW ).
"First, a few facts :
1/- The airplane landed at CGH on runway 35L.
That runway is 1940m long and the LDA - landing distance available - is 1880m.
The METAR reports at 1720 was :340/08 6000m RA BKN 900 ft OVC 7000 ft Temps 16 / 14 QNH 1018 hPa
2/- Two experienced pilots were at the controls, one TRE and a qualifying captain.
3/- 187 people were on board.
4/- The airplane stayed on the runway centerline until just reaching the end of the runway, where it veered left.
5/- It seems official that the airplane was dispatched with one - #2 - reverser inoperative.
6/- The airplane seemed very fast and apparently did not lose as much speed as it would normally do.
7/- Some pilots noticed standing water on the runway, which wasn't grooved.
I jotted a few figures, making assumptions as to the weight of the airplane :
1/- Dry operating weight 41,000 kg
2/- 181 passengers and luggage 18,000 kg
3/- Fuel remaining on board, with a planned diversion to Guarulhos 3,000 kg
The above give a landing weight at 62,000 kg or 62 tons.
At that weight, the required landing distances are :
for dry runway : 1490 m
for wet runway : 1690 m
for 3 to 6 mm of standing water : 2130 m
Those are the baseline figures for sea level and OAT < 40� C, without reversers and without auto brakes.
Congonhas being 2600 ft above sea level, a correction of 3% per thousand feet applies for a wet runway, and 4% for 3 to 6 mm of standing water.
The resulting landing distances then became :
for a wet runway : 1690 x 107.5% = 1822 m
for standing water :2130 x 110.5% = 2354 m
Compare these figures to the LDA in fact #1."
My first comment when I compare both sets of figures (mine come from an in-flight performance chart out of a QRH ) is that your results are very close to the *contaminated* runway data I obtained. Granted those are estimated performance, yours deduced from the actual braking achieved eventually by the crew.
Personally, I have never accepted the *wet* data outside big airports -those with looong runways- and at the flight preparation phase always gone *one state worse*, i.e in this case, my prep would have been with the quarter-inch standing water tables and the consequent reduction of the landing weight (fuel / freight / passengers). Furthermore, and it's one of the reasons I would dearly hear the pre-descent / landing briefing is whether they'd have been aware of the bad runway drainage and the presence, still visible the morning after the accident, of pools of water. That concept of pools of water is important for it means a risk of potential asymetric braking - a situation in which the use of autobrakes is discouraged.
I feel rather strongly about this aspect of this accident as I think that the dispatch of this flight hadn't been done with enough concern for safety. The thirty-five minute turnaround in Porto Alegre (they landed on frame 183400 and took off on frame 186060, leaving just under 45 minutes between them, to which I substracted 10 minutes taxi time.), didn't leave enough time for anything but a routine dispatch preparation.
IMO, this is an example of collective responsibility.
I'm thinking, for example, about the guidance concerning Loss of Braking. As in, how much extra runway might you need if you don't get the decel light (for whatever reason) and you follow the Loss of Braking SOP. Looking at data from this accident, it seems to me you could need 1950 m after TD (let's say at 250m beyond threshold), plus your procedural time for getting to stomping the pedals, which amounts to, say, 5 seconds (at 70 m/s) or 350 m. Total 2550m. You can reduce that to 2200 m if you choose to land with manual braking.
"First, a few facts :
1/- The airplane landed at CGH on runway 35L.
That runway is 1940m long and the LDA - landing distance available - is 1880m.
The METAR reports at 1720 was :340/08 6000m RA BKN 900 ft OVC 7000 ft Temps 16 / 14 QNH 1018 hPa
2/- Two experienced pilots were at the controls, one TRE and a qualifying captain.
3/- 187 people were on board.
4/- The airplane stayed on the runway centerline until just reaching the end of the runway, where it veered left.
5/- It seems official that the airplane was dispatched with one - #2 - reverser inoperative.
6/- The airplane seemed very fast and apparently did not lose as much speed as it would normally do.
7/- Some pilots noticed standing water on the runway, which wasn't grooved.
I jotted a few figures, making assumptions as to the weight of the airplane :
1/- Dry operating weight 41,000 kg
2/- 181 passengers and luggage 18,000 kg
3/- Fuel remaining on board, with a planned diversion to Guarulhos 3,000 kg
The above give a landing weight at 62,000 kg or 62 tons.
At that weight, the required landing distances are :
for dry runway : 1490 m
for wet runway : 1690 m
for 3 to 6 mm of standing water : 2130 m
Those are the baseline figures for sea level and OAT < 40� C, without reversers and without auto brakes.
Congonhas being 2600 ft above sea level, a correction of 3% per thousand feet applies for a wet runway, and 4% for 3 to 6 mm of standing water.
The resulting landing distances then became :
for a wet runway : 1690 x 107.5% = 1822 m
for standing water :2130 x 110.5% = 2354 m
Compare these figures to the LDA in fact #1."
My first comment when I compare both sets of figures (mine come from an in-flight performance chart out of a QRH ) is that your results are very close to the *contaminated* runway data I obtained. Granted those are estimated performance, yours deduced from the actual braking achieved eventually by the crew.
Personally, I have never accepted the *wet* data outside big airports -those with looong runways- and at the flight preparation phase always gone *one state worse*, i.e in this case, my prep would have been with the quarter-inch standing water tables and the consequent reduction of the landing weight (fuel / freight / passengers). Furthermore, and it's one of the reasons I would dearly hear the pre-descent / landing briefing is whether they'd have been aware of the bad runway drainage and the presence, still visible the morning after the accident, of pools of water. That concept of pools of water is important for it means a risk of potential asymetric braking - a situation in which the use of autobrakes is discouraged.
I feel rather strongly about this aspect of this accident as I think that the dispatch of this flight hadn't been done with enough concern for safety. The thirty-five minute turnaround in Porto Alegre (they landed on frame 183400 and took off on frame 186060, leaving just under 45 minutes between them, to which I substracted 10 minutes taxi time.), didn't leave enough time for anything but a routine dispatch preparation.
IMO, this is an example of collective responsibility.
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I can't remember any aviation accident where FDR and CVR data have leaked to the public only a few days after the event like it happened in this tragical accident.
BTW, it wouldn't not surprise me at all if some of the frequent posters in this thread are paid by AB.
BTW, it wouldn't not surprise me at all if some of the frequent posters in this thread are paid by AB.
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MY money !
hetfield,
Where shall I go ? I want my share of the dough !
BTW, it wouldn't not surprise me at all if some of the frequent posters in this thread are paid by AB.
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hetfield, I was convinced of this too and stated it on a previous post but Lemurian now claims he is not and he is one of the biggest Airbus supporters. Maybe some of them don't work for Airbus.
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remember that one of my ifs was that one of the pilots only recently had been trained to fly the A-320.
autobrake MED has a target [...]
Source: A320 FCOM 1.32.30
given that pilots have not responded to a *very specific* suggestion to activate it ("Retard")
OK, it's 95 kts they left the runway, not 90, so they have been more dead???
Ridiculous...
Ridiculous...
I agree with PBL, there is clear evidence that the manual braking had at least some effect. To add my own rough calculations for those who bother about:
The overall mean deceleration was 1.08 m/s˛, leading to a landing roll distance of 2.4 km. The MLG left the runway at approx. 101 knots, Accel Long and Vert give good hints that it took place at 18:48:48.5.
After applying full manual brakes, the deceleration was about 1.21 m/s˛. Had they applied max. brakes 5 s after MLG touchdown, i. e. 1 second after "spoilers nada" while rolling at 139 knots, they still would have left the runway 49.5 s later, but the overshooting velocity would have been something around 23 knots (42 km/h, 11.6 m/s). Assumption: Actual LDA was 1840 m, because I don't know the exact touchdown point yet. A variation of 50 m would roughly translate into 2 knots more or less.
Remember, all other parameters remain unchanged (lift dumpers, braking coefficients, thrust settings, left brakes not fully applied, ...) except the timing of applying brakes.
Jugdge yourself whether 23 versus 101 knots would have made a difference or not.
Last edited by TripleBravo; 17th Aug 2007 at 22:12. Reason: LDA assumption
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TripleBravo,
I feel we are going right into human factors at this one. Couldn't you get very much used to hearing that because it is heard at (almost) every landing? Once more, three times "retard" can well be heard when trying a very soft and comfortable landing and thus pulling back the levers very slowly, be it recommended or not. That is why I wouldn't be surprised when there is probably no immediate "neuron link" like "I heard retard => something is wrong".
That's the reason I would be advocating a simple (???) change to the voice call from "Retard...to Retard ONE (TWO). I think that only at that moment the mod proposed after the TPE accident would be assimilated by the crew.
PBL has the right words to describe it.
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Marciovp, post 1868, makes a statement that most of the 20 local A320 pilots interviewed did not think this crew left the #2 TL physically up in Cl. We need to let the investigators finish their job before we can conclude what happened with only part of the facts. A few here have decided the DFDR info leaked is fact and that is the end of it. Maybe we should wait for the official report.
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hetfield,
(This time, I'm serious again )
Some Brazilian friends have talked about the political implications of that accident. The first people to be blamed were the government and the military. And the furore went on growing so much that it had become *the* political issue of the moment.
The release of these - partial - recordings were the political means of throwing water on the fire. They succeded as the public is quite content of the perceived official proof of a *pilot error* and won't ask any further.
We're not *just* the public, are we ?
can't remember any aviation accident where FDR and CVR data have leaked to the public only a few days after the event like it happened in this tragical accident.
The release of these - partial - recordings were the political means of throwing water on the fire. They succeded as the public is quite content of the perceived official proof of a *pilot error* and won't ask any further.
We're not *just* the public, are we ?
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Could be a political "strategy", specially when they (government) are having a "hand" from Airbus. That statement "reminding" pilots to reduce both TLs to idle shows me Airbus knows something we don't.
Understandable? Yes, imagine grounding all A-320s around the world...
Acceptable? Not by me...
Rob
Understandable? Yes, imagine grounding all A-320s around the world...
Acceptable? Not by me...
Rob
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good job bubbers!
nice to know that somewhere there is a previous incident of airbus thrust lever not doing what it should
I hope you post it,so that those in brazil can check it out.
all the best
I hope you post it,so that those in brazil can check it out.
all the best
PBL;
The QRH data which is always employed for ECAM abnormals requiring corrections to landing distances and which, in one case, I used to calculate landing data (discussed in #113 and #120), requires a very aggressive touchdown and stopping regime. The AOM states that the distance is calculated from 50ft, that there is "little flare", followed by immediate, maximum braking until stopped. The distance does not take into account the effects of reverse thrust. Spoilers are assumed to be operating normally.
A wise crew (faced with an abnormality - not commenting on this crew), will also consult the other QRH tables which are labelled, Autoland Distance with Autobrake, (Config 3 or Full) to assess the difficulty of the landing. There are columns for Low and Med braking as well as for varying runway conditions and the inclusion of reverse, (not a high percentage, btw). I was impressed with the recently posted numbers for CGH with "no spoilers" - very interesting work.
The circumstances faced by this crew coupled with the time they had to assess deceleration rates and create alternative solutions was for all practical purposes, nil - not the actions, (which would have been immediate brake application), but the assessment and decision(s). I think the runway condition and precip certainly played a role in the accident if only in severity as did the timing of manual brake application. Like everyone else, I'm still examining the FDR traces as well. Can anyone get them to print? My pdf file won't permit it.
As to transducers, resolvers and whatnot, I have no idea, even though I have a full set of 320 AMMs on CD - the failure of such, while never impossible, is improbable, especially given industry experience.
The question of going-around has arisen from time to time through the posts with varying opinions on the potential for success. Many here are familiar with the Cranbrook 737 accident so it and the warning to never go-around after reverse has been selected need not be belaboured. Given this and the calculations made on the deceleration rates by PBL, it is likely stating the obvious (given the almost-2000 posts on the topic), but by the time the crew was aware of the seriousness of their situation (manual braking time, I suspect), the remaining time and operational circumstances they faced likely precluded a successful decision to either stop or go-around.
As to human factors and various aircraft types, I think the largest issues are training issues and not the so-called "helmet fire" syndrome. Humans make mistakes certainly but as a recent poster offered, the ejection drill was so second-nature that nothing entered the active consciousness and it was done accurately with success. The Airbus takes longer to get accustomed to (about one year) but thousands of crews have made the transition with success and without incident. The propensity of design (ergonomics) and humans to fail to interact with robust comprehension and easy success is the subject of many, many books and papers. When I first stepped into the cockpit of a 320 (after flying the B727, L1011 & B767), I frankly felt as though there was a "veil" between me and the airplane but after the transition training, and a year's time on the airplane, "what's it doing now?" was largely a humourous statement and not a real question.
The industry, not a specific aircraft design, has suffered the kind of occurence as happened at CGH and must in some way come to terms with its possibility albeit extremely rare. That said, the numbers as provided earlier regarding something like 50 million landings etc, certainly impress in terms of risk. In doing daily data analysis for a major 320 fleet, I can attest that there are far more serious issues outstanding.
I'd like to hear some thoughts on the written guidance on landing distances, and how it could accommodate slip-ups, but it doesn't appear to be the theme du jour.
A wise crew (faced with an abnormality - not commenting on this crew), will also consult the other QRH tables which are labelled, Autoland Distance with Autobrake, (Config 3 or Full) to assess the difficulty of the landing. There are columns for Low and Med braking as well as for varying runway conditions and the inclusion of reverse, (not a high percentage, btw). I was impressed with the recently posted numbers for CGH with "no spoilers" - very interesting work.
The circumstances faced by this crew coupled with the time they had to assess deceleration rates and create alternative solutions was for all practical purposes, nil - not the actions, (which would have been immediate brake application), but the assessment and decision(s). I think the runway condition and precip certainly played a role in the accident if only in severity as did the timing of manual brake application. Like everyone else, I'm still examining the FDR traces as well. Can anyone get them to print? My pdf file won't permit it.
As to transducers, resolvers and whatnot, I have no idea, even though I have a full set of 320 AMMs on CD - the failure of such, while never impossible, is improbable, especially given industry experience.
The question of going-around has arisen from time to time through the posts with varying opinions on the potential for success. Many here are familiar with the Cranbrook 737 accident so it and the warning to never go-around after reverse has been selected need not be belaboured. Given this and the calculations made on the deceleration rates by PBL, it is likely stating the obvious (given the almost-2000 posts on the topic), but by the time the crew was aware of the seriousness of their situation (manual braking time, I suspect), the remaining time and operational circumstances they faced likely precluded a successful decision to either stop or go-around.
As to human factors and various aircraft types, I think the largest issues are training issues and not the so-called "helmet fire" syndrome. Humans make mistakes certainly but as a recent poster offered, the ejection drill was so second-nature that nothing entered the active consciousness and it was done accurately with success. The Airbus takes longer to get accustomed to (about one year) but thousands of crews have made the transition with success and without incident. The propensity of design (ergonomics) and humans to fail to interact with robust comprehension and easy success is the subject of many, many books and papers. When I first stepped into the cockpit of a 320 (after flying the B727, L1011 & B767), I frankly felt as though there was a "veil" between me and the airplane but after the transition training, and a year's time on the airplane, "what's it doing now?" was largely a humourous statement and not a real question.
The industry, not a specific aircraft design, has suffered the kind of occurence as happened at CGH and must in some way come to terms with its possibility albeit extremely rare. That said, the numbers as provided earlier regarding something like 50 million landings etc, certainly impress in terms of risk. In doing daily data analysis for a major 320 fleet, I can attest that there are far more serious issues outstanding.
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Can anyone get them to print? My pdf file won't permit it.
If that's too complicated, another idea might be trying another PDF reader like Foxit Reader (http://www.foxitsoftware.com/downloads/ ) or PDF Reader (http://www.cadkas.de/downengpdf5.php ), but I have no experience with these.
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The larger picture...
Last year there was a terrible disaster in Brazil when a Boeing 737-800 from GOL Airlines collided over the jungle with a Embraer Legacy bought by US Excel Air. The Legacy was able to land safely at Cachimbo AirForce Base in Mato Grosso. The Boeing desintegrated in the air. One of the passengers at the Legacy was a journalist from NYTimes who has a blog: http://sharkeyonbrazil.*************/
Since that accident things in Brazil have been messy. The Brazilian government and the Air Force have been consistently saying that the equipment and software of the Brazilian Traffic Control is state of the art and safe. The disaster has been investigated by many groups: local police, federal police, House of Representative Committee, Senate Committee and CENIPA the Air Force investigative and preventive agency. CENIPA has not issued a final report. NTSB is helping. But the Federal Police and the House of Representative Committee have come out with final statements blaming the two Legacy pilots and four controllers in Brasilia. The controllers claimed that their equipments were faulty and they did not like being blamed by the Air Force that denies any problems with the equipments. At one point they were so scared of being criminally blamed that they made a strike and operations slowdowns... Now some of them are being persecuted by the Air Force for making a Motin. Just to give you all a taste of the political side of what goes on in Brazil.
Then came the TAM accident. The government did not want the runway at Congonhas to be blamed because it is administered by a government agency (Infraero). TAM did not want to be blamed. Airbus did not want to be blamed. The disaster has been investigated by all the agencies that got involved with the GOL disaster. CENIPA says that it will take about one year for a final report to be issued.
Since the accident TAM has decided that its planes will not longer land in wet runways with one reverser inoperant, and also that it will install the new warning signs in its planes to advise the pilots about the wrong TLs
positions. Airbus has issued a note saying that there was nothing wrong with the plane and advising again the pilots how to operate the A320 with one reverser out. Congonhas is grooving the runway and it will be done by September 8th. Today I saw in TV that they are going to install "nets"
at the ends of the runway (have no idea of how these nets will work) and also soft cement to brake the planes. (I guess paralell to the runway, in the ends).
The Minister of Defense has changed. The Chief of Infraero has changed, The officers of ANAC are under attack because they were supposed to regulate the airlines but they accepted thousand of free tickets from them. The new Minister of Defense diverted traffic from Congonhas to Guarulhos but he now wants the runway in Guarulhos also repaved and this will create problems. He doesn't want Congonhas to remain as a hub for Sao Paulo. He is also saying that he wants more space between the seats in the airplanes (indeed they have been shrinking). Some say that he wants to run for President in 2010...
Today, one month after the TAM disaster, relatives and friends of the victims made demonstrations in Congonhas, in front of the building where the plane crashed, and in Rio de Janeiro. Yes, as a said before, Policia Federal has interviewed 20 pilots and they all said that they did not believe that the two pilots at that flight would commit the elementary error that has been said they did. Also there are now reports of 11 planes that skidded in Congonhas the day before the disaster, one of them leaving the runway. On the day of the disaster also planes that landed before reported the runway as being slippery "as a soap".
To finish...I guess we will have to wait one year to hear a final report from CENIPA. Unfortunately CENIPA belongs to the Air Force that administers Traffic Controll in Brazil (military).
I guess there is a lot of work ahead before we go back to a state of art Air Traffic Control and safe airports in Brazil. Let´s hope and play that nothing else will happen in the near future.
Sometimes I see air disasters as a symptoms of larger problems involving a lot of variables.
Since that accident things in Brazil have been messy. The Brazilian government and the Air Force have been consistently saying that the equipment and software of the Brazilian Traffic Control is state of the art and safe. The disaster has been investigated by many groups: local police, federal police, House of Representative Committee, Senate Committee and CENIPA the Air Force investigative and preventive agency. CENIPA has not issued a final report. NTSB is helping. But the Federal Police and the House of Representative Committee have come out with final statements blaming the two Legacy pilots and four controllers in Brasilia. The controllers claimed that their equipments were faulty and they did not like being blamed by the Air Force that denies any problems with the equipments. At one point they were so scared of being criminally blamed that they made a strike and operations slowdowns... Now some of them are being persecuted by the Air Force for making a Motin. Just to give you all a taste of the political side of what goes on in Brazil.
Then came the TAM accident. The government did not want the runway at Congonhas to be blamed because it is administered by a government agency (Infraero). TAM did not want to be blamed. Airbus did not want to be blamed. The disaster has been investigated by all the agencies that got involved with the GOL disaster. CENIPA says that it will take about one year for a final report to be issued.
Since the accident TAM has decided that its planes will not longer land in wet runways with one reverser inoperant, and also that it will install the new warning signs in its planes to advise the pilots about the wrong TLs
positions. Airbus has issued a note saying that there was nothing wrong with the plane and advising again the pilots how to operate the A320 with one reverser out. Congonhas is grooving the runway and it will be done by September 8th. Today I saw in TV that they are going to install "nets"
at the ends of the runway (have no idea of how these nets will work) and also soft cement to brake the planes. (I guess paralell to the runway, in the ends).
The Minister of Defense has changed. The Chief of Infraero has changed, The officers of ANAC are under attack because they were supposed to regulate the airlines but they accepted thousand of free tickets from them. The new Minister of Defense diverted traffic from Congonhas to Guarulhos but he now wants the runway in Guarulhos also repaved and this will create problems. He doesn't want Congonhas to remain as a hub for Sao Paulo. He is also saying that he wants more space between the seats in the airplanes (indeed they have been shrinking). Some say that he wants to run for President in 2010...
Today, one month after the TAM disaster, relatives and friends of the victims made demonstrations in Congonhas, in front of the building where the plane crashed, and in Rio de Janeiro. Yes, as a said before, Policia Federal has interviewed 20 pilots and they all said that they did not believe that the two pilots at that flight would commit the elementary error that has been said they did. Also there are now reports of 11 planes that skidded in Congonhas the day before the disaster, one of them leaving the runway. On the day of the disaster also planes that landed before reported the runway as being slippery "as a soap".
To finish...I guess we will have to wait one year to hear a final report from CENIPA. Unfortunately CENIPA belongs to the Air Force that administers Traffic Controll in Brazil (military).
I guess there is a lot of work ahead before we go back to a state of art Air Traffic Control and safe airports in Brazil. Let´s hope and play that nothing else will happen in the near future.
Sometimes I see air disasters as a symptoms of larger problems involving a lot of variables.
Last edited by marciovp; 18th Aug 2007 at 03:35. Reason: typo
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woodvale wrote
I think this is a very constuctive attitude to everything we have learned so far on this thread. I've wondered about the reason why these two pilots handled the throttles so differently during the two landings they made that day with 1 TR inop. Has there been any briefing? Did they talk about the MEL? Did their professional relationship and/or ranking prevent them from talking it through or didn't they deem it necessary to discuss it?
Perhaps we'll never know, unless the CVR part that was not published might give investigators further information on this.
Nevertheless, I think woodvales resolve is worth following.
From now on I will brief differently for any take off or landing that involves non standard operation of the controls, I will ensure that the PNF specifically monitors my required actions in order to add his/her capacity to ensure they have been carried out...
Perhaps we'll never know, unless the CVR part that was not published might give investigators further information on this.
Nevertheless, I think woodvales resolve is worth following.