Ten to be indicted over TAM crash

[aguadalte]

Dear Colleague,
As I said before:

Airbuses are fantastic aircraft, but they could be better!

I do like the FBW concept, I just do not agree with non-moving throttles and non-feed-back side-sticks.
And in this thread I'm trying to explain that it is a huge injustice to simplistically hold those pilots responsible for something that just goes beyond a simple process of retarding both levers to land an aircraft.
The same applies to the flight safety manager of TAM. I don't think the Flight Safety Department has anything to do with this accident, although I'm well aware that I'm in no possession of all the information.
I'm not trying to hold anyone legally responsible for this accident, including Airbus Industrie. I'm trying to bring some light into the possibility of an improvement to the Airbus Industrie FBW concept. I defend the idea that moving throttles would have prevented this accident to happen, because you're more "involved" with the process of managing power, and that because of the complexity of the ATS system one can commit mistakes under catastrophic stress. The simpler the concept, the easier to handle.
Let me give you an example:
Here in Europe, manual geared automobiles were the standard. I was driving automatic geared cars for more than a decade when it happened to me that I had once to break hard to avoid an accident. My left foot went immediately to the embrayage (clutch).The contrary happens a lot, to people used to drive automatic geared cars, when driving manual geared ones. They just simply forget to use the embrayage when stopping in a red light, and the engine goes off...
What I intend to say is that, all of us tend to go back to basics when facing disaster and one has more chances to survive if the machine really handles as expected.
Fly Safe.
Aguadalte.

[CONF iture]

Originally Posted by PJ2

Well, I didn't "fail" to mention it mainly because it wasn't then and isn't now a problem endemic to Airbus and non-moving throttles - the very same thing, leaving a throttle open, has happened on Boeing aircraft.

So, would you direct me to such a report from a non FBW airbus ?
Remember, the case involves the next 3 repetitive facts :

• One deactivated thrust reverser
• Same thrust / throttle lever left in an open position during landing
• Overrun the runway, with catastrophic consequences for 2 out of 3

I do share your view that Airbus A/THR understanding and proficiency knowledge acquisition requires regular training. But as aquadalte mentioned, why such specific training has to become mandatory ?
Auto throttle doesn’t need much thinking thanks to its simplicity of operation, Airbus A/THR requires thinking + training … How is it any better ?

Manual operation of the Bus thrust levers is not a problem, it’s even a pleasure.
The transition between manual and automatic operation (and vice versa) lacks of simple simplicity … that’s where relies the culprit for "momentary confusion" as you call it yourself.

PJ2, (DC9, DC8, B727, L1011, B767, A320/319, A340/330 endorsed, past Airbus instructor, fully involved in flight safety and data work).

My next question is directed to a very experienced man obviously (and a good pilot also as you made it to your retirement !) but more particularly to someone who takes safety very seriously :
A simple modification of the RETARD auto call out could be implemented to make sure that the call out does not stop before ALL thrust levers are effectively retarded, which could help other crews not to inadvertently forget one of those thrust levers in the inappropriate CLB detent during landing.

Such a simple modification could help to prevent another Congonhas.

Why should we do without ?

What I, (and many, I suspect) am presently finding far more disconcerting is stories of avionics/software issues including spike detection and voting. Those are issues which may possibly be beyond a crew's ability to assess and successfully counter and this again isnt' only an Airbus issue.

For the spike detection and voting, I agree, but when the "protection" kicks in for no reason and overrides the pilot inputs, and sends the pax and crew in the roof, to this day, that is only an Airbus issue.

[Richard_Brazil]

Eleven to be indicted

Today's 'Folha de S.Paulo' updates the total to 11 to be accused, including two from the airline's pilot training area:

Prosecutors' Office suggests accusing 11 in TAM case
State Prosecutors' Office can only suggest, since case will go to Federal Prosecutors' Office
City Desk

The MPE (state Prosecutors' Office) yesterday concluded a brief on the 2007 TAM accident, suggesting the accusation of 11 people for the crime of an attack on the safety of air transport. The case should be passed on to the Federal Prosecutors' Office, which will return an indictment to the courts.

The Prosecutors' Office's list includes three more TAM employees whose names had not been indicated by the Civil Police: Orlando Bombini Júnior, Alex Frischmann and Alberto Fajerman - linked to crew training.

According to prosecutor Mário Luiz Sarrubbo, they were negligent because they did not explain to TAM's crews that they weren't landing in conformance with the manner indicated in the airplane's instruction manual, in relation to the throttle positions. Just the airplane that crashed had landed incorrectly 13 times.

The names of two Infraero employees - who okayed use of the runway on the day of the accident - were on the police's list, but were discarded by the Prosecutors' Office, under the argument that they were just following orders.

The Prosecutors' Office also suggests the following accusations: Marco Aurélio dos Santos de Miranda e Castro and Abd El Salam Kishk, of TAM, brigadier José Carlos Pereira, ex-president of Infraero, besides Milton Sérgio Silveira Zuanazi, Denise Abreu, Jorge Luis Brito Velozo, Marcos Tarcisio Marques dos Santos, Luiz Kazumi Miyada, all linked to Anac (the National Civil Aviation Agency) at the time of the accident.

[TOFFAIR]

Most threads here are so focussed on the old pro/anti airbus FBW philosophy, that you guys lost the complete picture! Im not sure how many of you know SBSP, but i can assure you any sim from MS to level D is much too decluttered to give you a feeling o approaching it. Doing training on a E190 (FBW) for a "special airport" certification, i learned that even though a landing might be practicable, given the many threats invloved prior to that mislanding a diversion and even a rejected landing should be considered. Consider the factors known to the captain at the approach: An ATR slipped off the RWY just one day earlier, Rwy contamination and heavy rain at the time, known poor rwy conditions, knowing rwy has no shoulders at both ends, knowing one reverse was inoperative, knowing they were at the high end of the weight limit (plus the last minute jumpseaters), inexperinced crew (at training) in an airport that requires special qualification, and for TAM policy does not allow FOs to land (not even on good wheater), still unfamiliar with aircraft (boeing offspring)... I think CRM wasnt unknoknw, why not practiced? What happened after touchdown, in my oppinion was so quick and all the discussion of what they did and what they could have done and what was wrong with the aircraft just weighs with bad luck... by the way, blaming the dead for the accident, neither brings anything back nor does it prevent similar situation...

[aguadalte]

bad luck

You're right TOFFAIR, they had bad luck. Unfortunately, bad luck is not a scientific reason for an accident...

I think CRM wasnt unknoknw, why not practiced?

Further, can you please enlighten me on that subject?

Regards,
aguadalte

[dvv]

aguadalte, moving throttle levers didn't prevent the F-OGYP crash.

[GlueBall]

Toffair . . .

Consider the factors known to the captain at the approach: An ATR slipped off the RWY just one day earlier, Rwy contamination and heavy rain at the time, known poor rwy conditions, knowing rwy has no shoulders at both ends, knowing one reverse was inoperative, knowing they were at the high end of the weight limit (plus the last minute jumpseaters), inexperinced crew (at training) in an airport that requires special qualification, and for TAM policy does not allow FOs to land (not even on good wheater), still unfamiliar with aircraft (boeing offspring)...

You are digressing from the fact that the airplane easily could have been stopped and would have stopped within the confines of the 6,365' wet pavement [as had numerous other A320s immediately prior to this accident] if only the operating captain in the left seat would have closed/retarded both thrust levers during flare or touchdown. This "instinctive" elementary function of moving the levers to the idle detent position even applies to the fly-by-wire A320s where the thrust levers are "switches" . . . irrespective of whether one reverser is DMI'd, irrespective of whether it's raining or snowing, or whether the runway is short and wet.

The pilots screwed up perhaps due to lack of training, lack of experience, absent mindedness, incompetence. . . .

[aguadalte]

you're right...but

aguadalte, moving throttle levers didn't prevent the F-OGYP crash.

dvv, you're right (I must concede), but there is a slight difference that is very important for this case: in the F-OGYP accident, the pilot was hand flying with Auto-Throttle OFF. The behavior of the levers is the same on both systems, when disconnected. I'm comparing the behavior of Auto-Throttle vs ATS, when connected. And as far as I know (the last a/c I flew with Auto-Trottle was the A310-300) when the Auto-Throttle is ON, if you retard one of the levers, the other tend to follow the retarded one. You have to positively (in the sense that this is an intentional decision) disconnect the Auto-Throttle to bring only one lever to the retard position. And that makes all of the difference between both systems...
Regards,
aguadalte