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Ten to be indicted over TAM crash

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Old 15th Nov 2008, 10:08
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Ten to be indicted over TAM crash

The criminal investigation into the TAM accident at Congonhas was completed yesterday and will recommend indictments against 10 as yet unnamed individuals for crimes against air safety. The penalty upon conviction is from 1 to 3 years.

The investigation spreads the blame around, but regards the behaviour of ANAC (the regulatory authority) as the main reason for the tragedy, followed in order of "responsibility" by Infraero (airport operator), TAM, and Airbus. How many indictments will be levelled against each of these organisations isn't yet known.

This is only the criminal investigation, the full technical report from CENIPA has yet to be released (it's not finished yet AFAIK), so precisely how much of this is based on fact and how much on political posturing isn't clear.

The Ministério Público Estadual will decide in the next few days whether to accept the recommendations from the investigation and go ahead with the prosecutions.

AB
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Old 15th Nov 2008, 15:55
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2500 pages in the report, but not published yet:

Brazil crash 'blamed on pilots, airline' - Breaking News - World - Breaking News
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Old 16th Nov 2008, 18:05
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Glueball,

You've done no more than demonstrate that you're in the remedial class there.

And you're only just keeping your head above water as it is.

Run along and let the grown-ups have their conversation, eh?

Now, shall we have a proper 'Airbus pilots are de facto disconnected from the power controls by non-moving levers' discussion? and get somewhere worthwhile?

If some of the designers and certifying regulators are going to be in the box, then I shan't feel so bad about this particular post-accident prosecution.
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Old 16th Nov 2008, 20:25
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for glueball :
*"sciolist"... Noun, archaic. "a person who pretends to be knowledgeable and well informed".
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Old 16th Nov 2008, 20:50
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I would have thought that if the aircraft is not slowing down you close the throttles and apply the brakes. I cant believe airbus pilots are so disconnected from the real world that they dont know this. For anyone interested I am not a "sciolists" tho I did learn that word on prune.
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Old 16th Nov 2008, 22:34
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Zorst, I can't for one millisecond believe that you are for real... your comment to Glueball (and I fully support your sentiment regarding his/her level of intelligence) is not dissimilar to my reflection on your own level of understanding/ignorance regarding Airbus' philosophy and Airbus' pilots procedural competence.

Having flown FBW Airbus aircraft for over 10 years now, I'm at a complete loss to understand what this concept of '...defacto disconnected from the power controls...' is that you (and rogerg) have mentioned.

Airbus power levers have to move at all critical phases to achieve the critical power application. By critical phases, I refer to Take-off and Landing. And just to keep our interest level up, we even have to move them to taxy about the airport! Quite conventional really.

There would probably be some other physiological reason why two experienced pilots (as evidenced by the fact that they were both Captains) failed to notice that one power lever was still in the climb detent. Never having been into the airport concerned, I can only go by all the correspondence that has been published in the media and on this forum.

On the basis of that reading, my humble opinion is that these two guys were already at a heightened stress/awareness level because of the physical vagaries of the runway they were using, the weather and subsequent surface conditions, and the nagging awareness of the MEL that they were operating under that would just make their arrival all the more difficult than the runway would normally make it (even on a lovely day).

We (all of us) only have so much excess RAM to use on a day-to-day basis; when it begins to be used up by stressors that don't normally occur, our ability to process begins to break down, and we then revert to our individual ability to 'priority-shed'. By that I mean that we unconsciously begin to prioritise what we need to do, and shed what we believe we don't have to worry about.

I'd guess that the two pilots were so ensconced in collectively doing their level-best to tick all the 'unusual/abnormal (in the common sense of the word, not the industry sense) boxes that this arrival presented, that a perfectly routine (though critical) action was overlooked. They then had to deal with the completely confounding situation of the aircraft failing to slow down as it 'normally' would be expected to, and had previously always done.

It is a nightmare scenario that any one of us could find ourselves in, given the same circumstances (Z, G and R - have you ever heard of the 'Swiss Cheese' model of accident-producing circumstance development?).

Unless there is clear-cut evidence of culpubility in an aviation accident, police add no practical worth to the investigation, the outcome of, or, more importantly, to the enhancement of future aviation safety.

And as writers, readers, participants and observers of this once-enviable (and I'd like to think it still is enviable) profession and industry, I think we should all be a little more circumspect in our criticism-based comments following tragedies; after all, it is only because of the accidents that have befallen the few, that we many have enjoyed the benefits of ever-safer flight.

Honor them, those whom circumstance has conspired to take, and let us respect the memory of them forever.
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Old 16th Nov 2008, 23:15
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RAD ALT ALIVE

That is without a doubt one of the most sensible responses I have ever seen to that old and tired anti-Airbus fear mongering we see all too often here on PPRuNe. Now if only you could convince the "law" officials in Brazil that prosecuting anyone for this tragic accident will do nothing except allow them to make political hay.
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Old 17th Nov 2008, 05:25
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Rad Alt Alive.
Thats what I meant, but with less words!
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Old 17th Nov 2008, 07:48
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J.O.

Much as I disagree with the criminalisation of accidents, in this case it may be a blessing in disguise. It may result in a shake up of ANAC and Infraero where we see industry professionals appointed to the higher positions instead of the political appointees that we currently have. That would be a very positive move which would only benefit everyone involved in aviation in Brazil, and those who operate in Brazilian airspace.

Given the nature of the legal system here that might seem a little naive but there are a lot of questions being asked about the administration and bringing these out into the open will only stimulate the move for real change.

AB
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Old 17th Nov 2008, 11:37
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alemaobaiano:

Here's my problem with the prosecutorial approach. The industry in general is willing to allow that most crew-related human error events are not criminal acts and that they are the consequence of a number of contributing factors. In other words, the people involved didn't intend to cause an accident. In most cases, how the events transpired "made sense to them at the time".

Is it not fair to assume that people within ANAC or Infraero were also well intended and were simply doing their best to work within the system they've been given? To me, the investigation and corrective actions should be focussed on fixing the entire system, including the political aspects of it. If officials go to jail, it is not a gaurantee that the system will be made better as a result. It's much more likely that you'll end up with an even more dysfunctional system with new rules written by administrators who don't understand the system in the first place. This is not a slight against Brazilian culture, but the system as it currently exists is the result of cultural norms. System safety improvements often require cultural change, and in this particular case, and the Gol mid-air collision case, culture change is needed to make the necessary improvements. Punishing people for living and acting within their cultural norms is something Al Queda does. It's not something we should do in aviation safety.

Last edited by J.O.; 17th Nov 2008 at 15:30.
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Old 17th Nov 2008, 12:20
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Rad Alt Alive

That is possibly the most sensible post I have read on this site.
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Old 17th Nov 2008, 15:29
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Angry

Nothing quite like blaming people and then prosecuting everybody that you can stick a charge on. Quite how this will advance the cause of safety I'll never know - it's a bit like screwing for virginity or imprisoning people in the cause of freedom! Don't you just love fair and just societies!

This sort of ridiculous action totally negates any form of accident investigation. This is because if (and I'm sure I'm preaching to the converted already) they are criminally liable, a different aircraft flown by a different crew from a different operator would have definitely produced a different outcome . Finally, who will now co-operate with the Brazillian authorities?

Brazil should be thrown out of ICAO.

Halfwits!

PM
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Old 18th Nov 2008, 08:52
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I think, we must make the difference between the errors and the deliberate faults.

-When the crew forgets to retract the TLs this is an error.
-When airport’s authorities stop the necessary renovation of the runway (grooving) and reopen it before the holidays this a deliberate fault
-When Airbus accepts the Taipei safety recommendation about a specific warning when one throttle is set to reverse while the other is above idle, but never send the service bulletin this is a fault
-etc
Justice must punish the faults
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Old 18th Nov 2008, 16:14
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Brazil should be thrown out of ICAO.
That would not bring anything, other than to confort the Brazilian Air Force in their paranoia that the whole world is againt them , and this would probably re-inforce their powers.

Also we should be careful ,as many self proclaimed " advanced" Countries are not doing any better. My own , France , is a good example of a poor weak regulator, an Investigation Bureau following political orders, and a Justice department wanting to score points in front of he public opinion. . The recent trials held after the Mt St Odile crash ( 14 years afrer the accident !) or the Gonesse Concorde one , are not any better than Brazil.

Greece and Cyprus are also coming to my mind as poor examples.

An excellent recent book is explaining quite well this " procecution issue" , whether it is in medecine, police or aviation. ( Balancing Safety and Accountability, Sidney Dekker ISBN 978-0-7546-7267-8)
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Old 18th Nov 2008, 16:46
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Rad Alt Alive
very well said,and we can honor them best by learning from what happened,and trying to better prepare oursleves.
While as pilots,we might somtimes like to see some 'ass kicking' action in order to get the airport operater/manufacturer/regulator to do the right thing,i am not sure this new trend towards prosecution is the right way forward.I would like to hope that there is still some pioneering zeal(and willingness to self rectify) left in all sections of the industry.
Meanwhile,experience and training continue to be the most useful tools of our trade.
Trying to develope and pass on optimal/correct "Priority-shed" skills is what i base my work on
Incidentally i find that Capts transitioning from other types with larger thrust levers(in the TAM case it was a 757 transition i think) sometimes take a while to get the "feel" of the 320 detents/gates.
I use the TAM example to highlight this aspect to them
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Old 18th Nov 2008, 18:09
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non-moving throttles

GlueBall,
Hard words like yours, normally don’t fit in this forum.
Although I tend to agree with you - that retarding throttles is what one has learned in school to land an aircraft (an airplane, not an helicopter…) - I would like to add that I personally feel that Airbus concept of "non-moving throttles" (and non-feed-backing side-sticks) are wrong and a human factor nonsense.
I remember when, in the early 90's, I first flew a FBW aircraft, (A330 SN002(?) test bird), invited by Airbus Industrie, to promote communality and AI family concept, together with Capt Baldomero Monterde (Iberia) and Pier Paolo Rachetti (Alitalia) (who soon would be one of the seven fatalities of a crashed A330 flight testing at Toulouse Blagnac) we had a debriefing with the AI test pilots that flew with us. Questioned about the technology, when I had the opportunity, I told them that I thought that their FBW aircraft had two "concept errors": those non-moving throttles (in fact they act as thrust limiting levers)and lack of other pilot movement feed-back on the side-sticks...I was promptly interrupted by one of the test-pilots who told the "class": Sorry folks, but Airbus Aircraft don't have "concept errors", they have "characteristics". (That must be the reason why, it took AI more than a decade to add that "double input" alert, to inform PF, that the PNF is moving his stick...)

Well, one of the "characteristics" of the A320 is that one comes to the Final with the levers on the Climb Detent while the engines are spooling up and down to cope with the Ground Speed Mini...
Despite of briefing the approach to Congonhas, and the DMI'd reverser, they failed to understand what was really going on during the landing flare and subsequent seconds...
Just imagine for a minute what were the conditions: an ex-Boeing Pilot Flying, being checked, DMI'd reverser, short and contaminated RWY, "tunnel vision" with the back-ground idea of imminent requirement to pull only one reverser and in the mean time: both levers in Climb Detent and both engines providing near Idle Thrust (that is why you get the auto call out "Retard, Retard, Retard!" to remind you to retard your levers!) When he pulled ATS Lever One to Idle, the number 1 went to Idle and the number 2 kept giving forward thrust...the rest of this sad story is well known.
Easy to blame the pilots. But, could it happen on an Auto-Throttled aircraft? What prompts a pilot to make the wrong move, against all off what he has learned, against the nature of flight, itself?

RAD ALT ALIVE,
I believe your words on this subject were one of the best contributions I’ve ever seen on PPrune.

I fly Airbuses for more than 17 years and although I feel comfortable flying them, I still think that the concept of “non-moving throttles” and the “non-feed backing side sticks” is a mistake.
Is it “natural” to fly an aircraft that (in some situations) doesn’t give you the feed-back of what’s going on?
Can you hear the auto call out of “Double Input” in the middle of a stressing cross wind and variable direction gusts short final to Funchal (Madeira), Horta or Pico (Azores) Runways? And if you hear it, during flare, will you have time to cope with a double input? I believe that most of us, in an uncomfortable situation, would tend to “avoid ground contact” and interfere with the controls…and if you have a yoke, you’ll find out sooner, (that the other guy is “also afraid to die”), but with a side-stick, there is a much more intellectual process, to understand the obvious…
And on the last seconds of our lives, .i.e., when facing a potential disastrous situation, we all tend to revert to basics…
Wasn’t much more user friendly the Auto-Throttle system, were one could “help” the AT, (when the system itself was a bit “lazy”) by overriding it with small inputs on the throttles to keep the speed on final?
You may feel quite comfortable with the Airbus ATS but, that doesn’t mean that one day you will not feel otherwise especially trying to land an A330 or a 340 in Madeira, on a rough rainy and windy night, after a 10 hour service from Caracas.

Airbuses are fantastic aircraft, but they could be better!
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Old 18th Nov 2008, 18:29
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Nothing quite like blaming people and then prosecuting everybody that you can stick a charge on. Quite how this will advance the cause of safety I'll never know - it's a bit like screwing for virginity or imprisoning people in the cause of freedom! Don't you just love fair and just societies!
Sort of a question I was going to ask. Seems to me this will hamper any "questioning" of anyone within a hundred miles of the accident. Why just ten, could they not go farther up the chain?
Always a big issue between criminal and civil liability in matters such as these. I have pretty much always understood that unless someone seriously went out of their way to kill others it was to be a civil matter.
Accidents are certainly a combination of things, but rarely intent to do harm is one of them.
Anybody??
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Old 19th Nov 2008, 19:40
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Here are the names

In hierarchy, they've gone all the way up - ex-heads of the Civil Aviation Commission and the government airport management company.

While there were noises about accusing someone from Airbus, there's only the government people and employees of the airline, TAM.

Wire service articles will shortly claim these people were "indicted". That's just a mis-translation. "Accused" or "named in the police inquiry" is correct.

The charge - placing aviation at risk - is the same used against the American pilots of the Legacy in the midair with Gol flight 1907 in September of 2006.


Ex-presidentes da Infraero e Anac são indiciados pelo vôo 3054 - Estadao.com.br
Cities - São Paulo

Wednesday, November 19, 2008, 15:52 | Online

Ex-presidents of Infraero and Anac are accused for flight 3054

Brigadier José Carlos Pereira and Milton Zuanazzi are on list of people who will answer for tragedy

by Eduardo Reina, of O Estado de S. Paulo
SÃO PAULO - The ex-presidents of the National Civil Aviation Agency (Anac) and the Brazilian Airport Infrastructure Company (Infraero) are among the ten indicted for the accident with the TAM A320 Airbus on July 17, 2007 at Congonhas Airport. Milton Zuanazzi and brigadier José Carlos Pereira, respectively of Anac and Infraero, were accused in the Flight 3054 tragedy.

The list with the names of those accused was released this Wednesday, the 19th, by the precinct captain of the 15th Precinct, Antonio Carlos Menezes Barbosa. In a press conference, he presented the inquiry's conclusions, which accused those responsible for the accident under Article 261 of the Criminal Code, for an attack on the safety of air transport. Each defendant could be sentenced to up to 6 years of detention.

Besides Zuanazzi and Pereira, the list of those accused includes Luiz Kazumi Miyada, Anac superintendent; Marcos Tarcísio Marques dos Santos, the agency's superintendent of operations; Denise Abreu, ex-commissioner of Anac; Jorge Luiz Velozo, director of Safety Management, Investigation and Prevention of Aeronautic Accidents; Marco Aurélio dos Santos de Miranda e Costa; Agnaldo Esteves, Anac employee; Esdras Barros, of Infraero and Abdel Salam Abdel el Salam Rishk, ex-manager of engineering and operations of TAM.
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Old 20th Nov 2008, 13:04
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Lots of sad people as a result of the accident, no question there.. But this sounds like even if we dont know who to blame, lets round up the usual suspects and have a trial. Somebody must pay and it also makes the government look as though they have solved the problem..
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Old 20th Nov 2008, 13:29
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Originally Posted by aguadalte
Airbuses are fantastic aircraft, but they could be better!
Agree.
That Airbus would have been even better by just keeping it humble.
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