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TAM 3054 Report released

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TAM 3054 Report released

Old 2nd Nov 2009, 17:33
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logic

Why is so dificult for engineering to "teach" computers some simple logic, like if you have weigh on wheels, at least one TL on reverse and the pilot applying the brakes, the pilot wants to slow down?
Give the pilot spoilers, cancel the order coming from the TL not in reverse and "refuse" to give power to that engine.

I know it is hard for a computer understand why the pilot wants to stop if he continues whith one TL on climb.

On the other hand, it should be even harder for the computer understand why the pilot wants to go around with one engine engaged on reverse.

Maybe the computer could say: "Whow, this guy wants to fly with one engine on reverse. Since we are on the ground anyway, I will cut thrust on the other engine, deploy spoilers and apply full auto brakes. This guy can try this stunt another day, not with me supervising (or protecting) him...

Last edited by Rob21; 2nd Nov 2009 at 17:39. Reason: typo/spelling
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Old 2nd Nov 2009, 17:51
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TAM accident report

One of the tenets of Human Factors or Safety Engineering is that the best way to prevent accidents is to make the hazard inpossible to cause an accident and the least effective way is to rely on training.

I can't think of a single reason why anybody would want one engine in climb thrust (or a significant amount of forward thrust) and one in reverse. I've asked around and no-one I've spoken to can either. Therefore, make it impossible to place (or keep) one in reverse if the other is in forward thrust above idle.


Cheers,


Dick
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Old 2nd Nov 2009, 17:54
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4-holer poler

I'd like to discuss the circumstances with you, if you would. You're one of the surviving pilots on this type of problem.

Cheers,


Dick
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Old 2nd Nov 2009, 17:58
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Maybe the computer could say: "Whow, this guy wants to fly with one engine on reverse. Since we are on the ground anyway, I will cut thrust on the other engine, deploy spoilers and apply full auto brakes. This guy can try this stunt another day, not with me supervising (or protecting) him...
...as they plow into the aircraft/vehicle that inadvertently enters the active runway.
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Old 2nd Nov 2009, 18:48
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only way, you can prevent such an accident is:

manual flight-manual thrust

when you control the throttle levers manually you know in which position they are. manual flight-automatic thrust is very dangerous and in my airline(european main carrier)forbidden.
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Old 2nd Nov 2009, 19:57
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4-holer poler: interesting contribution. I would tend to think that although rare this is not such an uncommon situation as one might think (asymmetric thrust leveller at landing). Fortunately most would catch it before it's too late.


This should warrant some more investigation by AB and some redesign of the automation logic.
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Old 2nd Nov 2009, 20:30
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Dick Newman:

Personally, I find it incredible that one pilot would not pull both thrust levers back to idle during the flare. Airbus has a unique design where the T/L's do not move during an autothrottle approach -- however the pilot is reminded by an automatic voice commend ("Retard," which leads to many jokes.)
According to the report, TAM had not updated the FWC to H2F3 standards. Hence the "Retard" call out stopped with only one of the levers in the idle detent. H2F3 was developed as a result of both accidents you mention. However, it came out as a SB, not an AD.

Cheers.
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Old 3rd Nov 2009, 04:00
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ULMFlyer and alemaobaiano, Obrigado for your help.


All I can see is the obvious failure of a system : The BEA should be a leader in the continuous research of SAFETY but instead they show their total inbreeding with Airbus.

Page 118 "Furthermore, the BEA thinks that the Congonhas event was not foreseeable"
Page 119 "Since the accident, Airbus has been studying new corrective actions to take in account this scenario, which is now known"

How do they dare writing that after Bacolod and Taipei ???

Already after the first accident there was a very simple modification to be applied on the RETARD callout logic to help to prevent a recurrence !

Now, as a recommendation in that direction is done once again (170/A/07 on page 115 ) Airbus simply choose to ignore it in its comments.
It is disconcerting.



Help again : In the present report, any further specific detail on what does include the FWC (H2F3) standard except the triggering of a specific warning associated to an ECAM message ENG X THR LEVER ABV IDLE ?
To my knowledge, it does not feature a modification in the RETARD callout logic (?) which is the purpose of the recommendation 170/A/07.
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Old 3rd Nov 2009, 05:06
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CONF iture

Help again : In the present report, any further specific detail on what does include the FWC (H2F3) standard except the triggering of a specific warning associated to an ECAM message ENG X THR LEVER ABV IDLE ?To my knowledge, it does not feature a modification in the RETARD callout logic (?) which is the purpose of the recommendation 170/A/07.

I had been under the impression that H2F3 did modify the callout logic. However, I just reread the relevant parts of the report and this is apparently not so. (The report actually reads a little ambiguously in Portuguese, but it became clearer when I was translating the relevant section on p.48 into English).

In any case, the only reference to H2F3 modifications is indeed in regard to the ECAM msg. So, I suppose you're right with respect to
recommendation 170/A/07. However, another criticism in the report that also applies to this recommendation is the fact that this callout will still sound even after both levers are already in the IDLE detent, say, at 10 ft AGL during flare. In the eyes of CENIPA, the callout is not serving its purpose if it doesn't recognize that both levers have already been retarded, and this ends up leading to some complacency on the part of flight crews.

Hope this helps.
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Old 3rd Nov 2009, 05:28
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Dick Newman said:

There was a related accident in Phoenix in Aug 02. The pilot pulled both into reverse, then remembered that the procedure was to only pull the operative T/R back. He pushed it back up -- unfortunately into enough forward thrust to cause a runway departure.
Dick, that's not quite right. Here is an excerpt from the NTSB report (NTSB Identification: LAX02FA266).

Note - the #1 Thrust Reverser was MEL'd.

The captain was the flying pilot for this leg of the flight and the airplane touched down on the centerline of the runway about 1,200 feet beyond its threshold. The captain moved both thrust levers into the reverse position and the airplane began yawing right. In an effort at maintaining directional control, the captain then moved the #1 thrust lever out of reverse and inadvertently moved it to the Take-Off/Go-Around (TOGA) position, while leaving the #2 thrust lever in the full reverse position.

The thrust asymmetry created by the left engine at TOGA power with the right engine in full reverse greatly increased the right yaw forces, and they were not adequately compensated for by the crew's application of rudder and brake inputs.
I figure that any aeroplane will spear you off the runway with that sort of thrust asymmetry.
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Old 3rd Nov 2009, 12:13
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All I can see is the obvious failure of a system : The BEA should be a leader in the continuous research of SAFETY but instead they show their total inbreeding with Airbus.

Page 118 "Furthermore, the BEA thinks that the Congonhas event was not foreseeable"
Page 119 "Since the accident, Airbus has been studying new corrective actions to take in account this scenario, which is now known"

How do they dare writing that after Bacolod and Taipei ???
CONF iture, as they acknowledge Bacolod and Taipei in the very next paragraph I don't see that they are saying anything outrageous. They point out that TAM didn't have H2F3 and that the revised procedure wasn't followed, neither of which can be laid at the door of Airbus or the BEA.

I notice that you are concentrating on the technical issues with Airbus, but from my point of view the report raises many more concerns about TAM. As a frequent flier here in Brazil facts such as a failure to follow basic procedures (three different techniques in the last three landings?) do not exactly fill me with confidence when I board a flight.

TTFN
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Old 3rd Nov 2009, 13:02
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Tam x Gol

Alemaobaiano,

This is why I don't fly TAM, they are specialists in "short cuts" on training.

I heard this from pilots who quit flying TAM for this reason (not adequate training).

I like GOL's method, in the cockpit we can always see an "old" pilot and a "kid". When the kid is flying, the old captain has his eye on him.
When the old captain is flying, the kid watch and learn.

Just like with maintenance, where they never install two engines with the same flight time...

abs,
Rob
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Old 3rd Nov 2009, 15:16
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Sorry, I implied, but didn't state it was due to asymmetric thrust.

Cheers


Dick
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Old 3rd Nov 2009, 16:17
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They're not my favourite airline either Rob, I too have heard similar comments from TAM pilots, something that I don't hear as much from those at other companies. However I am sometimes obliged to fly TAM for business reasons, so I can't cut them out completely.

TTFN
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Old 3rd Nov 2009, 23:42
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Dick - my reply was not intended to extract an apology from you.
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Old 4th Nov 2009, 00:39
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Smile Jet_A_Knight

I didn't take it that way.

Cheers
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Old 9th Nov 2009, 19:06
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Originally Posted by alemaobaiano
CONF iture, as they acknowledge Bacolod and Taipei in the very next paragraph I don't see that they are saying anything outrageous. They point out that TAM didn't have H2F3 and that the revised procedure wasn't followed, neither of which can be laid at the door of Airbus or the BEA.
Don’t you think it’s outrageous to pretend that Congonhas was not foreseeable when you know what happened in Bacolod and Taipei ?

They acknowledge Bacolod and Taipei but outrageously pretend that Congonhas was clearly different.
How was it different ?

All of these accidents are a direct consequence of pilots forgetting to place in the IDLE detent the thrust lever corresponding to the engine whose thrust reverser was inoperative

As early as 98 after Bacolod, the Philippines investigation team clearly identified that the RETARD callout could cease without having both thrust levers in idle detent (page 8 of the Philippino report)

Six years later, after Taipei, the Taiwanese investigation team made the clear recommendation to Airbus Company (page 102 of the Taiwanese report)
Reviewing the design of stop mode of Retard warning sounds or accommodating other warning methods to ensure that the warning will
continue before the thrust levers are pulled back to Idle notch after a touchdown has affirmed


The H2F3 response is totally inappropriate.
Who need another ECAM message when the obvious logical answer is simply to not cease the RETARD callout as long as both thrust levers are not on the IDLE stop.

Now – The similar recommendation is signified ONE MORE TIME to Airbus France SAS
RSV (A) 170/A/07
The optimization of the A-320 RETARD advisory (warning?) system, so that it will only execute the function for which it was designed, that is, to advise the crew to retard the thrust levers to the IDLE detent.


What is the BEA comment on recommendation 170/A/07 ?
NOTHING – ZERO – They just ignore it – Far more easier to flee than to have to face the fact.

All I can read is on page 119
Since the accident, the manufacturer has been studying new corrective actions to take into account this scenario, which is now known
Aside from the fact that the scenario was already known before, we would like to know what will be these corrective actions ?
What about a modification of the RETARD callout … finally ?

I am not in a position to dispute your concerns on TAM but all I can say is :
  • TAM was not involved in Bacolod
  • TAM was not involved in Taipei
  • I don’t think 4HolerPoler was working for TAM at the time (?)


To resume :
  1. Total lack of discernment on the part of Airbus.
  2. Obvious submission of the BEA.
What to expect now from AF447 'investigation' … !?
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Old 9th Nov 2009, 23:08
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What to expect now from AF447 'investigation' … !?
If one is to go on previous experience, then I fear, unfortunately, very little.
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Old 10th Nov 2009, 00:27
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CONF iture, you make a strong case for the sorry state of safety in our industry, but perhaps a bit one sided.
An accident investigation authority can make recommendations to a manufacturer for system change; these may or may not be accepted.
Changes can be proposed and mandated by the certification authority, although this action is unlikely without consultation with the manufacturer and more usually with other certification agencies.

The manufacturer did advise operators of the accident and the most probable cause; previously modifications had been proposed but not universally installed.

The industry and each operator have responsibility for maintaining safety, and thus with knowledge of previous problems, modification or procedural action could/should have been taken.

How was Congonhas different; for the reported conditions a normal operation may have had marginal landing distance safety factors. If the runway was flooded, then with CS25 rules, reverse could be claimed, but if not available then the landing should not be attempted.
We do not know what the crew knew or decided before landing, but on scant evidence there appears to be erroneous contributions from both the human (crew) and the wider organisational system.
We should not focus on a single entity for blame – fundamental attribution error. Nor be influenced by hindsight bias; a more open view might be that the industry still has much to learn from accident investigation and who and how remedial activities are implemented.

“You can take a horse to water, but it may not drink.”

Why System Safety Professionals Should Read Accident Reports.

What Can You Learn from Accident Reports?
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Old 10th Nov 2009, 07:59
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CONF iture

What was foreseeable was that an accident at Congonhas would happen, we had enough close calls prior to JJ3054 involving 737s and an ATR. The BEA position seems to be that:

1. TAM was well aware of the previous incidents
2. TAM knew about the modified software (not fitted due to cost)
3. TAM had adopted modified procedures as recommended (not used on this occasion)

So the BEA assertion is not unreasonable IMHO. Right or wrong is an entirely different question.

TTFN
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