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-   -   Ten to be indicted over TAM crash (https://www.pprune.org/rumours-news/351097-ten-indicted-over-tam-crash.html)

alemaobaiano 15th Nov 2008 10:08

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

Finn47 15th Nov 2008 15:55

2500 pages in the report, but not published yet:

Brazil crash 'blamed on pilots, airline' - Breaking News - World - Breaking News

Zorst 16th Nov 2008 18:05

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.

ATC Watcher 16th Nov 2008 20:25

for glueball :
*"sciolist"... Noun, archaic. "a person who pretends to be knowledgeable and well informed".

rogerg 16th Nov 2008 20:50

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.

RAD_ALT_ALIVE 16th Nov 2008 22:34

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.

J.O. 16th Nov 2008 23:15

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.

rogerg 17th Nov 2008 05:25

Rad Alt Alive.
Thats what I meant, but with less words!

alemaobaiano 17th Nov 2008 07:48

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

J.O. 17th Nov 2008 11:37

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.

al446 17th Nov 2008 12:20

Rad Alt Alive
 
That is possibly the most sensible post I have read on this site.

Piltdown Man 17th Nov 2008 15:29

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

SPA83 18th Nov 2008 08:52

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

ATC Watcher 18th Nov 2008 16:14


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)

leftseatview 18th Nov 2008 16:46

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

aguadalte 18th Nov 2008 18:09

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...:ugh:)

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.:ouch:

Airbuses are fantastic aircraft, but they could be better!:ok:

B Sousa 18th Nov 2008 18:29


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??

Richard_Brazil 19th Nov 2008 19:40

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.

B Sousa 20th Nov 2008 13:04

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..

CONF iture 20th Nov 2008 13:29


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.

aguadalte 20th Nov 2008 13:39

CONF iture,
Did you know that the "all new" A350 is planned to fit non feed back side sticks?
Well it seems that I'm the only one concerned about that...
Fly safe.
V

CONF iture 20th Nov 2008 15:30


Did you know that the "all new" A350 is planned to fit non feed back side sticks?
Well it seems that I'm the only one concerned about that...
My apology aguadalte, I have obviously not expressed myself correctly, but I'm with you 100%

Airbus has taken unnecessary steps.
By embracing a more humble attitude, they would have developed an even far better product, but now, by ignoring the very early critics, they are stuck in their technology options.

... not in a rush to experiment their coming automatic TCAS ...

Clandestino 20th Nov 2008 19:19


But, could it happen on an Auto-Throttled aircraft?
Lemmmesee... does B747 have autothrust or autothrottles? Keywords are Quantas and Bangkok.

EDIT: I apologise for mixing-up a couple of jumbo-overruns; Quantas at Bangkok wasn't caused by not retarding throttle(s), however, Air China at HongKong and Air France at Faaa, were.

Don't blame Airbus philosophy - while it's different compared to "conventional" aircraft and takes a lot of re-learning, there's no empirical evidence that it's less safe. However I do agree that FWC that shouts "RETARD!" untill all the levers are near idle would most likely prevent the accident but pulling all the throttles back for landing must have seemed so natural to AB designers that they never considered the scenario that was played at Congohas.

aguadalte 21st Nov 2008 00:21

Well, CONF iture an automatic TCAS, or any other device taking control of the aircraft, against previous consent of the pilots, seems dangerous and a huge step against pilot full authority on bord...

Clandestino,
Can you please elaborate on that Qantas Bangkok situation, as I recall it has nothing to do with the Auto-Throttle/Auto-Thrust concept. (And yes, I think 747's are Auto-throttled, not Auto-Thrusted).

Here's a summary of the accident, taken from a quick look on the internet and I call your attention on what is writen in bold letters (my bold):

It can be viewed in its entirety at http://www.basi.gov.au/acci/ojh/vh-ojh.pdf. A preliminary ATSB report of the accident cited the company's Oct. 1977 policy to use flaps 25 (as opposed to flaps 30) and idle reverse thrust under normal conditions. This policy obtained maximum life of the carbon brakes on the B747-400 and reduced costs associated with maintenance as well as noise levy charges (see ASW, Jan. 3, 2000). The Accident Flight
Had the crew used reverse thrust, they probably would have been able to bring the airplane to a safe stop. However, other aspects of cockpit procedures raise substantive issues of crew coordination. When the aircraft was about 3 meters (10 ft.) above the runway and floating farther down than the ideal touchdown point, the captain, who was the pilot not flying, advised the first officer to execute a go-around. The first officer pushed the thrust levers forward just as the main landing gear wheels touched the tarmac. The captain immediately cancelled the go-around, not by saying so, but by retarding the thrust levers. As the ATSB report said, "Those events resulted in confusion amongst the other pilots (first and second officer) and contributed to the crew not selecting (or noticing the absence of) reverse thrust during the landing roll."
According to the ATSB report, the jumbo jet actually accelerated for about a 1,000 ft. after touchdown (due to residual thrust) before beginning a slow decrease in speed, but not enough to avoid hurtling off the far end of the runway. Having decided to not get airborne, the crew was waterborne, aquaplaning down the rain-slicked runway.
The ATSB report is structured in such a way that it provides a brief description in each subject area, with an itemization of significant failures and significant inadequacies in defenses. The very brevity of this approach gives a hard edge and an attention-getting potency to its findings.
Regarding cockpit procedures, the ATSB said:
"During the examination of the performance of the aircraft on the runway, it became evident that the flaps 25/idle reverse thrust landing procedure used by the crew (and which was the 'preferred' company procedure) was not appropriate for operations on water-affected runways. The appropriate approach/landing procedure was flaps 30/full reverse thrust. This had the characteristics of a lower approach speed, of being easier to fly in terms of speed control and runway aim point (for most company pilots), and of providing maximum aerodynamic drag after touchdown when the effectiveness of the wheel brakes could be reduced because of aquaplaning. Had this configuration been used, the overrun would most probably have been avoided.

(quoted from an article on BNET)

Clandestino, You may not agree with my point of view but, your argumentation has missed the whole point.
When I asked if the Congonhas accident may have happened with an auto-throttled aircraft I meant that, when retarding only one of the throttles the other(s) tend to follow. In order to retard only one of the throttles you would have to disengage the Auto-Throttle and this means a positive and intentional action. In the Congonhas case, they commited a mistake, and were completely overriden by the system. The only thing in common in both cases was poor judgement.

V.

CONF iture 21st Nov 2008 02:56

Clandestino, I would not pretend Airbus A/THR concept is "less safe" but less straight forward, certainly.

These thrust levers could remain in a frozen position 99% of the air time and still assure all the necessary thrust changes … no wonder time to time, under stress, a crew forget about them …
A/THR disconnection takes some additional thinking … why should it be that way ?
Full thrust can be produced with both thrust levers still in the unrelated idle detent …

I think Airbus forgot to keep it simple.


However I do agree that FWC that shouts "RETARD!" untill all the levers are near idle would most likely prevent the accident but pulling all the throttles back for landing must have seemed so natural to AB designers that they never considered the scenario that was played at Congohas.
I am not aware of the logic in terms of frequency, repetition, volume change, behind the RETARD auto call-outs, but in this manual thrust landing the reminder never gave up.



Well, CONF iture an automatic TCAS, or any other device taking control of the aircraft, against previous consent of the pilots, seems dangerous and a huge step against pilot full authority on bord...
I know, I know, aguadaltebut !?

aguadalte 21st Nov 2008 12:49

technology
 
Since my early years in school, almost 30 years ago, in the Air Force, every Flight Instructor I had, emphasized the need for planning and judgment with the phrase: "fly ahead of your aircraft".

I think that what's at stake here, is the complexity of the FBW a/c A/THR System, as well as the Flight Control Laws and Side Stick input system logics.
As I view it: The problem with this systems is that, when you're in need of your full attention (for what's going awfully wrong), you have also to "intellectualize" in step of instinctively fly basic skills.

As you said earlier (CONF iture)

Airbus has taken unnecessary steps.
By embracing a more humble attitude, they would have developed an even far better product, but now, by ignoring the very early critics, they are stuck in their technology options.
That's the hard truth and we, pilots, have now to deal with that.
Some of us, just accept it without mental reservations, others prefer to be more assertive, despite of knowing that AI will not take their argumentations into consideration.
What most embarrasses us all, is that those "lunatic ideas" come from pilots within AI and AI a/c operators.
We're only humans and the idea that human error may be "avoided" by imposing automatic responses by the aircraft, may also be considered a human error, since those systems were also designed by Man.
TCAS, EGPWS, FANS, ILS, GPS, Auto-Pilot, Auto-Throttle and a lot of other systems were a good help and are useful tools for a safer aviation, as long as they are kept under full authority of the pilots. Regarding Manual Flight, I would tend to ask for a more strait forward approach and keep it simple and with a much more "honnest input response".
Apart from intervening in this forums my only way to push for a safer use of those apparatus is to express my concerns over certain events to my company's Safety Board and to highlight those (personally) questionable issues to my co-pilots.
What I can not accept is the simplistic idea that the Congonhas Captain just "forgot" that, to land an aircraft, one has to retard the Thrust Levers. I'm not Brasilian, nor a TAM pilot, I'm just trying to be fair and responsible on my understanding of what has really gone wrong. There is always a much more complex reason for an accident, than one may expect. To learn with other pilots mistakes and to prevent future accidents. Is it not, what this is all about?:E

Fly Safe,
V.

J.O. 21st Nov 2008 16:51

Sometimes we have to accept that something which in hindsight may seem completely impossible to us, is something that, to the individuals involved at the time, either makes perfect sense, or that they are simply overloaded to the point where they overlook what should be an obvious discrepancy. This is not limited to Airbus pilots either. The Helios B737 is another example of a crew missing something which "should" have been obvious.

GlueBall 22nd Nov 2008 14:22


". . . What I can not accept is the simplistic idea that the Congonhas Captain just "forgot" that, to land an aircraft, one has to retard the Thrust Levers."
Retarding the thrust levers upon touchdown, with or without reverser anomalies, requires no thought and no decision making, because it is an elementary, instinctive process applicable in all airplanes. Even during CAT-IIIB autoland, the pilot flying must keep his hand on all thrust levers, not only for the purpose of selecting reverse thrust, but to ensure that all thrust levers are in fact moved to idle detent upon touchdown.

This senseless loss of life is either a case of temporary crew insanity, or gross crew incompetence at best. The capt at the controls had retarded only the left thrust lever and applied reverse to the left engine while engine number 2 had continued to develop substantial forward thrust. The capt in the right seat lacked basic survival instinct in that he belatedly had failed to yank No.2 thrust lever to idle detent and stand on the brakes.

I wouldn't be surprised if the moderator who had deleted my previous post had done so in deference to TAM and its bullying insurers in their obvious media hyped efforts to shift blame to the airport operator, Infraero and ANAC.

The "criminal" investigation in Brasil, magnified by the media, [as is the debate in this thread] has engaged the usual hamster-wheel exercise in addressing: "Ambiguous Airbus logic," "non grooved runway", "short runway", "wet runway", "dangerous airport", "ATC," . . . anything but the obvious probable cause of "pilot error."

Yes, the pavement length is only 6365' . . . but it has been in service for many decades, wet and dry, for thousands of successful landings. The incident/accident rate for the amount of traffic is not extraordinary. Before the life of A320s, Trans-Brasil B727s had also operated at this airport. Remember?

J.O. 22nd Nov 2008 20:25


Yes, the pavement length is only 6365' . . . but it has been in service for many decades, wet and dry, for thousands of successful landings. The incident/accident rate for the amount of traffic is not extraordinary. Before the life of A320s, Trans-Brasil B727s had also operated at this airport. Remember?
How many people have said, "but we've always done it that way", as they gazed over the smoking hole. Just because they got away with it doesn't make it right or smart.

manrow 22nd Nov 2008 21:16

Too true J.O.!

clark y 23rd Nov 2008 01:23

Excellent thread despite drift off initial topic.

Glueball,

I dislike it when ever people like yourself say "what were they thinking?" or "how did they make a such simple stuff up?"
I don't think these guys were incompetent or insane. They got caught in a hole with too little time to recover. It was caused by what could be considered a flawed system.

Not sure if you're aware, but the simple act of not putting one lever into a set detent creates major problems. Think about this-
Not only does it mean reverse on one side, climb on the other but at a glance the engine indications would have initially appeared to be what they were looking for (i.e. REV1 green only), the other engine does go from close to idle to climb power at a steady pace without the other lever moving so your hands on the levers will not notice. You're busy looking out the window tracking the centre line, the other guy is looking for ground spoilers etc. Your ears will not notice ( you expect it to get noisy). Your reflexes will push the rudder in and keep the aircraft staight potentially without your knowledge. And the first sign of something wrong could be a call of "No spoiler- negative deccel". And don't try and put the ground spoilers up with the lever because, like the thrust levers, it does not neccessarily reflect the position of the actual spoilers and you can't do it anyway. Auto brake won't work without ground spoilers. You also can't go around because you have a reverser deployed. By this time your out of runway.

I only know the basics of the accident. What is written above is hypothetical as I have not read detailed reports but I have read the pilots manual for the A320 and flow this scenario in the sim. But that is as quick as it happens and anyone could have similar happen at anytime. Yourself included.

Having flown both moving and fixed throttles/thrust levers, moving are by far superior.
The aircraft in question was smart enough to know it was on the ground, but it was not smart enough to realise that one engine was reversed the other was at climb. Maybe Airbus could at least change the logic so that in ground mode, once reverse is selected on one, the other thrust lever position is ignored and fwd idle is maximum thrust.

Clark y

GlueBall 23rd Nov 2008 07:22

Captain clark y . . . I am not from another planet. I fly 74s and I have four (4) thrust levers in the palm of my hand upon flare and touchdown; whether CAT-IIIB autoland/AT or VMC flying manual. I'm not looking at instruments during the flare and touchdown phase; I'm looking outside, at the centerline or centerline lights, rain or shine.

Ensuring that the thrust levers are closed/retarded to idle detent is done instinctively, exclusively by feel.

I can also feel by the seat of my pants . . . the onset of even a subtle application of auto brakes, [brake pressure commensurate with reverse thrust], and I can feel the onset of decelaration . . . even with rain bouncing off the windscreen and wipers whacking back and forth . . . all that without any clues from instruments.

And if there is no immediate feel of decelaration, I get on the brakes manually; without first having to think, without first having to check any settings, switches or instruments. It's just common sense, basic survival "stay'n alive" instinct.

The two TAM captains, in opposite seats had successfully landed during their previous sector with the same reverser DMI'd. For reasons unknown and unexplainable, the operating captain of this sector obviously did not have both thrust levers in the palm of his hand because he had failed to retard No.2 thrust lever.

This bizarre, elementary breakdown of human performance could be due to lack of training, lack of work discipline, lack of common sense, lack of survival instinct, or temporary insanity.

aguadalte 23rd Nov 2008 16:13


Having flown both moving and fixed throttles/thrust levers, moving are by far superior.
The aircraft in question was smart enough to know it was on the ground, but it was not smart enough to realise that one engine was reversed the other was at climb. Maybe Airbus could at least change the logic so that in ground mode, once reverse is selected on one, the other thrust lever position is ignored and fwd idle is maximum thrust.
Clark Y,

Couldn't agree more. Auto-throttles are far superior, because you can feel the aircraft, through their movement. They just give you another clue of what is going on and ATS don't. AI has suppressed that clue of auto-throttle movement to the pilots, as it has done also with the side-sticks. You have to look at your instruments to see engine response.

CONF iture 23rd Nov 2008 19:50


Originally Posted by GlueBall
Even during CAT-IIIB autoland, the pilot flying must keep his hand on all thrust levers, not only for the purpose of selecting reverse thrust, but to ensure that all thrust levers are in fact moved to idle detent upon touchdown.

Just another case scenario ... This time thrust is automatically reduced even if both thrust levers are inadvertently forgotten in the climb detent.
Too many combinations, different circumstances different logic … but digest all of them !


This bizarre, elementary breakdown of human performance could be due to lack of training, lack of work discipline, lack of common sense, lack of survival instinct, or temporary insanity.
It would be over simplistic to blame the TAM accident on Airbus shoulders, but still, how does it seem recurrent for Airbus pilots to leave one thrust lever in the climb detent when one thrust reverser is deactivated, when other types look pretty immune to that scenario ?

clark y 23rd Nov 2008 23:04

Glueball, it is easy to blame these pilots but you're lucky to have feel. It takes a fair amount of time to get used to the fact that 99% of the time the thrust levers are just "limit switches". An A320 was lost back in March 1998 for the same problem i.e. 1 reverser unserviceable. On landing one engine was left in idle detent the other in climb detent. The result was the aircraft ran off the runway. Hopefully we can all learn from this.

As for the witch hunt to find someone to blame and or pay, pilots are always an easy target.

CONF iture 25th Nov 2008 18:05

I believe there is something really insidious in this auto thrust philosophy.

After spending hours forgetting about those frozen thrust levers, but still brilliantly managing any thrust variation between idle and climb thrust, we can tend to unconsciously obliterate their function and keep them out of the process.

Anytime there was an auto thrust adjustment on the 757, I can remember placing my hand on the levers, almost by reflex, just to feel them moving, and moving together, sometimes even to initiate that movement or also to delay it in other circumstances ...

There was a physical materialization of any thrust change, a kind of complete cycle :
  • Instruments
  • Brain
  • Arm Hand
  • Thrust levers
  • Instruments
Nothing like it on the Bus unless you decide to get rid of the automatic process.
The Arm Hand Thrust levers are useless elements of an automatic thrust adjustment.

But on three known occasions, crews forgot to fully reconstitute that physical link and failed to retard one of both thrust levers, which lead to very serious consequences.

Blaming the TAM accident on Airbus shoulders is over simplistic, but thinking that Airbus auto thrust conception has nothing to do with it is all that much.

aguadalte 26th Nov 2008 16:39

All of the "mechanical touching & feeling" components of the interface between pilot and aircraft, have been obliterated in the case of AI FBW concept (pilot-yoke (and trim) vs pilot side-stick; pilot A-Throttle vs pilot ATS).
I remember, when I came back to the A310, after almost 7 years riding A320's that I had to "learn" how to fly a conventional aircraft again. As I fly privately SE (Pitts S2B) I never had a real hard time to do so, but I must tell you that, things that I used to do instinctively on the B737's , like Rudder or Engine Trimming, now had to be done (at the beginning), as a "procedure" that was part of our normal scan. Sometimes I even had to call the attention of my newer PF F/O's (coming from A320's), after they engaged the A/P, that they should fine trim the aircraft. Because, on the FBW family there is no need to do it, normally.
We were left free of this functions even when hand-flying FBW birds. With ATS, non-feed back Side-Sticks and GSmini, most pilots don't even remember what was the VApp they have just used for landing...(if you don't believe it, just go ahead and ask them, after landing...)
We were not completely left off the loop, but close: we have no feed-back (and no need to trim), on our stick, when changing speeds and thrust settings; we have no feed-back on other pilot's inputs on his stick; no feed-back from the ATS levers, and, on a normal flight, one has only three actions to do on the ATS levers: Setting Take-Off Thrust, setting Climb Thrust and Retarding the levers over threshold for landing...:sad:
This might be "fantastic" for "monkeys", not for pilots.
As I said before, Airbuses are great aircraft, but they could be better.
V.

GlueBall 26th Nov 2008 23:23

So, during the landing, flare and touchdown of this Fly By Wire A320 [where thrust levers are just "switches"] would your right hand be resting on your knee, or on the thrust levers. . . ? Or is this procedure altogether more complex than just that on the A320...? :rolleyes:

40&80 27th Nov 2008 00:37

Cannot wait for the day some management ace decides in the name of safety that pilots should...."Fly mixed fleet"...and fly an airbus on one sector and a Boeing on another... on the same dark night!

aguadalte 27th Nov 2008 14:56

No GlueBall, (I'm currently flying A340/A330) and depending on weather, crew, flight time, airport experience and other conditions, when I decide to hand-fly the aircraft I also disengage the ATS.
Its not against SOPs, since my company leaves that decision (for trainning purposes) to the Captain, although AI philosopy is to make use of ATS and disconnect it only if ATS is not providing adequate response.
Let me tell you that, on the A310, I didn't feel the need for that "trainning" once, most of the time, one had to "accompany" the work of the Auto-Throttle, trim the aircraft for changing speeds and configurations, and feeling the reactions of the auto-throttle, receiving those clues from throttle movement.
V.


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