TAM Airlines Flight 3054

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TAM Airlines Flight 3054
Photograph of Flight 3054's tailfin being recovered by emergency workers.
Accident summary
Date July 17, 2007 (2007-07-17)
Summary Runway overshoot caused by high speed hydroplaning on rain-soaked runway
Site Congonhas-São Paulo Airport, São Paulo, Brazil
23°37′11″S 046°39′44″W / 23.61972°S 46.66222°W / -23.61972; -46.66222Coordinates: 23°37′11″S 046°39′44″W / 23.61972°S 46.66222°W / -23.61972; -46.66222
Passengers 181[1][2]
Crew 6[3]
Fatalities 199 (including 12 on the ground)[4]
Survivors 0
Aircraft type Airbus A320-233
Operator TAM Airlines
Registration PR-MBK[5]
Flight origin Salgado Filho International Airport, Porto Alegre, Brazil
Destination Congonhas-São Paulo Airport, São Paulo, Brazil

TAM Airlines Flight 3054 (JJ3054/TAM3054) was a scheduled domestic passenger flight between Porto Alegre and São Paulo, Brazil. On Tuesday, July 17, 2007, the Airbus A320-233 airliner flying this route overran the runway at São Paulo and crashed into a nearby TAM Express warehouse adjacent to a Shell filling station.[6][7][8] All 181 passengers - 19 of them TAM employees - and 6 crew on board were killed, along with 12 people on the ground.[1][9] It has surpassed GOL Flight 1907 marking the deadliest air disaster in Brazilian territory, and remains the deadliest aviation accident involving an Airbus A320.[4]

Aircraft and crew[edit]

The aircraft serving Flight 3054 was an Airbus A320-233, serial number 789, registration PR-MBK, powered by two International Aero V2500 turbofan engines. It was built in February 1998 and first entered service in March flying for TACA Peru as N454TA, later serving in the fleet of Pacific Airlines as VN-A168. The aircraft was owned by Pegasus Aviation before entering service with TAM in January 2007. As of April 20, 2007, the aircraft had flown almost 21,000 hours over 10,000 cycles.[5]

The aircraft was dispatched with the thrust reverser (a mechanical device to help slow the airplane down on landing) on the number 2 (right-side) engine deactivated, as it had jammed. TAM said in a statement that a fault in a reverser "does not jeopardize landings", and that no mechanical problem had been recorded on July 16, the day before the accident.[10] It was reported that the aircraft had no difficulty braking on the same runway one day prior to the fatal accident.[11] The deactivated thrust reverser on the number 2 engine was confirmed by Airbus on July 25.[12]

The flight was under the command of an experienced cockpit crew, consisting of Captain Henrique Stefanini Di Sacco (53) and Co-Pilot Kleyber Lima (54). Both pilots had been flying for over 30 years. The captain had accrued nearly 13,700 flight hours throughout his career and the co-pilot had almost 14,800 hours of flying experience.[13]

Flight chronology[edit]

The plane departed from Salgado Filho International Airport in Porto Alegre at 17:16 local time (20:16 UTC). At 18:50 local time (21:50 UTC), the flight made its ill-fated landing at Congonhas-São Paulo Airport.

Crash[edit]

An artist's rendering showing the path of the aircraft during its final moments

Flight 3054 was cleared to land at Congonhas' 35L runway. Reviews by government officials of the surveillance videos showed that despite the aircraft touching down at the normal touch-down point on the runway, it did not slow down normally, crossing the far end of the runway at around 90 knots (170 km/h).[14] The aircraft, bearing to the left, continued off the end of the runway. The runway is elevated above the surrounding area, and the aircraft's momentum carried it over the traffic on the adjacent Avenida Washington Luís, a major thoroughfare. After clearing the road, the aircraft exploded on impact with a four-story TAM Express facility, resulting in a large fire, and killing everybody on board instantly. The TAM Express building contained offices and a warehouse, and was located adjacent to a Shell gas station.[15]

The runway had recently been resurfaced, but it did not yet have water-channeling grooves cut into it to reduce the danger of hydroplaning.[6]

Surveillance video of Flight 3054 landing
Different angle video of Flight 3054 landing

Flight Data Recorder (FDR) information recovered after the crash and released by Brazilian authorities showed that immediately prior to touchdown, both thrust levers were in CL (or "climb") position, with engine power being governed by the flight computer's autothrottle system.[16] Two seconds prior to touchdown, an aural warning, "retard, retard," was issued by the flight's computer system, advising the pilots to "retard" the thrust lever to the recommended idle or reverse thrust lever position. This would disengage the aircraft's autothrottle system, with engine power then being governed directly by the thrust lever's position.

At the moment of touchdown, the spoiler lever was in the "ARMED" position.[16] According to the system logic of the A320's flight controls,[17] in order for the spoilers to automatically deploy upon touchdown not only must the spoiler lever be in the "ARMED" position, but both thrust levers must be at or close to the "idle" position. The FDR transcript shows that immediately after the warning, the flight computer recorded the left thrust lever being retarded to the rear-most position, activating the thrust reverser on the left engine, while the right thrust lever (controlling the engine with the disabled thrust reverser) remained in the CL position. The pilots had only retarded the left engine to idle because they thought that without thrust reverser, the right engine did not need to be retarded as well. Airbus autothrust logic dictates that when one or more of the thrust levers is pulled to the idle position, the autothrust is automatically disengaged. Thus, when the pilot pulled the left engine thrust lever to idle it disconnected the autothrust system. Since the right engine thrust lever was still in the "climb" detent, the right engine accelerated to climb power while the left engine deployed its thrust reverser. The resulting asymmetric thrust condition resulted in a loss of control and a crash ensued. Moreover, the A320's spoilers did not deploy during the landing run, as the right thrust lever was above the "idle" setting required for automatic spoiler deployment.[16]

Congonhas[edit]

The TAM Express warehouse prior to the crash.
The TAM Express warehouse shortly after the crash.
The warehouse after the crash.

Air safety in Brazil had been under increased scrutiny following the mid-air collision in September 2006 over the Amazon of Gol Transportes Aéreos Flight 1907 and an Embraer Legacy 600 (see Brazil's 2006-2007 aviation crisis). Congonhas was singled out for having safety issues relating to operations in wet weather due to its location and runway characteristics for the traffic it serves.

The 35L runway at Congonhas is 1,940 metres (6,360 ft) long. Congonhas' counterpart in Rio de Janeiro, the Santos Dumont Airport, has an even shorter runway, at 1,323 m (4,341 ft). Both airports receive the same type of traffic — ranging from small private planes to Boeing 737s and A320s. Many variables affect the landing distance of an aircraft, such as approach speed, weight and the presence of either a tailwind or a headwind. For an Airbus A320, a speed of just 20 knots (37 km/h) higher than normal can result in as much as a 25% increase in the runway length needed to stop an aircraft. Wet weather can also significantly reduce the braking performance of aircraft, leading to an increase in the minimum runway length requirement.[18]

Pilots have called Congonhas airport the "aircraft carrier," because of the runway's short length and because pilots are told to go-around if they overshoot the first 1,000 feet (300 m) of runway.[19]

In February 2007, a Brazilian judge briefly banned flights using Fokker 100, Boeing 737-700 and Boeing 737-800 aircraft in and out of the airport. The Airbus A320 was not among the aircraft banned, due to its manufacturer-stated braking distance being shorter than those of the banned aircraft. Pilots had complained that water had been accumulating on the runway, reducing aircraft braking performance and occasionally causing planes to hydroplane.[20] The judge claimed the runway needed to be 388 metres (1,273 ft) longer for these aircraft to operate safely. At the time, a spokeswoman from Brazil's National Civil Aviation Agency claimed "The safety conditions of the runway and the airport as a whole are adequate."[21] TAM also objected to the decision, with a spokesman stating "If the injunction stands, it will cause total chaos," claiming over 10,000 passengers per day would be inconvenienced.[21] The airport authorities appealed the decision, resulting in it being overturned the following day. An appeals court overruled the ban on the three types of planes, saying it was too harsh as it would have severe economic ramifications and that there were not enough safety concerns to prevent the planes from landing and taking off from the airport. "The runway was reopened because of popular pressure," Gianfranco Beting,[citation needed] an aviation consultant, said in a TV interview.[22][not in citation given]

Aftermath[edit]

The airport reopened on July 19, 2007 using an alternative runway.[11]

Many flights, including all OceanAir and BRA Transportes Aéreos, were transferred to Guarulhos International Airport, the major airport in São Paulo, due to the closure of the main runway at Congonhas and the ongoing investigation of the accident.

On July 20, Presidency Chief of Staff Dilma Rousseff announced plans to significantly reduce the number of flights operating at Congonhas. The plan included banning, within 60 days, all connection, stopover, charter, and international flights and the reduction in the number of private jets. The airport would only operate direct flights to certain cities in Brazil. The plan also called for a study of the expansion of São Paulo's two current airports and the construction of a third airport in the metropolitan area.[23]

State crime scene investigators terminated the search for remains on July 28, 2007;[24] as of that date, 114 bodies recovered from the site had been identified by the São Paulo Medical Examiner's Office as those of passengers.[25]

Investigation[edit]

The investigation was carried out by Brazil's Aeronautical Accidents Investigation and Prevention Center (Centro de Investigação e Prevenção de Acidentes Aeronáuticos, CENIPA). Data from the flight data recorder and cockpit voice recorder (CVR) were downloaded by the National Transportation Safety Board in the United States commencing July 20 and July 23 respectively.[12][26] Based on preliminary data from the FDR, on July 25 Airbus cautioned A320 operators to ensure that both thrust levers are set to idle during flare.[12] The transcript of the CVR was released on August 1.[27] It shows that the pilots were aware of the wet runway conditions and the deactivated thrust reverser.[28] The pilots' comments suggest that the spoilers did not deploy and that they were unable to slow the aircraft.[28] Crew error has not been ruled out.[29]

An investigation [30] by the Brazilian Public Safety Ministry released in November 2008 concluded that the pilots mistakenly retarded only the left engine to idle, because the right one had no thrust reverser working when in fact it was necessary to retard both engines in order for the spoilers to work. They also said that the National Civil Aviation Agency should have closed the airport on the night the plane landed because of heavy rains; that Congonhas airport authorities shared the blame because its runway had not been properly constructed with grooves to drain away excess rainwater, contributing to the crash; that the plane's manufacturer, Airbus, should have provided alarms warning the pilots that the braking system was failing; and that TAM failed to properly train its pilots, who did not act correctly in the emergency.

Final report[edit]

In September 2009, more than two years after the accident, CENIPA announced the results of official investigations. The report shows that one of the thrust levers, which control engines, was in position to accelerate when it should be in idle, but it was not proved if there was mechanical or human failure as the cause of the accident.[31][32][33]

The report suggests two hypotheses for the accident. In the first, there was a flaw in the power control of the plane's engines, which would have kept one of the thrust levers into acceleration, regardless of their actual position. In such circumstances, there was mechanical failure of the aircraft. In the second hypothesis, the pilot has performed a procedure different from that provided in the manual, and put the thrust lever in an irregular position, a configuration of human error for the accident.

In addition to the positions of the thrust levers, the report points to several factors that may have contributed to the accident, such as a high volume of rain on the day, with the formation of puddles on the runway, as well as the absence of grooving. The report does not blame the length of the runway for the accident.

Response[edit]

After the crash, President Luiz Inácio Lula da Silva ordered three days of national mourning.[34]

During the 2007 Pan American Games in Rio de Janeiro, the Brazilian athletes wore a black armband in remembrance of the victims.[35] The flags of all participating countries were flown at half mast on July 18. Matches involving a Brazilian athlete or team started with a minute of silence.

All matches of the Campeonato Brasileiro 2007[disambiguation needed] started with a minute of silence, while all players wore black armbands. Brazilian Formula One driver Felipe Massa had a black stripe on top of his helmet during the 2007 European Grand Prix, to commemorate the victims. Rubens Barrichello also had stripes on his helmet, and the two Red Bull Racing drivers David Coulthard and Mark Webber had small Brazilian flags on their helmets referring to the accident.

More than 5,000 Brazilians marched to the crash site on July 29, 2007, blaming their government's failure to invest in airport infrastructure for the crash. Many of the protesters also demanded the ousting of President Luiz Inacio Lula da Silva.[36]

Notable passengers[edit]

Among the passengers were:

Dramatization[edit]

Mayday (Also known as Air Crash Investigation in the UK, Australia, New Zealand and Asia and Air Emergency or Air Disasters in the United States) produced a one hour docudrama about the crash. The episode was entitled "Deadly Reputation" due to the poor reputation the airport (and specifically the runway) has among pilots.

See also[edit]

Gallery[edit]

References[edit]

  1. ^ a b "TAM confirms 187th passenger on flight 3054" (in Portuguese). Globo. 2007-07-20. Retrieved 2007-07-21. 
  2. ^ Associated Press (2007-07-21). "Brazil president vows thorough probe of crash: Da Silva unveils new safety steps after latest aviation disaster killed 191". MSNBC. Retrieved 2007-07-21. 
  3. ^ "Nota da TAM retifica informação e diz que Airbus 320 levava 176 pessoas" [TAM notice corrects information and says 176 died in Airbus 320] (in Portuguese). Agência Brasil. 2007-07-17. Retrieved 2007-07-17. 
  4. ^ a b "Accident Description". Aviation Safety Network. 2007-07-17. Retrieved 2007-07-19. 
  5. ^ a b Ionides, Nicholas (July 18, 2007). "BREAKING NEWS: TAM A320 crashes in São Paulo". Flight International. Retrieved February 23, 2014. 
  6. ^ a b "Pilot in Brazilian crash tried to abort landing, official says". CNN. 2007-07-18. Archived from the original on August 11, 2007. Retrieved 2007-07-20. 
  7. ^ "Incêndio permanece fora de controle; chances de sobrevivência diminuem" [Fire remains out of control; chances for survivors diminished] (in Portuguese). Folha de S. Paulo. 2007-07-17. Retrieved 2007-07-17. 
  8. ^ "Três vítimas do acidente com avião da TAM são atendidas no hospital Alvorada" (in Portuguese). Folha de S. Paulo. 2007-07-17. Retrieved 2007-07-17. 
  9. ^ (Portuguese) Globo.com, Globo G1 Noticias (Portuguese) Retrieved July 23, 2007
  10. ^ "Brazil plane 'flew with mechanical fault'". news.com.au. July 20, 2007. Retrieved July 20, 2007. [dead link]
  11. ^ a b "Focus of Brazil air crash shifts away from runway". Reuters. 2007-07-20. Retrieved 2007-07-20. 
  12. ^ a b c Learmount, David (2007-07-25). "Airbus cleared to release TAM accident flight recorder information". Flight International. Retrieved 2007-07-25. 
  13. ^ http://www.cenipa.aer.mil.br/cenipa/paginas/relatorios/pdf/3054ing.pdf
  14. ^ (Portuguese) Authorities say the plane was above normal speed O Estado de S. Paulo. Retrieved July 18, 2007.
  15. ^ "O acidente do avião da TAM" (in Portuguese). Agência Brasil. 2007-07-17. Retrieved 2007-07-17. [dead link]
  16. ^ a b c TAM Airbus 320-200, Flight No. 3054, PR-MBK. NTSB. July 24, 2007. Retrieved on September 5, 2007.
  17. ^ A320 Flight Controls Manual. Airbus. Retrieved on September 5, 2007
  18. ^ A320 Warsaw landing analysis Prof. Clive Leyman, City University of London. Retrieved July 18, 2007
  19. ^ Latimes.com Death toll in Sao Paulo crash at 189 and could rise (Associated Press via latimes.com) 2007-07-17, Retrieved 2009-02-03
  20. ^ "Deadly Reputation," Mayday
  21. ^ a b "Jets banned from São Paulo runway". BBC News. 2007-02-06. Retrieved 2007-07-18. 
  22. ^ "Up to 200 feared dead in Brazil crash". Reuters. 2007-07-17. Retrieved 2007-07-17. 
  23. ^ Confirmed: São Paulo will have a 3rd Airport (Portuguese), 20 July 2007
  24. ^ "Peritos concluem varredura nos escombros do prédio da TAM Express". Folha de S. Paulo (in Portuguese). 2007-07-31. Retrieved 2007-07-28. 
  25. ^ "Número de vítimas do acidente da TAM identificadas sobe para 104". Folha de S. Paulo (in Portuguese). 2007-07-28. Retrieved 2007-07-28. 
  26. ^ Learmount, David (2007-07-23). "Probe asks why Airbus A320 could not stop". Flight International. Retrieved 2007-07-23. 
  27. ^ Targett, Michael (2007-08-02). "TAM A320 crash - full transcript from cockpit voice recorder". Flight International. Retrieved 2007-08-02. 
  28. ^ a b Kaminksi-Morrow, David (2007-08-02). "Full cockpit-voice transcript of TAM A320 reveals clues to crash". Flight International. Retrieved 2007-08-02. 
  29. ^ Learmount, David (2007-11-16). "European JAA clarifies Airbus throttle handling rules following TAM crash". Flight International. Retrieved 2008-01-20. 
  30. ^ "Police charge 10 people in Brazil's worst plane crash". AFP (Agence France Presse) via haaba.com. 2008-11-19. Retrieved 2009-02-03. 
  31. ^ Final Report (PDF), Aeronautical Accidents Investigation and Prevention Center, October 27, 2009.
  32. ^ "Sem apontar culpados, Aeronáutica divulga relatório sobre acidente da TAM" (in Portuguese). Folha de S. Paulo. 
  33. ^ "Familiares das vítimas do voo 3054 da TAM reclamam de relatório da PF" (in Portuguese). Globo G1 Notícias. 
  34. ^ "Luto oficial de três dias por acidente da TAM" (in Portuguese). 
  35. ^ David Byrd (2007-07-18). "Brazilian Athletes Mourn Plane Crash Victims". Voice of America. Archived from the original on August 18, 2007. Retrieved 2007-07-23. 
  36. ^ "Brazilians blame gov't for jet crash". am New York. Associated Press. 2007-07-30. p. 9. 
  37. ^ Marcos Chagas and Aloisio Milani (2007-07-17). "Listas de nomes divulgada pela TAM ultrapassam previsão oficial de 176 passageiros" (in Portuguese). Agência Brasil. Archived from the original on September 28, 2007. Retrieved 2007-07-18. 71.Julio Cesar Redecker 
  38. ^ "Redecker estava no vôo da TAM que pegou fogo em SP" (in Portuguese). Brazilian Social Democracy Party. 2007-07-17. Archived from the original on September 28, 2007. Retrieved 2007-07-18. 
  39. ^ "Deputado do RS estava no vôo que sofreu acidente" (in Portuguese). Terra Brasil. 2007-07-17. Retrieved 2007-07-18. 
  40. ^ Marcos Chagas and Aloisio Milani (2007-07-17). "Listas de nomes divulgada pela TAM ultrapassam previsão oficial de 176 passageiros" (in Portuguese). Agência Brasil. Archived from the original on 2007-09-28. Retrieved 2007-07-18. 106.Paulo Rogerio Amoretty Souza 

External links[edit]

External images
Pre-accident pictures of aircraft at Airliners.net
Pre-accident pictures of aircraft at JetPhotos.net