TAM_Airlines_Flight_3054
TAM_Airlines_Flight_3054
Landing difficulties
On July 16, the day before the crash, four pilots who landed at the airport reported poor braking
conditions, including a TAM pilot who managed to stop his aircraft just a few meters before the end of
the runway. Between 12:25 pm and 12:28 pm, Infraero suspended operations at the airport to assess the
runway conditions and subsequently cleared it for use, reporting "no puddles and water slides." However,
at 12:42 local time on the same day, Pantanal Linhas Aéreas Flight 4763, an ATR 42-300, hydroplaned
after touching down on runway 17R. The aircraft veered to the left, striking a concrete box and a small
light pole before coming to rest on the grass between the runway and taxiway. All 25 people on board
survived with no injuries, but the aircraft was severely damaged and deemed beyond repair.[13][14]
Despite this incident, landings continued to be conducted normally at the airport.[15]
There were six crew members and 181 passengers on board. All 6 crew members as well as 171 of the
passengers were Brazilian; the 10 remaining passengers were of various other nationalities.[18] The flight
crew consisted of two captains (rather than the usual captain and first officer): Captain Henrique Stefanini
Di Sacco (53), and Captain Kleyber Aguiar Lima (54).[19] There were also four flight attendants, with an
additional 13 deadheading. Both pilots had been flying for over 30 years. Stefanini had logged 13,654
flight hours in his career (including 2,236 hours on the Airbus A320), and Lima 14,760 hours, with 237 of
them on the Airbus A320.[19]
Accident
Flight 3054 was cleared to
land at Congonhas's
Runway 35L. Reviews by
Flight 3054's route
government officials of the
surveillance videos showed
that despite the aircraft touching down without incident, it did not
slow down normally, veering to the left as it departed the far end
at around 90 knots (170 km/h; 100 mph).[22] The runway is
elevated above the surrounding area, and the aircraft's momentum
carried it over traffic on the adjacent Avenida Washington Luís, a
major thoroughfare, and crushed a four-story TAM Express
An artist's rendering showing the facility, resulting in a large fire. The TAM Express facility
path of the aircraft during its final contained offices and a warehouse, and was located adjacent to a
moments
Shell gas station. All 187 passengers and crew aboard died and the
aircraft was destroyed.[23]
The runway had recently been resurfaced, and did not yet have water-channeling grooves cut into it to
reduce the danger of hydroplaning.[6]
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.[24] 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 lever position. This would
disengage the autothrottle, with engine power then governed
directly by the thrust levers.
that Airbus autothrust logic dictates that, when one or more of the
thrust levers is pulled to the idle position, the autothrust is
automatically disengaged.[19] Thus, when the pilot pulled the left engine thrust lever to idle, it
disconnected the autothrust system and the computer did not retard the right engine power to idle. 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.[24] Since the right engine thrust lever was still in the
"climb" detent at that time, 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.
It only took 16 seconds from the incorrect positioning of the thrust levers to overrunning the runway with
an ensuing loss of control, and 26 seconds until the aircraft crashed.
Timeline
Source:[26]
Time
Congonhas
Aviation 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).
Aftermath
The airport reopened on July 19, 2007, using an alternative
runway.[17]
Many flights, including all OceanAir and BRA Transportes Part of the gears being lifted out of
Aéreos, were transferred to Guarulhos International Airport, the the warehouse
major airport in São Paulo, due to the closure of the main runway
at Congonhas and the ongoing investigation of the accident.[17]
Investigation
The investigation was carried out
by Brazil's Aeronautical Accidents
Investigation and Prevention
Center (Portuguese: Centro de
Investigação e Prevenção de
Acidentes Aeronáuticos; CENIPA).
Data from the flight data recorder
and cockpit voice recorder (CVR)
The wreckage of Flight 3054
were downloaded by the National
Transportation Safety Board
(NTSB) in the United States commencing July 20 and 23
respectively.[34][35] 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.[34] The transcript of the CVR was released on August Brigadier Jorge Kersul
Filho, leading the
1.[36] It shows that the pilots were aware of the wet runway conditions and
investigation into the
the deactivated thrust reverser.[37] The pilots' comments suggest that the
accident, during a press
spoilers did not deploy and that they were unable to slow the aircraft.[37] conference
Crew error had not been ruled out.[38]
An investigation[39] by the Ministry of Justice and Public Security released in November 2008 concluded
that the pilots mistakenly left the lever for the right engine to climb upon landing, due to a mistake in
landing procedures with the right thrust reverser being disabled from a prior maintenance, 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.[40]
Final report
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.[19][41][42]
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. This scenario would implicate mechanical failure of the aircraft as the cause of the
accident. The likelihood of this failure occurring is calculated at once per 400 billion flight hours, and
therefore highly improbable. 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. This scenario would
implicate human error as the cause of the accident.[19]
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. The BEA also cleared Airbus of any misdoing because they had proposed a system warning
modification regarding the incorrect thrust lever positions that TAM had rejected.[19]
Response
After the crash, President Luiz Inácio Lula da Silva ordered three
days of national mourning.[43]
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 Lula's ouster.[48]
International reactions
Argentina: President Néstor Kirchner called president Lula to express condolences.[49]
Chile: President Michelle Bachelet called president Lula to offer her condolences.[49]
China: President Hu Jintao expressed his condolences to the Brazilian government as
well as the friends and families of the victims.[50]
Germany: President Horst Köhler sent a telegram to President Lula expressing his
condolences to the families of the victims. According to a statement reported by the German
embassy in Brasilia, Germany would join the three-day mourning by lowering the flag at
half-mast at the embassy.[51]
Mexico: Former president Vicente Fox expressed his condolences.[52]
Peru: President Alan Garcia expressed his condolences and requested to talk with
president Lula.[49]
Spain: Felipe VI of Spain was in Brazil at the time of the accident and expressed
condolences.[53]
United States: President George W. Bush, his spokesman Sean McCormack, and
secretary of state Condoleezza Rice all expressed their condolences. Rice also called
Brazilian Foreign Minister Celso Amorim to express additional condolences.[49]
Vatican: Odilo Scherer, the Archbishop of São Paulo, received a telegram from Pope
Benedict XVI signed by the Vatican's secretary of state Tarcisio Bertone, expressing
condolences as well as a mass for the victims.[54]
Venezuela: Foreign minister Nicolás Maduro expressed his condolences to Brazil's
government and citizens.[55]
Memorial
On July 17, 2012, the fifth anniversary of the accident, a plaza
named Memorial Square was opened. Memorial Square was built
on the site of the TAM express warehouse (demolished on August
5, 2007), which is 8,318 square metres (89,530 sq ft) in area.[56]
There is a memorial with the names of the victims engraved as
well as a mulberry tree that survived the crash.[57] There is another
memorial in Porto Alegre called "Largo da Vida," where 199 trees
have been planted. The memorial is located near Salgado Filho
International Airport (the airport from which Flight 3054 Memorial at the site of the accident
departed).[58]
Legal action
On November 19, 2008, the 13,600-page police investigation was completed, which took 16 months of
research to produce, during which 336 people were heard.[59] Federal prosecutors were of the opinion
that the former director of the National Civil Aviation Agency (ANAC), Denise Abreu (who had taken up
the post in March 2006), and the flight safety officer of the airline, Marco Aurelio dos Santos de Miranda,
should both face criminal charges.[60] In 2011, the Brazilian Federal Public Ministry (Ministério Público
Federal—MPF) laid criminal charges against Abreu and Miranda, as well as Alberto Fajerman, TAM's
vice president of operations. They were accused of neglecting air transport safety by allowing the aircraft
to land in heavy rain on the notoriously short, recently resurfaced runway before cutting of grooves to
channel away excess rainwater. The trial began in São Paulo in 2013.[61] In 2014, MPF withdrew the
charges against Fajerman, for lack of evidence.[62] A second charge against Abreu of "documentary
falsehood" was dismissed in November 2014.[63] As of March 2015, no judgement had been handed
down on the other charges.
In 2014, TAM's insurer Itaú Seguros, the company responsible for paying compensation for the tragedy,
launched a lawsuit in Brazil against Airbus for R$350 million (US$156.2 million), according to Folha de
S. Paulo. Attorneys representing Airbus responded in a Brazilian court filing that Airbus accepts no
responsibility, laying the blame for the disaster with the cockpit crew, the airline and the poor state of the
runway.[64]
Notable victims
Among the victims were:
Júlio Redecker (aged 51), a Brazilian Social Democracy Party federal politician, member
and leader of the opposition in the Chamber of Deputies of Brazil.[65][66][67]
Paulo Rogério Amoretty Souza (aged 61), former chairman of the football team Sport Club
Internacional and attorney for Sport Club Corinthians Paulista.[68]
Márcio Rogério de Andrade (aged 35), former football player and FIFA agent at the time of
the crash. His spouse, his daughter and his brother-in-law also died in the disaster.[69]
Dramatization
The documentary television series Mayday, also known as Air Disasters, examined the crash and
investigation in a Season 11 episode titled "Deadly Reputation" (and alternatively "Nightmare Runway"
and "Disaster Runway"), which features interviews with investigators and a dramatic recreation of the
accident.[29]
See also
Brazil portal
Aviation portal
Philippine Airlines Flight 137 – Another Airbus A320 that crashed nine years earlier under
almost identical circumstances, with 3 fatalities
S7 Airlines Flight 778 – An Airbus A310 that crashed one year earlier also with a deactivated
thrust reverser, killing 125 people
TAP Flight 425 – A Boeing 727 that overran a runway and fell down an enbankment, killing
131
Air India Express Flight 812 – A Boeing 737 that overran a tabletop runway and plunged into
a ditch, killing 158
TACA Flight 390 – Another Airbus A320 that crashed into a neighborhood after overrunning
the runway, killing 199
Jeju Air Flight 2216 – A Boeing 737 that crashed into a concrete after a belly landing and
runway excursion, killing 179
References
Notes
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11. Sant'anna 2011, p. 240
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Bibliography
Sant'anna, Ivan (2011). "Parte 2 — Rota de Colisão" [Part 2 — Collision Course]. Perda
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External links
CENIPA External images
Final Report (http://sistema.cenipa.aer.mi Pre-accident pictures of aircraft at
l.br/cenipa/paginas/relatorios/rf/en/3054in Airliners.net (http://www.airliners.net/search?re
g_2007.pdf) Archived (https://web.archiv gistrationActual=PR-MBK&display=detail)
e.org/web/20191020210519/http://sistem
a.cenipa.aer.mil.br/cenipa/paginas/relatori Pre-accident pictures of aircraft at
os/rf/en/3054ing_2007.pdf) October 20, JetPhotos.com (https://www.jetphotos.com/regi
2019, at the Wayback Machine (Archive stration/PR-MBK)
(https://web.archive.org/web/2023101018
2743/https://sistema.cenipa.fab.mil.br/cen
ipa/paginas/relatorios/rf/en/3054ing_2007.pdf))
Final Report (https://sistema.cenipa.fab.mil.br/cenipa/paginas/relatorios/rf/pt/pr_mbk_17
_07_2007.pdf) (in Portuguese) (Archive (https://web.archive.org/web/20091122085144/h
ttp://www.cenipa.aer.mil.br/cenipa/paginas/relatorios/pdf/RF3054.pdf))
TAM Airlines
Comunicados TAM (http://www.tam.com.br/b2c/jsp/default.jhtml?adPagina=3&adArtigo=
10742) Archived (https://web.archive.org/web/20070824014254/http://www.tam.com.br/b
2c/jsp/default.jhtml?adPagina=3&adArtigo=10742) August 24, 2007, at the Wayback
Machine (in Portuguese) (Press releases from TAM regarding the incident) (Archive (http
s://web.archive.org/web/*/http://www.tam.com.br/b2c/jsp/default.jhtml?adPagina=3&adAr
tigo=10742))
TAM Informa (http://www.taminforma.com.br/)(in Portuguese) (Material from TAM Airlines
about the incident) (Archived (https://web.archive.org/web/20071011013704/http://www.t
aminforma.com.br/) October 11, 2007, at the Wayback Machine)
Bureau of Enquiry and Analysis for Civil Aviation Safety
Accident in São Paulo on 17 July 2007 (http://www.bea.aero/en/enquetes/saopaulo/saop
aulo.php) (Archive (https://web.archive.org/web/20120118154715/http://www.bea.aero/e
n/enquetes/saopaulo/saopaulo.php))
Accident survenu à São Paulo le 17 juillet 2007 (http://www.bea.aero/fr/enquetes/saopau
lo/saopaulo.php) (in French) (Archive (https://web.archive.org/web/20120119060240/htt
p://www.bea.aero/fr/enquetes/saopaulo/saopaulo.php))
Press Release (http://www.bea.aero/fr/enquetes/saopaulo/bfucp.pdf) - German Federal
Bureau of Aircraft Accident Investigation (in German) (Archive (https://web.archive.org/web/
20150620193353/http://www.bea.aero/fr/enquetes/saopaulo/bfucp.pdf))
Accident description (https://aviation-safety.net/database/record.php?id=20070717-0) at the
Aviation Safety Network
Cockpit Voice Recorder transcript and accident summary (https://tailstrike.com/database/17-
july-2007-tam-3054/)
In pictures: Brazil plane crash (BBC) (http://news.bbc.co.uk/2/hi/in_pictures/6903885.stm)
Video from Congonhas airport security camera, comparing a normal landing with TAM flight
3054's landing (http://noticias.uol.com.br/uolnews/brasil/2007/07/18/ult2486u946.jhtm) (in
Portuguese)
The World's Worst Airline (http://www.slate.com/id/2170727/nav/tap3/) Archived (https://web.
archive.org/web/20100113172330/http://www.slate.com/id/2170727/nav/tap3) January 13,
2010, at the Wayback Machine - Elizabeth Spiers
Plane Crashes in Brazil (https://www.nytimes.com/2007/07/18/world/americas/18brazil.html?
_r=2&hp&oref=slogin&oref=slogin)
List of passengers on Flight 3054 (http://i.a.cnn.net/cnn/2007/images/07/18/tam.list.pdf)
(Archive (https://web.archive.org/web/20130718185713/http://i.a.cnn.net/cnn/2007/images/0
7/18/tam.list.pdf))
Photographs (http://www.eupodiatamatando.com/2007/07/20/sobre-o-voo-3054/) (in
Portuguese) (Archive (https://web.archive.org/web/20081120191501/http://www.eupodiatam
atando.com/2007/07/20/sobre-o-voo-3054/))
CVR recording (https://www.youtube.com/watch?v=v=K3_A6Rvnnh0) on YouTube
Analysis of the accident and review of the CENIPA Final Report by a commercial aircraft
pilot and training captain (https://www.youtube.com/watch?v=wsL-flvKAvU) on YouTube