How a Series of Unfortunate Events Led to Unimaginable Disaster

HISTORY OF THE FLIGHT

On 17 July 2007, at 17:19 local time (20:19 UTC), the A-320, registration PR-MBK, operating as flight JJ3054, departed from Porto Alegre (SBPA) destined to Congonhas Airport (SBSP) in São Paulo city, São Paulo State.

There were a total of 187 souls on board the aircraft, being six active crewmembers and 181 passengers, including 2 infants and 5 extra crew members (not on duty). The weather prevailing along the route and at the destination was adverse, and the crew had to make a few deviations. Up to the moment of the landing, the flight occurred within the expected routine.

The aircraft was operating with the number 2 engine reverser de-activated, in accordance with the Minimum Equipment List (MEL). According to information provided to the TWR by crews that had landed earlier, the active runway at Congonhas (35L) was wet and slippery.

During the landing, at 18:54 local time (21:54 UTC), the crew noticed that the ground spoilers had not deflected, and the aircraft, which was not slowing down as expected, veered to the left, overran the left edge of the runway near the departure end, crossed over the Washington Luís Avenue, and collided with a building in which the cargo express service of the very operator (TAM Express) functioned, and with a fuel service station.

All the persons onboard perished. The accident also caused 12 fatalities on the ground among the people that were in the TAM Express building. The aircraft was completely destroyed as a result of the impact and of the raging fire, which lasted for several hours.

The accident caused severe damage to the convenience shop area of the service station and to some vehicles that were parked there. The TAM Express building sustained structural damages that determined its demolition.

FINAL REPORT

Official investigations conducted by CENIPA in September 2009, more than two years after the accident, revealed that one of the thrust levers controlling the engines was in an acceleration position when it should have been in idle. However, it was not determined whether this was caused by mechanical or human failure.

The report suggests two hypotheses for the accident:

The first hypothesis implicates mechanical failure, where a flaw in the power control of the plane's engines would have caused the thrust lever to remain in acceleration regardless of its actual position, with a likelihood of occurrence calculated at once per 400 billion flight hours.

The second hypothesis implicates human error, where the pilot performed a procedure different from the one provided in the manual and placed the thrust lever in an irregular position.

The report also identifies several other factors that may have contributed to the accident, such as heavy rain and the formation of puddles on the runway, as well as the absence of grooving.

However, the report does not attribute the accident to the length of the runway. Furthermore, the BEA cleared Airbus of any wrongdoing as they had proposed a system warning modification regarding the incorrect thrust lever positions, which TAM had rejected.

CURRENT RECOMMENDATION

These are the current (2023) guidelines for managing thrust levers when reversers are inoperative on the A320 aircraft, either due to in-flight failure or dispatch with deactivated reversers. The following recommendations should be followed:

IF AT LEAST ONE REVERSER IS OPERATIVE

When at least one reverser is operative, the suggested procedure is to select the reverser thrust on both engines during rejected takeoff (RTO) and at landing, following standard procedures. However, selecting reverser thrust may trigger the ENG 1(2) REVERSER FAULT ECAM caution, which reminds the flight crew that one reverser is not functioning.

IF NO REVERSERS ARE OPERATIVE

If no reversers are operative, it is generally recommended to avoid selecting reverser thrust during RTO and landing. However, the pilot flying (PF) should still set both thrust levers to the IDLE detent, in accordance with normal procedures.

THE IMPORTANCE OF FLIGHT CREW BRIEFING

During the flight crew briefing, it is vital to review the aircraft status. The briefing should cover any specific procedures, associated task sharing, and callouts related to the operational consequences of inoperative reversers. The flight crew must also review the status of the thrust reversers and determine if reverser thrust can be used. Furthermore, they should consider the operational effects of the inoperative reversers on aircraft handling during roll-out.

TO GO DEEPER

DISCLAIMER

The material contained in this document is to be used for training purposes only. Use at own risk, and do not use it for flight! - Your company FCOM and FCTM remain the final authority

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