TAM Airlines Flight 3054

TAM Airlines Flight 3054 was a regularly scheduled domestic passenger flight operated by TAM Airlines from Porto Alegre to São Paulo, Brazil. On the evening of 17 July 2007, the Airbus A320-233 serving the flight from Porto Alegre overran runway 35L at São Paulo's Congonhas Airport after touching down during moderate rain and crashed into a nearby TAM Express warehouse adjacent to a gas station. The aircraft exploded on impact, killing all 187 passengers and crew on board, as well as 12 people on the ground. An additional 27 people in the warehouse were injured. The accident remains the deadliest aviation disaster in Brazilian and South American history, and was the deadliest involving the Airbus A320 series until the bombing of Metrojet Flight 9268 in 2015 killing 224 people. It was the last major fatal aviation accident in Brazil until 2024, when Voepass Linhas Aéreas Flight 2283 crashed near São Paulo killing 62 people.
The accident was investigated by the Brazilian Air Force's Aeronautical Accidents Investigation and Prevention Center, and a final report was issued in September 2009. CENIPA concluded that the accident was caused by pilot error during the landing at São Paulo.

Background

Congonhas runway refit

On both of Congonhas Airport's runways, a slope prevented the drainage of accumulated water on the asphalt. The surface was already smooth due to excess rubber from the increased braking required on landing. There were no runway end safety areas, as Avenida Washington Luís, as well as several buildings and houses, were located at the end of runways 35L and 35R. On 24 July 2006, less than a year before the accident, a Boeing 737 of BRA Transportes Aéreos had difficulty stopping on runway 35L, but the pilots were able to bring the aircraft to a stop safely by performing a ground loop. Due to delays and flight cancellations caused by rains in early 2007, Infraero decided to resurface the airport's main runway. The installation of channeling grooves was planned to reduce the risk of hydroplaning. The resurfacing work was completed on June 29, but the grooves were not added. Infraero stated that adding the grooves would require an additional 30 days. Despite the incomplete refit, the Congonhas runway remained open for use during the 2006–07 Brazilian aviation crisis.

Landing difficulties

On 16 July, 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 damaged beyond repair. Despite this incident, landings continued to be conducted normally at the airport.

Aircraft and crew

The aircraft operating as Flight 3054 was a twin turbofan Airbus A320-233, serial number 789, registration PR-MBK; it was powered by two IAE V2500 engines. It was built in 1998 and had been operated by other airlines before entering service with TAM in January 2007, six months before the accident. The aircraft was owned by Pegasus Aviation and had flown more than 21,000 hours over 10,000 cycles before the crash.
The aircraft was dispatched with the thrust reverser on the starboard engine deactivated, as it had jammed. TAM said in a statement that a fault in a reverser "does not jeopardize landings" and no mechanical problem had been recorded on July 16, the day before the accident. The aircraft had no difficulty braking on the same runway a day before the fatal accident.
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. The flight crew consisted of two captains : Henrique Stefanini Di Sacco, and Kleyber Aguiar Lima. Four flight attendants were aboard.
Both pilots had been flying for over 30 years. Stefanini had logged 13,654 flight hours in his career, and Lima 14,760 hours, with 237 of them on the Airbus A320.

Nationality	Passengers	Crew	Ground	Total
Brazil	171	6	12	189
France	2	0	0	2
Argentina	2	0	0	2
Portugal	1	0	0	1
Sweden	1	0	0	1
United States	1	0	0	1
South Africa	2	0	0	2
Peru	1	0	0	1
Total	181	6	12	199

Flight chronology

Several players and coaches from the Grêmio football club were initially booked on Flight 3054, intending to catch a connecting flight in Congonhas and fly to Goiânia, for a game scheduled against the Goiás Esporte Clube. However, the club's management rescheduled the trip to the next day. The plane departed from Salgado Filho International Airport in Porto Alegre at 17:18 Brazilian Standard Time . It climbed to flight level 340. At 18:48 BRT, the flight made its landing at Congonhas-São Paulo Regional Airport.

Accident

Flight 3054 was cleared to land at Congonhas's Runway 35L. Reviews by 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. 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 facility, resulting in a large fire. The TAM Express facility contained offices and a warehouse, and was located adjacent to a gas station. All 187 passengers and crew died and the aircraft was destroyed.
The runway had recently been resurfaced, and did not yet have water-channeling grooves cut into it to reduce the danger of hydroplaning.
The aircraft's Flight Data Recorder showed that immediately prior to touchdown, both thrust levers were in CL position, with engine power being governed by the flight computer's autothrottle system. 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.
At the moment of touchdown, the spoiler lever was in the "ARMED" position. According to the system logic of the A320's flight controls, 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 remained in the CL position. One theory put forth by CENIPA is that the pilots may not have noticed that the right engine remained at CL because the Airbus autothrottle system, unlike other aircraft manufacturers, does not automatically move the levers when the autothrust controller changes engine settings. Therefore, the pilots may have thought that the right engine was at idle power without realizing 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. 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. 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:

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, a Boeing 737-800, and an Embraer Legacy 600.
The 35L runway at Congonhas is long. Congonhas's counterpart in Rio de Janeiro, the Santos Dumont Airport, has an even shorter runway, at. 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 landing speed of 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.
The airport is also known to be a dangerous airport in Brazil due to its runways.
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 of runway.
In June 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. The judge claimed the runway needed to be longer for these aircraft to operate safely. At the time, a spokeswoman from Brazil's National Civil Aviation Agency stated, "The safety conditions of the runway and the airport as a whole are adequate." 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.