Date:	Tuesday 17 July 2007
Time:	18:54
Type:	Airbus A320-233
Owner/operator:	TAM Linhas Aéreas
Registration:	PR-MBK
MSN:	789
Year of manufacture:	1998
Total airframe hrs:	20000 hours
Cycles:	9300 flights
Engine model:	IAE V2527-A5
Fatalities:	Fatalities: 187 / Occupants: 187
Other fatalities:	12
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	São Paulo-Congonhas Airport, SP (CGH) -   Brazil
Phase:	Landing
Nature:	Passenger - Scheduled
Departure airport:	Porto Alegre-Salgado Filho International Airport, RS (POA/SBPA)
Destination airport:	São Paulo-Congonhas Airport, SP (CGH/SBSP)
Investigating agency:	CENIPA
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
An Airbus A320-233 operated by TAM Linhas Aéreas of Brazil was destroyed when it suffered a runway excursion after landing at São Paulo-Congonhas Airport, Brazil.
TAM Flight 3054 was a regular passenger flight from Porto Alegre to São Paulo-Congonhas. The aircraft departed Porto Alegre at 17:19 with 181 passengers and 6 crew members on board.
The aircraft was operating with the number 2 engine reverser de-activated, in accordance with the Minimum Equipment List (MEL).
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.
According to information provided to the Tower controller by crews that had landed earlier, the active runway at Congonhas (35L) was wet and slippery. Runway 35L is a 6365 x 147 feet (1940 x 45 meters) asphalt runway with a Landing Distance Available of 1880 m.
In the beginning of 2007, the runways at Congonhas were subjected to a restoration to correct surface irregularities and correct problems of gradient, so as to prevent water accumulation. With the new pavement, the coefficient of friction of the runway surface was improved. However, since more time was be needed until the tarmac could be ready to receive the grooving, the airport administration decided to put the main runway in operation even without the grooves on 29 June 2007.

The flight touched down at 18:54 local time at a speed of 142 knots. Airbus had introduced a simplified procedure for landing with a deactivated thrust reverser in which crews had to select reversers for both engines after landing. Computer logic would which reverser was inoperative and thus block the increase in power. This simplified procedure however added an additional 55 meters in the calculations of the runway length required for landing if the runway was contaminated.
However, the flight crew failed to use this procedure and left the thrust lever of engine no.2 positioned at "CL".
This caused the autothrust to try to maintain the speed previously selected. Another consequence was the nondeflection of the ground spoilers, since, in accordance with their logic of operation, it is necessary that both thrust levers be at the "IDLE" position, or one of them be at "IDLE" and the other at "REV" (reverse), for the ground spoilers to be deflected.
The non-deflection of the ground spoilers significantly degraded the aircraft braking capability, increasing the distance necessary for a full stop of the airplane by about 50%.
Additionally the autobrake function, although armed, was not activated, because the opening of the ground spoilers is a prerequisite for such activation.
When the nose gear touched the runway, about 2.5 seconds after the left main gear, the number 1 engine thrust lever was moved to the "REV" position. With this action, the autothrust function of the aircraft was disconnected and the thrust lock function was activated, with the purpose of preventing the acceleration to reach the climb power level.
As a result, this function froze the number 2 engine power in the value it was at that moment (EPR2 = 1.18). The thrust lock function is disabled by the movement of the thrust lever, but since this movement did not occur, the number 2 engine remained with that power until the collision.
About six seconds after the main gear touched the runway, there was the first activation of the brakes by means of the pedals, which reached the maximum deflection five seconds later.
The FDR also recorded the use of the rudder and the differential braking by the pedals as the aircraft veered to the left.
Since the runway is at a higher elevation than the surrounding street and residential area, the A320 crossed over the Washington Luís Avenue, and collided with a concrete TAM Express building and a fuel service station at a ground speed of 96 knots.
All the persons onboard suffered fatal injuries. The accident also caused 12 fatalities on the ground among the people that were in the TAM Express building.
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.

1. Human factors
1.1 Medical aspect
a. Pain - Undetermined
At a certain moment, during the approach, the PIC reported having a mild headache. Although it was not possible to verify which type of headache it was, or even to evaluate its intensity, it is possible that this trouble may have influenced his cognitive and psychomotor capabilities during the final moments of the flight, when the unpredictability of the situation demanded a higher effectiveness of performance. This factor was considered undetermined due to the impossibility of confirming its contribution in factual terms.

1.2 Operational aspect
a. Training - A contributor
The theoretical qualification of their pilots was founded on the exclusive use of computer interactive courses (CBT), which allowed a massive training, but did not ensure the quality of the training received. In addition, the formation of the SIC was restricted to the “Right Seat Certification”, something that proved insufficient for him to deal with the critical situation experienced after the landing. Lastly, there was a perception among the crews interviewed that the training through the years and on account of the high demand resulting from the company’s growth was being abbreviated.
b. Application of the commands - Undetermined
One of the hypotheses considered in this investigation was that the pilot may have attempted to perform a procedure no longer in force at the time of the accident for the landing with a pinned reverser. This procedure consisted in the receding of both levers to the “IDLE” position during the flare at about a 10-foot altitude, and, after touching down, in activating the only reverser available, maintaining the thrust lever of the other engine in the “IDLE” position.
This procedure, though being more efficient from a braking perspective, could induce the crew to making mistakes, as there were several reports of occurrences in which there was a wrong setting of the levers, motivating the manufacturer to establish a new procedure, months before the accident. Thus, there is a high probability that the PIC inadvertently left one of the thrust levers in the “CL” position, placing the other one first in “IDLE” and later in the “REV” position.
This factor was considered undetermined due to the impossibility of confirming its contribution in factual terms.
c. Cockpit coordination - A contributor
Independently of the hypothesis considered, the monitoring of the flight at the landing was not appropriate, since the crew did not have perception of what was happening in the moments that preceded the impact. This loss of situational awareness hindered the adoption of an efficient and timely corrective action.
d. Forgetfulness by the pilot - Undetermined
It is possible that the pilot has inadvertently left one of the levers at the “CL” position, while trying to perform a procedure no longer in force for the operation with a pinned reverser.
This factor was considered undetermined due to the impossibility of confirming its contribution in factual terms.
e. Flight indiscipline - Undetermined
The procedure prescribed for the operation with a pinned reverser had been modified by the manufacturer and, according to the FDR recordings, the procedure in force was known to the crew and executed by them on the leg that preceded the accident.
However, as this procedure imposed an increase of up to 55 meters in the calculations of runway distance required for landing, it is possible that the PIC deliberately tried to perform adoption of a procedure no longer in force would characterize flight indiscipline.
This factor was considered undetermined due to the impossibility of confirming its contribution in factual terms.
f. Influence from the environment - Undetermined
The operating conditions of the Congonhas runway, may have affected the crew’s performance from a psychological perspective, considering the state of anxiety that was present in the cockpit.
In addition, the lack of luminosity resulting from the operation at night time, associated with the size and color of

21:00 UTC / 18:00 local time:
SBSP 172100Z 34008KT 6000 -RA BKN009 OVC070 16/14 Q1018=

22:00 UTC / 19:00 local time:
SBSP 172200Z 35008KT 7000 -RA BKN008 OVC070 15/14 Q1018=

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photo (c) Valter Campanato/ABr; São Paulo-Congonhas Airport, SP (CGH); 25 July 2007; (CC:by-sa)

photo (c) Valter Campanato/ABr; São Paulo-Congonhas Airport, SP (CGH); 25 July 2007; (CC:by-sa)

photo (c) Valter Campanato/ABr; São Paulo-Congonhas Airport, SP (CGH); 20 July 2007; (CC:by-sa)

photo (c) Valter Campanato/ABr; São Paulo-Congonhas Airport, SP (CGH); 25 July 2007; (CC:by-sa)

photo (c) Milton Mansilha/Agência LUZ/Abr; São Paulo-Congonhas Airport, SP (CGH); 17 July 2007; (CC:by-sa)

photo (c) Marcelo F. De Biasi, via Werner Fischdick; São Paulo-Guarulhos International Airport, SP (GRU/SBGR) [PP]; 07 June 2007

photo (c) Marcelo F. De Biasi, via Werner Fischdick; São Paulo-Guarulhos International Airport, SP (GRU/SBGR) [PP]; 30 June 2007

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