Date: 17th July 2007
Location: Congonhas Airport, São Paulo, Brazil
Aircraft: Airbus A320-233, registration PR-MBK
Flight Number: JJ3054
Operator: TAM Airlines
Flight Route: Porto Alegre (Brazil) to São Paulo (Brazil)
Passengers: 180
Crew: 6
Ground Fatalities: 13
Summary of Events
On 17th July 2007, TAM Airlines Flight JJ3054, an Airbus A320-233, crashed while attempting to land on Runway 35L at Congonhas Airport in São Paulo, Brazil. The aircraft failed to stop on the wet runway, overran the end, crossed a busy road, and struck a nearby building, igniting a massive fire. All 186 people on board were killed, along with 13 people on the ground, making it the deadliest aviation disaster in Brazilian history.
The investigation revealed that an asymmetrical thrust setting on the aircraft’s engines, combined with adverse runway conditions, prevented the crew from decelerating the aircraft effectively. The tragic incident highlighted the importance of robust landing protocols and infrastructure improvements for airports in densely populated urban areas.
Aircraft and Crew Information
The aircraft involved was an Airbus A320-233, a narrow-body twin-engine jet designed for short- to medium-haul flights. The specific aircraft, registration PR-MBK, had been in service for approximately seven years and had accumulated significant flight hours. Maintenance records indicated that the aircraft was in compliance with all regulatory requirements.
The crew consisted of two pilots and four cabin crew members. The captain had over 13,000 flight hours, including substantial experience on the Airbus A320, and the first officer had over 1,500 flight hours. Both pilots were qualified to operate the A320, and both had completed their required training, including familiarity with landing protocols for Congonhas Airport.
Sequence of Events
Flight JJ3054 departed from Porto Alegre and proceeded towards São Paulo’s Congonhas Airport, a high-traffic airport located within a dense urban area. The airport’s shorter runway length and frequent adverse weather conditions require precise control for safe landings. At the time of the incident, rain had made the runway surface slippery, adding to the landing challenge.
As the aircraft touched down on Runway 35L, the crew attempted to decelerate. However, due to an asymmetrical thrust setting, with the right engine thrust lever inadvertently left in the “climb” position, the aircraft did not decelerate as expected. Instead, the aircraft accelerated down the wet runway, unable to gain sufficient braking traction to slow down.
Despite the crew’s efforts to regain control, the aircraft failed to stop before the end of the runway. It overran the runway, crossed a busy road, and collided with a TAM Express building and a gas station, resulting in a powerful explosion and intense fire. All 186 people on board were killed, along with 13 people on the ground. The resulting fire destroyed the aircraft, the building, and nearby vehicles, complicating rescue efforts.
Weather and Runway Conditions
At the time of the crash, São Paulo was experiencing light rain, which had left the runway wet and slippery. Runway 35L at Congonhas Airport had a shorter length than most major airports, making it more challenging for deceleration under adverse conditions. Investigators found that while the runway met minimum regulatory requirements, it lacked a grooved surface, which would have provided better drainage and traction on wet surfaces.
The combination of a short, slippery runway and adverse weather made the landing more challenging, especially considering the thrust asymmetry created by the right engine’s “climb” setting.
Investigation and Analysis
The investigation into the crash was led by the Brazilian Aeronautical Accident Investigation and Prevention Center (CENIPA), with support from Airbus, the French Bureau of Enquiry and Analysis for Civil Aviation Safety (BEA), and the U.S. National Transportation Safety Board (NTSB). Key aspects of the investigation included the aircraft’s thrust settings, the runway’s condition, and crew actions during the landing attempt.
Asymmetrical Thrust Setting: The investigation found that the right engine’s thrust lever was inadvertently left in the “climb” position during landing, which provided thrust rather than the expected idle power needed for deceleration. This asymmetry meant that while the left engine reduced power, the right engine continued to provide forward thrust, effectively preventing the aircraft from slowing down on the runway. The crew’s awareness of the thrust setting discrepancy was limited, as they expected both engines to be at idle during rollout.
Runway Conditions and Infrastructure: Runway 35L’s lack of grooving meant that rainwater could pool on the surface, reducing traction for landing aircraft. This lack of surface friction further exacerbated the inability of Flight JJ3054 to stop in time. Congonhas Airport’s runway length is shorter than standard for major international airports, which, combined with wet conditions, increased the risk of runway excursions.
Crew Actions and Training: The investigation found no evidence that the crew was aware of the right engine’s thrust setting discrepancy. Standard operating procedures require a thorough check of engine settings before landing, but it is unclear if operational pressure or weather conditions contributed to the oversight. The crew was experienced and well-trained, but the combination of adverse conditions and the thrust asymmetry created an almost unrecoverable situation.
Airport Safety Enhancements: The runway at Congonhas, located in a densely populated area with limited space for overrun areas, lacked safety features such as an engineered materials arrestor system (EMAS) that could have helped stop the aircraft in an overrun scenario.
Conclusions
The crash of TAM Airlines Flight JJ3054 was attributed to an asymmetrical thrust condition resulting from the right engine’s thrust lever being inadvertently left in the “climb” position. This error, combined with a wet, ungrooved runway and short stopping distance, prevented the aircraft from decelerating and led to the runway excursion. The lack of adequate runway safety features and drainage further contributed to the fatal outcome.
The incident underscored the critical importance of robust landing protocols, runway safety infrastructure, and the need for clear pre-landing checks to ensure correct engine settings. The crash has since prompted major changes in Brazilian aviation safety regulations and infrastructure improvements at airports across the country.
Recommendations
Based on the findings, several key recommendations were made to improve aviation safety and prevent similar incidents:
1. Installation of Grooved Runway Surfaces: Airports should implement grooved runway surfaces at high-traffic locations to improve drainage and traction, particularly in wet conditions. Congonhas Airport and similar facilities should prioritize grooved surfaces to reduce hydroplaning risks.
2. Enhanced Pre-Landing Checklist Protocols: Airlines should reinforce pre-landing checklist protocols to ensure both engine thrust levers are in the appropriate position for landing. This includes additional training on the importance of symmetrical thrust during landing.
3. Runway Safety Areas and EMAS Installation: Airports with shorter runways and limited overrun areas, particularly in urban settings, should consider installing engineered materials arrestor systems (EMAS) to help prevent accidents in the event of a runway excursion.
4. Improved Crew Awareness of Runway Conditions: Airlines should provide updated information on runway conditions, including traction and braking performance in adverse weather, to help crews make more informed decisions regarding landing.
5. Increased Operational Oversight During Adverse Conditions: Airlines should ensure that crews receive adequate training for landing in adverse conditions, emphasizing the importance of diversion if runway conditions pose additional risks.
Safety Lessons and Industry Impact
The crash of TAM Airlines Flight JJ3054 was a watershed event in Brazilian aviation history, prompting significant regulatory changes and infrastructure improvements. The tragedy highlighted the risks associated with landing on shorter runways in adverse conditions, particularly at airports surrounded by urban development. In response, Brazil’s aviation authorities mandated grooved surfaces for runways at high-traffic airports, installed safety systems, and enforced stricter pre-landing protocols for crews.
This incident has had a lasting impact on global aviation practices, leading to greater awareness of the importance of runway infrastructure and the need for precise thrust management during landing.
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