July 17, 2007
Sao Paulo, Brazil
TAM
Airbus 320-233
PR-MBK
The jet airliner crashed while attempting to land in heavy rain at Congonhas airport.
The plane skidded off the end of the runway across a major roadway and struck a gas
station and building, bursting into flames. The right engine had a malfunctioning reverser.
In this situation, the correct procedure was for the pilot to retard both throttles to idle
and then advance both throttles to reverse, as if he had no problem with the reversers.
The former procedure, which was changed by Airbus, was to take both throttles to idle,
and then advance just the throttle corresponding to the engine with the operating reverser.
It was changed by Airbus because there had been several incidents where the pilot forgot
to bring both throttles back to idle, leaving one engine reversed and the other thrusting
forward. The downside to this change was it would lengthen the stopping distance. The
pilot was so concerned about the short and slippery runway that he chose to switch to
the old procedure and got it wrong. A contributing factor was the heavy rain and wind
and the fact that the newly resurfaced runway had not had grooves installed yet.
HOT = Crew member "hot" microphone voice or sound source
CAM = Cockpit-area microphone
* = Unintelligible word
APP = Approach control
PA = Public address
Start of Transcript
18:18:24.4 (all times are local time) [start of recording]
18:18:24.5 PA-1 [captain makes speech to passengers]
18:18:53.4 CAM-? [sound of whistling]
18:20:25.0 CAM [sound of flight attendant door open request]
18:20:28.1 CAM-1 is ok?
18:20:29.7 CAM-3 [flight attendant says that everything in the cabin is OK, and the asks where will they be landing]
18:20:33.3 CAM-1 I have just informed.
18:20:34.7 CAM-3 I didn't hear - sorry - her talking.
18:20:37.7 CAM-1 but she heard, Congonhas.
18:20:39.3 CAM-3 is it Congonhas? It’s great, so. she might have heard. thank you.
18:43:04.3 HOT-1 remember, we only have one reverse.
18:43:06.9 HOT-2 yes... only the left.
18:43:24.0 HOT-1 glideslope, LOC blue... LOC star. [LOC star means an asterisk is displayed on the FMA, which means the loc capture]
18:43:26.6 HOT-2 checked.
18:43:27.1 HOT-1 autopilot one plus two.
18:43:29.4 HOT-1 flaps one.
18:43:30.7 HOT-2 speed checked.
18:43:36.7 HOT-1 clear status.
18:43:41.8 HOT-2 clear status.
18:43:43.8 HOT-2 clear.
18:43:48.2 RDO-2 going to intercept the localizer, TAM three zero five four.
18:43:52.2 APP TAM three zero five four, reduce speed for the approach... and call the tower on frequency one two seven point one five, good afternoon.
18:44:00.0 RDO-2 one two seven one five, over.
18:44:01.7 HOT-1 good afternoon.
18:44:06.4 HOT-1 flaps two.
18:44:08.1 CAM-2 speed checked.
18:44:20.0 HOT-2 flaps at two.
18:44:22.3 RDO-2 Sao Paulo tower, this is TAM three zero five four.
18:44:26.1 TWR TAM three zero five four, reduce minimum speed for approach, the wind is north with zero six. I will report when clear three five left.
18:44:33.4 RDO-2 good evening, reducing to the minimum possible [speed].
18:44:36.3 HOT-1
landing gear down.
18:44:37.7 HOT-2 landing gear down.
18:44:53.9 HOT-1 flaps three.
18:44:55.1 HOT-2 speed checked.
18:44:57.4 HOT-2 flaps three.
18:45:03.9 HOT-1 flap full.
18:45:05.7 CAM-2 speed checked, flaps full.
18:45:10.6 HOT-1 standby final checklist
18:45:12.0HOT-2 standing by.
18:45:12.9 CAM-1 glide star, set missed approach altitude.
18:45:15.0 CAM-2 ALT * *.
18:45:21.0 CAM-2 six thousand feet.
18:45:44.0 CAM [sound of windshield wipers operating]
18:45:52.1 CH2 [sound of outer marker beacon heard on channel 2]
18:46:03.2 HOT-1 final checklist.
18:46:04.6 HOT-2 final checklist, passing DIADEMA [name of the outer marker beacon]
18:46:10.4 PA-2 cabin crew, clear to land. [prepare for landing]
18:46:14.0 CAM-2 cabin crew.
18:46:15.2 CAM-1 advised.
18:46:16.0 CAM-2 auto thrust.
18:46:17.8 CAM-1 speed.
18:46:20.0 CAM-2 * *.
18:46:21.1 CAM-1 landing no blue.
18:46:22.6 CAM-1 ECAM MEMO [Electronic Centralized Aircraft Monitor - check memo status]
18:46:23.8 HOT-1 landing, no blue.
18:46:24.9 HOT-2 landing no blue.
18:46:26.1 HOT-1 okay?
18:46:26.7 HOT-2 okay... what?
18:46:28.6 HOT-2 okay.
18:46:30.8 HOT-? *.
18:46:30.8 HOT-2 final checklist complete.
18:46:33.8 CAM-1 runway in sight, landing.
18:46:41.7 CAM-1 ask him [the tower] about the rain condition, the runway condition, and if the runway is slippery.
18:46:57.0 RDO-2 TAM on final approach, two miles away. could you confirm conditions?
18:47:01.7 TWR it's wet, and it is slippery. I will report three five left clear, three zero five four.
18:47:06.1 RDO-2 already on final.
18:47:07.5 TWR the aircraft is starting the departure.
18:47:10.7 HOT-1 wet and slippery!
18:47:22.0 HOT-2 the aircraft is starting the takeoff run.
18:47:34.3 TWR TAM three zero five four, three five left, clear to land, the runway is wet, and is slippery and the wind is three three zero at eight. knots.
18:47:40.6 HOT-2 three three zero at eight, is the wind.
18:47:42.9 HOT-1 checked.
18:47:43.9 TWR three zero five four?
18:47:45.3 RDO-2 three zero five four, roger.
18:47:46.4 FWC four hundred.
18:47:49.8 HOT-1 is the landing clear?
18:47:50.7 HOT-2 clear to land.
18:47:52.3 HOT-1 land green, manual flight.
18:47:53.7 CAM [sound of autopilot disconnect tone]
18:47:54.1 HOT-2 checked.
18:47:54.8 HOT-1 inhibit the glide [GPWS aural warning] for me please.
18:47:55.7 CAM [sound of triple click indicating reversion from CAT II or III to CAT I approach mode (manual flight approach)]
18:47:56.9 HOT-2 what?
18:47:58.8 FWC three hundred.
18:47:59.3 HOT-1 inhibit the glide for me.
18:48:00.6 HOT-2 okay.
18:48:03.0 HOT-2 inhibit.
18:48:05.8 HOT-2 middle.
18:48:11.6 FWC two hundred.
18:48:14.9 HOT-2 one dot now. okay.
18:48:16.8 HOT-1 okay.
18:48:21.0 FWC twenty.
18:48:21.6 FWC retard.
18:48:23.0 FWC retard.
18:48:24.5 CAM [sound of thrust lever movement]
18:48:24.9 CAM [sound of increasing engine noise]
18:48:25.5 GPWS retard
18:48:26.3 AM [sound similar to touchdown]
18:48:26.7 HOT-2 reverse number one only.
18:48:29.5 HOT-2 spoliers nothing.
18:48:30.8 HOT-1 aaiii. [sigh]
18:48:33.3 HOT-1 look this.
18:48:34.4 HOT-2 decelerate, decelerate.
18:48:35.9 HOT-1 it can't, it can't.
18:48:40.0 HOT-1 oh my god..... oh my god.
18:48:42.7 HOT-2 go go go , turn turn turn turn.
18:48:44.6 HOT-2 turn turn to... no, turn turn.
18:48:45.5 CAM [sound of crushing noises]
18:48:49.7 CAM-? (oh no) [male voice]
18:48:50.0 CAM [pause in crushing noises]
18:48:50.6 CAM-? [sound of scream, female voice]
18:48:50.8 CAM [sound of crushing noise]
[end of rec rding]
18:48:51.4 End of transcript