TAM 3045 CVR Transcript

[cancidas]

very interesting to read, and sheds light on how the situation could have been avaoided. got this from Flight Global:


TAM A320 crash - full transcript from cockpit voice recorder
By Michael Targett

TAM A320 7/17/07 Sao Paulo Brazil

Cockpit Voice Recorder – Transcript


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 then 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
18:45:12.0
HOT-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
CAM [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 recording]
18:48:51.4
End of transcript

the crew did not disengage the autothrottles, and whne the airplane touched down it wanted to maintain airspeed. the spoilers didn't deploy because the engines didn't idle to allow the weight-on-wheels sensor to pick up the weight of the airplane. it was a chain reaction that could have been avoided much earlier on.

this proves to me, that too much automation is a bad thing. the pilot should fly the airplane and not the other way around.

[Nonstop2AUH]

Is the implication here that the crew was supposed to disengage the autothrottle during the landing checklist (despite calling checklist complete), and therefore the 'retard' of the throttle had no affect? Or that they didn't retard the throttle on landing? I've watched some Airbus landing videos on YouTube and sometimes it seems like the crew doesn't actually touch the throttle levers when the 'retard' command is issued, but perhaps this is related to what mode the system is in.

[DHG750R]

In the Airbus' , the act of disconnecting the autothrust (Airbus' verbage) is accomplished simply by moving the throttles to the idle detent, remember the thrust lever does not move in response to engine power changes - ala Boeing.

The circumstances are similar to what happened to an HP A320 a few years back where one throttle was moved back into the TOGA position after touchdown while the other remained in reverse. Ironically it too had 1 inoperative T/R

http://aviation-safety.net/database/rec ... 20020828-1 (http://aviation-safety.net/database/record.php?id=20020828-1)

[cancidas]

maybe they shouldn't fly the airplanes with a deferred reverser bucket. sounds like it could be a glitch in the FADEC software.

[T-Bird76]

So let me get this straight...the plane in fully configured for landing but because a switch isn't thrown it remains at speed? What's the reason for this? Its sounds to me like a simple automatic safety feature that should disengage or warn the pilots of the error.

[DHG750R]

What's being reported is the Right hand thrust lever was not retarded to idle, therefore the RH engine was still producing thrust for the approach. This also meant the autospoilers did not deploy and autobrakes were similarly disabled.


TAM A320 crew did not retard right-hand thrust lever
By David Kaminski-Morrow

Information on the TAM Airbus A320 accident shortly to be made available to operators will show that the crew retarded only the thrust lever for the left-hand engine during touchdown, leaving the other in its forward position.

Industry sources say the information, to be set out in a communique, shows that the crew made a normal approach to Sao Paulo Congonhas Airport on 17 July with auto-thrust selected – the aircraft operating under a ‘managed thrust’ regime – and the thrust levers in the ‘climb’ position.

For reasons yet to be explained, the pilot, in the final moments before touchdown, retarded only the thrust lever for the left-hand engine – first into the ‘idle’ position, then into ‘reverse’. This action disconnected the auto-thrust, as per its design. The failure to move the right-hand engine’s thrust lever to the reverse position runs contrary to the standard operating procedure which calls for both levers to be set to ‘idle’ and then 'reverse' – even with a thruster reverser inoperative.

It is unclear why the right-hand engine thrust lever was left in position. Newly-released cockpit-voice transcripts have notably highlighted the crew’s awareness that only the left-hand engine had an operable thrust-reverser; the right-hand reverser had been deactivated. This, however, should not have made a difference to the thrust retardation procedure.

As the aircraft began to slow after touchdown the thrust being produced by the right-hand engine remained at the level it was at when the auto-thrust had disconnected. With the thrust lever forward the spoilers would not have deployed, and the auto-brake would have similarly been inhibited.

In the cockpit transcript the co-pilot appears to state that the A320’s spoilers did not activate on touchdown and, as the situation develops, the pilots are heard to say that they cannot slow the aircraft. Flight-data recorder information indicates that the pilots repeatedly pressed on the brakes in a bid to stop the jet but did not retard the right-hand thrust lever.

[Nonstop2AUH]

Fascinating and sad. I looked around online for an explanation of how this system works, and found this on retired UA Capt. Meryl Getline's website. Pretty good at describing this in layman's terms...

http://www.fromthecockpit.com/Throttle_Retard.html

[PhilDernerJr]

Though it does sound like pilot error and you'd expect them to know the plane better than that, it sounds as though this Airbus system is more of a hassle and hazard than a help.

[DHG750R]

Definitely , it seems panic and fear took hold pretty quick , I can only imagine how that must've felt

[Informant]

So let me get this straight...the plane in fully configured for landing but because a switch isn't thrown it remains at speed? What's the reason for this? Its sounds to me like a simple automatic safety feature that should disengage or warn the pilots of the error.

Well you're right thats not how it should be...and it isn't. In the airbus the moment you bring back the throttles from the position that the A\T system is holding the speed, The A\T system will be disengaged. Now as for the number 2 engine still producing power? Unless the PF had lost some fingers, its hard to see how he could have missed pulling both throttles back.


Though it does sound like pilot error and you'd expect them to know the plane better than that, it sounds as though this Airbus system is more of a hassle and hazard than a help.
Look at this a photographer claiming pilot error. We don't know all the facts as of yetso this shouldn't be possibility yet. But if you want to get into it? Why wasn't the airport closed? The controllers knew weather was bad. Why didn't they divert flights?
Oh I forgot because these are the same Brazilian Air Force controllers that tried to screw over those two American pilots. Remember that?


spoilers did not activate on touchdown
This might be a maintenance problem, on the aircraft I fly and have flown, spoilers are activated when either
A)The main gears touch down and set off weight sensors in the bogies.
B)The main gears reach a certain speed after touchdown.


maybe they shouldn't fly the airplanes with a deferred reverser bucket. sounds like it could be a glitch in the FADEC software.
It was probably okay to do in the minimum no go book.


I've watched some Airbus landing videos on YouTube and sometimes it seems like the crew doesn't actually touch the throttle levers when the 'retard' command is issued, but perhaps this is related to what mode the system is in.

You can just switch from mode to mode. The aircraft does it manually. And as for not seeing the crew move the throttles to idle it may in fact be because they 1) are at idle, or 2) Using the power for a smoother touchdown. That retard 'command' or warning will always go off no matter what and then you will get the instruction on your PFD to 'FLARE'. The aircraft just wants to remind the crew that if they have power they will float and even climb during the flare if there is too much power.

More than crew error, this seems like another issue with the quality airframes that Airbus is making.

[cancidas]

It was probably okay to do in the minimum no go book.

maybe that no go book (MEL) list needs to be shortened. to fly an airplane onto a contaminated runway without reversers isn't my idea of fun. on a short, steep and wet runway i'd want everything that could help me stop working to help me stop.

[Informant]

n a short, steep and wet runway i'd want everything that could help me stop working to help me stop.


We better go to the local Airport Authority with that.

[DHG750R]

TAM now says it will require both reversers to be operative for operating to CGH and SDU ( Santos-Dumont ) , sounds wise to me..


TAM reverses thrust reverser policy; aircraft landing at Congonhas must have both activated
Thursday August 16, 2007
TAM told a Brazilian congressional panel holding hearings on last month's A320 crash that it no longer allows aircraft to land at Sao Paulo Congonhas or Rio de Janeiro Santos Dumont without both thrust reversers activated, a change in policy put in place after the accident.

The airline has admitted that the right thrust reverser was deactivated during a maintenance check several days before the July 17 crash at CGH that killed 199 people, including all 187 aboard (ATWOnline, July 30). But it downplayed that as a potential cause and said turning off the reverser was in accordance with regulations "stipulated by. . .Airbus and approved by [Brazil's] National Civil Aviation Agency."

Marco Aurelio Castro, TAM's head of security, testified this week that shortly after the accident the carrier mandated that aircraft landing at CGH and SDU, which have short runways, must have both thrust reversers activated, the Associated Press reported. Castro said that despite the policy change, the airline doubts the inoperative thrust reverser caused the crash. It had not revealed the policy change publicly.

Airbus VP-Flight Safety Yannick Malinge testified before the same committee last week that "there was no mechanical error or malfunction of the computers onboard" leading to the crash and said it was "premature" to cite the deactivated thrust reverser as a cause.

Legislators serving on the panel expressed outrage last week when it was revealed by Brazil's air force that in contrast to government regulations covering commercial aircraft, the A319 that transports President Luiz Inacio Lula da Silva must have both thrust reversers activated at all times. The "security rule" was in place long before the accident but covers only the president's aircraft, air force officials testified.

[hiss srq]

It sounds wise but even so all calculations are to be done without TR. As I said before, all additional stopping ability realized with it is just an added bonus.