Description

On 17 July 2007, an Airbus A320 (PR-MBK) being operated by TAM Airlines on a scheduled domestic passenger flight (JJ3054) from Porto Alegre to São Paulo Congonhas and making a night landing in normal ground visibility failed to decelerate normally after touchdown on runway 35L and departed the side of the paved surface near its end and became briefly airborne from the elevated terrain before crashing into a building beyond the airport perimeter. Both the building and the aircraft were destroyed by the impact and a fierce fire which followed and all 187 occupants and 12 people on the ground were killed.

Investigation

An Investigation was carried out by CENIPA, the Brazilian Aeronautical Accidents Investigation and Prevention Centre. Data from the SSFDR and 30 minute SSCVR was successfully downloaded and provided important evidence to assist the Investigation.

It was found that both pilots were experienced but that the Co-pilot, a former flight engineer who had recently been recruited by TAM as a Captain had recently completed his A320 type conversion with TAM and had only 237 hours experience on the aircraft type. At the time of the accident, a shortage of co pilots had led to him being cleared for co pilot duties only.

It was established that four days prior to the accident, the aircraft had been released to service in accordance with the applicable Minimum Equipment List (MEL) with the number 2 engine reverser de-activated. It was noted that on the accident flight, it was tankering fuel uplifted at Porto Alegre.

The airport at Congonhas, stated to have been the busiest international airport in Brazil at the time of the accident, is situated in an elevated position in the centre of São Paulo. It had two asphalt runways, the main runway, 17R/35L, which was at the time 1945 metres long and the auxiliary runway, 17L/35R, which was at the time 1435 metres long. Earlier landing aircraft on the day of the accident had advised the TWR that the active runway, 35L, was “wet and slippery”. At the time of the accident, neither runway had a Runway End Safety Area, the provision of which was an ICAO Standard under Annex 14. This situation had not been notified to ICAO in accordance with the article 38 of the Chicago Convention on International Civil Aviation.

Meteorological Terminal Air Report (METAR) and SPECI reports for Congonhas timed shortly before and just after the accident indicated that light rain had been falling, the lowest cloud had been between 800 feet aal and1600 feet aal with visibility between 6km and 8km and the surface wind from between 320º and 350º at 8-12 knots.

The en route part of the flight and the approach to runway 35L at destination were uneventful. Shortly after the aircraft passed 20 feet agl, the CVR recorded the occurrence of the “RETARD” auto callout three times. At this time, the DFDR recorded the left engine thrust lever moving to "IDLE" whilst the right engine thrust lever remained at the ‘CL’ (MAX CLIMB) position - a thrust lever angle position of 25° ahead of ‘IDLE’.

After touchdown at 142 KCAS, the left engine thrust lever was moved to the “REV” position but the right engine thrust lever remained in same position as previously. FDR readings of the EPR were found to correspond to those which would be expected for the recorded thrust lever positions for both engines. Three seconds after the nose landing gear touched down on the runway, there was a sudden yaw to the left which would have corresponded to the selection of the left engine thrust lever to reverse. The Co-pilot confirmed the activation of the left engine reverser and also called the non-deployment of the ground spoilers.

The failure of the ground spoilers to deploy was recorded on the FDR as was the non-activation of the armed autobrakes, which it was noted was a direct consequence of the absence of ground spoiler deployment which alone would have reduced aircraft braking performance by almost 50%. In response to the failure to decelerate, both pilots applied and held maximum manual brake pressure but the rate of deceleration did not improve and was still recorded as almost 100 knots at the final impact of the aircraft with the building below the end of the runway.

Downloaded FDR data did not provide any evidence that aquaplaning had occurred although the Investigation considered that there was “a high probability that the pilots were led to believe that the lack of the expected deceleration after landing was a result of… the wet runway” even though it was apparent that they were aware almost immediately that the ground spoilers had not deployed.

Since the ‘RETARD’ auto callout had sounded after the left hand thrust lever was moved to the flight idle position during the flare to land (because the A/T was still engaged and the right hand thrust lever was in the CL position), it was considered that there was a ‘high probability’ that during the landing, the aircraft commander had “inadvertently” left the right hand thrust lever in the CL position whilst placing the left hand thrust lever initially at flight idle and then into reverse.

It was calculated that landing with an inoperative reverser on a wet runway with one thrust lever in ‘REV’ and the other in ‘CL’ even without considering the thrust provided by the No 2 engine, in excess of 2000 metres would have been necessary for the aircraft to come to a complete stop, In effect, once the aircraft had touched down with no ground spoiler deployment on such a relatively short runway, the excursion off the runway at speed rapidly became inevitable.

Having concluded that the lack of deceleration which led to the overrun had been a consequence of the pilots’ failure to notice that the right engine thrust lever was in the ‘CLIMB’ detent, it was also found that:

• The broader context for the accident was the consequences of the rapid growth of the Operator, TAM, which had “accentuated the effects of the lack of coordination among its diverse sectors, hindering the oversight at all management levels”.
• Because the A320 Service Bulletin (SB) which brought the Flight Warning Computer (FWC) up to the ‘H2F3’ production standard for new aircraft by introducing an ‘ENG X THR LEVER ABV IDLE’ message on the Electronic Centralized Aircraft Monitor (ECAM) if either thrust lever was above ‘IDLE’ during the landing roll was not made mandatory by the Regulator, TAM were not required to adopt it and they did not do so voluntarily.

Potential Contributing Factors, defined in accordance local practice as “a condition (act or fact, or a combination of the two) which, together with other ones, in sequence or as a consequence, leads to or allows the occurrence of an aeronautical accident….or which contributes to the aggravation of its consequences” were considered and categorised as either ‘Human Factors’ or ‘Material Factors’. Those factors “whose contribution was effectively established, regardless of the degree at which such contribution occurred” were identified as such and other factors “whose contribution, however possible, was not confirmed” were categorised as “undetermined”. This distinction was qualified by the statement that such categorisation reflects only the ability “to confirm, with a reasonable degree of certainty, the presence of such factors among the actions and/or conditions which preceded the accident, and (it does) not imply the assignment of values or degrees of importance to any of them”.

The ten factors determined to be contributing were as follows:

• Pilot Training - the means to theoretical qualification for pilots at TAM relied exclusively on CBT but the quality of this training was not assured In addition, the training of the SIC pilot was restricted to “Right Seat Certification”, something that proved insufficient for him to deal with the critical situation experienced after the landing.
• Cockpit coordination - 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.
• Management planning - the situation at TAM during rapid expansion was unsatisfactory. At the time of the accident, the operator had a disproportional number of Captains in comparison with the number of Co-pilots, a fact that obliged the scheduling sector to form crews with two Captains. Thus, although complying with the minimum regulatory requirement, such a practice may have contributed to the creation of a climate of complacency in the cockpit.
• Low relevant experience of the Co-pilot - despite his long experience in commercial jets, the Co-pilot had only about 200 flight hours in aircraft of the A-320 type. Also, his experience in the function of co-pilot was restricted to the “Right Seat Certification” training received.
• Management oversight - TAM routinely allowed the crew to be composed of two Captains, with the occupant of the right-hand seat having done only “Right Seat Certification” training. Besides, the lack of coordination between the several sectors of the company, especially between the sectors of operation and training, determined the lack of an appropriate monitoring of the processes and of the quality of the pilots’ professional training.
• Perception error - although perceiving that the ground spoilers had not deflected, the pilots were not able to associate the non-deflection with the positioning of the thrust levers. In addition, there is a high probability that the pilots were led to believe that the lack of the expected deceleration after landing was a result of the conditions of operation with a wet runway
• Lack of perception - considering the hypothesis of a failure in the thrust control system, the contingent stimulus generated from the loss of resistance to the movement of the thrust levers may not have been perceived by the pilot(s).
• Loss of situational awareness - emerged as a result of the very lack of perception on the part of the pilots. In this respect, the automation of the aircraft, however complex, was not capable of providing the pilots with sufficiently clear and accurate stimuli, to the point of supporting their understanding of what was happening in the moments just after the landing.
• Regulation - although having already considered the availability of reversers as a requirement for operations at Congonhas since at least since April 2006, the Regulator only formalised this after the accident had occurred.
• Design - there was no pilot alerting for the case of one thrust lever in the ‘REV’ position and the other at ‘CL’.

A total of 83 Safety Recommendations were issued to 9 different recipients as a consequence of the Investigation, 60 of these on 8 occasions as it progressed and the remaining 23 with the issue of the Official Report at its conclusion. Minor changes have been made to the originally-published English language translation of the Recommendations reproduced below in the interests of clarity but none of these changes alter the intent of the original wording.

Some local abbreviations which will be unfamiliar to many and which are used in the Safety Recommendations are as follows:

AAL, the INFRAERO Local Airport Administration

ANAC, National Civil Aviation Agency

CENIPA, Aeronautical Accident Investigation and Prevention Center

IAC, Civil Aviation Instruction

INFRAERO, Brazilian Airport Infrastructure Enterprise

MGM, General Maintenance Manual

RBAC, Brazilian Civil Aviation Regulation

RBHA, Brazilian Aeronautical Certification Regulation

SIPAER, Aeronautical Accident Investigation and Prevention System

It was noted that local regulations established through SIPAER required that “each one of the identified factors (contributing or undetermined) be subject to at least one safety recommendation”.

All the Recommendations made are presented here in the order in which they were issued (although the Official Report presents them by recipient) and they were as follows:

Issued on 21 July 2007:

• that ANAC should immediately restrict the operation on the 17R/35L runway (main runway) of Congonhas Airport to the condition of a “dry runway”. (A) 45/ A / 07

Issued on 17 September 2007:

• that ANAC should consider the 17R/35L (main) and the 17L/35R (auxiliary) runways of Congonhas Airport as useable only when their surface characteristics meet the skid resistance requirements prescribed in IAC 4302, dated 28 May 2001, taking into account Safety Recommendation (A) 45 / A / 07. (A) 46 / A / 07
• that ANAC should evaluate the condition of the 17R/35L (main) and 17L/35R (auxiliary) runways of Congonhas Airport, based on the results of the friction and surface texture measurement tests of their pavements, executed and forwarded by the Airport Administration after the construction, re-surfacing, maintenance or periodic inspection of the runways, in accordance with IAC 4302 dated 28 May 2001. (A) 47 / A / 07
• that ANAC should maintain effective control of the execution by the Airport Administration of the friction and surface texture measurement tests concerning the pavements of the 17R/35L (main) and 17L/35R (auxiliary) runways of the Congonhas Airport after the construction, resurfacing, maintenance or periodic inspection of the runways, in accordance with the IAC 4302, dated 28 May 2001. (A) 48 / A / 07
• that ANAC should establish parameters and procedures so as to guarantee the safety of air operations on the 17L/35R (auxiliary) runway of Congonhas Airport in the event of rain. (A) 49 / A / 07
• that ANAC should make provisions for the evaluation of the performance of large size jet aircraft (more than 60,000 pounds), which operate or are expected to use the Congonhas Airport runway system, based on demonstrations of real operations with special landing techniques on wet runways, according to the method prescribed in the IAC 3502-121 0888, establishing the operational flight parameters and procedures, as well as the infrastructure, to guarantee the safety of the landing and take-off operations at the airport. (A) 50 / A / 07
• that ANAC should inform the various companies operating at Congonhas Airport that, for purposes of planning the air operations on the 17R/35L (main) and 17L/35R (auxiliary) runways, their respective Operation Managements, based on information published by the INFRAERO by means of NOTAM, on the friction and surface texture requirements in accordance with the IAC 4302, dated 28 May 2001, must carry out runway analysis for their various types of equipment in order to adjust to the existing conditions of the aforementioned runways. (A) 51 / A / 07
• that ANAC should monitor the action taken to record progressive changes in the friction and surface macro-texture parameters of the Congonhas Airport main runway by the airport administration, so as to have technical data and information capable of facilitating and expediting the evaluation of the special maintenance plan to be proposed by the airport administration. (A) 52 / A / 07
• that ANAC should determine the establishment of a Runway End Safety Area (RESA), in accordance with the technical standards set by the ICAO Annex 14, as one of the priority infrastructure improvements to be established for Congonhas Airport, adjusting the other components of the runway system to the operational safety requirements of the runways and thus guaranteeing the safety of landing and takeoff operations as recommended in (A) 50 / A/ 07, even though it may imply the shortening of the current length of the main and auxiliary runways. (A) 53 / A / 07
• that AAL Congonhas should monitor the surface characteristics of the 17R/35L (main) and 17L/35R (auxiliary) runways of Congonhas Airport in accordance with the IAC 4302, dated 28 May 2001 and promptly implement the appropriate corrective actions for the restoration of required safety standards whenever the levels of surface friction or surface texture are below the prescribed minimums, immediately informing pilots by means of a NOTAM of the conditions of the aforementioned runways. (A) 54 / A / 07
• that AAL Congonhas should forward to ANAC the results of the measurement of friction and surface texture tests of the pavements of the 17R/35L (main) and 17L/35R (auxiliary) runways of Congonhas Airport after any construction, resurfacing, maintenance or periodic inspection as established by IAC 4302, dated 28 May 2001. (A) 55 / A / 07
• that AAL Congonhas should take measurements of the friction coefficient and surface macrotexture of the 17R/35L (main) runway of Congonhas Airport taking account of the cutting of grooves and forward the results to the ANAC, as prescribed in the IAC 4302, dated 28 May 2001. (A) 56 / A / 07
• that AAL Congonhas should take measurements of the friction coefficient and surface macrotexture of the 17R/35L (main) runway of Congonhas Airport, at least every fortnight so as to track changes of those parameters resulting from rubber build-up caused by landing and takeoff operations on the 17R/35L (main) runway. (A) 57 / A / 07
• that AAL Congonhas should submit, for the approval by the ANAC, a special plan of maintenance of the 17R/35L (main) runway of Congonhas Airport based on results obtained through the procedure determined in Safety Recommendation (A) 57 / A / 07. (A) 58 / A / 07
• that Airline Companies operating at Congonhas should adjust the performance of their aircraft for operations at Congonhas Airport by considering the possibility of using the 17L/35R (auxiliary) runway for landings and takeoffs in rainy weather. (A) 59 / A / 07
• that TAM Airlines should emphasise the strict adherence of the technical crews to the MEL of the A319, A320 and A321 equipment, relative to the item 78-30 – OPERATIONAL PROCEDURES – EXHAUST – THRUST REVERSER, which deals with the operation of the aircraft with a thrust reverser locked-out. (A) 60 / A / 07
• that CENIPA should publish to the Brazilian aeronautical community, in the form of an Operational Publication and other existing means of communication, the content of these Safety Recommendations in order to maintain a high level of perception and situational awareness. (A) 61 / A / 07
• that CENIPA should carry out a Special Flight-Safety Inspection of the TAM Airlines Company, in accordance with the NSCA 3-3, item 6.2.2. (A) 62 / A / 07
• that CENIPA should carry out a Special Flight-Safety Inspection of the INFRAERO AAL at Congonhas in accordance with the NSCA 3-3, item 6.2.2. (A) 63 / A / 07

Issued on 2 October 2007:

• that Airlines operating under RBHA 121 should study the practicability of adjusting the operation of their aircraft at airports defined by them as “airports operation under special condition” and examine the possibility of not permitting landings and takeoffs by aircraft with locked out thrust reversers. (A) 143 / A / 07

Issued on 21 November 2007:

• that ANAC should set procedures for RBHA 121 operators to include in the descent briefing an analysis of the runway length necessary for landing and the actions to be taken in case of non-functioning of the ground spoilers and/or brakes. Such analysis has the objective of defining the immediate start of any go-around which may become necessary. (A) 144 / A / 07
• that ANAC should study the viability of setting norms for RBHA 121 operators to include in the procedure following touchdown confirmation of the functioning of the ground spoilers before the activation of the thrust reverser. This sequence has the objective of allowing a touch-and-go landing, in case of non-functioning of the ground spoilers. (A) 145 / A / 07
• that ANAC should establish procedures for RBHA 121 operators to carry out training of touch-and-go landings after the malfunction of ground spoilers and/or brakes in flight simulators with the objective of demonstrating the characteristics of the aircraft performance under those conditions. (A) 146 / A / 07
• that ANAC should update the pertinent documentation so as to officially document the procedures recommended in Safety Recommendations (A) 144 / A / 07, 145 / A / 07 and 146 / A / 07. (A) 147 / A / 07
• that ANAC should evaluate the practicality of establishing deactivated thrust-reverser landing training for RBHA 121 operators with the objective of implementing such training. (A) 148 / A / 07
• that ANAC should study the need to establish parameters for fuel tankering by RBHA 121 operators when proceeding to land in limiting conditions in relation to the landing envelope. (A) 149 / A / 07

Issued on 18 December 2007:

• that INFRAERO should make provisions for the repositioning and/or calibration of the level of illumination of the parking ramp reflectors at the new passenger terminal at Congonhas Airport so as to prevent the dazzling of pilots during the landing and takeoff operations at the main runway (17R / 35L). [(A) 153 / A / 07]
• that INFRAERO should reformulate the procedures utilised in the processing of Prevention Reports (RELPREV) so as to prioritise their quick receipt by Local Airport Administrations, their immediate analysis and review and the prompt implementation of any pertinent preventative actions. (A) 154 / A / 07
• that INFRAERO should implement procedures which establish the active participation of the AAL in the oversight of works executed in their airports, aiming at guaranteeing full appreciation of the physical modifications being made and their compatibility with operational practices. (A) 155 / A / 07
• that CENIPA should publish to the Brazilian aeronautical community, in the form of an Operational Publication and other existing means of communication, the content of these Safety Recommendations, in order to maintain a high level of perception and situational awareness. (A) 156 / A / 07

Issued on 28 December 2007:

• that ANAC should study, in coordination with the certification organisations of other countries and with aircraft manufacturers, whether there is a need to establish procedures for aircraft certified under RBHA 25 which define corrective action when the ground spoilers do not deploy after touchdown. (A) 169 / A / 07
• that ANAC should monitor and evaluate, in coordination with the EASA, the proposed modification of the RETARD auto call-out system on the A-320 aircraft in terms of safety requisites and time for its implementation, so that it performs only the function for which it was designed, namely, to advise the crew to place the thrust levers in the “IDLE” position. (A) 171 / A / 07
• that ANAC should issue, in the short term, an Airworthiness Directive so that the design of the A-320 aircraft includes a warning system to allow the crew to identify an incorrect setting of the thrust levers and take the necessary corrective actions to maintain the safety of the operation. (A) 172 / A / 07
• that ANAC should establish certification criteria under RBHA 25 to require that aircraft designs already certified and aircraft designs in the process of certification have their power control systems and their warning systems optimised, so as to allow the identification of thrust levers which are incorrectly positioned during critical phases of flight. (A) 173 / A / 07
• that ANAC should monitor and evaluate, in coordination with EASA, the proposal to modify the actuation logic of systems responsible for the deceleration of A-320 aircraft, in terms of safety requirements and time for its implementation, so that it considers the clear intention of the crew to make a landing and guarantees the effectiveness of the deceleration, even if the thrust levers are incorrectly positioned. (A) 175 / A / 07
• that ANAC should evaluate, for aircraft certified under the RBHA 25, the advantages and disadvantages of selecting thrust reversers before verifying the deployment of ground spoilers and study the need to establish the best procedure from the perspective of flight safety. (A) 177 / A / 07
• that Airbus France should establish a procedure for the A-320 aircraft model, regarding the landing phase, defining a corrective action to be taken by the crew when the ground spoilers do not deflect after the touchdown. (A) 168 / A / 07
• that Airbus France should optimize the RETARD auto call-out system of the A-320 aircraft, so that it executes only the function to which it was designed, that is, advise the crew to set the thrust levers in the “IDLE” position. (A) 170 / A / 07
• that Airbus France should enhance the logic of functioning of the systems responsible for the deceleration of the A-320 aircraft, so that it considers the clear intention of the crew to land and ensures the effectiveness of the deceleration, even if there is an incorrect positioning of the thrust levers. (A) 174 / A / 07
• that Airbus France should evaluate the advantages and disadvantages of utilising the thrust reverser before verifying the deflection of the ground spoilers in the A-320 aircraft, and to establish a more proper procedure from the perspective of flight safety. (A) 176 / A / 07

Issued on 18 April 2008:

• that ANAC should ensure the real effectiveness of theoretical training, considering the feasibility of the adoption of training systems that utilise computers as a basic tool for learning (CBT) and the need to establish mechanisms for a better monitoring and evaluation of the teaching method applied during this phase. (A) 10 / A / 07
• that ANAC should re-evaluate the requirements established for the professional development and knowledge-updating for technical crew members in the aviation industry under RBHA 121, notably in relation to the syllabus and training hours, aiming at adjusting them to the real needs observed at the operators. (B) 11 / A / 07
• that TAM Airlines should carry out an internal audit of all the operation, training and maintenance processes conducted within the company, aiming at the gathering of non-conformities in relation to the regulation in force, as well as measuring the effectiveness of those processes. (B) 12 / A / 08
• that TAM Airlines should re-evaluate the Training Program, aiming at adjusting it to the real needs of the operation and considering the need for a better monitoring of the crew technical-operational conditions, the adequacy of the contact hours currently adopted and the efficacy of the methodology applied to theoretical training. (B) 13 / A / 08
• that TAM Airlines should refine the processes of performance monitoring of crews during their operational life in the company from the very beginning of the training, so as to allow for the timely correction of operational deviations. (B) 14 / A / 08
• that TAM Airlines should establish distinct training processes for the professional formation and updating of pilots, based on the crew performance monitoring mentioned in the Safety Recommendation (A) 14 / A / 08. (B) 15 / A / 08
• that TAM Airlines should unify the management of the practical and theoretical training of the crews, with the purpose of obtaining a better control of the quality of the professional formation and knowledge updating. (B) 16 / A / 08
• that TAM Airlines should establish mechanisms to ensure the standardisation of Flight Instructors, in order to improve the training, improve adherence to the prescribed operational procedures and provide familiarisation and experience to instructors on operating in the right-hand seat of the airplane. (B) 17 / A / 08
• that TAM Airlines should create incentive mechanisms to motivate flight instructors, besides acknowledging the importance of their role. (B) 18 / A / 08
• that TAM Airlines should establish criteria so that occupation of the right-hand seat of the aircraft flight deck is limited to Co-pilots, Instructors or Captains undertaking instructor training courses. (B) 19 / A / 08
• that TAM Airlines should re-structure CRM training, with the purpose of increasing the perception of the organisational culture influence on crewmember performance, while making it a permanently favourable element for the safety of operations. (B) 20 / A / 08
• that TAM Airlines should establish systematised processes for the oversight of training, technical-operational and maintenance activities, throughout the various management levels, seeking to obtain a coordinated action from the various sectors of the company for the benefit of the safety in the operations. (B) 21 / A / 08
• that TAM Airlines should re-structure the prevention activities conducted by the Safety sector, considering the possibility of having SIPAER accredited elements in the other sectors of the company, so as to increase the capillarity of the Safety Sector, consequently improving the safety mentality in the company, and increasing the effectiveness of prevention. (B) 22 / A / 08
• that TAM Airlines should create programs for the dissemination of the lessons learned about operational safety investigations (from accidents, high risk incidents, prevention reports, etc.) which adopt practices not restricted to the utilisation of electronic mail, favouring the personal involvement of the flight safety sector workers, along with the other employees. (B) 23 / A / 08
• that TAM Airlines should establish systematised processes to allow the company Safety Function to adequately manage the risks associated with operational activities, including the impacts the ICAO regarding the SMS (Safety Management System). (B) 24 / A / 08
• that TAM Airlines should refine the criteria and practices concerning the announcement of changes in operational procedures, aiming at guaranteeing the updating of all the crews, encouraging their commitment, and allowing for a better interaction between the crews and the operations sector. (B) 25 / A / 08
• that TAM Airlines should re-affirm, before the crewmembers, the policy of the company relative to the adoption of the go-around manoeuvre as a preventative tool, so as to make it clearer and explicit, thus preventing possible deviations which compromise the operational safety. (B) 26 / A / 08
• that Airbus France should evaluate the need to restructure the sequence of the texts contained in the manuals of the A-320 aircraft, so as to facilitate and expedite their handling, especially during a flight. (B) 27 / C / 08
• that CENIPA should refine the monitoring mechanisms, favouring a more proactive identification of hazards and management of risks associated with aspects of the operation of the companies regulated by RBHA 121. (B) 28 / C / 08

Issued on 2 June 2008:

• that ANAC should study the need for a contingency plan for the monitoring of the technical operational and maintenance routine at TAM Airlines so as to ensure that the practices adopted by the Company guarantee the operation with safety and meet all the requirements established in the legislation in force. (A) 95 / A / 08

Issued on 27 October 2009:

• that ANAC should refine inspection processes so as to ensure that Operators fully report cases of recurrent failures and of failures, malfunctioning and defects, in accordance with RBHA 21. (A) 176 / 09
• that ANAC should revise the acceptance process contained in the TAM Airlines’ General Maintenance Manual, to take account of the impact that the grouping of failures monitored by the quality system for correction during the execution of more comprehensive checks may have on flight safety. (A) 177 / 09
• that ANAC should refine the inspecting mechanisms so as to ensure that Operators ensure traceability of events by means of proper recording and backup mechanisms. (A) 178 / 09
• that ANAC should implement inspecting actions regarding the start and/or completion of the processes of certification of all airports where certification is mandatory in accordance with the regulations in force. (A) 179 / 09
• that ANAC should evaluate the creation of Runway End Safety Areas (RESA) as prescribed in the RBAC 154/2009 at aerodromes included in the criteria established by RBAC 139 and inform the ICAO about contingent differences in Brazil relative to the Standards and Recommended Practices of Annex 14 to the Convention on International Civil Aviation. (A) 180 / 09
• that ANAC should revise the content of IAC 2328-0790 in order to include in the pertinent regulation a requirement for the obtaining of prior approval from ANAC regarding any project that results in alteration of the runway pavement (no matter what the objective is - renovation, repairing, resurfacing, etc.) which may lead to changes in the coefficient of friction, the macrotexture or any other characteristic capable of affecting the performance of the aircraft during landing and takeoff operations. (A) 181 / 09
• that ANAC should, in coordination with the Airspace Control Department and observing ICAO Standards And Recommended Practices, revise the regulation in force which establishes procedures, assignments and responsibilities relative to the suspension and re-establishment of landing and takeoff operations at airports on account of temporary unavailability or changes to the physical and/or operational characteristics of the runways. (A) 182 / 09
• that ANAC should refine the regulatory processes to allow for the immediate adoption of preventative measures for well known situations, so that the slowness of such processes does not diminish their prevention efficiency. (A) 183 / 09
• that ANAC should promote a widespread dissemination of this Report, mainly to its internal public, as well as to the airline companies subject to RBHA 121 and to airport administrations. (A) 184 / 09
• that INFRAERO should adopt appropriate provisions in order to allow the start of the certification processes of airports under its administration that are not still certified and whose certification is mandatory in accordance with the regulations in force. (A) 185 / 09
• that INFRAERO should emphasise the need for coordination between the public security / civil defence agencies and the COMAER organisations in Complete Aeronautical Emergency Exercises (EXEAC) so as to ensure that the SIPAER investigators can work at the accident site at the earliest possible time without compromising safety. (A) 186 / 09
• that INFRAERO should refine the educational activities prescribed in the Enterprise’s Aeronautical Accidents Prevention Program, so as to guarantee the understanding by personnel of the purpose and ways to use each of the SIPAER voluntary reporting tools, stressing the responsibilities of the Enterprise’s SIPAER-Link relatively to the treatment of the information received. (A) 187 / 09
• that INFRAERO should refine the supervision processes relative to the execution of works in the movement area of the airports under its administration, or in other areas that may impact on the airport operations, so as to ensure compliance with all the requirements of the respective approved project. (A) 188 / 09
• that INFRAERO should submit for the prior approval by ANAC any project which may involve alteration to or renovation of the landing and takeoff runway pavement (independently of the nature of such work such as renovation, repair, resurfacing etc.) and that may lead to changes in the coefficient of friction, macrotexture or any other characteristic capable of affecting the performance of aircraft when landing or taking off. (A) 189 / 09
• that TAM Airlines should revise the control processes of the maintenance records with the objective of ensuring the necessary traceability of the events. (A) 190 / 09
• that TAM Airlines should revise the control processes of the maintenance records with the objective of ensuring the adequate management of the risk associated with the combinations of grouped failures to be monitored by the quality system, in the cases mentioned in the item 4.3.1 of the MGM. (A) 191 / 09
• that TAM Airlines should revise the procedures and controls established for the records entered in Aircraft Technical Records sheets, with the objective of preventing misinterpretation and/or misunderstanding resulting from illegibility, erasures, lack of standardisation in the language used and lack of data. (A) 192 / 09
• that TAM Airlines should establish mechanisms to ensure the effective communication of failures, malfunctioning and defects to the ANAC, as prescribed in the RBHA 121. (A) 193 / 09
• that TAM Airlines should refine the voluntary reporting tool through the company’s corporate computer net, so that the identification of the report writer be no longer obligatory, thus preventing the inhibition of the participation of the employees in the processes of accident prevention. (A) 194 / 09
• that TAM Airlines should refine the educational activities prescribed in the company’s Aeronautical Accidents Prevention Program, so as to guarantee the understanding by the personnel of the purpose and ways of utilisation of each one of the SIPAER voluntary reporting tools, stressing the responsibilities of the Enterprise’s SIPAER-Link relatively to the treatment of the information received. (A) 195 / 09
• that TAM Airlines should reiterate, before the pilots, the importance of the compliance with the prescribed phraseology for the communications with air traffic control units, mainly in what refers to the provision of accurate information on the number of persons on board, endurance and alternate aerodrome. (A) 196 / 09
• that TAM Airlines should reiterate the importance of the utilisation of flight data monitoring for the detection and treatment of deviation from the standards, ensuring the implementation of the necessary preventative actions (such as, additional training, revision of procedures, etc.), as well as the provision of appropriate feedback to the crews. (A) 197 / 09
• that the International Civil Aviation Organisation should study the possibility of issuing a specific guidance as for the comprehensiveness of the applicability of the ICAO Annex 8 Standards And Recommended Practices referring to Human Factors in the context of design certification and continuing airworthiness. (A) 198 / 09

The Final Report was approved on 27 October 2009 and published initially in the Portuguese language and then subsequently in English translation (to which the above link provides direct access).

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