On October 31st, the 26th anniversary of the TAM Fokker 100 accident shortly after taking off from Congonhas Airport in Sao Paulo. The accident had an impact on several parts, agencies and companies, from 1996 to the present day many things have been improved, in this article you will this tragic accident and also learn about the changes.
The aircraft and the accident
On a routine sunny morning and good weather for flying, TAM, considered at the time the best regional airline in the world, flew from Congonhas to Santos Dumont in Rio, the famous air bridge. On the morning of October 31, 1996, the person scheduled to fly Flight 402 was Fokker 100 registration PT-MRK.
The PT-MRK was a new aircraft, received by TAM in 1993 directly from the Fokker factory in Holland. Powered by two Rolls-Royce Tay engines, the aircraft was configured to carry up to 100 engers in a single class. The aircraft stood out from the rest due to its painting, nicknamed 'Number 1' in allusion to the award received by the company the previous year.
In command of the aircraft were the experienced 35-year-old Commander José Antônio Moreno and 27-year-old First Officer Ricardo Luís Gomes Martins. As it was a Thursday and early in the morning, the flight had 90 engers on board and most of them were executives at work, mainly people connected to large financial institutions.
Everything ready for departure and the PT-MRK proceeded to Congonhas Airport's runway 17R around 08:25 in the morning. At 08:26, the TAM 402 receives authorization to take off and in a few seconds, the pilots start the movement to take off. Check out the transcript of the conversation between the pilots:
08: 26: 02 - 1st Officer: At 02 starting.
08: 26: 03 - Commander: TOGA. (The expression means the combination of 'Take-off' and 'Go-Around')
08: 26: 04 - 1st Officer: Take-off, take-off green. (A 'beep' is heard in the cabin)
08: 26: 06 - Commander: Ai.. ai.. what is it?
08:26:08 – 1st Officer: This is manual.
08:26:10 – Captain: The auto-throttle.. it's out, okay. (A double 'beep' is heard in the cabin)
08:26:15 – Commander: The auto-throttle is out. (The 1st Officer adjusts the thrust levers and advises the Captain)
08:26:19 – 1st Officer: Thrust Check. (The Fokker 100 exceeds 80 knots of speed)
08:26:32 – 1st Officer: V-one
The PT-MRK reaches a speed of 131 knots and takes off about two seconds later at an angle of attack of 10º. At the same moment an 'impact' is felt and there is a loss of power in engine number 2. As soon as the aircraft left the ground, the shells of reverse number 2 were activated momentarily.
In the cockpit, no alarm was triggered during the reverse operation, but the thrust lever of engine two was immediately moved back to the idle position and this caused the shells to open in mid-flight. This was one of the safety systems on the F100 that prevented the reverses from being engaged during engine acceleration.
The pilots interpreted the engine failure linked to the failure of the auto-throttle, and immediately the reverse closed again allowing the power lever to be placed forward, accelerating engine 2 again. However, the reverse opens twice more and soon after, the system locks the engine 2 handle again at idle.
The PT-MRK was still at low speed at a low altitude, the aircraft with the difference in power began to turn to the right. Commander Moreno immediately tried to stabilize the aircraft, at the same time the 1st Officer again put the lever of engine 2 forward, but now the two levers returned to idle causing a great loss of power.
Still without any warning due to the reverse being activated, they insistently try to put the levers at full power and also try to turn off the auto-throttle. With the reduction in power, the aircraft has a speed of 126 knots in flight. Already in despair, the pilots continue trying at all costs to regain control of the aircraft.
Once again the levers are pushed forward, but the steel cabling that prevented the reverse from opening failed, and allowed the reverse to stay engaged even with the engine accelerating. A few seconds later, a strong vibration was felt, indicating that the aircraft was going to stall.
With engine number 1 at almost full power and engine 2 unable to apply power, the Fokker 100 leans to the right and begins to lose lift. In the last moments of the recording, it is still possible to hear the alarm of the aircraft's proximity to the ground and the last words of the Captain.
The PT-MRK hits a two-story building with its wing, then the roofs of other houses before hitting Rua Luís Orsini de Castro in the Jabaquara neighborhood, killing all occupants on board and a few more people on the ground.
Final report: Contributing factors and recommendations
The CENIPA report indicated that the psychological aspect (Human Factor) of the pilots cooperated for the accident, with the lack of written and practical instructions contributing to the non-recognition of the abnormal situation during the flight.
The individual aspect of the pilots in handling the entire situation on board also contributed to the accident. With the lack of sound and visual warnings of the facts, the lack of adequate training for this type of situation provoked a reaction of 'surprise' and diversion of attention on the part of the pilots.
The material factor, which involves the manufacture of the aircraft and its components, also contributed to the accident. The flawed design of the Fokker 100 aircraft, flaws in the safety systems and in the management of the throttles and reversers seriously failed. Some operational factors were evaluated as indeterminant.
Other aspects such as 'External Inspection' of the aircraft before departure, 'Taking Action Below 400 Ft' and 'Inappropriate Actions' in view of the failures presented by the aircraft, were factors considered to have contributed to the accident.
The report indicated recommendations to the Primary Approval Bodies, the IFI/CTA Approval Division, Fokker, CENIPA and CECOMSAER, FAA, DOWTY AEROSPACE HYDRAULICS, TAM Linhas Aéreas and DAC (Former ANAC).
You can check all the contributing factors and the conclusion in CENIPA's final report by clicking here.
Since the Fokker accident, several measures have been taken to improve air safety in Brazil, especially TAM, which changed its procedures regarding training and procedures carried out in the overhaul and maintenance of its aircraft.
TAM changed the aircraft's logbook in order to improve all the records of failures and breakdowns of the aircraft, making it possible to leave a copy of each record at the Airport of origin of the aircraft.
The company was recommended to start an intense program of training and verification of abnormal situations in flight with the Fokker in conjunction with the aircraft manufacturer. Specifically, TAM was also recommended to deepen the training in the flight simulators regarding the opening of the reverses in all phases of the flight.
Improve theoretical training and training in flight simulators on situations involving thrust levers and not making decisions below 400 feet of altitude, in addition to deepening and also improving CRM – Crew Resource Management recommendations and training.
Congonhas Airport
Considered one of the most risky airports due to its proximity to houses and buildings, the terminal located right in the center of São Paulo was the protagonist of another major air accident in Brazil. In 2007, TAM Flight 3054 failed to brake on runway 35L in Congonhas, crossed the runway and collided with the company's own building.
At the time of the accident with the Fokker 100 on flight 402, Congonhas Airport had an intense movement of aircraft, as the highest concentration of domestic flights, mainly connections, were through the most centralized terminal in São Paulo.
The Discovery Channel made a documentary a few years ago about the accident.
