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Congonhas Airport Aeronautical Accident Report


Despite technological advancements, aviation accidents still occur, threatening the air transport sector. To reduce their number, it is vital to investigate past incidences and acquire critical insights to promote the future enhancement and effective risk management. The provided report focuses on the analysis of TAM Airlines Flight 3054 to outline the central issues preconditioning the collapse and avoid them in the future. Thus, Airbus A320 aircraft (registration PR-MBK) operated by TAM Airlines as flight JJ3054 did a runway excursion during landing in Brazil’s Congonhas Airport in São Paulo at 18:54 local time (21:54 UTC) on July 17, 2007 (TAM airlines, 2017). It swerved leftwards near the departure end, where it collided with a warehouse and a petrol station, bursting into flames and killing 187 passengers and crew members and 12 people on the ground (First lawsuit in Brazil plane crash filed in U.S., 2007). The results of the investigation show that mishap was preconditioned by a combination of human and material factors and unfavorable operational conditions that included maneuvering in a tight space and landing on a wet and slippery runway.

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Analysis of the Airport Safety Condition at the Time of the Accident

The analysis of TAM Airlines Flight 3054 involved experts from various states and international agencies and resulted in the formulation of some theories about the major causes of the crash. Most investigators agree that several human and material factors should be viewed as the leading causes of the catastrophe (Brazil trial over plane crash that killed 199, 2013). The identified human factors are training, cockpit coordination, pilot forgetfulness, flight indiscipline, environmental influences, pilotage judgment, management planning concerns, flight planning problems, pilot experience, anxiety, management oversights, perception error, stress, and loss of situational awareness (Phillips, 2007). The main material factor is the Airbus A320 plane’s design, which allows landing to occur even when one throttle lever is at the reverse (REV) position, and the other is at climb (CL) (Phillips, 2007). That is why the following debates and studies focused on these aspects.

The flight was also followed by precipitation, meaning that the weather conditions were difficult and could be viewed as one of the possible factors preconditioning the crash. The aircraft had set on Congonhas Airport twice before the calamity; at 11:11 and 14:32 local time (17 July 2007 – TAM 3054, no date). On the first occasion, the recorded volume of precipitation was 1.5 millimeters per hour, while no rainfall was recorded in the second instance (TAM airlines, 2017). When the disaster occurred during the third landing, the recorded precipitation was 0.6 millimeters per hour (TAM airlines, 2017). Congonhas Tower and São Paulo Approach controllers informed the crew that the main runway was wet and slippery (Galagedera, Pasindu, and Adikariwattage, 2020). The airport’s automatic terminal information service (ATIS) also conveyed the same information, but officials had not conducted a formal inspection of the pavement.

The absence of a runway end safety area (RESA) and poor management of the essential zones may have also contributed to the fatal crash. An airport inspection at the beginning of 2005 had noted the missing RESA as nonconformity to standards (Aviation safety network, 2007). The airport authority – Brazilian Airports Infrastructure Enterprise (INFRAERO) – responded by promising to conduct a detailed aeronautical study in the future (CENIPA, 2009). INFRAERO had until August 30, 2006, to correct the anomaly, but it was yet to do so when the disaster occurred in 2007 (Phillips, 2007). However, following continuous pilot grievances, INFRAERO had provided a tentative solution to another runway problem in the years leading up to the collision.

The problem pertained to pilot complaints about the difficulty of operating in rainy conditions. Specifically, pilots reported an elevated risk of aquaplaning even in light precipitation. The given phenomenon occurs when moisture enters the space between the pavement and the rotating areophane tire, causing water pressure and expanding the wheel’s area not contacting the ground (CENIPA, 2009). It means that water reduces friction on the runway and complicates the plane’s maneuverability during takeoff and landing (CENIPA, 2009). At the critical aquaplaning speed, the tire has no friction with the pavement; it is supported solely by the water molecules. The solution to this dangerous situation involves using high micro- or macro-textured surfaces as pavement (CENIPA, 2009). Surfaces with low micro- and macro-textural properties are avoided because they are slippery when such complex conditions are observed (CENIPA, 2009). Long distances are also necessary to stop an aircraft on a slippery runway, but this does not eradicate the risk of losing directional control.

At the same time, there is another approach to managing this issue. The cutting or development of grooves on a runway is a proven and effective method of preventing and eliminating aquaplaning and skidding in wet conditions (CENIPA, 2009). Grooving facilitates drainage, stopping the development of a water film on the pavement. In most cases, these grooves are transversal and measure about six millimeters in depth and width. In November 2005, INFRAERO replaced the grooving-treated pavement of the main runway with a rugged one to reestablishing desired friction levels in the most critical segments (Routes – changes to the operation at Congonhas Airport, 2020). The reasons for this procedure included numerous pilots’ complaints and the approaching of the rainy season (Dias, 2020). The temporary solution would remain until the implementation of a more definitive answer. Indeed, INFRAERO planned to recover the entire runway and correct the longitudinal and transversal declivities. Notably, the provisional emergency response was conventional and INFRAERO’s most technically and operationally viable option.

Apart from the aerodrome conditions, mechanical issues with the Airbus aircraft may have also influenced the occurrence of the crash. Investigations show that the plane’s power control system (PCS) ignored other operational inputs and focused on the positioning of one of the levers at CL (Brazil plane ‘flew with mechanical fault, 2007). PCS’s prioritization of CL positioning should not have happened because the aircraft had touched the ground, had its spoilers armed, and put the number one engine thrust lever at the REV position (Brazil plane ‘flew with mechanical fault, 2007). It also had auto braking armed, and the pilot had applied maximum braking pressure to the pedals. Still, the system interpreted CL positioning of one of the levers as the pilot’s desire to continue flying, not to land. Notably, the lever at the CL position lacked a safety mechanism to block an unintentional wrong positioning (Brazil plane ‘flew with mechanical fault, 2007). With the feedback that a thrust levers’ positioning was at CL, the plane neither actuated autobraking nor deployed the ground spoilers. Additionally, that response about CL positioning compromised the braking process, preventing the aircraft from decelerating (CENIPA, 2009). In such a way, there is a combination of weather conditions, human factors, and some technical issues that can be viewed as the major causes of the crash and people’s deaths.

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Assessment of the Current Condition

Today, Congonhas International Airport is still open and functions. In 2019, before the COVID-19 pandemic struck, it was the second busiest airport in Brazil (Dias, 2020). After the 2007 accident, INFRAERO introduced several changes to eradicate operational challenges. The improvements included new operational restrictions and the paving of the main runway (Carvalho, Slama and Nassi, 2014). The airport operates day and night and has aids on both the primary runway thresholds (Carvalho, Slama and Nassi, 2014). It also has approach lights, very high frequency (VHF) omnidirectional range/distance measuring equipment (VOR/DME), non-directional beacon (NDB), visual approach slope indicator (VASIS), and night signaling (São Paulo Congonhas Airport to commence resurfacing its runway, 2020). It has two asphalt takeoff and landing runways, with the main one measuring 1945 by 45 meters and the auxiliary one 1435 by 45 meters (São Paulo Congonhas Airport to commence resurfacing its runway, 2020). International and domestic flights for goods and passengers use the runways.

In 2020, INFRAERO commenced and completed the renovation works at the airport. The 32-day construction delivered a better drainage capacity and more excellent grip to the pavement (Brazil to tender repaving works at Congonhas airport, 2020). The renovation works were part of the government’s plan to fuel economic development to mitigate COVID-19 effects (Infraero releases flights in Congonhas airport, 2020). The selected contractor milled the old asphalt lining, executed a structural asphalt layer with headland grooving, applied a porous friction surface layer, and added horizontal signage (Routes – changes to the operation at Congonhas Airport, 2020). These renovation works were necessary to improve the runway and increase the airport’s safety.

Other than the physical renovations, Congonhas also imposed several restrictions on the use of the facility. One of them is the prohibition of the landing operation, depending on the airplane’s conditions (Pacheco, Camargo and Halawi, 2020). In Brazil, the Regulamento Brasileiro Da Aviação Civil (RBAC) 121 regulates the flight dispatch process. Part of it states that the airplane shall land at the destination airport using 60 percent of the runway’s length (Pacheco, Camargo and Halawi, 2020). It also specifies that no dispatch shall occur if the destination runway is wet and slippery when the plane arrives unless the runway’s length is 115% of the actual landing distance or longer (Pacheco, Camargo and Halawi, 2020). INFRAERO reduced the runway at the airport to accommodate a 280 meters RESA (Pacheco, Camargo and Halawi, 2020). INFRAERO decided to cut the runway distance rather than increase it because there was no room for expansions; buildings surround the airport. The reduction of the runway distance to accommodate RESA followed RBAC 154.

INFRAERO also introduced and implemented changes touching on in-flight landing distance (IFLD) and electronic flight bag (EFB) following the accident. The new regulation requires pilots to calculate the IFLD once they are airborne (CENIPA, 2009). In other words, the pilot has to disregard the landing distances that were verified while dispatching the plane. The assessment of the IFLD considers factors that may affect the landing distance, including the runway conditions, aircraft status, and performance degradation due to in-flight failures (CENIPA, 2009). The EFB in-flight landing distance comprehensively analyses the prevailing conditions to determine the landing distance performance. The EFB calculations add a seven-second flare, which gives a protection layer to make differences if a need to do so arises.

In such a way, Congonhas Airport can handle regular domestic flights, international air transport, and general aeronautical services. Moreover, some improvements were made to enhance safety and risk management to avoid new accidents. However, it remains surrounded by tall buildings and residential apartments, and locals have demanded the facility’s closure, citing intolerable noise and potential aviation incidents. People fear that continuous exposure to these hazards might negatively impact their health and well-being. The local concerns are legitimate because pilots have to conduct departures and approaches over residential buildings. However, Congonhas’ services’ demand remains high due to its proximity to the central business district. Indeed, the airport installed a slots system to manage fights, with 30 openings available per hour.

Proposal for Improvement

Based on the previous research of the aspects preconditioning the crash and on the current state of Congonhas Airport, one of the proposals for improvements is that INFRAERO should buy more land. Owning additional land in the vicinity will allow the airport to expand the runway and create a longer RESA. At the moment, with no expansion space, some properties may be dangerously close to the facility and must be demolished. To improve aviation safety and protect aircraft and passengers, INFRAERO should buy the surrounding property, especially the one close to the runway, even though the cost of acquiring it may be high. After the purchase, INFRAERO should reinstate the runway’s former length while utilizing the newly acquired property as space for creating RESA. Buying neighboring plots is an effective way of removing any nearby hazards, including business buildings and apartments close to the airport.

Congonhas Airport should also ensure that the runway is in excellent condition by regularly monitoring its mechanical design. Although the airport did a repaving of the runway between August and September 2020, it should continue monitoring its state to ensure peak operation and minimize risks associated with this factor (Infraero releases flights in Congonhas airport, 2020). Notably, although friction for new surfaces is often high, the air traffic can polish its grains, leading to a gradual and steady loss of the pavement’s textural properties that facilitate resistance (CENIPA, 2009). When the planes polish the pavement, they smoothen the grains, rendering them ineffective in delivering desired traction levels, especially during rainy seasons (CENIPA, 2009). Constant monitoring of the runway will help the airport’s administration to avoid these problems. Ongoing maintenance work at the facility will ensure that the property always remains reliable. It will also help professionals to identify potential hazards or factors that may affect the facility’s effectiveness.

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Since handling large jets using the facility may present unique challenges, Congonhas Airport must have provisions that let it evaluate these aircraft’s performance, especially in wet conditions. The July 17, 2007 accident involved a relatively large plane that performed a runway excursion because its size required a longer runway to stop. The provisions should specify that aircrafts weighing 60,000 pounds and more should only land at the facility after demonstrating simple operations with special landing techniques, especially on wet and slippery runways. The airport must also regularly examine its infrastructure to ensure that landing and takeoff operations occur safely. Such provisions are essential, mostly because of the facility’s location at the center of São Paulo. Large planes using the airport must demonstrate the ability to make safe maneuvers in tight spaces without accidents or incidents.

Lastly, the airport authority must consult with other air transportation business stakeholders and agencies to ensure that only safe and mechanically sound airplanes are operated. An airplane’s airworthiness must be considered when developing new standards, especially those touching on the plane’s maintenance (CENIPA, 2009). For instance, an aircraft should undergo more intense tests and checks before and after every flight. These maintenance operations might identify and rectify potential problems, averting calamities. Speaking about TAM Airlines Flight 3054 accident, the in-depth investigation of the plane, and improved maintenance operations could have helped to identify the problem and report it, avoiding the crash. Officials should also extend the checks to pilots to ensure that they are healthy and capable of conducting a flight. Congonhas Airport must have a room for examining pilots before dispatching planes.

The effectiveness of the given solution can be evaluated by using the following benchmarks:

  1. The airport has a longer RESA because of newly available lands.
  2. The state of runways is monitored regularly, and issues are reported.
  3. The aircraft performance is evaluated constantly.
  4. All stakeholders are tested and examine whether they are ready to perform a flight.

Following these measures, it is possible to determine whether the proposed solution is working and the risk of new accidents is minimized due to the application of lessons learned from the TAM Airlines Flight 3054 disaster.


Today, the increased number of people involved in aviation industry demands practical safety measures to avoid accidents and crashes. Continuous improvement of the approach to planning and executing flight operations is the key to maintaining effective and reliable facilities. The experience associated with TAM Airlines Flight 3054 accident shows a need to consider human factors, aircraft states, and weather conditions to protect all individuals and avoid victims. The airports should have effective RESA management, improved and in-depth checks of aircraft, and constant monitoring of the crew’s preparedness levels to operate effectively and safely. The work of civil aviation demands the collaboration of all stakeholders to avoid new accidents and mitigate existing risks.

Reference List

Aeronautical Accidents Investigation and Prevention Center (CENIPA) (2009) Final report. A – Nº 67/CENIPA/2009. Web.

17 July 2007 – TAM 3054 (no date) Web.

Phillips, T. (2007) ‘200 feared dead after plane crashes at São Paulo, The Guardian, July. Web.

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Aviation safety network (2007) Web.

Brazil plane ‘flew with mechanical fault’ (2007) Web.

Brazil to tender repaving works at Congonhas airport (2020) Web.

Brazil trial over plane crash that killed 199 (2013) Web.

Carvalho, D., Slama, J. and Nassi, D. (2014) ‘A complementary metric to define a buffer zone in Brazilian airports’, Journal of Transport Literature, 8(4), pp. 316-328. Web.

Dias, M. (2020) ‘Air transportation in Brazil: São Paulo Congonhas Airport’, Global Scientific Journal, 8(2), pp. 3244-3252. Web.

First lawsuit in Brazil plane crash filed in U.S. (2007) Web.

Galagedera, B., Pasindu, R. and Adikariwattage, V. (2020) ‘Evaluation of operational risk factors at runway high speed exits’, Transportation Research Procedia, 48(6), pp. 32-46. Web.

Infraero releases flights in Congonhas airport (2020) Web.

Pacheco, G., Camargo, M. and Halawi, L. (2020) ‘An evaluation of the operational restrictions imposed to Congonhas Airport by Civil Aviation Instruction 121-1013’, International Journal of Aviation, Aeronautics, and Aerospace, 7(2), pp. 1-11. Web.

Routes – changes to the operation at Congonhas Airport (CGH), São Paulo (2020) Web.

São Paulo Congonhas Airport to commence resurfacing its runway (2020) Web.

TAM airlines – Airbus A320 (PR-MBK) flight JJ3054 (2017) Web.

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