Through the rain, a passenger jet’s landing lights pierce the night sky. In the cockpit, one vital system is intentionally disabled – it’s permissible, yet a silent subtraction from their margin of safety.

The seasoned pilots prepare, aware of the challenge, but unaware of the precise danger lurking below them on the short asphalt runway that glistens in the rain. Touchdown.

But the aircraft doesn’t slow down as expected. Instead, the runway end rushes horrifyingly closer and closer.

Why isn’t it stopping?

This is the story of TAM Flight 3054.

Brazil, July 17, 2007. The flight was a scheduled trip from Porto Alegre (SBPA) to Congonhas Airport (SBSP) in São Paulo, a route that usually takes a little over 90 minutes.

For important context, back in 2007 when this flight took place, Brazil was going through somewhat of an aviation crisis. Rapid market growth following the decline of flag carrier Varig had severely strained the country’s aviation infrastructure, including airports and air traffic control. These events led to a stressful environment for many aviation professionals.

Also, TAM itself was undergoing significant expansion. While it did technically meet regulatory minimums, CENIPA (the Aeronautical Accident Investigation and Prevention Center) noted that TAM’s A320 training program involved fewer hours in ground school, cockpit procedures trainers, and full flight simulators compared to Airbus’s recommendations. This led some to believe that TAM’s rapid expansion had potential impacts on safety margins.

The flight deck of an Airbus A320, bathed in the dim glow of instruments, was commanded by an experienced Captain. He had logged over 13,500 flight hours, with over 2,200 hours on the A320 family. The captain’s peers viewed him as calm, studious, and competent, though his flight performance was considered average, which he offset with diligent study and strict adherence to procedures. While an experienced pilot at a professional peak, he showed limited adaptability and some delayed responses in emergencies during training sessions on the simulator.

To his right sat the co-pilot serving as Acting First Officer. He joined the airline six months prior and was also qualified as a captain. He was adapting to the aircraft’s autothrust system, a change from his prior autothrottle experience.

The main difference between the two different systems is that Autothrottle (typically used by Boeing) physically moves the thrust levers to control speed, whereas Airbus’s autothrust manages engine power with the levers often remaining in a fixed detent. The Acting First Officer reportedly had resumed piloting in the previous year, 2006, after a four-year break. With total flight hours of just shy of 15,000, he had accumulated just 237 hours on the A320.

It might seem unusual that two captains were flying together, but this can sometimes occur due to scheduling requirements or other operational reasons. Two captains can present unique Crew Resource Management, or CRM, challenges. The authority gradient between two captains might be less clear than let’s say between a captain and a first officer.

This could potentially affect communication and decision-making, particularly given the Acting First Officer’s limited experience on the A320 and potential unfamiliarity with First Officer duties after being used to flying as Captain in command. While both crew members were considered proficient and had completed their required training, the context of their pairing together added another layer of complexity to the flight.

The aircraft, an Airbus A320, a hugely popular, technologically advanced twin-jet airliner, was maintained according to requirements. However, on this particular flight, it operated with the thrust reverser on the number two engine deactivated due to a hydraulic leak. This condition was permitted by the Minimum Equipment List.

Think of the Minimum Equipment List as a carefully considered, officially sanctioned list that allows an aircraft to fly even if certain non-critical components aren’t working, but only for a limited time and often with specific operational precautions. While flying without one of its two thrust reversers was technically allowable, it meant the aircraft had one less tool in its arsenal for slowing down after landing – and this is worth keeping in mind!

The thrust reverser had been inoperative for the past four days, and the aircraft had completed several flights in this configuration without any recorded issues.

When an Airbus with IAE V2500 engines lands and needs to slow down quickly, the pilot activates the thrust reversers. Think of it like this: panels on the sides of the engines slide open, uncovering special vents. Instead of the engine fans pushing air backward to move the plane forward, these vents redirect that air forward.

This creates a powerful blast that acts like a brake, significantly reducing the aircraft’s speed on the runway. While legally permissible, the absence of one reverser reduced the aircraft’s stopping capability, a critical factor on wet runways.

On board were 181 passengers and 6 crew members, including the two pilots, bringing the total headcount to 187.

At 5:19 pm local time, the aircraft had a normal take off from Porto Alegre and as it climbed, it set course for São Paulo.

As they climb to cruise altitude of flight level 210 or 21,000 feet, let’s take a quick look at their destination. Congonhas Airport was a notorious challenge for flight crew. Imagine a concrete ribbon, otherwise known as Runway 35L, at just 6,381 feet, a mere 1,945 meters, in the very heart of São Paulo’s sprawling urban expanse.

It was a runway demanding precision, a thin margin for error, especially when slick with rain. Despite it being a challenging runway, this particular aircraft, Papa Romeo Mike Bravo Kilo, had already made two successful landings there earlier that day.

Adding to the challenge, the runway had been recently resurfaced, but the crucial grooving, designed to channel water away and improve grip, was missing, a detail that would soon prove critical. And beyond the tarmac, no welcoming expanse of open land offering a safety buffer known as a Runway End Safety Area or RESA. Instead, the dense fabric of the city itself pressed in, a stark reminder of the high stakes of every landing and takeoff.

The regulatory environment surrounding Congonhas wasn’t entirely straightforward. Brazil’s National Civil Aviation Agency (ANAC), was the oversight body. At the time, the airport’s own certification process was apparently still incomplete. Furthermore, the decision to reopen the recently resurfaced main runway without the planned safety grooving had been made without ANAC’s direct involvement.

The flight crew picked up the latest weather. It was inclement. Persistent rain had fallen. The METAR weather report for indicated visibility 6,000 meters (3.7 miles), a ceiling between 800 and 1,600 feet, light rain, and winds from the north at 8 to 12 knots. The runway was undeniably wet.

Meanwhile in the cabin, the passengers, likely unaware of the drama unfolding on the flight deck, were probably beginning to settle in for the landing. Most of them were likely oblivious to the fact that the very runway they were approaching had been the scene of a similar incident just the day before. An ATR 42, also attempting to land in rainy conditions, had hydroplaned, skidded off the runway, and sustained substantial damage. Fortunately, all occupants had escaped unharmed.

Multiple crews landing at Congonhas had reported braking action as poor. The airport operator, INFRAERO, had procedures involving temporary closure and friction measurement using a Mu-Meter during rain. This procedure was followed earlier that day, and based on the measurements, the runway was subsequently reopened for operations, though it remained wet and slippery.

As the aircraft neared São Paulo, the flight crew began their landing preparations. They reviewed the landing data, noting the aircraft’s weight of approximately 63.5 tons. This was below the 64.5-ton maximum for the prevailing conditions. The ATIS, or Automatic Terminal Information Service, reported visibility as more than 10 kilometers and clouds scattered at 1,000 feet and broken at 2,000 feet. This information was valid at 21:00 UTC.

Air traffic control echoed the concern, relaying reports from other aircraft – the runway was slippery. They also learned that Congonhas had been temporarily closed earlier for friction testing, a clear indicator of the challenging conditions, before being reopened some time later.

This combination of factors – a short, ungrooved, wet runway known for rubber accumulation and reduced friction, recently involved in a hydroplaning incident, an aircraft with reduced deceleration capacity, regulatory oversight issues, and the absence of a safety buffer zone – created a high-risk scenario. Just how much margin for error remained?

Standard Operating Procedures for landing with the deactivated number two reverser on a wet, slippery runway were, let’s just say, really critical! The Airbus A320’s automation requires specific pilot actions for landing. The thrust levers, normally in the CL (Climb) detent during autothrottle-managed approach, must both be retarded to the IDLE position at touchdown. This action signals the aircraft’s systems to automatically deploy ground spoilers to increase braking effectiveness and it enables the selection of reverse thrust. The aircraft’s automatic braking can only kick in once the ground spoilers are deployed.

However, with the number two reverser deactivated, the correct procedure was to move both levers to IDLE, THEN select reverse only on the operative number one engine, leaving the number two lever at IDLE. And this procedure is something else worth keeping in mind!

As they descended on the ILS approach to runway 35L, communications were standard. At one stage during the approach, the pilot gave a yawn and complained of a mild headache. As the autopilot guided the A320 on its descent, the Captain, very much aware of their single operative thrust reverser, instructed the First Officer to contact the tower: “Ask him about the rain condition, the runway condition, and if the runway is slippery.”

The First Officer promptly radioed Congonhas Tower: “TAM on final approach, two miles away. Could you confirm conditions?” The tower’s voice came back, “It’s wet, and it is slippery. I will report Three Five Left clear, three zero five four.” Shortly after this exchange, the Captain emphatically acknowledged the challenging conditions with a knowing, “Wet and slippery!” remark.

A few moments later, the tower provided an update on other traffic, stating, “The aircraft is starting the departure.” Subsequently, the tower issued the full landing clearance: “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.” The First Officer then relayed the wind information to the Captain.

Below the cloud base, the runway lights appeared. As the aircraft descended through 20 feet, the “RETARD” auto call-out was announced and the left thrust lever was moved towards IDLE.

At 6:54 pm local time, the wheels touched down on runway 35L, within the designated touchdown zone and the left thrust lever was moved into the REVERSE position. However, the right lever, controlling engine number two with the deactivated reverser, remained in the CLIMB detent. Rain continued to fall on the ungrooved surface, slick with accumulated rubber deposits.

The Acting First Officer uttered, “Spoiler, nothing”, recognising that the spoilers had not automatically deployed upon landing. To their horror, the aircraft was not slowing down. “Decelerate, decelerate!” was urgently called out by the Acting First Officer to which the Captain replied, “it can’t, it can’t”. They applied maximum manual brakes but it was no use. Deceleration was impossible as the aircraft used up more and more of the runway at high speed.

Neither pilot seemed to realise that one lever was still commanding forward thrust to the right engine, while the other lever was in the REV detent, commanding reverse thrust on the left engine. This action caused an asymmetric thrust condition – reverse on the left, forward on the right causing the aircraft to veer off to the left. “Go go go, turn turn turn turn” pleaded the Acting First Officer.

Still traveling at approximately 96 knots (or 110 mph), the aircraft departed the left side of the runway near the end. At 6:54:35 pm, the A320 crashed through the airport perimeter, traversed Washington Luís Avenue, and slammed into a TAM Express cargo building and an adjacent gas station. The crash impact and resulting intense fire sadly claimed the lives of all 187 people on board and 12 individuals on the ground. The total time from touchdown to the crash impact was around 25 seconds.

What caused the spoilers to not automatically deploy? According to the final report, TAM 3054’s crash was primarily caused by incorrect thrust lever positions on landing.

The left lever was moved to REVERSE but the right lever remained in CLIMB throughout the landing roll until impact. The thrust levers in different positions prevented the spoilers and autobrakes from automatically engaging and it maintained forward thrust on the right engine WHILE the left engine was in reverse. The resulting asymmetric thrust and lack of braking assistance, combined with the reduced friction of a wet, ungrooved runway surface slick with rubber deposits, made it impossible for the aircraft to stop within the available runway length or to maintain directional control.

Contributing factors to the accident included training inconsistencies, procedural confusion, airport and regulatory shortcomings and the lack of an adequate runway end safety area (RESA).

The report noted that an optional Airbus modification for the Flight Warning Computer, which included enhanced warnings for thrust lever position during landing, was available but had NOT been incorporated by TAM.

The potential CRM challenge, given that there were two captains on the flight deck, was noted but NOT found to be a major concern compared to the thrust lever error.

Key safety recommendations urged improved pilot training on automation, mandated runway grooving and safety areas, and enhanced aircraft warning systems.

The TAM 3054 crash, Brazil’s deadliest aviation accident, resulted in widespread public outcry and intense scrutiny of the country’s aviation safety infrastructure and regulatory oversight.

The investigation’s recommendations led to significant changes in Brazilian aviation. Calls for operational restrictions at Congonhas and the urgent need for runway grooving were among the key outcomes spurred by the tragedy.

📄 SOURCES
Final report: https://finalreports.net/2007/tam-3054.pdf