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TAM Airlines Flight 3054

From Alfawiki
TAM Airlines
IndustryAirline
Headquarters
São Paulo
,
Brazil
Area served
Domestic Brazil
ProductsPassenger air transport

TAM Airlines Flight 3054 was a domestic passenger service operated by TAM Airlines, flying from Porto Alegre to São Paulo, Brazil. On July 17, 2007, the Airbus A320-233 assigned to this route overran runway 35L at São Paulo amid moderate rainfall and crashed into a nearby TAM Express warehouse adjacent to a gas station. The aircraft exploded upon impact, resulting in the deaths of all 187 passengers and crew aboard, along with 12 individuals on the ground, while 27 others sustained injuries inside the warehouse.

At the time, this incident was the deadliest aviation tragedy in South America and held the record as the most fatal accident involving an Airbus A320 until 2015. It also remained Brazil’s most catastrophic air disaster until 2024.

The investigation was led by the Brazilian Air Force's Aeronautical Accidents Investigation and Prevention Center (CENIPA), which concluded in September 2009 that pilot error during the landing phase was the main contributing factor.

Congonhas runway refurbishment

Both runways at Congonhas Airport (35L/17R and 35R/17L) had a gradient that hindered effective water drainage from the asphalt surface. Additionally, frequent braking had caused significant rubber accumulation, increasing slipperiness. The runway ends lacked safety areas because Avenida Washington Luís and surrounding buildings bordered these zones. On July 24, 2006, a BRA Transportes Aéreos Boeing 737 encountered difficulty stopping on runway 35L but managed to come to a halt safely by executing a ground loop maneuver. Following disruptions caused by rain in early 2007, Infraero—the airport operator—decided to resurface the main runway and intended to add grooving channels to mitigate hydroplaning risks. While resurfacing was completed by June 29, grooves were not installed because that would have required an extra 30 days. Despite incomplete improvements, the runway remained operational throughout the 2006–07 Brazilian aviation crisis.

Challenges during landing

On July 16, one day prior to the accident, four pilots reported inadequate braking conditions at Congonhas Airport. Among them was a TAM pilot who stopped just a few meters short of the runway's end. Infraero briefly suspended operations from 12:25 pm to 12:28 pm to evaluate conditions before reopening the runway without detecting any standing water or slippery spots. However, at 12:42 pm, Pantanal Linhas Aéreas Flight 4763 (an ATR 42-300) hydroplaned on runway 17R, veering left and striking a concrete box and light pole before coming to rest on grass. All 25 occupants survived uninjured, although the aircraft sustained damage beyond repair. Despite this event, landings continued as normal at Congonhas.

Aircraft and crew

Flight 3054 was operated using an Airbus A320-233 with serial number 789 and registration PR-MBK, equipped with two IAE V2500 engines. Manufactured in 1998, it joined TAM’s fleet in January 2007 after service with other carriers. Owned by Pegasus Aviation, this aircraft had accumulated over 21,000 flight hours across more than 10,000 cycles before the crash.

At dispatch, the starboard engine’s thrust reverser was deactivated due to a mechanical jam. TAM indicated that this malfunction "does not compromise landings," and no technical issues were reported on July 16, the day before the accident. The aircraft had successfully landed on the same runway without braking difficulties on that day.

There were six crew members and 181 passengers onboard. Of these, six crew and 171 passengers were Brazilian nationals; the remaining ten passengers came from various countries. Notably, the flight crew included two captains: Henrique Stefanini Di Sacco (53) and Kleyber Aguiar Lima (54), both with over three decades of flying experience. Stefanini had logged a total of 13,654 flight hours (2,236 on A320), while Lima accumulated 14,760 hours (237 on A320). The cabin crew consisted of four flight attendants.

Nationality Passengers Crew Ground Total
Brazil 171 6 12 189
France 2 0 0 2
Argentina 2 0 0 2
Portugal 1 0 0 1
Sweden 1 0 0 1
United States 1 0 0 1
South Africa 2 0 0 2
Peru 1 0 0 1
Total 181 6 12 199


Flight timeline

Initially, several members of the Grêmio football team and coaching staff were scheduled to board Flight 3054 to connect at Congonhas and continue to Goiânia for a match against Goiás Esporte Clube. Nevertheless, the club postponed their journey to the following day.[1] The aircraft took off from Salgado Filho International Airport in Porto Alegre at 17:18 Brazilian Standard Time (BRT) (20:18 UTC) and ascended to flight level (FL) 340 ().[2] At 18:48 BRT (21:48 UTC), it touched down at Congonhas-São Paulo Regional Airport.[2]

Crash details

Flight 3054 received clearance to land on Runway 35L at Congonhas. Surveillance footage revealed that although the aircraft made a typical touchdown, it failed to decelerate as anticipated and veered left after departing the runway at approximately .[3] The runway is elevated above Avenida Washington Luís, a major city avenue. The plane’s momentum carried it over traffic lanes and into a four-story TAM Express building next to a gas station, igniting a significant fire. All 187 passengers and crew lost their lives; the aircraft was completely destroyed.[4]

Although the runway had been recently resurfaced, it lacked grooved channels designed to disperse water and minimize hydroplaning hazards.[5]

Data from the Flight Data Recorder (FDR) indicated that both thrust levers were set to CL ("climb") position prior to touchdown, with engine power controlled by the autothrottle system.[6] Two seconds before landing, an audible warning "retard, retard" instructed pilots to pull the thrust levers back to idle, which would disengage the autothrottle.

At touchdown, the spoiler lever was set to "ARMED."[6] For spoilers on an A320 to deploy automatically, both thrust levers must be near idle. The FDR recorded the left thrust lever being fully retarded, activating its thrust reverser, but the right lever remained in CL position. CENIPA hypothesizes that pilots might not have noticed this because Airbus autothrottle systems do not physically move the levers when adjusting power.[7] Pulling only the left lever back to idle disengaged autothrust without reducing power on the right engine. As a result, spoilers failed to deploy since the right lever was above idle.[6] This caused the right engine to accelerate while the left applied reverse thrust, generating asymmetric thrust and loss of control. The aircraft overran the runway within 16 seconds of this incorrect lever setting and crashed after 26 seconds.

Incident timeline

Time Event
UTC Local time (UTC−03:00)
20:19 17:19 Flight 3054 departs Salgado Filho Airport after taxiing on Runway 35L
21:20 18:20 Flight commences approach to Congonhas Airport
21:43 18:43 Pilots execute landing checklist
21:47 18:47 Flight 3054 receives clearance to land on runway 35L
21:48:24 18:48:24 Thrust levers set incorrectly
21:48:26 18:48:26 Flight 3054 touches down on runway
21:48:30 18:48:30 Aircraft begins veering left
21:48:40 18:48:40 Flight 3054 overruns runway, steering leftward
21:48:50 18:48:50 Flight 3054 crashes into TAM Express building; all onboard and 12 ground fatalities occur.


Congonhas

In the wake of Brazil's aviation crisis between 2006 and 2007, highlighted by the mid-air collision involving Gol Transportes Aéreos Flight 1907, the focus on aviation safety within the country intensified considerably.

The length of Runway 35L at Congonhas Airport measures . In comparison, Santos Dumont Airport in Rio de Janeiro features an even shorter runway of . Both facilities accommodate a range of aircraft, from small private planes to larger commercial jets such as the Boeing 737 and Airbus A320. Variables including aircraft weight, approach velocity, and prevailing wind conditions play critical roles in determining the necessary runway length for safe landings. For example, an Airbus A320 landing at a speed just above normal can require up to 25% more runway distance. Additionally, wet runway surfaces degrade braking efficiency, thereby increasing the minimum runway length needed.

Due to its limited runway size, Congonhas is widely regarded as one of Brazil's most demanding airports for pilots. It has earned the nickname "aircraft carrier," with strict operational protocols advising pilots to abort landings if they pass beyond the first portion of the runway.

In June 2007, a judicial order temporarily prohibited Fokker 100 and Boeing 737-700/800 aircraft from operating at Congonhas over safety concerns related to water accumulation and hydroplaning risks. The Airbus A320 was exempt from this ban based on manufacturer data indicating shorter braking distances. The judge also recommended extending the runway by to enhance operational safety. Despite these measures, Brazil's National Civil Aviation Agency affirmed that Congonhas complied with existing safety regulations. TAM Airlines opposed the ruling, emphasizing that it would disrupt service for more than 10,000 passengers daily.

Aftermath

On July 19, 2007, Congonhas Airport resumed operations using an alternative runway. Due to the closure of its main runway and ongoing investigations into the accident, numerous flights—including all those operated by OceanAir and BRA Transportes Aéreos—were relocated to Guarulhos International Airport, São Paulo’s primary airport.

The following day, Presidency Chief of Staff Dilma Rousseff announced a plan to drastically reduce flight operations at Congonhas. Within two months, all connecting flights, stopovers, charter services, international routes, and private jet movements were to be prohibited. The airport would thereafter handle only direct flights to selected Brazilian cities. This strategy also involved exploring expansions at São Paulo’s existing airports and considering the development of a third metropolitan airport.

By July 28, 2007, state crime scene investigators had concluded their search for remains; by that time, 114 bodies recovered had been identified by São Paulo’s Medical Examiner’s Office as victims from the flight.

Investigation

The investigation was led by Brazil's Aeronautical Accidents Investigation and Prevention Center (CENIPA). Data from the flight data recorder and cockpit voice recorder were retrieved with assistance from the U.S. National Transportation Safety Board (NTSB) between July 20 and July 23. Following preliminary analysis of flight recorder data, Airbus issued a recommendation on July 25 advising A320 operators to ensure both thrust levers are set to idle during flare maneuvers. The cockpit voice recorder transcript released on August 1 revealed that pilots were aware of wet runway conditions and a malfunctioning thrust reverser; their statements indicated spoilers did not deploy properly and they struggled to decelerate the aircraft. Crew error remained a possible factor.

A report published in November 2008 by Brazil’s Ministry of Justice and Public Security determined that pilots had inadvertently left the right engine thrust lever in "climb" position upon touchdown due to improper procedures while that engine’s thrust reverser was disabled following maintenance. Proper spoiler deployment required both engines’ thrust levers to be retarded. The report also criticized several parties: the National Civil Aviation Agency for failing to close the airport during heavy rainfall; Congonhas management for inadequate runway drainage design; Airbus for not providing alarms alerting pilots to braking system failure; and TAM for insufficient pilot training and emergency preparedness.

Final report

In September 2009, more than two years following the incident, CENIPA published its definitive investigation findings. The document disclosed that one of the thrust levers, responsible for engine control, was positioned to accelerate when it should have been set to idle. However, the report did not definitively establish whether the cause was mechanical malfunction or human error.

Two main theories were considered: firstly, a mechanical defect in the engine power control system that might cause a thrust lever to remain in acceleration regardless of its actual setting—an occurrence estimated to happen once every 400 billion flight hours, thus extremely unlikely. Secondly, the possibility of pilot error involving an abnormal thrust lever position inconsistent with standard operating procedures.

Other factors cited included heavy rainfall producing water accumulation on the runway and the lack of grooving to aid drainage. The investigation did not attribute any fault to the runway’s length. The BEA absolved Airbus of responsibility, noting that Airbus had suggested a modification to warn pilots of incorrect thrust lever positions, which TAM had declined to implement.

Response

In the aftermath of the tragedy, President Luiz Inácio Lula da Silva declared a national mourning period lasting three days.

During the 2007 Pan American Games held in Rio de Janeiro, Brazilian athletes donned black armbands as a tribute to the victims; on July 18, flags from all participating nations were flown at half-staff, and events involving Brazilian teams commenced with a moment of silence.

Similarly, matches in the 2007 Campeonato Brasileiro began with a minute of silence and players wore black armbands. In Formula One, Brazilian drivers Felipe Massa and Rubens Barrichello incorporated commemorative stripes on their helmets, while Red Bull Racing’s David Coulthard and Mark Webber displayed small Brazilian flags on their helmet designs.

On July 29, 2007, a crowd exceeding 5,000 Brazilians gathered at the crash location to protest government underfunding of airport infrastructure and called for President Lula’s resignation.

International reactions

The global response was marked by widespread expressions of sympathy and condolences.

  • : President Néstor Kirchner contacted President Lula to convey his sympathies.
  • : President Michelle Bachelet extended her condolences to Lula.
  • : President Hu Jintao offered his sympathies to Brazil’s government and families affected.
  • : President Horst Köhler sent a message of condolence to Lula; Germany observed three days of mourning by lowering its embassy flag.
  • : Former president Vicente Fox expressed his condolences.
  • : President Alan García conveyed his sympathies and sought dialogue with Lula.
  • : Felipe VI of Spain, who was present in Brazil at that time, expressed condolences.
  • : President George W. Bush, spokesperson Sean McCormack, and Secretary of State Condoleezza Rice all communicated their sympathies; Rice also reached out directly to Brazilian Foreign Minister Celso Amorim.
  • : Archbishop Odilo Scherer received a condolence message from Pope Benedict XVI, which included a mass dedicated to the victims.
  • : Foreign Minister Nicolás Maduro extended condolences to both Brazil’s government and its citizens.

Memorial

On July 17, 2012, marking five years since the tragedy, Memorial Square was inaugurated at the location of the former TAM express warehouse, an area of 8,318 m² that had been demolished in 2007. This commemorative space includes a monument inscribed with the names of those who lost their lives, alongside a mulberry tree that withstood the impact. Additionally, near Salgado Filho International Airport in Porto Alegre—the origin point of Flight 3054—another tribute called "Largo da Vida" was established, featuring 199 trees planted in memory of the victims.

Legal action

After a comprehensive police inquiry spanning 16 months and involving testimonies from 336 individuals, the final report comprising 13,600 pages was submitted on November 19, 2008. Federal prosecutors brought negligence accusations against Denise Abreu, former director of the National Civil Aviation Agency (ANAC), and Marco Aurelio dos Santos de Miranda, TAM’s flight safety officer. In 2011, Alberto Fajerman, TAM’s vice president of operations, was also charged for authorizing landings on a shortened runway that had recently been resurfaced but lacked sufficient drainage for rainwater. The judicial proceedings commenced in São Paulo in 2013. By 2014, charges against Fajerman were dismissed due to lack of evidence; later that year, allegations against Abreu were also dropped. Ultimately, all individuals charged were acquitted.

In the same year, TAM’s insurer Itaú Seguros initiated a R$350 million (approximately US$156 million) lawsuit against Airbus within Brazil. Airbus refuted any liability, attributing the accident to pilot error, airline operational decisions, and runway conditions.

Notable victims

Among those who perished were:

Dramatization

The incident and subsequent investigation were featured in the documentary series Mayday, known as Air Disasters in some regions. This coverage appeared in Season 11’s episode titled "Deadly Reputation" (also referred to as "Nightmare Runway" and "Disaster Runway"), which included interviews with investigators as well as a dramatized reenactment of the event.

See also

Bibliography

External links

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