1 00:00:02,035 --> 00:00:05,706 NARRATOR: Every flight begins and ends here, 2 00:00:06,373 --> 00:00:10,444 a strip of asphalt scorched by jet engines and marred with rubber. 3 00:00:10,711 --> 00:00:12,379 (TIRES SCREECHING) 4 00:00:12,513 --> 00:00:15,182 But not all runways are created equal. 5 00:00:15,649 --> 00:00:18,485 One of the world's most notorious is 6 00:00:18,619 --> 00:00:21,455 {\an8}runway 35-L at Congonhas Airport in Brazil. 7 00:00:23,257 --> 00:00:25,726 It could surprise you at any moment. 8 00:00:26,293 --> 00:00:32,799 NARRATOR: In July 2007, TAM Airlines Flight 3054 becomes its latest victim. 9 00:00:33,600 --> 00:00:36,503 Decelerate! Decelerate! 10 00:00:36,637 --> 00:00:38,539 It can't! It can't! 11 00:00:39,339 --> 00:00:41,608 (LOUD CRASH) 12 00:00:43,343 --> 00:00:46,046 {\an8}NARRATOR: The runway claims 199 lives. 13 00:00:47,247 --> 00:00:50,483 It would be carefully scrutinized, its history reviewed. 14 00:00:51,952 --> 00:00:55,489 Investigators desperately need to know why runway 35-L 15 00:00:55,622 --> 00:00:56,790 is so dangerous... 16 00:00:56,924 --> 00:00:58,959 35-L. 35-L. 17 00:00:59,092 --> 00:01:01,269 {\an8}NARRATOR: Before more lives are lost. 18 00:01:07,000 --> 00:01:08,883 MAN (OVER RADIO): Mayday, mayday! 19 00:01:10,370 --> 00:01:12,372 (THEME MUSIC PLAYING) 20 00:01:34,027 --> 00:01:36,910 {\an8}NARRATOR: Heavy rains pound Brazil's largest city. 21 00:01:39,466 --> 00:01:43,770 São Paulo sees this kind of deluge regularly during the winter rains. 22 00:01:45,606 --> 00:01:49,309 The downpour snarls traffic to and from Congonhas Airport. 23 00:01:52,813 --> 00:01:57,017 800 kilometers away, TAM Airlines Flight 3054 is 24 00:01:57,150 --> 00:02:00,654 on route from the southern Brazilian city of Porto Alegre. 25 00:02:01,688 --> 00:02:05,559 The Airbus A320 is headed for São Paulo 90 minutes away. 26 00:02:11,532 --> 00:02:15,469 For the 181 passengers onboard, 27 00:02:15,602 --> 00:02:17,426 it's a routine domestic flight. 28 00:02:21,608 --> 00:02:23,461 But there's been an unexpected development for 29 00:02:23,544 --> 00:02:25,812 Captain Henrique Stephanini Di Sacco. 30 00:02:27,614 --> 00:02:31,318 He and his first officer Kleyber Lima have just learned 31 00:02:31,451 --> 00:02:33,537 that the heavy rain has temporarily shut 32 00:02:33,620 --> 00:02:38,358 down runway 35-L, the main runway at their destination. 33 00:02:39,526 --> 00:02:42,162 Did they say when it would reopen? 34 00:02:42,296 --> 00:02:44,097 No. 35 00:02:44,231 --> 00:02:46,584 Let's prepare an alternate just in case. 36 00:02:49,436 --> 00:02:51,088 HENRIQUE: (ON PA) Ladies and gentlemen 37 00:02:51,171 --> 00:02:52,690 it looks like due to the weather 38 00:02:52,773 --> 00:02:55,059 we may not be able to land at Congonhas as planned. 39 00:02:55,142 --> 00:02:58,025 I will keep you advised as I get more information. 40 00:03:06,720 --> 00:03:10,368 NARRATOR: Congonhas Airport is one of the busiest in the world. 41 00:03:13,126 --> 00:03:17,998 Planes take off and land here every 90 seconds 42 00:03:18,332 --> 00:03:22,870 carrying a steady stream of people and cargo into the country's economic hub. 43 00:03:26,673 --> 00:03:29,476 But Congonhas is also notorious among pilots. 44 00:03:34,948 --> 00:03:38,252 The airport lies in the heart of the city, crowded on all 45 00:03:38,385 --> 00:03:42,623 sides by apartment buildings, offices and roadways. 46 00:03:51,765 --> 00:03:57,437 Runway 35-L is less than 2,000 meters long, short for large jets. 47 00:03:59,173 --> 00:04:03,777 Even worse, it's built on a hilltop with a sharp drop off on all sides. 48 00:04:07,848 --> 00:04:09,750 The risk the airport poses, 49 00:04:09,883 --> 00:04:12,269 due to its construction, due to its geography, 50 00:04:12,352 --> 00:04:14,588 it does not allow for simple mistakes. 51 00:04:24,031 --> 00:04:26,484 NARRATOR: Captain Carlos Camacho is the flight safety director 52 00:04:26,567 --> 00:04:28,391 of the Brazilian Pilot's Union. 53 00:04:31,138 --> 00:04:33,550 {\an8}As you approach the runway your adrenalin 54 00:04:33,640 --> 00:04:35,275 {\an8}is really pumping. 55 00:04:35,409 --> 00:04:38,586 {\an8}For us pilots it's like landing on an aircraft carrier. 56 00:04:45,485 --> 00:04:47,238 NARRATOR: It makes Congonhas one of the most 57 00:04:47,321 --> 00:04:49,321 treacherous airports in the world. 58 00:04:56,263 --> 00:04:59,263 In fact, a Pantanal Airlines commuter plane spun out 59 00:04:59,366 --> 00:05:01,969 of control while landing just the day before. 60 00:05:03,670 --> 00:05:06,740 And a few months ago, disaster was narrowly averted 61 00:05:06,874 --> 00:05:10,110 when a Boeing 737 came skidding to a stop, 62 00:05:10,878 --> 00:05:15,115 just inches before the steep embankment at the end of runway 35-L. 63 00:05:21,788 --> 00:05:24,658 When pilots begin landing at Congonhas, 64 00:05:24,791 --> 00:05:26,343 they're more worried than when operating 65 00:05:26,426 --> 00:05:28,695 at any other national airport. 66 00:05:34,201 --> 00:05:38,038 NARRATOR: Flight 3054 is at cruising altitude south of São Paulo 67 00:05:38,172 --> 00:05:43,243 when the crew gets news that runway 35-L is back in operation. 68 00:05:43,377 --> 00:05:46,180 ATC: (OVER RADIO) 3054 35L is the active runway. 69 00:05:46,313 --> 00:05:48,431 NARRATOR: There's no need to divert. 70 00:05:52,119 --> 00:05:54,538 HENRIQUE: Ladies and gentlemen, this is your captain speaking. 71 00:05:54,621 --> 00:05:56,924 I have some good news for you. 72 00:05:57,057 --> 00:05:59,459 The runway at Congonhas has reopened. 73 00:05:59,593 --> 00:06:02,863 We'll arrive as scheduled shortly before 7:00 p.m. 74 00:06:02,996 --> 00:06:04,364 (CLAPPING) 75 00:06:04,498 --> 00:06:07,585 NARRATOR: The relief of the passengers is not shared by the pilot. 76 00:06:07,668 --> 00:06:10,786 Stephanini has an additional challenge on this flight. 77 00:06:11,038 --> 00:06:14,208 Remember, we only have one reverser. 78 00:06:14,341 --> 00:06:17,144 Yes. Only the left. 79 00:06:18,445 --> 00:06:21,932 NARRATOR: He will have to land at one of the world's most challenging airports 80 00:06:22,015 --> 00:06:24,898 with less than the usual amount of stopping power. 81 00:06:27,087 --> 00:06:30,264 One of the Airbus's two thrust reversers isn't working. 82 00:06:30,791 --> 00:06:32,826 The devices are designed to slow 83 00:06:33,026 --> 00:06:35,968 the aircraft on landing by reversing engine thrust. 84 00:06:38,031 --> 00:06:41,384 If I was the pilot that day I would be extremely concerned 85 00:06:41,468 --> 00:06:44,468 knowing that one of my reversers wasn't functioning. 86 00:06:45,772 --> 00:06:49,309 ATC: TAM 3054, 35-L clear to land. 87 00:06:50,677 --> 00:06:54,748 {\an8}NARRATOR: Stephanini will be landing on the infamous runway 35-L. 88 00:06:57,384 --> 00:06:59,470 ATC: (OVER RADIO) The runway is wet and it's slippery. 89 00:06:59,553 --> 00:07:01,355 The wind is 3-3-0 at 8 knots. 90 00:07:05,292 --> 00:07:08,940 The crew was informed of poor braking conditions on the runway. 91 00:07:11,765 --> 00:07:14,236 NARRATOR: The Airbus is on final approach. 92 00:07:15,836 --> 00:07:19,056 Even though the autopilot could get the plane to the runway, 93 00:07:19,139 --> 00:07:22,257 the Captain decides to take over the controls himself. 94 00:07:23,443 --> 00:07:25,212 Land green. Manual flight. 95 00:07:28,682 --> 00:07:30,501 NARRATOR: He wants to bring the plane 96 00:07:30,584 --> 00:07:33,204 in as close to the runway threshold as possible. 97 00:07:33,287 --> 00:07:35,699 He needs every inch of runway he can get. 98 00:07:36,089 --> 00:07:38,926 {\an8}HENRIQUE: 35-L. 35-L. 99 00:07:40,394 --> 00:07:43,096 The concern was that after touching down, 100 00:07:43,230 --> 00:07:45,149 the pilots needed to be sure that they would 101 00:07:45,232 --> 00:07:49,069 be able to stop their plane before the end of the runway. 102 00:07:51,071 --> 00:07:54,777 NARRATOR: The passengers only know that they'll soon be landing. 103 00:07:59,680 --> 00:08:00,731 VOICE: (OVER COMPUTER) 300. 104 00:08:00,814 --> 00:08:02,182 300. 105 00:08:02,983 --> 00:08:05,986 NARRATOR: Now they are only 300 feet above the city. 106 00:08:07,921 --> 00:08:10,980 The Airbus is lined up with the center of the runway. 107 00:08:11,358 --> 00:08:12,860 KLEYBER: Middle. 108 00:08:12,993 --> 00:08:15,896 HENRIQUE: The runway conditions. 109 00:08:16,029 --> 00:08:17,081 VOICE: (OVER COMPUTER) 200. 110 00:08:17,164 --> 00:08:18,932 200. 111 00:08:21,735 --> 00:08:23,337 100.100. 112 00:08:23,470 --> 00:08:25,839 - One dot now? - Okay. 113 00:08:26,373 --> 00:08:29,894 NARRATOR: The plane's wheels will touch the Congonhas tarmac in seconds. 114 00:08:29,977 --> 00:08:32,479 VOICE: (OVER COMPUTER) 20. Retard. 115 00:08:39,786 --> 00:08:42,656 As the plane touches down their worries about 116 00:08:42,789 --> 00:08:45,492 landing are only just beginning. 117 00:08:47,494 --> 00:08:49,747 NARRATOR: Captain Stephanini applies reverse thrust to 118 00:08:49,830 --> 00:08:52,599 the A320's only working reverser. 119 00:08:57,938 --> 00:09:00,291 The pilot would have to activate the reverser on 120 00:09:00,374 --> 00:09:01,592 the engine that had a working 121 00:09:01,675 --> 00:09:05,913 reverser as fast as possible to initiate deceleration. 122 00:09:08,315 --> 00:09:10,845 NARRATOR: But the plane is not slowing down. 123 00:09:11,785 --> 00:09:13,170 Reverse number one only. 124 00:09:13,253 --> 00:09:15,806 NARRATOR: At this rate, it will use up the entire 125 00:09:15,889 --> 00:09:20,627 1945 meters of runway in less than 30 seconds. 126 00:09:23,564 --> 00:09:24,965 Ah. 127 00:09:32,372 --> 00:09:33,740 Decelerate! 128 00:09:33,874 --> 00:09:35,475 It can't! 129 00:09:37,110 --> 00:09:40,581 The pilots operated the footbrakes with the pedals, 130 00:09:40,714 --> 00:09:44,218 pressing on them for a long time. 131 00:09:46,720 --> 00:09:48,606 - Look at this. - NARRATOR: Now... 132 00:09:48,689 --> 00:09:49,857 Look at this. 133 00:09:49,990 --> 00:09:53,108 NARRATOR: The aircraft mysteriously pulls to the left. 134 00:09:54,228 --> 00:09:55,729 Turn, turn! 135 00:09:55,863 --> 00:09:58,922 NARRATOR: It's almost as if it has a mind of its own. 136 00:09:59,967 --> 00:10:01,969 (SCREAMING) 137 00:10:02,836 --> 00:10:04,638 My God. My God. 138 00:10:09,009 --> 00:10:12,212 (SCREAMING) 139 00:10:14,381 --> 00:10:15,949 (LOUD CRASH) 140 00:10:25,158 --> 00:10:28,629 NARRATOR: Flight 3054 has slammed into a TAM Airlines 141 00:10:28,762 --> 00:10:31,331 building and an adjacent gas station. 142 00:10:31,999 --> 00:10:34,588 Nearly 200 firefighters descend on the scene. 143 00:10:36,937 --> 00:10:41,909 They face a raging fuel fire burning at almost 1000 degrees Celsius. 144 00:10:51,251 --> 00:10:54,254 The devastation horrifies Dr. Douglas Ferrari. 145 00:10:59,193 --> 00:11:02,763 {\an8}The explosion spread fire throughout the entire area. 146 00:11:02,896 --> 00:11:05,349 There was a fire in the gas station killing the people 147 00:11:05,432 --> 00:11:06,917 who were filling up their tanks, 148 00:11:07,000 --> 00:11:10,237 burning the whole structure, turning it unrecognizable. 149 00:11:14,975 --> 00:11:17,194 NARRATOR: He had hoped to treat survivors. 150 00:11:17,277 --> 00:11:19,630 But now he fears there might not be any. 151 00:11:22,983 --> 00:11:25,552 We had three, four cars on fire. 152 00:11:25,686 --> 00:11:29,923 In one of these cars I saw a mother with her child. 153 00:11:30,057 --> 00:11:31,658 Dead. 154 00:11:35,629 --> 00:11:38,453 NARRATOR: The entire plane is engulfed in flames. 155 00:11:38,999 --> 00:11:41,235 There's little hope for anyone inside. 156 00:11:44,805 --> 00:11:47,307 But now there is a new danger. 157 00:11:47,441 --> 00:11:50,611 Huge quantities of fuel in the storage tanks beneath 158 00:11:50,744 --> 00:11:53,274 the gas station could blow up at any moment. 159 00:11:55,782 --> 00:11:59,620 The aircraft broke its wings on impact and 160 00:11:59,753 --> 00:12:02,456 spilled fuel throughout the entire area. 161 00:12:06,527 --> 00:12:09,175 There was a risk of the gas station exploding. 162 00:12:14,268 --> 00:12:18,289 NARRATOR: Rescuers hope they can save people in the TAM Airlines building. 163 00:12:18,372 --> 00:12:23,477 But with the fire raging out of control, they will have to act fast. 164 00:12:30,884 --> 00:12:34,788 We tried to rescue the people from inside the building. 165 00:12:34,922 --> 00:12:36,957 I was anxious to help them. 166 00:12:47,167 --> 00:12:51,344 {\an8}NARRATOR: Dr. Ferrari makes a grim find inside the TAM Airlines offices. 167 00:12:51,738 --> 00:12:54,741 {\an8}DOUGLAS: The airplane wing blocked the way. 168 00:12:54,875 --> 00:12:57,177 It prevented people from escaping. 169 00:12:59,880 --> 00:13:03,383 I was behind the firefighter accompanying me 170 00:13:03,517 --> 00:13:05,753 while he moved bodies to the sidewalk. 171 00:13:09,022 --> 00:13:11,058 It was a horrible feeling. 172 00:13:16,530 --> 00:13:18,883 NARRATOR: But they do locate some office workers in another 173 00:13:18,966 --> 00:13:22,069 part of the building and rush them to safety. 174 00:13:25,372 --> 00:13:27,124 On the right side of the building where 175 00:13:27,207 --> 00:13:30,461 there was no obstruction there was time for people to get out. 176 00:13:30,544 --> 00:13:32,779 About 10 or 20 people made it. 177 00:13:37,417 --> 00:13:40,065 NARRATOR: No one in the aircraft has survived. 178 00:13:40,220 --> 00:13:43,690 199 people are dead including a dozen people 179 00:13:43,824 --> 00:13:46,226 in the gas station and the TAM building. 180 00:13:46,727 --> 00:13:50,139 It's the worst aviation accident in South American history. 181 00:13:53,066 --> 00:13:56,403 The black boxes will not last long in the heat. 182 00:13:57,504 --> 00:14:01,225 NARRATOR: Lieutenant Colonel Fernando Camargo is an accident investigator 183 00:14:01,308 --> 00:14:04,578 with CENIPA, the country's aviation safety agency. 184 00:14:05,612 --> 00:14:09,950 {\an8}In modern aircraft the recorders are the, 185 00:14:10,083 --> 00:14:12,319 {\an8}the core of any investigation. 186 00:14:12,452 --> 00:14:18,625 So when we arrived at the crash site and we saw that strong fire, 187 00:14:18,759 --> 00:14:23,297 we got really concerned about the integrity of the data. 188 00:14:24,097 --> 00:14:26,517 NARRATOR: He knows the intense heat could already be damaging 189 00:14:26,600 --> 00:14:28,777 the plane's data and voice recorders. 190 00:14:29,503 --> 00:14:33,707 Valuable evidence that could help explain the crash may already be lost. 191 00:14:36,977 --> 00:14:39,730 Colonel Camargo and his team know that just the day before 192 00:14:39,813 --> 00:14:42,983 another plane slid off runway 35-L. 193 00:14:44,451 --> 00:14:50,490 We knew that we would have to run a complete investigation on the runway. 194 00:14:53,861 --> 00:14:56,247 NARRATOR: If a rain-slicked runway caused this crash, 195 00:14:56,330 --> 00:14:59,032 disaster could strike again soon. 196 00:14:59,633 --> 00:15:04,004 The pressure is on to figure out exactly what happened to Flight 3054. 197 00:15:05,572 --> 00:15:09,276 I knew that there was a video from the surveillance system. 198 00:15:09,409 --> 00:15:11,729 That's the time of the accident. That must be it. 199 00:15:11,812 --> 00:15:14,298 NARRATOR: The airport surveillance system captured 200 00:15:14,381 --> 00:15:16,634 the doomed Airbus speeding down the runway. 201 00:15:16,717 --> 00:15:20,988 This video could solve a lot of issues. 202 00:15:21,788 --> 00:15:23,690 Let's see it again please. 203 00:15:24,458 --> 00:15:29,930 FERNANDO: But the crash was outside the range of the cameras. 204 00:15:31,198 --> 00:15:33,617 Can we look at this from a different angle? 205 00:15:33,700 --> 00:15:38,289 NARRATOR: Even without the crash on tape, the video could hold important clues. 206 00:15:38,906 --> 00:15:43,010 Do you have tape of other A320s landing? 207 00:15:46,847 --> 00:15:48,916 Okay go ahead and play it now. 208 00:15:49,783 --> 00:15:54,321 We compared these timeframes from one aircraft to another. 209 00:16:00,827 --> 00:16:02,396 Nine seconds. 210 00:16:02,529 --> 00:16:05,933 A regular landing, the aircraft would take, uh, 211 00:16:06,099 --> 00:16:11,104 something about nine seconds to pass over this camera. 212 00:16:11,338 --> 00:16:13,740 Okay now the crash plane please. 213 00:16:15,509 --> 00:16:18,645 And the accident aircraft took three seconds. 214 00:16:19,313 --> 00:16:21,148 Three seconds. 215 00:16:21,415 --> 00:16:23,584 That puzzled us a little bit. 216 00:16:28,622 --> 00:16:30,641 Why was the crash plane going three times faster 217 00:16:30,724 --> 00:16:32,489 than the regular A320 landing? 218 00:16:39,099 --> 00:16:40,885 NARRATOR: Four hours after the accident, 219 00:16:40,968 --> 00:16:43,937 firefighters are still battling the intense blaze. 220 00:16:45,172 --> 00:16:47,541 The fire was a strong fire with a lot of 221 00:16:47,674 --> 00:16:49,843 fuel to keep it burning. 222 00:16:51,178 --> 00:16:52,997 NARRATOR: Camargo is desperate to gain access to 223 00:16:53,080 --> 00:16:56,080 the tail section which contains the two black boxes. 224 00:16:57,851 --> 00:17:01,922 They concentrated the fight in the rear of the aircraft. 225 00:17:03,223 --> 00:17:04,909 NARRATOR: Finally, firefighters beat back 226 00:17:04,992 --> 00:17:07,463 the flames enough to get at the recorders. 227 00:17:11,832 --> 00:17:13,734 But it may be too late. 228 00:17:17,504 --> 00:17:22,476 They can be submitted to fire 'til a certain temperature. 229 00:17:23,177 --> 00:17:26,883 After that there's no guarantee that the data will be preserved. 230 00:17:28,916 --> 00:17:32,336 NARRATOR: The recorders will be sent to Washington to be examined 231 00:17:32,419 --> 00:17:34,949 at the National Transportation Safety Board. 232 00:17:43,030 --> 00:17:46,767 {\an8}Now, investigators can focus on the infamous runway 35-L. 233 00:17:48,168 --> 00:17:50,688 {\an8}They examine the surface for clues that might explain 234 00:17:50,771 --> 00:17:54,508 why flight 3054 went so badly out of control. 235 00:17:59,213 --> 00:18:03,150 We walked through the runway, uh, searching for evidence, 236 00:18:03,283 --> 00:18:06,520 the marks of the aircraft, the point where it veered 237 00:18:06,653 --> 00:18:08,322 off the runway. 238 00:18:14,895 --> 00:18:16,463 It's still wet. 239 00:18:17,764 --> 00:18:20,588 NARRATOR: The water is pooling, creating puddles. 240 00:18:21,001 --> 00:18:23,413 That shouldn't happen on a modern runway. 241 00:18:25,005 --> 00:18:29,009 {\an8}When this water gets in contact with the landing gear, the tires, 242 00:18:29,142 --> 00:18:31,678 {\an8}it can generate what we call hydroplaning, 243 00:18:31,812 --> 00:18:33,564 and this is a problem because a pilot will 244 00:18:33,647 --> 00:18:36,783 have little or no control of his aircraft. 245 00:18:42,089 --> 00:18:46,325 NARRATOR: Camargo and his team wonder why water is pooling on the runway. 246 00:18:46,527 --> 00:18:50,704 They study files from the government agency that runs Congonhas Airport. 247 00:18:54,234 --> 00:18:57,871 They learn that runway 35-L had been completely resurfaced 248 00:18:58,005 --> 00:19:00,340 just one month before the accident. 249 00:19:04,945 --> 00:19:08,949 In 2007, the runway at Congonhas underwent repairs. 250 00:19:09,082 --> 00:19:11,802 It had been offering a very low level of traction. 251 00:19:11,885 --> 00:19:14,021 There were many reports of skids. 252 00:19:14,888 --> 00:19:19,477 NARRATOR: For years, pilots had been complaining about the slippery conditions. 253 00:19:22,663 --> 00:19:27,267 They knew that the pavement need to be reconstructed 254 00:19:31,538 --> 00:19:36,543 because the surface allowed the water to accumulate. 255 00:19:37,544 --> 00:19:39,179 HENRIQUE: 35-L. 35-L. 256 00:19:43,750 --> 00:19:45,836 NARRATOR: The runway had been resurfaced. 257 00:19:45,919 --> 00:19:48,589 That should have solved the water problem. 258 00:19:49,089 --> 00:19:51,625 It reopened just weeks before the crash. 259 00:19:53,093 --> 00:19:55,917 The new surface seemed to be a major improvement. 260 00:19:58,365 --> 00:20:04,204 The airport operated for about a month in dry weather with no problems. 261 00:20:05,806 --> 00:20:08,159 NARRATOR: But then, three days before the crash... 262 00:20:08,242 --> 00:20:10,477 (LIGHTNING AND THUNDER) 263 00:20:10,611 --> 00:20:12,946 ...heavy rains began. 264 00:20:15,482 --> 00:20:17,351 And with the rain, 265 00:20:17,484 --> 00:20:23,557 older problems that were supposed to be solved came back. 266 00:20:27,794 --> 00:20:31,749 On the night of the accident the biggest problem was still the water. 267 00:20:31,832 --> 00:20:35,035 Aircraft were still reporting difficulties braking. 268 00:20:41,008 --> 00:20:44,126 ATC: (OVER RADIO) The runway's wet, and it's slippery. 269 00:20:47,881 --> 00:20:51,618 In theory, there was no more depressions 270 00:20:51,752 --> 00:20:54,188 on the runway to accumulate water. 271 00:20:54,321 --> 00:20:57,758 So what could cause water to accumulate? 272 00:21:02,262 --> 00:21:04,315 NARRATOR: He discovers that the repair work lacked 273 00:21:04,398 --> 00:21:06,133 a critical safety feature. 274 00:21:06,767 --> 00:21:09,415 FERNANDO: Grooving to be done at a later date. 275 00:21:09,670 --> 00:21:11,138 No wonder it was wet. 276 00:21:16,176 --> 00:21:19,176 NARRATOR: Special grooves that carry away rainwater. 277 00:21:19,947 --> 00:21:22,477 Without them, rain would collect in puddles. 278 00:21:25,819 --> 00:21:28,889 The repairs still lacked the necessary upgrade. 279 00:21:29,022 --> 00:21:31,175 It was very difficult to interrupt the operation of 280 00:21:31,258 --> 00:21:34,561 the main runway in order to install the grooves. 281 00:21:44,004 --> 00:21:46,924 NARRATOR: Evidence is mounting that a compromised surface on 282 00:21:47,007 --> 00:21:51,879 runway 35-L played a key role in Brazil's worst airline accident. 283 00:21:53,213 --> 00:21:56,534 Colonel Camargo is concerned that Brazil's notorious rains 284 00:21:56,617 --> 00:21:58,552 may bring more runway disasters. 285 00:22:02,189 --> 00:22:04,241 Soon after the accident we recommended 286 00:22:04,324 --> 00:22:10,364 the suspension of the operations of regular aircraft in rainy conditions. 287 00:22:12,733 --> 00:22:14,652 NARRATOR: The airport authority complies, 288 00:22:14,735 --> 00:22:18,038 shutting down runway 35-L until answers are found. 289 00:22:23,277 --> 00:22:25,996 But the main runway at one of the world's busiest airports 290 00:22:26,079 --> 00:22:27,668 can't stay closed for long. 291 00:22:28,882 --> 00:22:31,001 They must find out what caused this accident 292 00:22:31,084 --> 00:22:32,386 as soon as possible. 293 00:22:33,687 --> 00:22:36,657 Their focus turns to the A320's thrust reversers. 294 00:22:44,464 --> 00:22:48,641 The plane's maintenance records reveal why only one of them was working. 295 00:22:50,103 --> 00:22:53,106 Four days before the crash, mechanics deactivated 296 00:22:53,240 --> 00:22:56,652 the right engine's thrust reverser for routine maintenance. 297 00:22:56,910 --> 00:22:59,746 (MUMBLING) 298 00:23:00,914 --> 00:23:04,201 But the aircraft had then flown without incident for four days. 299 00:23:04,284 --> 00:23:06,787 No action required? 300 00:23:08,021 --> 00:23:12,433 NARRATOR: Not only had the plane landed repeatedly with one thrust reverser, 301 00:23:14,228 --> 00:23:17,731 it had even landed safely on runway 35-L. 302 00:23:24,004 --> 00:23:25,823 FERNANDO: This plane landed on the same runway, 303 00:23:25,906 --> 00:23:28,459 on the same runway, that day, with the same problems, 304 00:23:28,542 --> 00:23:32,346 had only one thrust reverser, just one thrust reverser. 305 00:23:32,479 --> 00:23:34,381 No issues whatsoever. 306 00:23:34,915 --> 00:23:37,680 NARRATOR: So why had this landing gone so wrong? 307 00:23:40,787 --> 00:23:42,055 (LOUD CRASH) 308 00:23:47,127 --> 00:23:50,281 NARRATOR: Colonel Fernando Camargo travels to Washington, D.C. 309 00:23:50,364 --> 00:23:53,517 Technicians at the National Transportation Safety Board 310 00:23:53,600 --> 00:23:56,020 will help him try to recover data stored in 311 00:23:56,103 --> 00:23:59,673 flight 3054's badly burned flight recorders. 312 00:24:04,978 --> 00:24:08,966 First, they look for a temperature sensitive chip that could provide a clue 313 00:24:09,049 --> 00:24:11,418 as to how bad the heat damage might be. 314 00:24:12,619 --> 00:24:15,255 {\an8}There is an indicator that turns 315 00:24:15,389 --> 00:24:19,893 {\an8}the color if it was exposed to 316 00:24:20,027 --> 00:24:26,066 a temperature above that one that it was manufactured to support. 317 00:24:27,701 --> 00:24:30,287 NARRATOR: Even though the boxes are designed to survive a fierce 318 00:24:30,370 --> 00:24:33,207 fire of up to 1,000 degrees Celsius, 319 00:24:33,340 --> 00:24:35,635 the chip's appearance is worrying news. 320 00:24:37,644 --> 00:24:44,117 These boards were submitted to a fire that exceeded its limitation. 321 00:24:45,185 --> 00:24:49,538 NARRATOR: They test the circuit board to see if any of the memory survived. 322 00:24:51,658 --> 00:24:55,095 Without the data, the investigation into flight 3054 323 00:24:55,229 --> 00:24:56,994 would be effectively crippled. 324 00:24:58,498 --> 00:25:02,069 Colonel Camargo may never know why 199 people died 325 00:25:02,202 --> 00:25:04,137 at Brazil's busiest airport. 326 00:25:06,373 --> 00:25:09,021 But the circuit board test provides some hope. 327 00:25:10,110 --> 00:25:11,545 Okay, we got something. 328 00:25:11,678 --> 00:25:14,114 Fortunately, everything works okay. 329 00:25:14,248 --> 00:25:17,117 We could recover 100% of the data. 330 00:25:17,751 --> 00:25:18,852 Here we go. 331 00:25:18,986 --> 00:25:22,273 NARRATOR: The information paints a picture of the plane's performance. 332 00:25:22,356 --> 00:25:23,657 The speed is fine. 333 00:25:23,790 --> 00:25:26,010 NARRATOR: In the critical seconds before the crash. 334 00:25:26,093 --> 00:25:28,028 They came down fine. 335 00:25:30,163 --> 00:25:31,282 Brakes were engaged. 336 00:25:31,365 --> 00:25:33,467 The brakes were engaged. 337 00:25:33,600 --> 00:25:35,886 NARRATOR: The data confirms that the foot brakes were working 338 00:25:35,969 --> 00:25:39,540 properly and that the A320 did not skid or slide. 339 00:25:41,175 --> 00:25:42,809 Here. Here. 340 00:25:42,943 --> 00:25:46,597 NARRATOR: Then, Camargo discovers that the plane's two engines were inexplicably 341 00:25:46,680 --> 00:25:50,317 - operating against each other. - Engine one. 342 00:25:50,450 --> 00:25:55,956 NARRATOR: The plane's left engine was in reverse to help slow the aircraft down. 343 00:25:57,991 --> 00:26:01,815 But the right engine, the one with the disabled thrust reverser... 344 00:26:01,962 --> 00:26:04,014 - It's powering up. - ...was doing the opposite. 345 00:26:04,097 --> 00:26:06,016 For takeoff. It's supposed to be idling. 346 00:26:06,099 --> 00:26:10,158 NARRATOR: Instead of winding down, it was accelerating to climb power. 347 00:26:10,938 --> 00:26:13,006 - Decelerate! - It can't! 348 00:26:14,775 --> 00:26:16,961 NARRATOR: With one engine at full power, the pilots didn't 349 00:26:17,044 --> 00:26:19,633 have a chance to stop their aircraft in time. 350 00:26:20,981 --> 00:26:23,383 This aircraft was braking. 351 00:26:23,884 --> 00:26:25,870 - Oh, my God. - Look at this. Look at this. 352 00:26:25,953 --> 00:26:30,824 But it would take around one more kilometer for it to stop. 353 00:26:32,359 --> 00:26:34,945 {\an8}NARRATOR: The lopsided thrust pushed the plane to the left. 354 00:26:35,028 --> 00:26:36,864 KLEYBER: Turn! 355 00:26:37,264 --> 00:26:41,802 The right engine really was increasing thrust. 356 00:26:43,971 --> 00:26:47,708 There was, uh, no means available for the pilot to 357 00:26:47,841 --> 00:26:50,844 avoid the aircraft to veer off to the left. 358 00:26:54,848 --> 00:26:56,750 Could be this. 359 00:26:56,884 --> 00:26:59,069 So engine two was thrusting when it should have been idling. 360 00:26:59,152 --> 00:27:01,839 That would explain the veer off to the left, right? 361 00:27:01,922 --> 00:27:04,024 So what does this mean? 362 00:27:04,458 --> 00:27:06,544 NARRATOR: Now Colonel Camargo needs to figure out why 363 00:27:06,627 --> 00:27:10,745 the right engine was at full power when it should have been in reverse. 364 00:27:12,332 --> 00:27:16,403 At that time we could establish, roughly, 365 00:27:16,537 --> 00:27:20,874 two main lines of investigation. 366 00:27:21,842 --> 00:27:24,811 One, mechanical failure. 367 00:27:25,812 --> 00:27:28,182 And the other one, 368 00:27:28,315 --> 00:27:29,716 pilot error. 369 00:27:33,487 --> 00:27:36,540 NARRATOR: Colonel Camargo brings in human factors investigators 370 00:27:36,623 --> 00:27:40,727 Lieutenant Colonel Marcia Fajer and First Lieutenant Vanessa Dias. 371 00:27:40,861 --> 00:27:47,100 The pilot is Henrique Stephanini Di Sacco, age 53, from São Paulo. 372 00:27:48,402 --> 00:27:51,405 13,654 flight hours. 373 00:27:54,241 --> 00:27:58,445 {\an8}The pilot who was in command was a very experienced pilot, 374 00:27:58,579 --> 00:28:00,397 {\an8}he knew the aircraft very well. 375 00:28:00,480 --> 00:28:05,185 His First Officer was Agular Kleyber Lima, age 54, from Porto Velho. 376 00:28:05,953 --> 00:28:08,422 14,760 flight hours. 377 00:28:11,625 --> 00:28:16,037 He had enough training to do a good job including in an emergency situation. 378 00:28:19,333 --> 00:28:21,519 NARRATOR: Their job is to determine if the crew somehow 379 00:28:21,602 --> 00:28:24,121 made an error that could have caused one engine to 380 00:28:24,204 --> 00:28:26,006 stay at full power. 381 00:28:29,643 --> 00:28:33,526 {\an8}Machines are straightforward because they work in predictable ways. 382 00:28:33,714 --> 00:28:37,168 Humans are infinitely more complex in the way they think and act. 383 00:28:37,251 --> 00:28:40,604 It's much harder to analyze their behavior in an accident. 384 00:28:43,123 --> 00:28:45,926 You know but I just, I can't believe that this 385 00:28:46,059 --> 00:28:48,629 pilot would make that kind of mistake. 386 00:28:50,564 --> 00:28:51,632 Okay. 387 00:28:51,765 --> 00:28:54,685 NARRATOR: The human factors team must now conduct a psychological study 388 00:28:54,768 --> 00:28:58,945 of the crew to understand how they might have committed a fatal misstep. 389 00:29:03,110 --> 00:29:04,662 We attempted to reconstruct 390 00:29:04,745 --> 00:29:08,451 the individual history of each crew member and their experience. 391 00:29:09,917 --> 00:29:12,736 Ladies and gentlemen, this is your captain speaking. 392 00:29:12,819 --> 00:29:14,505 I have some good news for you. 393 00:29:14,588 --> 00:29:16,373 And try to create a picture that could help us 394 00:29:16,456 --> 00:29:18,926 explain what happened in the cockpit. 395 00:29:24,665 --> 00:29:26,650 NARRATOR: Colonel Camargo still believes 396 00:29:26,733 --> 00:29:28,851 a mechanical failure is more likely. 397 00:29:29,303 --> 00:29:32,223 He now turns his attention to the complicated mechanics that 398 00:29:32,306 --> 00:29:34,542 link the thrust levers to the engines. 399 00:29:35,175 --> 00:29:39,293 He must determine if a failure there led to the mysterious power surge. 400 00:29:41,715 --> 00:29:45,485 We began studying this thrust system, 401 00:29:45,619 --> 00:29:50,257 each and every component of the system from 402 00:29:50,390 --> 00:29:53,360 the lever to the engine. 403 00:29:54,228 --> 00:29:56,113 We've been through it. We know it's not the FADEC. 404 00:29:56,196 --> 00:29:58,215 NARRATOR: There's nothing wrong with the engines. 405 00:29:58,298 --> 00:30:02,122 That leaves only one component that could have caused the problem. 406 00:30:02,536 --> 00:30:05,256 The mechanism that links the throttles to the engines, 407 00:30:05,339 --> 00:30:09,743 a device called an artificial feel unit or AFU. 408 00:30:10,511 --> 00:30:13,347 Investigators wonder if that device failed, 409 00:30:13,480 --> 00:30:15,766 leaving the engines at full power even though 410 00:30:15,849 --> 00:30:18,285 the pilots set the lever to idle. 411 00:30:18,719 --> 00:30:20,955 But such a failure is highly unlikely. 412 00:30:25,259 --> 00:30:29,429 FERNANDO: It's really a remote possibility, 413 00:30:29,563 --> 00:30:35,169 400 billion hours of flight for us to have 414 00:30:35,302 --> 00:30:37,538 one occurrence of that. 415 00:30:40,841 --> 00:30:45,430 NARRATOR: Still, he needs to rule out the AFU as a possible cause of the crash. 416 00:30:45,646 --> 00:30:49,470 But he's not sure the unit can even be found amongst the wreckage. 417 00:30:51,051 --> 00:30:53,887 Computers, all the avionics, 418 00:30:54,021 --> 00:30:55,656 everything was, was gone. 419 00:30:58,992 --> 00:31:01,612 NARRATOR: Luckily, one of the few pieces to have survived 420 00:31:01,695 --> 00:31:04,798 the fire is the piece investigators now need. 421 00:31:04,932 --> 00:31:06,200 The AFU. 422 00:31:07,034 --> 00:31:09,053 It's sent to a specialized laboratory that can 423 00:31:09,136 --> 00:31:11,489 scan the metal for microscopic markings. 424 00:31:14,508 --> 00:31:15,576 Look. 425 00:31:16,376 --> 00:31:20,280 It got melted in such a way that you can work with it. 426 00:31:20,414 --> 00:31:22,216 So we could check something. 427 00:31:23,584 --> 00:31:26,504 NARRATOR: The 3D scanner allows them to look for nicks or 428 00:31:26,587 --> 00:31:29,235 scratches that would indicate the unit failed. 429 00:31:32,492 --> 00:31:34,011 FERNANDO: I'm looking for any, 430 00:31:34,094 --> 00:31:35,996 any unusual marks in this area. 431 00:31:36,129 --> 00:31:39,333 If we could find out any mark, 432 00:31:39,466 --> 00:31:44,371 any evidence of the position of this gear we could go after 433 00:31:44,505 --> 00:31:49,610 the lever and, uh, find out the real position of the thrust lever. 434 00:31:50,611 --> 00:31:54,494 NARRATOR: But they can find no evidence that the AFU malfunctioned. 435 00:31:54,948 --> 00:31:57,017 Okay pack it up. Let's go home. 436 00:31:57,851 --> 00:31:59,720 We found nothing. 437 00:31:59,853 --> 00:32:01,321 No mark, no evidence. 438 00:32:03,156 --> 00:32:05,776 NARRATOR: Colonel Camargo concludes mechanical failure was 439 00:32:05,859 --> 00:32:09,565 {\an8}not to blame for the improper power setting on the right engine. 440 00:32:10,163 --> 00:32:12,283 He has to assume, that for some reason, 441 00:32:12,366 --> 00:32:16,203 the crew left the right engine lever at full power 442 00:32:16,336 --> 00:32:18,205 after the Airbus landed. 443 00:32:20,240 --> 00:32:22,876 KLEYBER: Turn! Turn! 444 00:32:23,744 --> 00:32:25,879 (SCREAMING) 445 00:32:26,013 --> 00:32:27,098 HENRIQUE: My God. My God. 446 00:32:27,181 --> 00:32:30,150 HENRIQUE: (OVER CVR) Turn. Turn. Turn. Turn! 447 00:32:33,253 --> 00:32:34,638 NARRATOR: Back in São Paulo, 448 00:32:34,721 --> 00:32:36,273 the human factors team turns to 449 00:32:36,356 --> 00:32:38,859 the cockpit voice recorder, or CVR. 450 00:32:39,393 --> 00:32:42,079 HENRIQUE: (OVER CVR) I have some good news for you, runway looks... 451 00:32:42,162 --> 00:32:44,982 NARRATOR: They need to understand the pilots' state of mind as they 452 00:32:45,065 --> 00:32:47,595 approached São Paulo the night of the crash. 453 00:32:51,972 --> 00:32:54,024 The CVR enables us to get an idea of 454 00:32:54,107 --> 00:32:56,643 the interaction between crew members. 455 00:32:59,413 --> 00:33:01,665 NARRATOR: They learn that Captain Stephanini was 456 00:33:01,748 --> 00:33:03,734 quite concerned about the runway conditions. 457 00:33:03,817 --> 00:33:05,469 HENRIQUE: Ask them about the rain, 458 00:33:05,552 --> 00:33:09,957 runway conditions, if the runway's slippery. 459 00:33:10,090 --> 00:33:12,125 TAM on final approach. 460 00:33:12,259 --> 00:33:13,493 Two miles away. 461 00:33:13,627 --> 00:33:16,363 Could you confirm conditions? 462 00:33:16,496 --> 00:33:19,379 ATC: (OVER RADIO) It's wet and it's slippery 3054. 463 00:33:21,635 --> 00:33:23,136 Wet and slippery. 464 00:33:25,105 --> 00:33:27,307 The pilot is already tense. 465 00:33:27,441 --> 00:33:29,660 And then he finds out that runway conditions are 466 00:33:29,743 --> 00:33:32,079 worse than usual, slippery and rainy. 467 00:33:33,046 --> 00:33:38,652 The tension can affect the pilot's perception, his concentration. 468 00:33:43,123 --> 00:33:45,225 {\an8}35-L, 35-L. 469 00:33:49,696 --> 00:33:51,882 NARRATOR: It now appears that Stephanini's anxiety 470 00:33:51,965 --> 00:33:57,271 about 35-L and not the runway itself was the main cause of this crash. 471 00:33:58,138 --> 00:34:00,741 Camargo now focuses on the crew's actions. 472 00:34:02,943 --> 00:34:04,128 I think it's ready sir. 473 00:34:04,211 --> 00:34:05,579 Thank you. 474 00:34:06,813 --> 00:34:08,833 NARRATOR: He needs to understand how the power levers 475 00:34:08,916 --> 00:34:10,681 were handled before the crash. 476 00:34:11,418 --> 00:34:13,170 Using data from the flight recorder, 477 00:34:13,253 --> 00:34:16,557 investigators focus first on the landing just prior 478 00:34:16,690 --> 00:34:18,692 to the one at Congonhas. 479 00:34:19,493 --> 00:34:23,864 We discover that the same pilot, the captain, 480 00:34:23,997 --> 00:34:28,035 was the one operating the aircraft in 481 00:34:28,168 --> 00:34:31,338 the previous land and in Congonhas. 482 00:34:32,206 --> 00:34:34,358 First, how did they land in Porto Alegre? 483 00:34:34,441 --> 00:34:36,677 Okay. 484 00:34:37,077 --> 00:34:39,489 Both levers full forward during approach. 485 00:34:42,382 --> 00:34:45,569 NARRATOR: They learn that during the previous landing in Porto Alegre, 486 00:34:45,652 --> 00:34:48,755 Captain Stephanini pulled back both thrust levers, 487 00:34:48,889 --> 00:34:52,259 (BEEPING) 488 00:34:52,392 --> 00:34:53,694 (TIRES SCREECHING) 489 00:34:53,827 --> 00:34:57,475 exactly the right procedure for landing with only one reverser. 490 00:34:57,865 --> 00:35:00,000 {\an8}And now both levers to reverse. 491 00:35:01,502 --> 00:35:03,687 {\an8}At the time of the accident, the correct procedure 492 00:35:03,770 --> 00:35:08,075 {\an8}was for the pilot to take both throttles to idle 493 00:35:09,343 --> 00:35:13,547 {\an8}and both throttles to reverse as if you had 494 00:35:13,680 --> 00:35:15,782 no problem with the reversers. 495 00:35:15,949 --> 00:35:18,202 NARRATOR: They've established that Captain Stephanini 496 00:35:18,285 --> 00:35:20,504 carried out the correct procedure for landing 497 00:35:20,587 --> 00:35:23,411 with one thrust reverser on the day of the crash. 498 00:35:27,060 --> 00:35:28,929 No reverser number two. 499 00:35:29,062 --> 00:35:30,631 Auto brakes on. 500 00:35:30,764 --> 00:35:32,766 And the speed is dropping. 501 00:35:33,333 --> 00:35:37,571 It puzzled me because of the fact that 502 00:35:37,704 --> 00:35:41,308 a captain knew the procedure. 503 00:35:41,441 --> 00:35:45,612 He performed the correct procedure 504 00:35:45,746 --> 00:35:48,715 hours before in the previous landing. 505 00:35:49,550 --> 00:35:51,035 NARRATOR: So what did he do differently 506 00:35:51,118 --> 00:35:53,620 two and a half hours later in São Paulo? 507 00:35:53,754 --> 00:35:56,690 Okay, now Congonhas. 508 00:35:56,823 --> 00:35:58,592 MAN: Left lever to idle. 509 00:35:58,725 --> 00:36:01,212 NARRATOR: The data shows that Captain Stephanini's handling 510 00:36:01,295 --> 00:36:03,380 - of the thrust levers. - MAN: Then reverse. 511 00:36:03,463 --> 00:36:06,684 NARRATOR: Was very different on his landing in São Paulo. 512 00:36:06,767 --> 00:36:08,552 VOICE: (OVER COMPUTER) 20. Retard. Retard. 513 00:36:08,635 --> 00:36:10,621 NARRATOR: Instead of throttling back both levers, 514 00:36:10,704 --> 00:36:12,223 he only put the left engine in idle, 515 00:36:12,306 --> 00:36:15,342 leaving the right one at full power. 516 00:36:19,112 --> 00:36:21,849 Then, once the aircraft had touched down, 517 00:36:21,982 --> 00:36:24,785 he activated only the left reverser, 518 00:36:24,918 --> 00:36:27,487 again leaving the right engine at full. 519 00:36:33,227 --> 00:36:34,845 {\an8}FERNANDO: That is quite different. 520 00:36:34,928 --> 00:36:36,230 I don't get it. 521 00:36:36,363 --> 00:36:39,266 How could a guy that knew the aircraft, 522 00:36:39,399 --> 00:36:44,071 that knew the correct procedure, that, uh, 523 00:36:44,204 --> 00:36:46,773 executed a correct procedure, 524 00:36:46,907 --> 00:36:51,512 how could he do something different? 525 00:36:52,880 --> 00:36:54,665 NARRATOR: It doesn't seem to make sense. 526 00:36:54,748 --> 00:36:56,200 We could really use your help on this. 527 00:36:56,283 --> 00:36:59,636 NARRATOR: Until Camargo enlists the help of another pilot. 528 00:37:01,355 --> 00:37:03,808 It's only then that he discovers an important detail 529 00:37:03,891 --> 00:37:06,260 that could explain what the captain did. 530 00:37:08,428 --> 00:37:11,816 It turns out there was an older, outdated procedure for landing 531 00:37:11,899 --> 00:37:14,434 an A320 with a single thrust reverser. 532 00:37:15,302 --> 00:37:16,954 Could you demonstrate it for me please? 533 00:37:17,037 --> 00:37:18,656 NARRATOR: It starts out the same. 534 00:37:18,739 --> 00:37:20,958 But then there's an important difference. 535 00:37:21,041 --> 00:37:23,377 The former procedure, uh, 536 00:37:23,510 --> 00:37:28,615 was taking both levers to idle 537 00:37:28,749 --> 00:37:32,286 and then just the lever corresponding 538 00:37:32,419 --> 00:37:35,923 to the engine with the reverser operating normally 539 00:37:36,056 --> 00:37:38,959 that would be taken to reverse position. 540 00:37:40,460 --> 00:37:43,514 NARRATOR: But that is not what Captain Stephanini did. 541 00:37:43,597 --> 00:37:47,656 He left the right engine at full power instead of bringing it to idle. 542 00:37:48,468 --> 00:37:50,688 If he was attempting the old procedure, 543 00:37:50,771 --> 00:37:52,105 he got it wrong. 544 00:38:00,814 --> 00:38:03,033 Investigators learn that Captain Stephanini would 545 00:38:03,116 --> 00:38:06,520 {\an8}not have been the first pilot to make that mistake. 546 00:38:06,653 --> 00:38:09,536 {\an8}There had been several accidents around the world. 547 00:38:09,990 --> 00:38:12,893 {\an8}The cause was identical: 548 00:38:13,026 --> 00:38:17,231 {\an8}pilots mishandling the procedure for landing with a disabled reverser, 549 00:38:17,364 --> 00:38:20,634 {\an8}inadvertently leaving one thrust lever at full power. 550 00:38:24,004 --> 00:38:28,742 That old procedure led pilots to error. 551 00:38:32,012 --> 00:38:35,015 NARRATOR: Airbus finally modified the procedure to 552 00:38:35,148 --> 00:38:37,501 reduce the risk of precisely that error. 553 00:38:39,286 --> 00:38:43,991 The manufacturer changed the procedure and determined that both 554 00:38:44,124 --> 00:38:47,111 levers would come down together to the idle position, 555 00:38:47,194 --> 00:38:49,980 and then right after touching the ground both would 556 00:38:50,063 --> 00:38:52,122 {\an8}come down to the reverser position. 557 00:38:56,069 --> 00:38:58,989 NARRATOR: Captain Stephanini was familiar with both the old and 558 00:38:59,072 --> 00:39:02,249 the new procedure for landing with a disabled reverser. 559 00:39:03,677 --> 00:39:08,215 It now seems on flight 3054 he may have tried to use the old one. 560 00:39:09,750 --> 00:39:12,786 The question for investigators, is why? 561 00:39:17,858 --> 00:39:22,296 NARRATOR: Investigators still can't understand why the crew of flight 3054 562 00:39:22,429 --> 00:39:25,253 {\an8}left an engine at full power after touching down. 563 00:39:25,699 --> 00:39:27,768 Did they get it wrong? 564 00:39:27,901 --> 00:39:30,154 NARRATOR: But after interviewing other pilots, 565 00:39:30,237 --> 00:39:32,823 they do understand why using the older procedure 566 00:39:32,906 --> 00:39:35,789 would have made sense that rainy day at Congonhas. 567 00:39:37,811 --> 00:39:41,832 It would bring the plane to a stop much more quickly than the new one. 568 00:39:41,915 --> 00:39:47,120 That could explain why the captain would go for 569 00:39:47,254 --> 00:39:51,191 a former procedure that he knew that 570 00:39:51,325 --> 00:39:54,761 was more efficient than the current one. 571 00:39:55,829 --> 00:39:58,149 NARRATOR: Investigators theorize that in reaction to 572 00:39:58,232 --> 00:40:00,634 deteriorating conditions at Congonhas... 573 00:40:00,767 --> 00:40:02,169 HENRIQUE: Wet runway. 574 00:40:02,302 --> 00:40:04,338 One reverser. 575 00:40:04,471 --> 00:40:07,291 I'm gonna buy us some runway and use the old procedure. 576 00:40:07,374 --> 00:40:10,060 NARRATOR: He was trying to ensure that he'd have as much 577 00:40:10,143 --> 00:40:14,014 {\an8}distance as possible to stop on the notorious runway 35-L. 578 00:40:15,182 --> 00:40:17,117 But he made a costly error. 579 00:40:17,251 --> 00:40:19,620 Under those circumstances. 580 00:40:19,753 --> 00:40:21,405 Remember, we only have one reverser. 581 00:40:21,488 --> 00:40:23,457 One reverser. Manual flight. Wet. 582 00:40:23,590 --> 00:40:26,460 One reverser. One reverser. Manual flight. 583 00:40:26,593 --> 00:40:31,198 It is completely understandable that he had 584 00:40:31,331 --> 00:40:34,334 tried a former procedure and, 585 00:40:34,468 --> 00:40:38,639 under such a pressure, made a mistake. 586 00:40:49,516 --> 00:40:51,535 NARRATOR: Lieutenant Vanessa Dias recreates 587 00:40:51,618 --> 00:40:54,324 the final moments of the flight in a simulator. 588 00:40:57,658 --> 00:40:58,909 Okay engine one to idle. 589 00:40:58,992 --> 00:41:01,128 Engine two stays at climb. 590 00:41:01,261 --> 00:41:03,848 NARRATOR: She notices that in a dark cockpit it would have been 591 00:41:03,931 --> 00:41:07,067 difficult to see the position of the thrust levers. 592 00:41:07,201 --> 00:41:08,486 VOICE: (OVER COMPUTER) 20. 593 00:41:08,569 --> 00:41:10,204 Retard. Retard. 594 00:41:10,337 --> 00:41:13,040 Engine one to reverse. Don't touch number two. 595 00:41:13,173 --> 00:41:17,311 Brakes. 596 00:41:17,444 --> 00:41:23,116 (ALARMS BEEPING) 597 00:41:24,318 --> 00:41:26,620 Okay so. 598 00:41:29,056 --> 00:41:33,660 In the simulator, we were able to program in every known factor, 599 00:41:33,794 --> 00:41:38,131 the chronology of events, whether it was cloudy or raining, 600 00:41:38,265 --> 00:41:40,418 the wet surface, the slippery surface, 601 00:41:40,501 --> 00:41:43,971 the position of the levers. 602 00:41:44,771 --> 00:41:48,536 We also went off the runway and had an accident in the simulator. 603 00:41:51,111 --> 00:41:53,264 NARRATOR: Lieutenant Dias believes she now understands 604 00:41:53,347 --> 00:41:57,150 why TAM Airlines flight 3054 ended in tragedy. 605 00:42:01,221 --> 00:42:06,059 Captain Stephanini had done everything he could to ensure the A320 would touch 606 00:42:06,193 --> 00:42:10,230 down on runway 35-L with as much room ahead of him as possible. 607 00:42:12,966 --> 00:42:14,168 Land green. 608 00:42:14,301 --> 00:42:15,469 Manual flight. 609 00:42:17,704 --> 00:42:20,458 NARRATOR: But the prospect of landing on the treacherous runway 610 00:42:20,541 --> 00:42:23,911 {\an8}had so unnerved him that he bungled a simple procedure. 611 00:42:26,046 --> 00:42:31,118 It's possible that tension might block a crucial motor response. 612 00:42:31,251 --> 00:42:33,987 It can affect the pilots ability to react. 613 00:42:40,327 --> 00:42:43,481 NARRATOR: There was no alarm to warn them that one engine was 614 00:42:43,564 --> 00:42:46,800 {\an8}speeding up while the other was in reverse. 615 00:42:51,371 --> 00:42:54,558 First Officer Lima tried to figure out what was going wrong. 616 00:42:54,641 --> 00:42:55,809 Decelerate! 617 00:42:55,943 --> 00:42:57,361 NARRATOR: But in a dark cockpit... 618 00:42:57,444 --> 00:42:58,612 It can't! 619 00:42:58,745 --> 00:43:01,682 NARRATOR: Overwhelmed by a landing going badly, 620 00:43:01,815 --> 00:43:04,852 he didn't notice the abnormal thrust lever settings. 621 00:43:05,485 --> 00:43:07,888 Decelerate! Decelerate! 622 00:43:08,021 --> 00:43:09,623 HENRIQUE: It can't! 623 00:43:12,059 --> 00:43:16,354 The pilots were unable to understand what was happening to their aircraft. 624 00:43:18,832 --> 00:43:21,869 Ah! Look at this! 625 00:43:22,002 --> 00:43:25,639 NARRATOR: A runway with a dangerous reputation... 626 00:43:25,772 --> 00:43:28,609 so unnerved a crew, that they made a mistake. 627 00:43:28,742 --> 00:43:30,043 KLEYBER: Turn! Turn! 628 00:43:30,177 --> 00:43:33,647 NARRATOR: That ended up killing 199 people. 629 00:43:35,582 --> 00:43:38,785 Oh, my God! Oh, my God! 630 00:43:39,753 --> 00:43:41,855 (SCREAMING) 631 00:43:44,224 --> 00:43:47,661 (LOUD CRASH) 632 00:43:53,567 --> 00:43:56,703 NARRATOR: Since the crash of flight 3054, 633 00:43:56,837 --> 00:44:00,955 the runways at Congonhas have been grooved and are regularly inspected. 634 00:44:01,608 --> 00:44:05,314 New rules are in place dictating wet weather landing procedures. 635 00:44:06,947 --> 00:44:12,586 In, uh, rainy weather you need to have all of your reversers operating. 636 00:44:14,321 --> 00:44:18,825 NARRATOR: But despite these efforts to improve safety at Congonhas, 637 00:44:18,959 --> 00:44:20,959 many pilots doubt it's any better. 638 00:44:22,863 --> 00:44:25,332 Congonhas is not safer today. 639 00:44:25,465 --> 00:44:27,752 It continues to be a dangerous airport. 640 00:44:27,835 --> 00:44:30,921 Only a total ban on operations in wet or rainy conditions 641 00:44:31,004 --> 00:44:34,575 would improve the safety of this airport. 642 00:44:36,577 --> 00:44:38,496 NARRATOR: What's clear is that even today, 643 00:44:38,579 --> 00:44:43,217 35-L is a runway that cannot shake its deadly reputation. 644 00:44:43,650 --> 00:44:45,385 {\an8}HENRIQUE: 35-L. 35-L.