The name “Congonhas Airport” is associated in the minds of many aviation industry professionals with the largest airplane crash in South America’s history. In 2007, TAM Airlines A320 Flight 3054 veered off of the runway while landing and crashed into a fuel station and an air cargo service building. All 187 passengers and 12 crew members that were on board were killed in the explosion that resulted. An investigation into the causes of the crash blamed the airport’s officials and criminally investigated them, ultimately finding that the blame was shared across multiple different parties. As a result of the catastrophe, Congonhas Airport was forced to adopt a series of safety measures aimed at preventing such a situation from reoccurring. It also lost much of its traffic, which was redirected to other Brazilian airports. This report aims to determine what the safety conditions were at the time of the crash, what has changed since, and what improvement opportunities remain.
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Conditions at the Time of the Crash
The primary reason for the crash taking place was that, during the landing, the weather at the airport was rainy. The severity of the situation was sufficient for Tan et al. (2017) to classify the runway as damaged and unsuitable for landing. Rain makes runways slippery, making it more difficult for an airplane to slow down and increasing the danger of the process. While airports take measures to mitigate the problem, they cannot eliminate it entirely due to the nature of runway materials and the persistence of rain. Per Mateou and Michaelides-Mateou (2016), the crew was informed of the problem, but, for some reason, the aircraft did not slow down as expected once it touched down. Subsequently, the crew lost control of the aircraft, which caused it to perform the maneuver that led to the crash. The investigation found that the airplane was misconfigured for the landing, though whether that was a mechanical breakage or human error is unclear.
With that said, Congonhas Airport shares some of the responsibility for the crash. Its safety management system was inadequate for the purposes that it was designed to fulfill, particularly with regard to maintaining the runway. Meyer Jr. et al. (2020) claim that the runways’ grooving system was not performing adequately at the time of the accident, which should have been considered a sufficient cause for closure. Grooving is a measure designed to reduce hydroplaning, which is a large contributor to the extension of the plane’s required landing runway lengths when the surface is wet. It drains water to the side of the runway while improving wheel friction, and its effects are critical to modern aviation. Failure to address such a significant problem indicates the existence of a broader issue on the part of the airport’s management.
The grooving issue was known before the accident occurred and reported to the leadership in a timely manner. However, Meyer Jr. et al. (2020) state that the issue was ignored, with the airport’s leadership refusing to close down the airport on rainy days and the regulator, Infraero, failing to act, as well. While the airport was able to operate without difficulties in most cases despite the technical failure of not having working grooving, once a faulty airplane came in on a rainy day, the result was a highly fatal crash. A more appropriate solution would be to plan grooving adjustments and implement them as soon as possible, closing the airport in risky conditions such as rain. The most likely reason why this action was not taken was likely the financial cost of doing so and losing potentially massive amounts of traffic and revenue.
The issue is further compounded by the fact that the disaster could be anticipated, as the day before the Flight 3054 crash, the airport had to be closed because of a similar incident. Meyer Jr. et al. (2020) note that a different plane had skidded at the same location the day before the disaster, leading to concern. As a result, the airport’s management and Infraero had adequate warning of the potential problems, having narrowly avoided a disaster. Moreover, Meyer Jr. et al. (2020) claim that the plane that would later crash had also come very near disaster a short time previously, only stopping several meters from the runway’s end. Infraero made measurements for the runway’s water level but deemed it unnecessary to close a few minutes before the disaster. Despite clear warning indications, landings continued, leading to the crash and the deaths of nearly 200 people.
With that said, a further investigation reveals deeper systemic issues that led to the airport having a landing strip with no grooving. Meyer Jr. et al. (2020) highlight the fact that the runway where the crash happened was newly repaired, and opened two weeks prior as a part of a large-scale safety improvement reform project. However, despite the purported aims of the project, the new landing strip did not have grooving incorporated into it, leading to complaints from pilots. By 2007, grooving was a well-established procedure that had been used for decades, but the management of Congonhas chose to open the runway before it was completed, delaying it until later. Regardless, the newness of the landing strip may explain the management’s reluctance to close it again for renovations, creating additional losses and suffering reputation damage. Alternately, it may be proposed that the airport’s regulators presumed the safety measures they had taken to be adequate.
Current Conditions Assessment
Following the catastrophe and the investigation into its causes, the Brazilian government imposed a set of restrictions on Congonhas that aimed to address the causes. According to Pacheco Júnior, Camargo, and Halawi (2020), the main provisions of the directive include a “Minimum Equipment List, Extra Fuel Load Limitations, Wet Runway Landing Obligations, and Prohibition of Takeoff and Landing” (p. 1). The requirements are generally more stringent than they were before the crash to reflect improvement over their inadequacy. The directive remains in place to this day, restricting the airport’s operations for purposes of ensuring safety. The airport has independently taken measures to improve its safety in response to the crash, as well. It identified a number of specific problems, particularly those that caused the accident, and worked to resolve them.
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The runway where the accident occurred was closed until another set of renovations, which included grooving, could be completed. Moreover, it was redesigned to fit the new requirements put forward by the government regulations. A runway end safety area (RESA) was established at each end of the runway. Its purpose is to minimize the damage to the aircraft in case that an issue such as that which affected Flight 3054 by removing dangerous obstacles from the path. With that said, the runway could not be expanded due to reasons explained below, and, per Pacheco Júnior, Camargo, and Halawi (2020), the creation of the RESAs led to a virtual reduction in the length of the runway by 280 meters. This lower effective length means that fewer aircraft satisfy the conditions put forward by regulators for landing at Congonhas. Additionally, Brazil as a whole has made efforts to improve its aviation safety situation.
Following the 2006-2007 aviation crisis and the crash in which it culminated, the government of Brazil recognized the dangers of continuing in a disorganized manner. It began looking for improvement opportunities and taking them wherever possible, reforming Infraero and the overall aviation framework in the nation. Additionally, it began working with international organizations to improve its aviation standards to match worldwide examples of excellence. Currently, Szyliowicz and Zamparini (2018) claim that Brazil exceeds global standards in all of its safety indicators, qualifying as a Category 1 member per the US FAA’s International Aviation Safety Assessment Program (IASA). The system evaluates all of the system’s aspects, such as laws, operations, organization, accident investigation, and airport quality. As such, the evaluators investigated the Congonhas Airport and found that it matched the standards they put forward.
With that said, the conditions at the airport still demonstrate opportunities for improvement or potential issues. Smith (2018) describes Congonhas as an airport with a notoriously short runway, which makes landings challenging. With that said, this situation does not necessarily present a safety risk as long as the pilot is aware of the situation and their landing is planned accordingly. Moreover, it can be challenging to expand the airport’s runway due to the land requirements needed to do so. Young and Wells (2019) describe it as constrained in its expansion by the lack of available land nearby, as it is surrounded by residential districts. As such, there is limited opportunity to add new runways or expand currently existing ones. Other measures need to be taken to ensure that takeoffs and landings are safe and accessible to a variety of aircraft.
There are also issues with regard to the rules constraining the airport, as they have stayed unchanged over the last 13 years. Pacheco Júnior, Camargo, and Halawi (2020) call for a revision to the practices, declaring them unnecessarily restrictive considering the new technologies that have developed since the 2007 crash. In particular, more advanced landing distance measurement systems were developed and deployed on board most or all current and future aircraft. They can take the condition of the machine into account during the flight, including potential malfunctions, and determine whether it is safe to attempt landing at a particular airport. As a result of this improvement and many others, aircraft that do not satisfy the minimum equipment list can typically land at Congonhas safely in many cases. However, the legislation still restricts them from doing so, and they are forced to fly to another airport in a potentially overly cautious move.
Safety Improvement Suggestions
The first proposal for Congonhas Airport and its regulators would be to review the rules that currently govern its operations. The fact that they have not changed in 12 years is problematic because aviation is a continuously evolving industry where new technologies and standards are constantly being developed. The recommendation by Pacheco Júnior, Camargo, and Halawi (2020) to revise the minimum equipment list because it does not affect the aircraft’s takeoff or landing risks is an example of a potentially outdated policy. Moreover, new risks have likely been identified in the course of operations, which also need to be taken into consideration and addressed. While some problems that are no longer significant may be removed from the standards, other, more relevant ones may be added. Overall, the revised rules are likely to reflect current needs better while still addressing the conditions that caused the 2007 crash and other prominent risks.
With that said, a singular revision of the rules will likely be inadequate in the long term. Over time, the new regulations will also become outdated, as the evolution of aviation is a continuous process. As such, it is necessary to create a safety management system at Congonhas that is also capable of operating in an ongoing manner. New developments in airline safety need to be recognized swiftly and incorporated into operations before a similar risk manifests at the airport. Such safety management systems have been implemented at many facilities, as Young and Wells (2019) describe. Such frameworks typically avoid the top-down hierarchical model that contributed to the 2007 catastrophe, preferring a more stakeholder-oriented approach. As such a system does not appear to have been implemented, its creation should be considered a high priority for the airport.
As indicated in the pertinent section, there were numerous complaints from pilots about the quality of the runway in 2007. If they had been taken into consideration in a timely manner, the Flight 3054 catastrophe could likely have been avoided. As Cortes, Rodrigues, and Cusick (2017) highlight, most safety management systems rely on the collection and analysis of such feedback from all involved parties. In doing so, the safety managers’ perspective of the situation at the airport broadens as they are exposed to different viewpoints. Moreover, by involving more people, the system increases the possibility that innovative and effective solutions that address the problem with minimal side effects will be developed. However, to implement such a system, it is first necessary to establish robust communications with all stakeholders and begin collecting feedback and discussing it.
With that said, current concerns are not the only area that a safety management system needs to take into account. Cortes, Rodrigues, and Cusick (2017) highlight the importance of proactive and predictive safety, which aims to forecast potential accidents and address them before they can take place. It uses modern technology to collect data about non-accidents and simulate the conditions under which they may have resulted in a more negative outcome. The airport’s systems are then adjusted to eliminate the possibility of these dangerous conditions occurring, effectively minimizing the threat. With that said, proactive and predictive safety requires an excellent risk assessment framework, which is a convoluted system too large to describe in this report. Congonhas Airport has likely developed an excellent system for the purpose, but, as with the regulation that governs it, it may be outdated.
As such, it is necessary to introduce contemporary risk assessment methods as well as findings from other airports to match whether they match the results produced by Congonhas’s current systems. Ketabdari, Giustozzi, and Crispino (2018) conduct a sensitivity analysis for two different airports that may also be applicable to Congonhas, identifying the factors that are the most significant contributors to accidents. Through such a review, it may be possible to identify weaknesses in the rules, such as the one described above. Lastly, Ketabdari, Giustozzi, and Crispino (2018) identify the tendency of airports to avoid reporting minor incidents to relevant authorities. For the purposes discussed above, such practices are not permissible since they deprive the airport and its regulators of valuable data that may help improve safety in the long term.
Overall, the 2007 Flight 3054 crash was presumably the result of conscious misconduct on the part of Congonhas Airport authorities. They put a runway without grooving into service and ignored the warnings and complaints about the risks. As a result, after several cases where the accident nearly occurred, an airplane crashed, killing all of the passengers. The airport undertook large-scale changes as a result, aimed at improving safety and preventing such an incident from occurring again. Now, it satisfies world standards in this regard and serves aircraft and passengers with a high degree of safety. However, the rules may be becoming outdated, as no continuous safety improvement framework was put into place. Rectifying this problem will likely be the most significant step toward improvement, establishing a stakeholder-oriented system that actively collects feedback and takes it into account. Moreover, the airport would benefit from the adoption of contemporary methods and frameworks for accident modeling and risk assessment, which would also likely lead to revisions in the rules and improved overall safety.
Cortes, A. I., Rodrigues, C. C. and Cusick, S. K. (2017) Commercial aviation safety. 6th edn. New York, NY: McGraw-Hill Education.
Ketabdari, M., Giustozzi, F. and Crispino, M. (2018) ‘Sensitivity analysis of influencing factors in probabilistic risk assessment for airports’, Safety Science, 107, pp. 173-187.
Mateou, A. and Michaelides-Mateou, S. (2016) Flying in the face of criminalization: the safety implications of prosecuting aviation professionals for accidents. London: CRC Press.
Meyer Jr, V., e Cunha, M.P., Mamédio, D.F. and Nogueira, D.P. (2020) ‘Crisis management in high-reliability organizations: lessons from Brazilian air disasters’, Disaster Prevention and Management: An International Journal. Web.
Pacheco Júnior, 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). Web.
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Smith, P. (2018) Cockpit confidential: everything you need to know about air travel. Naperville, IL: Sourcebooks.
Szyliowicz, J. S. and Zamparini, L. (eds.) (2018) Air transport security: issues, challenges and national policies. Cheltenham: Edward Elgar Publishing, Incorporated.
Tan, H. W. A., Chew, S. H., Wu, J. and Wu, H. (2017) Multi-layer pavement system under blast load. Singapore: Springer Singapore.
Young, S. and Wells, A. T. (2019) Airport planning & management. 7th edn. New York, NY: McGraw-Hill Education.