Air.Crash.Investigation.S11E01.Deadly Reputation (TAM Airlines Flight 3054)

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Transcript

00:00Every flight begins and ends here.

00:05A strip of asphalt scorched by jet engines and marred with rubber.

00:11But not all runways are created equal.

00:15One of the world's most notorious is runway 35L at Congonhas Airport in Brazil.

00:22It could surprise you at any moment.

00:25In July 2007, TAM Airlines Flight 3054 becomes its latest victim.

00:42The runway claims 199 lives.

00:46It would be carefully scrutinized, its history reviewed.

00:51Investigators desperately need to know why runway 35L is so dangerous.

00:58Before more lives are lost.

01:21São Paulo, Brazil

01:33Heavy rains pound Brazil's largest city.

01:39São Paulo sees this kind of deluge regularly during the winter rains.

01:45The downpour snarls traffic to and from Congonhas Airport.

01:51800 kilometers away, TAM Airlines Flight 3054 is en route from the southern Brazilian city of Porto Alegre.

02:01The Airbus A320 is headed for São Paulo 90 minutes away.

02:10For the 181 passengers on board, it's a routine domestic flight.

02:21But there's been an unexpected development for Captain Henrique Stefanini di Sacco.

02:27He and his first officer, Kleiber Lima,

02:30have just learned that the heavy rain has temporarily shut down runway 35L,

02:35the main runway of their destination.

02:39Did they say when it would reopen?

02:42No.

02:44Let's prepare an alternate just in case.

02:47Ladies and gentlemen, it looks like due to the weather we may not be able to land at Congonhas as planned.

02:54I will keep you advised as I get more information.

03:05Congonhas Airport is one of the busiest in the world.

03:10Planes take off and land here every 90 seconds,

03:16carrying a steady stream of people and cargo into the country's economic hub.

03:24But Congonhas is also notorious among pilots.

03:32The airport lies in the heart of the city,

03:35crowded on all sides by apartment buildings, offices and roadways.

03:48Runway 35L is less than 2,000 meters long, short for large jets.

03:56Even worse, it's built on a hilltop with a sharp drop-off on all sides.

04:02The risk the airport poses, due to its construction, due to its geography,

04:07it does not allow for simple mistakes.

04:19Captain Carlos Camacho is the flight safety director of the Brazilian Pilots' Union.

04:24As you approach the runway, your adrenaline is really pumping.

04:28For us pilots, it's like landing on an aircraft carrier.

04:38It makes Congonhas one of the most treacherous airports in the world.

04:44In fact, a Pantanal Airlines commuter plane

04:47spun out of control while landing just the day before.

04:51And a few months ago, disaster was narrowly averted

04:55when a Boeing 737 came skidding to a stop,

04:58just inches before the steep embankment at the end.

05:04The plane was hit by an aircraft carrier,

05:07and the Boeing 737 came skidding to a stop

05:10just inches before the steep embankment at the end of runway 35L.

05:21When pilots begin landing at Congonhas,

05:24they're more worried than when operating at any other national airport.

05:29Flight 3054 is at cruising altitude south of Sao Paulo

05:33when the crew gets news that runway 35L is back in operation.

05:383054, 35L is the active runway.

05:41There's no need to divert.

05:47Ladies and gentlemen, this is your captain speaking.

05:50I have some good news for you.

05:52The runway at Congonhas has been cleared.

05:56The runway at Congonhas has reopened.

05:59We'll arrive as scheduled shortly before 7pm.

06:03The relief of the passengers is not shared by the pilot.

06:07Stefanini has an additional challenge on this flight.

06:10Remember, we only have one reverse, sir.

06:13Yes. Only the left.

06:17He will have to land at one of the world's most challenging airports

06:21with less than the usual amount of stopping power.

06:26One of the Airbus' two thrust reversers isn't working.

06:30The devices are designed to slow the aircraft on landing

06:33by reversing engine thrust.

06:37If I was the pilot that day, I would be extremely concerned

06:41knowing that one of my reversers wasn't functioning.

06:45TAN 3054, 35L, clear to land.

06:50Stefanini will be landing on the infamous runway 35L.

06:56The runway is wet and it's slippery.

06:58The wind is 330 at 8 knots.

07:04The crew was informed of poor braking conditions on the runway.

07:11The Airbus is on final approach.

07:15Even though the autopilot could get the plane to the runway,

07:18the captain decides to take over the controls himself.

07:22Land green. Manual flight.

07:27He wants to bring the plane in as close to the runway threshold as possible.

07:32He needs every inch of runway he can get.

07:3535L, 35L.

07:39The concern was that after touching down,

07:42the pilots needed to be sure that they would be able to stop their plane

07:46before the end of the runway.

07:50The passengers only know that they'll soon be landing.

07:58300, 300.

08:02Now they are only 300 feet above the city.

08:07The Airbus is lined up with the center of the runway.

08:10Middle.

08:12The runway conditions.

08:15200, 200.

08:21100, 100.

08:23One dot now.

08:25The plane's wheels will touch the Congonhas tarmac in seconds.

08:2920. Retard.

08:39As the plane touches down,

08:41their worries about landing are only just beginning.

08:46Captain Stefanini applies reverse thrust

08:49to the A320's only working reverser.

08:57The pilot would have to activate the reverser

08:59on the engine that had a working reverser

09:01as fast as possible to initiate deceleration.

09:07But the plane is not slowing down.

09:11Reverse number one only.

09:12At this rate, it will use up the entire 1945 meters of runway

09:18in less than 30 seconds.

09:31Decelerate.

09:33It can't.

09:36The pilots operated the foot brakes with the pedals.

09:41Pressing on them for a long time.

09:46Look at this.

09:47Now.

09:48Look at this.

09:49The aircraft mysteriously pulls to the left.

09:55It's almost as if it has a mind of its own.

10:02Oh my God!

10:12No!

10:14No!

10:28Flight 3054 has slammed into a TAM Airlines building

10:32and an adjacent gas station.

10:34Nearly 200 firefighters descend on the scene.

10:37They face a raging fuel fire,

10:39burning at almost a thousand degrees Celsius.

10:52The devastation horrifies Dr. Douglas Ferrari.

11:00The explosion spread fire throughout the entire area.

11:03There was a fire in the gas station.

11:05Killing the people who were filling up their tanks.

11:07Burning the whole structure.

11:09Turning it unrecognizable.

11:15He had hoped to treat survivors.

11:17But now he fears there might not be any.

11:23We had three, four cars on fire.

11:26In one of these cars, I saw a mother with her child.

11:31Dead.

11:33Dead.

11:38The entire plane is engulfed in flames.

11:41There's little hope for anyone inside.

11:47But now there is a new danger.

11:50Huge quantities of fuel in the storage tanks beneath the gas station

11:54could blow up at any moment.

11:59The aircraft broke its wings on impact.

12:02And spilled fuel throughout the entire area.

12:09There was a risk of the gas station exploding.

12:17Rescuers hope they can save people in the TAM Airlines building.

12:21But with the fire raging out of control,

12:25they will have to act fast.

12:33We tried to rescue the people from inside the building.

12:37I was anxious to help them.

12:49Dr. Ferrari makes a grim find inside the TAM Airlines offices.

12:55The airplane wing blocked the way.

12:58It prevented people from escaping.

13:02I was behind the firefighter accompanying me

13:07while he moved bodies to the sidewalk.

13:12It was a horrible feeling.

13:19But they do locate some office workers in another part of the building

13:23and rush them to safety.

13:28On the right side of the building, where there was no obstruction,

13:31there was time for people to get out.

13:34About 10 or 20 people made it.

13:40No one in the aircraft has survived.

13:43199 people are dead,

13:45including a dozen people in the gas station and the TAM building.

13:49It's the worst aviation accident in South American history.

13:56The black boxes will not last long in the heat!

14:00Lieutenant Colonel Fernando Camargo

14:02is an accident investigator with CENIPA,

14:05the country's aviation safety agency.

14:08In modern aircraft, the recorders are the core of any investigation.

14:15So when we arrived at the crash site and we saw that strong fire,

14:22we got really concerned about the integrity of the data.

14:26He knows the intense heat could already be damaging

14:29the plane's data and voice recorders.

14:32Valuable evidence that could help explain the crash may already be lost.

14:39Colonel Camargo and his team know that just the day before,

14:42another plane slid off runway 35L.

14:46We knew that we would have to run a complete investigation on the runway.

14:56If a rain-slicked runway caused this crash, disaster could strike again soon.

15:02The pressure is on to figure out exactly what happened to flight 3054.

15:08I knew that there was a video from the surveillance system.

15:12That's the time of the accident, that must be it.

15:15The airport surveillance system captured the doomed airbus speeding down the runway.

15:20This video could solve a lot of issues.

15:24Let's see it again, please.

15:27But the crash was outside the range of the cameras.

15:33Can we look at this from a different angle?

15:36Even without the crash on tape, the video could hold important clues.

15:41Do you have tape of other A320s landing?

15:49OK, go ahead and play it now.

15:52We compared the time frames from one aircraft to another.

16:04Nine seconds.

16:05A regular landing, the aircraft would take something about nine seconds to pass over this camera.

16:14OK, now the crash plane, please.

16:16And the accident aircraft took three seconds.

16:21Three seconds?

16:23That puzzled us a little bit.

16:29Why was the crash plane going three times faster than a regular A320 landing?

16:34Four hours after the accident, firefighters are still battling the intense blaze.

16:40The fire was a strong fire with a lot of fuel to keep it burning.

16:46Camargo is desperate to gain access to the tail section, which contains the two black boxes.

16:53They concentrated the fire on the tail section.

16:57Finally, firefighters beat back the flames enough to get at the recorders.

17:06But it may be too late.

17:11They can be submitted to fire until a certain temperature.

17:17After that, there's no going back.

17:20They can be submitted to fire until a certain temperature.

17:26After that, there's no guarantee that data will be preserved.

17:31The recorders will be sent to Washington to be examined at the National Transportation Safety Board.

17:38Now, investigators can focus on the infamous Runway 35L.

17:43They examine the surface for clues that might explain why Flight 3054 went so badly out of control.

17:54We walked through the runway, searching for evidence, marks on the runway.

18:02It's still wet!

18:05The water is pooling, creating puddles.

18:09That shouldn't happen on a modern runway.

18:13When this water gets in contact with the landing gear,

18:17it creates a puddle.

18:20This puddle is called a puddle.

18:23It's a puddle of water.

18:25When this water gets in contact with the landing gear, the tires,

18:30it can generate what we call hydroplaning.

18:33And this is a problem because a pilot will have little or no control of his aircraft.

18:42Camargo and his team wonder why water is pooling on the runway.

18:47They study files from the government agency that runs Congonhas Airport.

18:56They learn that Runway 35L had been completely resurfaced just one month before the accident.

19:07In 2007, the runway at Congonhas underwent repairs.

19:12It had been offering a very low level of traction.

19:15There were many reports of skids.

19:18For years, pilots had been complaining about the slippery conditions.

19:25They knew that the pavement needed to be reconstructed.

19:34Because the surface allowed the water to accumulate.

19:46The runway had been resurfaced.

19:49That should have solved the water problem.

19:52It reopened just weeks before the crash.

19:55The new surface seemed to be a major improvement.

20:01The airport operated for about a month in dry weather with no problems.

20:08But then, three days before the crash, heavy rains began.

20:15And with the rain, all the problems that were supposed to be solved came back.

20:27On the night of the accident, the biggest problem was still the water.

20:32Aircraft were still reporting difficulties breaking.

20:36In theory, there was no more depressions on the runway to accumulate water.

20:43So, what could cause water to accumulate?

20:51The aircraft were still reporting difficulties breaking.

20:55The aircraft were still reporting difficulties breaking.

20:58The aircraft were still reporting difficulties breaking.

21:00Accumulate.

21:05He discovers that the repair work lacked a critical safety feature.

21:10Proving to be done at a later date.

21:13No wonder it was wet.

21:19Special grooves that carry away rainwater.

21:23Without them, rain would collect in puddles.

21:26The repairs still lacked the necessary upgrade.

21:29The repairs still lacked the necessary upgrade.

21:32It was very difficult to interrupt the operation of the main runway in order to install the grooves.

21:47Evidence is mounting that a compromised surface on runway 35L

21:51played a key role in Brazil's worst airline accident.

21:56Colonel Camargo is concerned that Brazil's notorious rains may bring more runway disasters.

22:05Soon after the accident, we recommended the suspension of the operations of regular aircraft in rainy conditions.

22:15The airport authority complies, shutting down runway 35L until answers are found.

22:21But the main runway at one of the world's busiest airports can't stay closed for long.

22:31They must find out what caused this accident as soon as possible.

22:36Their focus turns to the A320's thrust reversers.

22:47The plane's maintenance records reveal why only one of them was working.

22:52Four days before the crash, mechanics deactivated the right engine's thrust reverser for routine maintenance.

23:03But the aircraft had then flown without incident for four days.

23:10Not only had the plane landed repeatedly with one thrust reverser,

23:17it had even landed safely on runway 35L.

23:22This plane landed on the same runway, on the same runway that day, with the same problems.

23:29It had only one thrust reverser, just one thrust reverser. No issues whatsoever.

23:35So why had this landing gone so wrong?

23:52Colonel Fernando Camargo travels to Washington, D.C.

23:57Technicians at the National Transportation Safety Board will help him try to recover data stored in Flight 3054's badly burned flight recorders.

24:11First, they look for a temperature-sensitive chip that could provide a clue as to how bad the heat damage might be.

24:18There is an indicator that turns the collar if it was exposed to a temperature above that one that it was manufactured to support.

24:33Even though the boxes are designed to survive a fierce fire of up to a thousand degrees Celsius, the chip's appearance is worrying news.

24:42These boards were submitted to a fire that exceeded its limitation.

24:50They test the circuit board to see if any of the memories survived.

24:57Without the data, the investigation into Flight 3054 would be effectively crippled.

25:04Colonel Camargo may never know why 199 people died at Brazil's busiest airport.

25:12But the circuit board test provides some hope.

25:16Okay, we got something.

25:18Fortunately, everything works okay. We could recover 100% of the data.

25:24Here we go.

25:25The information paints a picture of the plane's performance.

25:29Speed is fine.

25:30In the critical seconds before the crash.

25:32It came down fine.

25:36Brakes were engaged. Brakes were engaged.

25:39The data confirms that the foot brakes were working properly and that the A320 did not skid or slide.

25:47Here. Here.

25:48Then Camargo discovers that the plane's two engines were inexplicably operating against each other.

25:55Engine one.

25:56The plane's left engine was in reverse to help slow the aircraft down.

26:03But the right engine, the one with the disabled thrust reverser, was doing the opposite.

26:11Instead of winding down, it was accelerating to climb power.

26:20With one engine at full power, the pilots didn't have a chance to stop their aircraft in time.

26:26This aircraft was breaking.

26:28Oh, my God. Yes. Look at this.

26:30But it would take around one more kilometer for it to stop.

26:36The lopsided thrust pushed the plane to the left.

26:42The right engine really was increasing thrust.

26:48There was no means available for the pilot to avoid the aircraft to veer off to the left.

26:59Could be this.

27:01So engine two was thrusting when it should have been idling.

27:04That would explain the veer off to the left, right?

27:07So what does this mean?

27:09Now Colonel Camargo needs to figure out why the right engine was at full power when it should have been in reverse.

27:17At that time, we could establish roughly two main lines of investigation.

27:25One, mechanical failure.

27:29And the other one, pilot error.

27:36Colonel Camargo brings in human factors investigators,

27:40Lieutenant Colonel Marcia Farger and First Lieutenant Vanessa Diaz.

27:44The pilot is Enrique Stefanini Di Sacco, age 53, from Sao Paulo.

27:52Age 53 from Sao Paulo, 13,654 flight hours.

28:01The pilot who was in command was a very experienced pilot.

28:05He knew the aircraft very well.

28:07His first officer was Egear Cleber Lima, age 54, from Puerto Velo.

28:1214,760 flight hours.

28:16He had enough training to do a good job, including in an emergency situation.

28:25Their job is to determine if the crew somehow made an error

28:29that could have caused one engine to stay at full power.

28:36Machines are straightforward because they work in predictable ways.

28:40Humans are infinitely more complex in the way they think and act.

28:43It's much harder to analyze their behavior in an accident.

28:49I can't believe that this pilot would make that kind of mistake.

28:57The human factors team must now conduct a psychological study of the crew

29:02to understand how they might have committed a fatal misstep.

29:06We attempted to reconstruct the individual history of each crew member

29:10and their experience.

29:14Ladies and gentlemen, this is your captain speaking.

29:16I have some good news for you.

29:18And tried to create a picture that could help us explain

29:21what happened in the cockpit.

29:28Colonel Camargo still believes a mechanical failure is more likely.

29:33He now turns his attention to the complicated mechanics

29:36that link the thrust levers to the engines.

29:39He must determine if a failure there led to the mysterious power surge.

29:46We began studying the thrust system,

29:50each and every component of the system,

29:53from the lever to the engine.

29:58We've been through it. We know it's not the fatal...

30:00There's nothing wrong with the engines.

30:02That leaves only one component that could have caused the problem.

30:06The mechanism that links the throttles to the engines,

30:09a device called an artificial field unit, or AFU.

30:14Investigators wonder if that device failed,

30:17leaving the engines at full power even though the pilots set the lever to idle.

30:22But such a failure is highly unlikely.

30:31It's really a remote possibility.

30:35400 billion hours of flight for us to have one occurrence of that.

30:47Still, he needs to rule out the AFU as a possible cause of the crash.

30:51But he's not sure the unit can even be found amongst the wreckage.

30:56Computers, all the avionics, everything was gone.

31:04Luckily, one of the few pieces to have survived the fire

31:08is the piece investigators now need, the AFU.

31:12It's sent to a specialised laboratory that can scan the metal for microscopic markings.

31:20Look.

31:22It got melted in such a way that you can't work with it,

31:26so we could check something.

31:29The 3D scanner allows them to look for nicks or scratches

31:33that would indicate the unit failed.

31:38I'm looking for any unusual marks in this area.

31:42If we could find out any mark, any evidence of the position of this gear,

31:48we could go after the lever and find out the real position of the thrust lever.

31:56But they can find no evidence that the AFU malfunctioned.

32:01OK, pack it up, let's go.

32:04We found nothing. No mark, no evidence.

32:09Colonel Camargo concludes mechanical failure was not to blame

32:13for the improper power setting on the right engine.

32:16He has to assume that for some reason

32:19the crew left the right engine lever at full power after the airbus landed.

32:39Back in Sao Paulo, the human factors team turns to the cockpit voice recorder, or CVR.

32:47They need to understand the pilot's state of mind

32:50as they approach Sao Paulo the night of the crash.

32:57The CVR enables us to get an idea of the interaction between crew members.

33:05They learn that Captain Stefanini was quite concerned about the runway conditions.

33:09Ask him about the rain.

33:11The runway conditions.

33:13Is the runway slippery?

33:16Tam, on final approach.

33:18Two miles away. Could you confirm conditions?

33:22It's wet and it's slippery, 3054.

33:27Wet and slippery.

33:31The pilot is already tense.

33:33And then he finds out that runway conditions are worse than usual.

33:36Slippery and rainy.

33:40The tension can affect the pilot's perception, his concentration.

33:4735L, 35L.

33:53It now appears that Stefanini's anxiety about 35L,

33:57and not the runway itself, was the main cause of this crash.

34:01Camargo now focuses on the crew's actions.

34:06I think it's ready, sir. Thank you.

34:10He needs to understand how the power levers were handled

34:13before the crash.

34:15Using data from the flight recorder,

34:17investigators focus first on the landing just prior to the one at Congonhas.

34:22We discovered that the same pilot, the captain,

34:27was the one operating the aircraft

34:30in the previous land and in Congonhas.

34:35First, how did they land in Porto Alegre?

34:38OK.

34:40Both levers full forward during approach.

34:45They learned that during the previous landing in Porto Alegre,

34:49Captain Stefanini pulled back both thrust levers.

34:57Exactly the right procedure for landing with only one reverser.

35:01And now, both levers to reverse.

35:04At the time of the accident,

35:07at the time of the accident,

35:09the correct procedure was for the pilot to take both throttles to idle

35:14and both throttles to reverse,

35:17as if you had no problem with the reversers.

35:21They've established that Captain Stefanini

35:24carried out the correct procedure for landing with one thrust reverser

35:28on the day of the crash.

35:32No reverser number two.

35:35Auto brakes on.

35:37And speed is dropping.

35:39It puzzled me because of the fact

35:43that a captain knew the procedure.

35:47He performed the correct procedure

35:51hours before in the previous landing.

35:55So what did he do differently two and a half hours later in Sao Paolo?

36:00OK, now Congonhas.

36:03Left lever to idle.

36:05The data shows that Captain Stefanini's handling of the thrust levers

36:09was very different on his landing in Sao Paolo.

36:13Instead of throttling back both levers,

36:16he only put the left engine in idle,

36:19leaving the right one at full power.

36:25Then, once the aircraft had touched down,

36:28he activated only the left reverser,

36:31again leaving the right engine at full.

36:39That is quite different. I don't get it.

36:42How could a guy that knew the aircraft,

36:46that knew the correct procedure,

36:49that executed a correct procedure,

36:53how could he do something different?

36:59It doesn't seem to make sense...

37:01We could really use your help on this.

37:03...until Camargo enlists the help of another pilot.

37:07It's only then that he discovers an important detail

37:11that could explain what the captain did.

37:14It turns out there was an older, outdated procedure

37:18for landing an A320 with a single thrust reverser.

37:21Could you demonstrate it for me, please?

37:23It starts out the same, but then there's an important difference.

37:27The former procedure was taking both levers to idle,

37:34and then just the lever corresponding to the engine

37:39with the reverser operating normally,

37:42that would be taken to reverse position.

37:46But that is not what Captain Stefanini did.

37:49He left the right engine at full power

37:52instead of bringing it to idle.

37:54If he was attempting the old procedure, he got it wrong.

38:06Investigators learn that Captain Stefanini

38:09would not have been the first pilot to make that mistake.

38:12There had been several accidents around the world.

38:15The cause was identical.

38:18Pilots mishandling the procedure for landing with a disabled reverser.

38:23Inadvertently leaving one thrust lever at full power.

38:30That old procedure led pilots to error.

38:38Airbus finally modified the procedure

38:41to reduce the risk of precisely that error.

38:47The manufacturer changed the procedure

38:49and determined that both levers would come down together

38:52to the idle position, and then, right after touching the ground,

38:56both would come down to the reverser position.

39:02Captain Stefanini was familiar with both the old and the new procedure

39:06for landing with a disabled reverser.

39:09It now seems on flight 3054 he may have tried to use the old one.

39:15The question for investigators is why?

39:23Flight 3054

39:28Investigators still can't understand why the crew of flight 3054

39:32left an engine at full power after touching down.

39:38But after interviewing other pilots,

39:40they do understand why using the older procedure

39:43would have made sense that rainy day at Congonhas.

39:47It would bring the plane to a stop much more quickly than the new one.

39:52That could explain why the captain would go for a former procedure

39:59that he knew that was more efficient than the current one.

40:06Investigators theorize that in reaction to deteriorating conditions at Congonhas...

40:11One runway, one reverser.

40:14I'm going to buy us a runway and use the old procedure.

40:18He was trying to ensure that he'd have as much distance as possible

40:21to stop on the notorious runway 35L.

40:25But he made a costly error.

40:27Under those circumstances...

40:29Remember, we only have one reverser.

40:31One reverser, manual flight. Wet.

40:33One reverser, one reverser, manual flight.

40:36It is completely understandable that he had tried a former procedure

40:43and under such a pressure made a mistake.

40:52Flight simulator

40:59Lieutenant Vanessa Diaz recreates the final moments of the flight in a simulator.

41:07Okay, engine one to idle, engine two stays at climb.

41:11She notices that in a dark cockpit,

41:13it would have been difficult to see the position of the thrust levers.

41:1720, retard, retard.

41:20Engine one to reverse, don't touch number two.

41:23Brakes.

41:39In the simulator, we were able to program in every known factor.

41:45The chronology of events, whether it was cloudy or raining,

41:48the wet surface, the slippery surface, position of the levers.

41:54We also went off the runway and had an accident in the simulator.

42:01Lieutenant Diaz believes she now understands

42:03why TAM Airlines Flight 3054 ended in tragedy.

42:11Captain Stepanini had done everything he could

42:13to ensure the A320 would touch down on runway 35L

42:17with as much room ahead of him as possible.

42:23Land green, manual flight.

42:27But the prospect of landing on the treacherous runway

42:30had so unnerved him that he bungled a simple procedure.

42:37It's possible that tension might block a crucial motor response.

42:41It can affect the pilot's ability to react.

42:48There was no alarm to warn them

42:51that one engine was speeding up

42:54while the other was in reverse.

43:00First Officer Lima tried to figure out what was going wrong.

43:03Decelerate.

43:05But in a dark cockpit,

43:07overwhelmed by a landing going badly,

43:10he didn't notice the abnormal thrust lever settings.

43:14Decelerate.

43:16Decelerate.

43:22Pilots were unable to understand what was happening to their aircraft.

43:31A runway with a dangerous reputation

43:35so unnerved a crew that they made a mistake

43:39that ended up killing 199 people.

43:46Oh, my God! Oh, my God!

44:04Since the crash of Flight 3054,

44:07the runways at Congonhas have been grooved

44:10and are regularly inspected.

44:12Rules are in place dictating wet weather landing procedures.

44:17In rainy weather,

44:19you need to have all of your reversers operating.

44:24But despite these efforts to improve safety at Congonhas,

44:29many pilots doubt it's any better.

44:33Congonhas is not safer today.

44:35It continues to be a dangerous airport.

44:38Only a total ban on operations in wet or rainy conditions

44:41would improve the safety of this airport.

44:46What's clear is that even today,

44:4935L is a runway that cannot shake its deadly reputation.

45:11For more UN videos visit www.un.org

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