Fire fighters work hard to contain the fire that erupted when the airline smashed into a nearby storage building. (Photographer Eugenio Goulart)
A Tragedy Foretold: The TAM Airlines Disaster
NFPA Journal®, January/February 2008
By Marcelo Lima
On July 17, 2007, at 6:47 p.m., Brazil’s TAM Linhas Aéreas Flight 3054 attempted to land at the Congonhas airport, which is in the state of São Paulo and is the busiest airport in Brazil. Arriving from the city of Porto Alegre with 187 people on board, the TAM airline’s Airbus A320 touched down in a normal manner, but as it traveled the short runway, the crew and the control tower realized something was very wrong.
The airplane was moving too fast. Barely 24 seconds after touching the ground, it overran the end of the tarmac, became airborne again, and flew across a city avenue jammed with cars before striking the TAM airline’s three-story cargo storage building outside the airport and exploding. The accident left 199 dead, including passengers, crew, building occupants, and passerbys.
It is the largest loss of life plane crash in the history of Brazil and it happened just 10 months after the mid-air collision of a Gol Boeing 737-800 and an Excel Air Legacy jet. That collision left 154 dead.
State of tension and chaos
At the time of the crash, Brazilian civil aviation officials were going through a severe management crisis. Since September 2006, the population faced so-called “aerial blackouts,” which included extremely long lines at airports, long flight delays, and canceled flights. After the Gol accident, Brazilians added safety fears to their worries and placed more pressure on the aviation industry. In the months that followed, the crisis gained strength, leaving Brazilians in permanent state of tension and chaos at the country’s airports.
The timing of the TAM airline’s crash and its loss of life dramatically underlined the fragility of the system and the lack of a quick solution to the country’s aerial problems.
Congonhas Airport opened on April 24, 1936 in an area far from the city center known as Vila Congonhas. The airport was in the middle of a vast area of open ground, where medium-sized aircraft such as McDonnell-Douglas DC-3s and Junkers Ju-52s commonly landed. Even though it was remote, the airport was not subject to the floods affecting the Campo de Marte, São Paulo’s main landing runway. It was the perfect spot for an airport that at the time served a city of one million.
Congonhas was São Paulo’s main airport for many years, but after the 1985 construction of the larger Guarulhos Airport, it was used for national flights only. Eventually, Congonhas and Guarulhos became the main airports of São Paulo’s metropolitan region, which now has a population of 16 million. Despite its smaller size, Congonhas is used more often due to its accessible location within the city than the distant Guarulhos Airport.
A massive renovation of Congonhas began in 2003, which included the modernization of the passenger terminals and boarding area, construction of new parking areas, and modification of the road system. By 2006, 18.5 million passengers used Congonhas despite its size limitations.
Despite the renovations, Congonhas still suffered from chronic problems. First, the 1,939-meter (6,361-foot) runway is too short for big aircraft. Second, the airport, which previously dominated the landscape in the middle of an empty countryside, is now part of a huge city and surrounded by tall buildings. The aging airport was also feeling the effects of Brazil’s tough environment. In February 2007, Brazilian courts ordered the closing of the airport during heavy rain. Water would accumulate on the main runway, and any airplane landing on it risked skidding. Recently, the main runway was closed for 45 days to fix this problem.
The atmosphere and the accident
The Gol aircraft collision with the Legacy Jet sparked a civil aviation crisis and generated ample discussion of air safety conditions in Brazilian air space. People accused air controllers of technical ineptness and protested equipment failures and the lack of investment in the air safety structure; nearly bring about the collapse of Brazilian civil aviation.
In the middle of this crisis, TAM Flight 3054, with 181 passengers and 6 crew members, left Porto Alegre, in the south of the country, at 5:16 p.m. The flight progressed smoothly.
The weather was rainy in São Paulo, and air traffic in Congonhas was heavy. A day earlier, a Pantanal ATR-42 aircraft arriving from the São Paulo city of Araçatuba skidded while landing at Congonhas Airport. No one was injured.
The air-traffic control tower, as is a procedure on rainy days, informed Flight 3054 that the runway was slippery and authorized the landing. The pilot and co-pilot acknowledged that the right engine reverser was “feathered,” meaning it had been deactivated by TAM’s maintenance personnel, and only the left engine reverser could be used to aid in the airplane’s braking. According to information provided by the airline, using one engine reverser when braking was normal procedure, and was foreseen in the aircraft manufacturer’s operations manual.
The Airbus A320 touched down 300 meters (984 feet) from the start of the runway and at 240 kilometers per hour (149 miles per hour). Instead of starting to reduce speed, as expected, the plane continued to travel at high speed along the runway. It completed the rest its trajectory in only 24 seconds.
As it reached the end of the tarmac, the plane made a wide turn to the left and crossed a stretch of grass-covered land until it reached the airport’s limits. There’s a difference in levels of approximately 10 meters (32 feet) between the Congonhas runway and the Avenida Washington
Luis, which travels parallel to the airport. The A320 lifted off again, flew just 60 meters (196 feet) over the avenue, and then hit the second floor of the three-story TAM cargo storage building
and a gas station in front of the building.
The aircraft destroyed the building’s support pillar upon impact and the top floor collapsed onto the floor below. The collapse completely crushed the first 12 meters (39 feet) of fuselage. With the crushing impact, the jet fuel quickly flowed and two explosions erupted, causing a fire that engulfed the building. The impact also destroyed the only emergency staircase in the building, which impeded the exit of the third floor occupants. Two of them, in an act of desperation,
jumped to their death.
Immediately after the accident, all landing and take-off operations were shut down at the airport. The Avenida Washington Luis traffic was suspended and fire fighter teams began to arrive at the scene.
In November 2006, the São Paulo State Fire Department (SPFD) participated in a disaster simulation involving all emergency response personnel in the city. Ironically, the simulation involved an airplane crashing into the city and landing on top of a gas station.
For the simulation, a 1:1 scale replica of a medium aircraft and a mock-up of the city were built. During the training, the model airplane was suspended from a wire, lifted, and “flown” over the houses.
Practicing their salvage and rescue techniques were São Paulo’s Emergency Rescue and Attention Group (Grupo de Resgate e Atendimento a Urgências, GRAU), which is responsible for emergency medical services at a state level; the Emergency Mobile Attention Service (Serviço de Atendimento Móvel de Urgência, SAMU), which coordinates municipal emergency medical services; and the Traffic Engineering Company (Companhia de Engenharia de Trânsito, CET), which is responsible for traffic control and civil defense in São Paulo.
As realistic as the training was, the real situation proved to be infinitely more frightening.
The flash and the boom induced by the explosion drew the attention of the surrounding neighborhoods. The first call to number 193 of the fire department was placed at 6:51 p.m. The Congonhas Airport and the Campo Belo fire fighters arrived first. Fire fighters controlled the fire while attempting to rescue the TAM employees still in the storage building. Seventeen people were rescued.
According to Coronel Nelson de Almeida, sub-chief of the SPFD, initial communications were very confusing in the middle of this scene of destruction. Coronel Nelson says that the situation stabilized approximately one hour after the disaster, when the command post was established in a single location, according to the procedures of the Emergency Operations Command System (Sistema de Comando de Operações de Emergência, SICOE).
SICOE is a command system for emergency situations and is similar to the Incident Command System (ICS) used in the United States. SICOE allows for communications, normally confusing in a catastrophe situation, to be centralized and coordinates the various support organizations. It was adopted by the SPFD after the June 11, 1996 explosion of the Plaza Shopping Mall, in Osasco. The shopping center was devastated when accumulated gas below the food court exploded. The blast and fire and killed 45 people and injured another 482.
Search and rescue
Throughout the night and into the next day, 205 fire fighters with 91 vehicles worked the scene. At 9:14 p.m., the fire service brought the main fire under control, but there were still hot spots in parts of the collapsed building.
Hydrants and tanker trucks supplied the water for the fire fighting. São Paulo is a city with an extremely small number of urban hydrants, making it dependent on fire apparatus-supplied water. This factor was one that the SPFD dealt with often and according to Coronel Nelson, at no point was there a shortage of water, which would have compromised the fire fighting.
At 11:25 p.m., close to four and a half hours after the crash, fire fighters extracted bodies through the tail of the plane. That was the beginning
of the laborious and dangerous work of search and rescue.
On July 20, three days after the crash, the fire department announced that it was ending the search and extraction of the bodies in the front buildings and the right side of the TAM building. According to press reports, Fire Chief Coronel Manuel da Silva Araújo said that continuing the extraction work was impossible due to the risk of collapse. Additionally, fire fighters were still facing several secondary fires. However, the search of the wreckage of the TAM Airbus A320 in the left building, which is nearest to the gas station, would continue.
By July 22, the fire department ended the search for bodies and human remains in the TAM Express building, in what had turned into the worst disaster in the history of Brazilian aviation. According to fire fighters, the chances of finding new remains was practically nonexistent,
once all the remaining building structures had been searched. The work of fire fighters thus turned to the monitoring of the structures that were at risk of collapsing.
Officially, the operation of the SPFD ended 20 days after the accident, on August 5, 2007 at 4:02 p.m., with the demolition of the building with an implosion. TAM donated the land to the city and in that spot a park and a memorial will be built in honor of the victims of the accident.
During those 20 days, 900 fire fighters and 323 of the most diverse vehicles were used. In the hours that followed the impact, when the greatest flow of personnel took place, 205 fire fighters and 91 SPFD vehicles were at the scene of the accident, in addition to the vehicles and personnel of other emergency response services. An estimated 800 cubic meters (211,337 gallons) of water and 920 liters (243 gallons) of foam extract were used.
Despite the human tragedy, the fire fighter operations were considered a success, showing a good level of preparation and planning. As in all large-scale operations, valuable lessons resulted from the TAM Airbus A320 accident.
According to Major José Luís F. Borges, sub-chief of the 5th GB of SPFD, this operation exhibited specific difficulties that fire fighters needed to overcome without incurring unnecessary risk, while simultaneously being able to do their job as quickly as possible.
The fire load was extremely high due to the amount of fuel in the plane and the speed at which it burned. This caused the fire to spread and quickly engulf the entire building. According to information provided by TAM, the aircraft had the capacity to carry 29,840 liters (7,882 gallons) of fuel. During the impact, it should still have had between 6,875 liters (1,816 gallons) and 7,875 liters (2,080 gallons) of fuel in its tanks. In addition, the amount of combustible materials in the building contributed to the intensity of the fire.
There was constant risk of explosion because of the fuel on the plane and the fuel stored at the gas station in front of the TAM building. The gas station had fuel tanks and one alcohol tank that amounted to 105,000 liters (27,738 gallons) of fuel and did not directly contribute to the fire. The tanks were emptied in the early morning hours of July 19.
Due to the force of the impact of the plane, the explosions and the high temperatures of the fire, the search and later identification and accounting
of the victims proved to be extremely difficult. The bodies were photographed, tagged, and transported to the Legal Medical Institute. Search dogs were brought in to search for body parts, and this was the first time that these canines were used to identify charred bodies. Search-and-rescue work was also difficult because the building was at risk of collapsing.
The volatile scene also complicated the task of preserving the integrity of the victims’ belongings, TAM’s property, and valuables inside the building.
The fire fighters gathered the belongings and photographed, recorded, and placed them under custody for future delivery to family members.
In addition, other concerns such as the need to manage media requests, the removal of unauthorized people from the areas near the accident, and the traffic congestion of the access ways to the disaster area, were all difficulties that the SPFD needed to overcome in order for the operation to be successful.
The operation proved both the success of several programs developed by the SPFD and how the inclusion of them contributed positively to the progress of the operation. According to Coronel Nelson, the use of the Emergency Operations Command System was essential in the organization of the rescue activities and centralization of information. Unfortunately, few fire departments in Brazil and Latin America use this system.
The education and training of the SPFD’s fire fighters have always been a priority, and this investment was an important factor that contributed to the success of the operation, according to Major José Luís F. Borges, sub-chief of the 5th GB of SPFD. The SPFD has a set of 48 handbooks that deal with specific fire scenarios. In addition, as a personnel development policy, all fire fighters are tested annually to evaluate their knowledge and are classified according to the results of those tests.
An important factor was the disaster preparation implemented by the department. The sad coincidence is that just a few months prior fire fighters took part in a large-scale simulation with a scenario very similar to the July 17, and this incident was invaluable to those on scene. The simulation was part of SPFD’s annual training program.
A problem that is frequently mentioned by responders to most large emergencies is the difficulties fire fighters and the other emergency response organizations have communicating. To solve this problem, SPFD’s fire fighters use an interconnection modular unit in the command post, which permits different communication systems to talk to each other.
With a disaster this complex, the SPFD quickly had to integrate working with a large number of emergency services, among them the state and municipal Civil Defense, which is responsible for supplying material support, activation of other organizations, registration of neighboring realty, and guidance to residents; the Military Police, which is responsible for the safety and isolation of the scene; and the Legal Medical Institute, which worked exhaustively in the identification of victims. Also invaluable were the efforts made by the Salvation Army, which coordinated the reception of donations and provided meals for the emergency personnel.
Investigations into the accident’s causes are still ongoing. However, an important lesson regarding emergency exits can be learned from this accident.
One of the basic principles to guarantee the safety of occupants of a building, required by NFPA 101®, Life Safety Code®, and by several other international building codes, is the requirement of always having at least two emergency exits in a building. That requirement is made in order to have an alternative escape route in case one of the exits is blocked for whatever reason. São Paulo state legislation does not require multiple emergency exits.
When the Airbus A320 hit the building, it destroyed the only emergency staircase through which the occupants could exit the building. A view of the TAM storage building and gas station. The plane hit the building’s second story and destroyed a support pillar, which collapsed the third story onto the floor below.
Those people, including the ones that jumped from the third floor, could be alive today if the building had had a second emergency exit. This strong possibility was made obvious when of the nine bodies found in the building, seven were in the top, third floor, and that the two occupants who jumped where also on the third floor.
We know that important changes to legislation happen, unfortunately, as a result of great tragedies. We would all benefit if, after this accident, the SPFD changes its project approval criteria and starts requiring a minimum of two emergency exits in any new construction or renovations.
SPFD operations for the Flight 3054 incident shows the importance of planning, training, and the benefits of an Emergency Command System for coordinating the work of several response teams. Within the many successes of this operation, the 900 fire fighters that participated in this episode need to be recognized. During the 20 days that this operation took place, only one fire fighter was injured, and all the victims were found.
This article would not have been possible without the collaboration of Coronel Nelson de Almeida, sub-chief of the São Paulo State Fire Department, and Major Flávio Bianchini, Interim Chief of the SPFD, and Major José Luís F. Borges, sub-chief of the 5th GB of SPFD.
Marcelo Lima is an NFPA member and a risk management consultant with Lima & Lago Consultores, in São Paulo, Brazil.