阅读巴西天马航空3054号班机的调查报告(节选),回答16-20题 AIRCRAFT Model: AIRBUS A-320 Registration: PR – MBK OPERATOR: TAM Linhas Aéreas S/A ACCIDENT Date/time: 17 JULY 2007 – 21:54 UTC Location: Congonhas Airport (SBSP) County, State: São Paulo – SP. TYPE: Loss of Control on the Ground 1. FACTUAL INFORMATION 1.1 History of the flight On 17 July 2007, at 17:19 local time (20:19 UTC), the Airbus aircraft, model A-320, registration PR-MBK, operating as flight JJ3054, departed from Porto Alegre (SBPA) destined to Congonhas Airport (SBSP) in São Paulo city, São Paulo State. There were a total of 187 souls on board the aircraft, being six active crewmembers and 181 passengers, including 2 infants and 5 extra crew members (not on duty). The weather prevailing along the route and at the destination was adverse, and the crew had to make a few deviations. Up to the moment of the landing, the flight occurred within the expected routine. The aircraft was operating with the number 2 engine reverser de-activated, in accordance with the Minimum Equipment List (MEL). According to information provided to the TWR by crews that had landed earlier, the active runway at Congonhas (35L) was wet and slippery. During the landing, at 18:54 local time (21:54 UTC), the crew noticed that the ground spoilers had not deflected, and the aircraft, which was not slowing down as expected, veered to the left, overran the left edge of the runway near the departure end, crossed over the Washington Luís Avenue, and collided with a building in which the cargo express service of the very operator (TAM Express) functioned, and with a fuel service station. All the persons onboard perished. The accident also caused 12 fatalities on the ground among the people that were in the TAM Express building. The aircraft was completely destroyed as a result of the impact and of the raging fire, which lasted for several hours. The accident caused severe damage to the convenience shop area of the service station and to some vehicles that were parked there. The TAM Express building sustained structural damages that determined its demolition. 1.2 Personal injuries Injuries Crewmembers Passengers Third Parties Fatal 6 181 12 Serious -- -- -- Minor -- -- -- Unhurt -- -- -- 1.3 Damages sustained by the aircraft The aircraft was completely destroyed. 1.4 Other damages The fuel service station convenience shop area and some of the vehicles parked there sustained severe damage. The TAM Express building sustained structural damages that determined its demolition. 1.5 Information on the flight crew involved a. Flight hours PIC SIC Total.......................................................................... 13,654:40 14,760:00 Total in the last 30 days.......................................... 32:41 88:22 Total in the last 24 hours........................................ 03:13 08:22 On this type of aircraft............................................... 2,236:43 237:48 On this type in the last 30 days................................... 32:41 88:22 On this type in the last 24 hours................................. 03:13 08:22 NB: The information on the SIC flight hours refers to those effectively flown by him as a pilot. His flight hours as a Flight Engineer were not included. b. Professional formation No information was found relatively to the training institution where the PIC did the course to become a private pilot. His license was earned on 2 December 1975. He earned his ATP license on 23 August 1991, through the operator. The SIC was graduated by the “Universidade Mackenzie” Aero Club of São Paulo, and earned his license as a private pilot on 11 December 1974. His ATP license was earned on 12 September 1986. ...... 1.10 Information on the aerodrome The S?o Paulo/Congonhas International Airport is a public airport administered by the INFRAERO (Brazilian Airports Infrastructure Enterprise). It operates day and night VFR/IFR, with an Instrument Landing System (ILS) on both thresholds of the main ruway, as well as NDB, VOR/DME, approach lights, night signaling and VASIS. It has two asphalt landing-and-takeoff runways: the main runway (17R/35L), measures 1945 x 45 meters; and the auxiliary runway (17L/35R), measures 1435 x 45 meters.
3.2 Contributing factors According to the SIPAER regulations, a contributing factor is a condition (act or fact, or a combination of the two) which, together with other ones, in sequence or as a consequence, leads to or allows the occurrence of an aeronautical accident, incident or ground occurrence, or which contributes to the aggravation of its consequences. The contributing factors are classified in accordance with the approach utilized by the operational safety, namely Human Factors or Material Factors. Below, a list is presented with all the factors whose contribution was effectively established, regardless of the degree at which such contribution has occurred. Also, the factors whose contribution, however possible, has not had a confirmation established along the investigation, in which case they were labeled as undetermined. The SIPAER regulation establishes, in addition, that each one of the identified factors (contributing or undetermined) be subject to at least one safety recommendation. Thus, any factor that has, either effectively or potentially, contributed to the consummation of the accident will be the object of a preventative and/or corrective action. The classification of the factors as either contributing or undetermined just reflects one’s capability to confirm, with a reasonable degree of certainty, the presence of such factors among the actions and/or conditions which preceded the accident, and do not imply the assignment of values or degrees of importance to any of them. 3.2.1 Human factors The Human Factors constitute the operational safety approach of the biological complex of the human being, and deals with the Medical, Psychological and Operational Aspects. 3.2.1.1 Medical aspect The Medical Aspect corresponds to the area of the Human Factors in which there is the involvement of medical and physiological knowledge that is researched in order to define the presence of variables of this nature and the form of its participation in the events. a. Pain - Undetermined 3.2.1.2 Operational aspect The Operational Aspect corresponds to the area of Human Factors relative to the performance of the human being in the activities directly associated with the flight. a. Training – A contributor b. Application of the commands – Undetermined c. Cockpit coordination – A contributor d. Forgetfulness by the pilot - Undetermined e. Flight indiscipline – Undetermined f. Influence from the environment – Undetermined g. Judgment of pilotage – Undetermined h. Management planning – A contributor i. Flight planning – Undetermined j. Little experience of the pilot – A contributor k. Management oversight – A contributor 3.2.1.3 Psychological aspect In the psychological aspect, one considers the participation of individual, psychosocial or organizational psychological variables in the performance of the person involved. a. Anxiety - Undetermined b. Perception error – A contributor c. Stress - Undetermined d. Lack of perception – A contributor e. Loss of situational awareness – A contributor f. Organizational climate - Undetermined g. Regulation – A contributor h. Training - Undetermined 3.2.2 Material factors The Material Factors represent an approach regarding the operational safety of the aircraft, including its components, as well as items of equipment and information technology systems used in the airspace control, in their aspects of design, manufacturing, handling of material, and failures not associated with the maintenance services. a. Design – A contributor It deals with the participation of the aircraft or component design, on account of inappropriateness of the material established; of the controls, lights or instruments, on account of their shape, size, installation or positioning; or of the inappropriate setting of operation and/or preventative maintenance parameters. It was verified that, for an A-320 airplane proceeding to land, it is possible to place one of the thrust levers at the “REV” position and the other at “CL”, and no alerting device will advise the pilots in an efficient way. This situation may put the aircraft in a critical condition and, depending on the time it takes the crew to identify this configuration, and on the runway parameters, a catastrophic situation may occur. In the specific case of this accident, even with the aircraft on the ground (Weight on Wheels -WOW), with the number 1 engine thrust lever at the “REV” position, with the ground spoilers armed, with the autobrake selected, and with application of maximum braking pressure on the pedals, the power control system gave priority to the information that one of the levers was at “CL”, and this lever did not have any safety devices regarding a possible inadvertent setting. 4. SAFETY RECOMMENDATIONS A Safety Recommendation is a measure whose nature is either preventative or corrective and is determined by the Aeronautical Authority or SIPAER-Link within its respective area of responsibility, aiming at eliminating or mitigating the risk generated by a latent condition or active failure. 16、对是次空难,下列叙述正确的是? A、是次空难由法国事故调查委员会主导调查 B、是次空难发生在里约热内卢 C、降落的跑道是事发机场最短的一条 D、肇事飞机注册号为PR-MBK 17、本次空难造成的死亡人数是? A、12 B、181 C、199 D、265 18、对于机组的资历,下列叙述正确的是? A、副驾驶只有不多的驾驶A320经验 B、机组都曾经当过飞行工程师 C、在事发前一个月内机长还驾驶过其他飞机 C、在事发前一个月该机组一直一起飞行 19、根据调查报道,下列叙述正确的是? A、降落后自动油门让右发动机加大推力以便维持设定的速度 B、在着陆时油门杆都已经收回IDLE位 C、机组人员在着陆时没有打开反推 D、飞机的FEDAC存在故障 20、对于调查的结论,下列叙述正确的是? A、调查组直接发出命令要求有关部门做好改进措施 B、天气恶劣是是次空难的主要原因 C、飞机的设计存在一定的缺陷 D、机组协调不善对是次空难没有影响