Netflix is releasing the three-part documentary series “A Tragedy Foretold: Flight 3054,” which delves into the details of the events at São Paulo’s Congonhas Airport, an incident that remains the deadliest air disaster in the history of Brazil and Latin America.

What really happened that day, and what caused the crash? Was it human error?

The series explores the catastrophic accident of TAM Airlines Flight 3054 on July 17, 2007. The crash claimed the lives of all 187 people aboard the Airbus A320 and 12 people on the ground, totaling 199 fatalities, leaving an indelible mark on the nation and its aviation sector.

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This three-part docuseries, co-produced in the U.S. and Brazil, promises an in-depth examination of the tragedy, exploring not only the sequence of events that led to the crash but also its profound human, technical, and political consequences. Its goal is to investigate the chain of failures that contributed to the disaster and analyze its impact within the context of a broader crisis affecting Brazilian aviation at the time.

The Docuseries: Unraveling the Tragedy

“A Tragedy Foretold: Flight 3054” (originally titled “Congonhas: Tragédia Anunciada” in Portuguese) is a collaboration between Pródigo Filmes and Sobretudo Produção, both Brazilian production companies with experience in documentaries and narrative features. Pródigo Filmes has worked on various projects, while Sobretudo Produção, based in Rio and led by siblings Angelo and Bárbara Defanti, is known for bringing Brazilian culture to the screen, with works including the feature film The Angel’s Club (2022) and the documentary Verissimo (2024).

Angelo Defanti, known for his work as a writer, director, and producer on projects like The Angel’s Club and the documentary Verissimo, created the series and directed all three episodes. The series was written by Defanti alongside Fábio Leal. Executive producers include Beto Gauss, Francesco Civita, Bárbara Defanti, and Renata Grynszpan.

The series adopts an investigative narrative style, described as a blend of “emotion and journalistic rigor.” It seeks to go beyond simple explanations, focusing on the intricate facts, the devastating human cost to victims’ families, and the broader institutional repercussions. To achieve this depth, the production utilizes never-before-seen eyewitness testimonies and archival documents.

Key themes interwoven throughout the series include the deep and lasting impact on the families who lost loved ones, a detailed investigation into the multiple failures that contributed to the accident, and the examination of the human, technical, and political aftermath that unfolded. Ultimately, the series explores how this single event left a lasting impact on Brazilian aviation history and safety culture.

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Revisiting the Accident: A Chain of Failures

On the evening of July 17, 2007, TAM Airlines Flight 3054, an Airbus A320-233 with registration PR-MBK, was operating a scheduled domestic flight from Salgado Filho International Airport in Porto Alegre to Congonhas Airport in São Paulo. The aircraft was carrying 181 passengers and 6 crew members. The flight crew consisted of two highly experienced captains: 53-year-old Henrique Stefanini Di Sacco, with over 13,600 flight hours, and 54-year-old Kleyber Aguiar Lima, with over 14,700 hours. A friend later recalled Captain Di Sacco as one of the “nicest and happiest” people he had ever met.

Upon landing on Congonhas’ Runway 35L during moderate rain, the aircraft touched down but failed to decelerate normally. Surveillance video showed it veered left and exited the end of the runway at approximately 90 knots (170 km/h or 100 mph). Congonhas’ runway is elevated, and the aircraft’s momentum carried it across the busy Washington Luís Avenue below. It then crashed into a four-story TAM Express warehouse building, located next to a Shell gas station, and exploded violently, causing a massive fire.

The human toll was staggering. All 187 people on the aircraft perished instantly. Tragically, 12 people working in the TAM Express building also died, bringing the total death toll to 199. Another 27 people on the ground sustained injuries. The victims represented various nationalities, though the majority were Brazilian.

The official investigation conducted by Brazil’s Aeronautical Accidents Investigation and Prevention Center (CENIPA) identified pilot error as the primary cause. Information from the Flight Data Recorder (FDR) revealed a critical mistake during the landing roll. Immediately before touchdown, both thrust levers were in the “CL” (climb) position. An automatic “retard, retard” warning sounded two seconds before landing, prompting the pilots to move the levers to idle to disengage the autothrottle. However, the FDR showed that only the left thrust lever was moved to the reverse position. The right lever, controlling the engine whose thrust reverser had been deactivated due to a fault (an approved maintenance deferral), remained in the CL position.

This action had multiple critical consequences due to the Airbus A320’s system logic. Pulling only one lever to idle disengaged the autothrottle system. With the right lever still in CL, the right engine accelerated to climb power, while the left engine deployed its reverser. This created a severe asymmetric thrust condition, leading to a loss of control. Furthermore, the A320’s ground spoilers, crucial for braking, are designed to deploy automatically only when both thrust levers are at or near idle. Because the right lever was not retarded, the spoilers never deployed. CENIPA theorized that the pilots might not have realized the position of the right lever, partly because, unlike some other aircraft, the A320’s autothrottle system does not automatically move the physical levers.

While the incorrect lever configuration was the precipitating event, the accident is widely seen as an example of the “Swiss Cheese Model” of accident causation, where multiple layers of defenses fail simultaneously.

Several factors created the conditions for the disaster:

Pilot Action: The critical error in handling the thrust levers during the landing roll.

Aircraft Configuration: The deactivated thrust reverser on the right engine, while permissible, complicated the landing procedure, especially under the specific conditions. Procedures required specific pilot action when landing with an inoperative reverser, which may have been misapplied.

Aircraft Systems: The specific logic of the Airbus A320’s autothrottle and spoiler deployment systems played a role in the sequence of events.

Airport Environment: Congonhas’ Runway 35L was notoriously challenging: short, known for being slippery when wet, and lacking grooving after recent resurfacing, increasing the risk of hydroplaning. There was no adequate Runway End Safety Area (RESA), with a major avenue and buildings immediately beyond the runway end. Pilots had reported poor braking conditions in the preceding days.

Systemic Context: The accident occurred during a period dubbed Brazil’s “aviation crisis,” characterized by widespread operational issues.

No single “hole” caused the accident, but their alignment allowed the tragedy to unfold. The docuseries’ stated intention to investigate “each failure in the chain of events” suggests it will likely explore this complex interplay of contributing factors.

Context and Consequences: The Brazilian Aviation Crisis and Safety Reforms

The TAM Flight 3054 disaster did not occur in isolation. It happened during a turbulent period for Brazilian civil aviation, often referred to as the “aviation crisis.” This period saw months of nationwide flight delays, cancellations, and growing concerns about air traffic control infrastructure and safety oversight. The system was already under strain following the mid-air collision of Gol Transportes Aéreos Flight 1907 in September 2006, which had led to labor stoppages and complaints from air traffic controllers about working conditions.

Specific concerns about Congonhas Airport’s main runway, 35L, were well-documented before the TAM crash. Its short length, location in a dense urban area, and propensity for slipperiness in wet conditions were known hazards. A judge had even attempted to restrict larger aircraft operations in February 2007 due to safety concerns, although the ruling was overturned. Critically, the runway had recently been resurfaced but lacked the crucial grooving needed to help drain water and prevent hydroplaning, work that was scheduled but not yet completed at the time of the crash.

The scale and horror of the Flight 3054 accident served as a brutal catalyst for change, forcing authorities and the industry to confront long-standing issues. The disaster prompted “significant discussions about aviation safety in Brazil.” In the wake of the crash, tangible changes were implemented, including the addition of grooving to the Congonhas runway and adjustments to operating procedures and potentially limitations on aircraft size or operations during adverse weather conditions.

The accident left a lasting scar on Brazilian aviation history, and its consequences continue to shape discussions about air travel safety in the country. While the tragedy spurred reforms, highlighting the often reactive nature of safety improvements driven by catastrophes, questions may persist regarding accountability and the long-term effectiveness of the changes implemented. The docuseries is positioned to explore not only the reforms undertaken but also, potentially, these lingering questions.

Where to Watch “A Tragedy Foretold: Flight 3054”

Netflix

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