[plane intercom beeps]
[airplane engine humming]
THE STORY OF THE DEADLIEST AVIATION CRASH IN LATIN AMERICAN HISTORY
[dramatic theme music playing]
A TRAGEDY FORETOLD: FLIGHT 3054
[music ends]
[tense music playing]
[lights click on dramatically]
My name is Denise Abreu,
former director of ANAC.
In 2007, at the time of the accident,
I was the agency's vice president.
[interviewer] If you could say anything to Denise Abreu, what would you say?
To Denise Abreu?
I'd tell her to put herself in the shoes
of the families who lost their children, fathers, mothers.
I would ask her how she can lay her head on her pillow and sleep.
[interviewer] You know that most of the family members
cite you as one of the culprits.
If you could say something to those families, what would you say?
I only regret that they still can't understand
that…
they were manipulated into convincing themselves
that one single person was to blame.
RESPECT FOR LIFE
[indistinct chanting]
[dramatic music playing]
[reporter] Their pain, and that of so many other families
became fuel for their fight.
We had protests every month.
[crowd chanting] Respect! Respect!
[slide projector clicks]
[Dario] Other movements decided to join in on our protests.
AT SÉ, "I'M TIRED" TURNED INTO "LULA OUT!"
Because we had visibility.
SHOW YOUR OUTRAGE WITH A MINUTE OF SILENCE FOR BRAZIL
All the movements that approached us and joined us
wanted to appropriate the visibility we had at that time, you know?
I didn't lose anyone, but the population's in pain.
Enough! This must end!
We also had an audience with Governor Ieda Cruz.
She asked, "How are you guys organized?" And I said, "What do you mean, Governor?"
[camera click]
"Well, if you're not an association, then you're nothing."
[Roberto] That was August, a month later.
In October, AFAVITAM was born.
ASSOCIATION OF FAMILY AND FRIENDS OF TAM FLIGHT JJ3054 VICTIMS
[crowd chanting in Portuguese]
[crowd chanting, in English] Justice!
Truth!
"Life, truth, justice" was our motto.
WE WANT TRUTH AND JUSTICE
We want to know the truth.
[Dario] And justice, which was the due punishment
of those who could have prevented this tragedy.
[music fades out]
[reporter 1] The excessive calm of ANAC's director
bothered some congressmen.
You look like a TAM flight attendant, so calm, so placid.
[band plays national anthem]
[interviewer] Do you remember the day you got your Santos Dumont Medal?
Absolutely.
Three days after the accident.
However, although there were five directors,
for some reason, it was only offensive for a woman to receive the medal.
[tense music playing]
[reporter 2] The National Civil Aviation Agency
confirmed the accident between a GOL plane
and a Legacy executive jet.
[interviewer] Was this your first time on national TV?
But definitely not the last.
[dramatic thuds]
Many of my coworkers told me,
"Denise, don't go, you're overexposing yourself."
And that was actually used against me, with things that I'd never said
being taken as true without any proof.
"WHAT DID YOU EXPECT? BODIES?"
I don't regret even a single second
of having been slapped in the face by one of the mothers.
They tried to defend me and I said, "Leave her alone. I'd do worse."
[music intensifies then stops]
Flight delays were what they called the Aviation Blackout, right?
[airport intercom chimes]
They closed the airspace. There was no way to fly.
-[intriguing music playing] -[people laughing]
I was photographed hours after the riot…
DENISE ABREU IN THE LINE OF FIRE
…and exposed to the nation as a woman indifferent
to the challenges faced by the population using civil aviation.
But unfortunately, a picture is worth a thousand words
and they decided to weaponize an image of a woman smoking a cigar,
which at the time, and for the military world,
was almost an unforgivable crime.
[percussive military music playing]
You have to understand the context this country was in, right?
We were coming from a dictatorship.
It had taken us years to build a Ministry of Defense…
JOURNALIST
…subject to the orders of the government, instead of the military.
There had never been a woman in charge of Brazilian civil aviation,
dealing with an airspace control that was 100% militarized.
Just imagine what it was like for them to salute a woman.
"She doesn't know what she's talking about."
"This isn't her field."
"We actually know how to manage this."
They call you "sweetheart" a lot, they put you down a little.
"You still have a lot to learn."
I learned from great public administrators
to delegate tasks
and demand results vehemently,
which can be interpreted as having a "bulldozer style."
Depending on the point of view, it might even be true.
[music continues]
Just as much as she exaggerated the role she played…
FORMER ANAC DIRECTOR
…they also exaggerated her responsibility, you know?
But she put herself in the spotlight, didn't she?
[interviewer] What were you accused of, Denise?
Could you summarize it for me?
[music ends]
[reporter] The investigation covers 5,400 pages.
So far, 300 people have been interviewed.
This afternoon, the police, the DA's Office
and representatives of the victims' families
met to assess the course of the investigations.
We are on the right track, we are sure of that.
My name is Mário Luis Sarrubbo.
At the time, in 2007,
I was the first criminal prosecutor…
FORMER PROSECUTOR DA'S OFFICE
…in the Jabaquara District Attorney's Office.
[no audible dialogue]
There are always several investigations into a plane crash.
There is an investigation by CENIPA, the aviation authorities.
CENTER FOR PREVENTION AND INVESTIGATION OF AVIATION ACCIDENTS
It's an investigation with the sole purpose
of figuring out the causes
to prevent it from happening again.
[suspenseful music playing]
Our investigation, which is being conducted
by the Civil Police, State Police, Federal Police, DA's Office and so on,
is an investigation that seeks to find those responsible in order to punish them.
[airplane engines roaring]
One of our lines of investigation is that the runway
may have contributed to this accident.
[camera clicks]
[man] I think the issue of the runway was discussed in a way, more passionately,
because there were previous reports days before…
FORMER FEDERAL PROSECUTOR
…even the previous day, of aircraft sliding down the runway, slipping,
so everything pointed to the runway being one of the main factors.
[car horns honking]
[reporter 1] Over the last four years,
six planes have skidded off the runway at Congonhas.
[Antonio] It was full of potholes, in a terrible state,
so much that it was reported in the media, every now and then,
that plane tires would get blown out.
[reporter 1] Five months before the accident involving the TAM Airbus,
the DA's Office had already warned that a plane could crash
into the avenue outside the airport.
Meanwhile,
there was a Conduct Adjustment Agreement
filed by the DA's Office,
demanding the repaving and the regrooving of both runways at Congonhas.
[reporter 2] During the first stage of the project, which lasted 45 days,
technicians removed the old asphalt,
corrected the angle of the runway and laid a new layer of asphalt.
[Consuelo] They were doing the renovations,
but the school break was coming
and they decided that they would allow the planes to land there.
[reporter 3] The runway was reopened without grooving,
which helps with water drainage.
Since it was July, a dry month, the runway wouldn't be slippery
but… it started raining.
[thunder rumbling]
[rain pattering]
And it didn't stop. It rained on Monday, it rained on Tuesday.
[reporter 4] Notes on the air traffic controllers' logbook
reveal that the day before the accident, three airplanes had balked landings,
and eight reported that the runway was slippery.
[reporter 5] A day before the accident with the TAM Airbus,
a Pantanal airline plane skidded while landing on the main runway.
The Pantanal plane, when it skidded off the runway the day before,
was perhaps a message for the authorities
that was easy enough to understand, and it wasn't.
It was disregarded.
[unsettling music playing]
On July 16th, 2007, I received the Mike Bravo Kilo aircraft.
I was the next plane to approach Congonhas Airport…
PILOT
…after the Pantanal plane touched the grass, the Pantanal ATR.
I could see the aircraft damaged on the grass,
and I started landing.
[plane whooshes]
I landed,
and the plane started skidding.
It skidded a lot. A lot.
I did everything I could to stop it.
Then finally, the copilot said, "It's stopping, it's stopping."
And we stopped almost at the end of the runway.
[interviewer] Do you have an estimate, in meters?
[sighs] Meters…
I'd say… one meter.
[chuckles] Yeah.
After that, it was just the ravine
and a pile of gravel at the end of a… of the runway.
BRASÍLIA AIRPORT DAY OF THE ACCIDENT
[Consuelo] And then there's this story that is truly unbelievable.
On that day, July 17, 2007,
the ANAC team was going to have a meeting in São Paulo,
to also discuss the issue of the runway and everything.
And the ANAC directors left earlier in the day
on that very same TAM airplane.
It was exactly the same aircraft
that, at six in the afternoon,
exploded in an accident here in Congonhas.
And then, of course, a lot of stuff goes through your head, you know?
Was it sabotage? Wasn't it sabotage? What happened?
It wasn't me, but I had a feeling of, "It could have been me."
[tense music playing]
[reporter] At 5:04 that afternoon, a GOL plane informed the control tower
that the runway was slippery.
Three minutes later, landings and takeoffs were suspended.
RUNWAY CLOSED
The water level on the runway was measured and it was cleared at 5:30 p.m.
RUNWAY OPEN
From then until the time of the crash, 40 planes landed on that runway
without any issues.
[tires squeal]
When the TAM plane touched down,
the rainfall was 0.6 millimeters,
below light rain levels by international standards,
which are between one and five millimeters.
The information was repeated several times,
that there was only 0.6 millimeters of water
on the Congonhas runway,
which is barely a drizzle.
[man] According to the report by Infraero employees,
there was no water on the runway.
It was wet, but there was no standing water,
which is why it ended up being cleared.
The tires were also tested and there was no sign of hydroplaning.
Whether or not there was a problem with the runway,
whether it or the airport were inadequate,
this is an important discussion, but when it comes to the accident itself,
the runway doesn't seem to have played a major role.
[reporter] The data from the TAM Airbus' black boxes
and the conversations between the flight controllers and the pilots
are now with investigators.
[reporter 2] The leader of the inquiry, Congressman Marco Maia,
opened the envelopes with the documents
and the CD with the transcripts of conversations between the pilots,
recorded by the TAM plane's black boxes.
[pilot] TAM approaching at two miles, could you please confirm the conditions?
[interviewer] So, tell me. What was the impact of the black box data?
Look, it was a huge surprise.
[dramatic thud]
[ominous music playing]
[thunder rumbling]
JULY 17, 2007
6:18 P.M.
[beeping]
BLACK BOX AUDIO
CAPTAIN KLEYBER LIMA CAPTAIN HENRIQUE STEPHANINI
[echoing footsteps]
[flight attendant] A passenger asked where we're going to land.
[Kleyber] Well, I've just said it.
[flight attendant] Oh, sorry, I didn't hear it.
-[Kleyber] But she did, it's in Congonhas. -[flight attendant] Congonhas?
[Dario] The airport had just been reopened after the rain in São Paulo.
Due to the conditions, this flight could have been diverted to Guarulhos.
From his conversation with the tower,
you could tell that the pilot was worried.
[Kleyber] Ask her if it's raining in São Paulo.
[Stephanini] Control, can you inform TAM 3054
whether or not it's raining in Congonhas?
[air traffic controller] Runway wet and slippery, 35 left free, 3054.
[Kleyber] Wet and slippery.
He even repeats it, right?
The black box shows that he repeats it later, he's concerned.
[Kleyber] Wet and slippery.
[Dario] He was worried about the runway.
Especially if he knew that the runway had been closed
before it was cleared for them to land.
CONGONHAS AIRPORT
They could have landed at another airport.
The captain has the final say, he could have said,
"I'm not going to land here, period."
But there is a whole chain of events.
Because once I land that plane at Congonhas,
it's going to fly to another destination.
And if I land that plane in Guarulhos,
it's no longer able to do what it's supposed to do.
That's a problem for the flight network.
[crowd murmur]
[Roberto] And by the way, at that time, there was this problem
of the so-called Aviation Blackout.
Most airlines, not just TAM,
didn't like it when flights were diverted to other airports.
So they put pressure on the pilots.
-[no audible dialogue] -[indistinct chatter]
[agitated chattering]
[Consuelo] The pilots, the flight attendants.
And it was an absurd amount of pressure on everyone, you know?
People were working to their limit.
[Kleyber] Oh, well…
[babbles]
I've got this headache, you know? I don't know why.
[Stephanini] It's the time change.
-[Kleyber] You think so? -[Stephanini] Yeah.
The change in the weather.
[tense music playing]
Yeah, we were always tired. We flew a lot.
Of course, everything was within the law.
Is it legal? Yes. Sometimes it's legal, but it's morally wrong, you know?
We are pilots, but we are also human.
Captains Kleyber Lima and Henrique Stephanini di Sacco
were very experienced pilots.
They had over 13,000 hours of flight time,
which is equivalent to 20 years of experience.
And there were two pilots. Not a pilot and a copilot.
It's a whole different dynamic.
Due to the crisis that was happening, which was huge,
and the lack of personnel, TAM didn't have a copilot,
so they had a pilot in the copilot's seat.
PILOT'S SEAT - COPILOT'S SEAT
That shouldn't happen, because they are different jobs.
When one is sitting on the left and the other is on the right,
it doesn't matter if he is the pilot or the copilot.
The role he will perform is either pilot flying, or pilot monitoring.
I don't see it as a problem. That doesn't… It doesn't seem like a problem to me.
[interviewer] Aren't they two different roles?
Two different instincts in the cockpit?
Instinct?
Maybe, but that also varies from person to person, right?
So, even from a psychomotor standpoint,
he'd be used to operating the plane with his right hand.
PILOT
And the copilot would have to use his left hand to fly.
That's not a very serious problem, but it takes some getting used to.
At the time, the plane was also at full capacity
for passengers and cargo.
It was also carrying a lot of fuel, uh,
because there was an economic advantage in refueling in Porto Alegre
compared to São Paulo.
[Consuelo] Since the price of fuel and the taxes
were much higher in São Paulo,
they filled this plane's tank up to the limit
that would be recommended to land at an airport with a short runway.
[beeping]
[Antonio] So, the tank was full to the brim.
It had over two extra tons of fuel,
which is why it burned for so long.
[explosion]
[Rodrigo] I think what people were saying,
the rumor that was going around, was that, somehow,
the pilots of the aircraft had a major involvement in the accident.
But no one knew exactly what.
-[plane intercom beeps] -[indistinct radio conversation]
[beeps]
[somber music playing]
THRUST LEVERS
This terminology, like thrust levers, reverser, pinned reverser,
all of this only came to me during the investigation.
I had never heard those expressions before.
LEFT THRUST LEVER - RIGHT THRUST LEVER
The thrust lever is like the gas pedal in a car.
In an airplane, the thrust lever is what gives you the engine power.
In this aircraft, there are two thrust levers,
so each lever controls one engine.
There are a few different positions for the thrust levers.
REVERSE
There's a middle position for the thrust levers,
called "idle," or neutral.
(NEUTRAL)
Forward, the flight position, is called "climb."
(ACCELERATION)
And then, backward, which is called "reverse."
REVERSE (BRAKES)
Thrust reversers are a feature on aircrafts that help them slow down.
[José] They are surfaces that open and redirect the gas forward,
to help with braking.
[Kleyber] Remember, we only have one reverser.
[Stephanini] Yeah. Only the left one.
So at the time, the airplane was operating with the right reverser pinned.
[Gustavo] A pinned reverser is when you have a reverser
that's not being used for whatever reason,
and you put a pin in it, a manual pin, a physical lock on it.
A nonoperational reverser is perfectly normal, okay? To this day, people tell me,
"Oh, it was the reverser," but that is not what caused the accident.
[camera clicks]
[man] All the calculations are made so that the aircraft
can stop within the limits of the runway…
AVIATION CONSULTANT
…without using the reverser. That is, only using the brakes
on the aircraft's wheels and the aerodynamic brakes.
Also known as spoilers.
-[beeping] -[wind rustling]
[José] When the plane touches down,
in the case of the reverser being pinned, you would
pull the thrust levers from climb to idle…
and immediately move both levers to reverse,
including the pinned one.
REVERSE
6:46 P.M. 7 MINUTES BEFORE THE ACCIDENT
[Kleyber] Prepare for landing.
[Stephanini] Prepare for landing.
Cabin crew, prepare for landing.
[ominous music playing]
[wind rustling]
-[Kleyber] Ready for landing? -[Stephanini] Ready for landing.
[Antonio] Before the renovations,
the runway was in much worse shape than it was on the 16th, the 17th.
But since it had no grooving,
the surface reflected the city lights.
-[interviewer] It was like a mirror? -Yeah, it sure was.
[interviewer] What is that like for a pilot?
Well, it's…
It's a really, really, really bad feeling.
Then he went down,
and he kept going down under terrible conditions.
[plane intercom beeps]
[soft music playing]
He touched down correctly.
But he only moved the lever with the good reverser
and, unfortunately,
the other one kept accelerating.
REVERSE - CLIMB FLIGHT 3054 LANDING
REVERSE - REVERSE NORMAL LANDING
They contradicted each other.
One was braking and the other was accelerating.
It kept going at full speed, no one could stop a plane like that.
[air traffic controller] Control tower 01, confirmed?
-Zero-one. -[Stephanini] No spoilers.
Based on that, with all the logic of braking of an aircraft,
we can say it performed as expected.
FLIGHT 3054 LANDING NORMAL LANDING
Since the spoilers weren't activated, there was no automatic braking.
[Kleyber] Oh! Look at this!
[Stephanini] Slow down. Slow down.
[Kleyber] I can't! I can't!
They couldn't understand what was happening.
[Gustavo] When we land, we expect the sequence of events to be the same.
Then you touch down and the sequence of events is different.
You're like, "What's going on?"
It took approximately seven seconds, if I remember correctly, after touchdown,
for the manual brakes to be activated.
[Antonio] Both of them applied the brakes.
But the plane kept accelerating.
They didn't try to take off again.
If one engine is accelerating and the other is braking,
it's obvious the plane will turn sideways.
[air traffic controller] 3562 taking off from auxiliary runway.
[Stephanini] Come on, turn, turn! Turn, turn!
[shouts] No, turn, turn!
[Kleyber] God!
[dramatic thud]
[steady, high-pitched ring]
COCKPIT AUDIO
"SLOW DOWN, SLOW DOWN" "I CAN'T, I CAN'T!"
BLACK BOX REVEALS PILOT ERROR
[melancholic music playing]
[reporter 1] How could such an experienced pilot
make such a simple mistake?
Kleyber is not here to defend himself.
[camera click]
It is difficult for a pilot to accept certain things.
"Of course my copilot will move the lever, it's intuitive."
"That's instinct, every pilot does it."
[camera click]
[Rodrigo] Why would such an experienced crew do such a thing?
[camera click]
Why did they move the levers wrong? Why did they do that?
It needs to be analyzed.
It's a conclusion that only CENIPA can make based on their analysis.
[reporter 2] Eleven months later, the Air Force concludes their report
on the causes of the accident.
That's crucial. You ask, "Was the main cause of the accident
the mishandling of the thrust lever?"
According to official reports, it was.
But it wasn't the only cause.
FINAL REPORT
[emotional music playing]
ISSUE: AIRPLANE CRASH
CONCLUSION
[reporter 3] The CENIPA report pointed out errors by Infraero,
TAM and Airbus, the aircraft manufacturer.
QUADRANTS - GEAR
ACCIDENTS WITH INADVERTENT POSITIONING OF THRUST LEVERS
You see, four identical accidents had already happened before.
[ominous music playing]
UNITED STATES
[reporter 4] In March 1998 in the Philippines,
an Airbus that was also flying with the reverser pinned,
slid off the runway after sudden acceleration
because the levers weren't on idle.
The same power symmetry,
that is, one lever accelerating, the other reversing.
They had a smaller number of victims
because they happened at airports with larger runways,
which had safety areas, and that helped.
BACOLOD AIRPORT, PHILIPPINES
PHOENIX AIRPORT, USA, 2002 RUNWAY
AIRPORT OF TAIPEI, TAIWAN, 2004 RUNWAY
[reporter 4] Even so, the French manufacturer Airbus
did not make the installation of a sound alarm mandatory,
to warn against a possible position error.
There should be a sound alarm to warn the pilot and the captain
that they were in the wrong position
so they could correctly activate the aircraft's thrust levers.
Similar to what happens when you don't fasten your seatbelt,
the car starts making this sound, like, beep-beep-beep-beep-beep
until you notice that something is wrong.
[mechanical voice repeating warning sound in French]
[in English] But they didn't issue a recall, because if they had,
they would have had to pay for all their planes to have this alarm replaced.
They didn't do that.
So that the airlines would do it on their own and pay for it.
And TAM decided not to install it, right?
It's a cost, you have to ground the plane,
you have to install this equipment, upgrade it.
So it's all about the money game.
It's a safety item, but who's going to pay for the installation of this safety item?
[rain pattering]
[ethereal music playing]
RUNWAY
WET RUNWAY
DANGEROUS CONDITIONS
[Sarrubbo] Then there's the runway.
It wasn't, let's say,
the direct cause of the accident. But it undoubtedly had, in my opinion,
in the… in my statement, it played a significant role.
[reporter] For four hours, Captain Marco Aurélio Incerti
and copilot Daniel Alves da Silva
spoke about the procedures adopted during the flight.
The two pilots flew the TAM Airbus from Congonhas to Confins, in Minas
and then on the return trip.
They then handed the plane over to the crew who died in the crash.
The pilots confirmed the information in the black box.
Since January, the Airbus manual has recommended that both thrust levers
be placed in the reverse position as soon as the plane touches down.
But the captain stated that he only pulled the left lever
and left the right one in the idle position, or neutral.
The runway was slippery and wet, and then he used a different procedure.
According to him, this helps the aircraft slow down.
The police now want to know if the captain of Flight 3054
adopted the same procedure as the previous pilot.
[rain pattering]
[Antonio] He saw the runway reflecting the lights,
and had the information that it was wet and slippery.
And probably what happened is that at the time of landing, he said,
"Well, it's raining, we're heavy."
And then he decided to land following the old procedure
instead of the new one.
REVERSE - (NEUTRAL)
[Antonio] Since he knew
that the old method would help him save 50 meters,
he did it according to the old method.
OLD LANDING PROCEDURE SAVES 55 METERS ON RUNWAY
3054 LANDING
I… I am convinced
that forgetting and leaving the lever on climb
was due to his excessive caution in trying to ensure the landing.
It was a consensus among pilots that,
in those circumstances, at Congonhas,
it was safer to land that way.
If they already knew that the pilots
were doing something that was not recommended by the manufacturer,
why did they allow it to happen?
And who is responsible for supervising it?
ANAC is not inside the plane, it's actually the airline's responsibility
to supervise how pilots operate.
DISTRICT ATTORNEY'S OFFICE JULY 12, 2011
4 YEARS AFTER THE ACCIDENT
[intriguing music playing]
[reporter 1] Four years of waiting,
four years of memories.
[reporter 2] Almost four years after the accident,
Attorney General Rodrigo de Grandis
justified the decision to criminally charge Denise Abreu,
former director of the National Civil Aviation Agency,
Alberto Fajerman, who was TAM's Vice President of Operations,
and Marco Aurélio Castro,
the company's flight safety director at the time.
You might ask, "Could other people have been indicted?" Possibly.
But not with the same level of probative force.
[Roberto] And he explained it to me,
"These three people that I am indicting,
there is no doubt whatsoever about their guilt."
[Dario] There was no way to charge Airbus, because, unfortunately,
our justice system doesn't punish business entities.
You have to target individuals, and there was no way to identify that.
Who is the person who said that
a safety procedure on a flight is not mandatory?
[reporter 3] The prosecution claims that they knew about problems with the plane
and the runway that contributed to the tragedy.
And let me tell you something,
I still don't understand why they were indicted.
It was a raffle.
"And we're going to indict Fajerman, Castro and Denise Abreu."
The feeling I had during the investigation,
was that this tragedy was just waiting to happen.
So much so that the DA's Office itself, colleagues from the civil area,
tried to close the runway.
And ANAC went to the Court of Appeals to try to reverse this decision
and reopen the runway.
Denise Abreu went to the judge's office,
and they utilized a certain rule,
well, supposedly it was a rule,
to support their argument to reopen the runway.
A rule that determined that no plane could land at Congonhas with a pinned reverser
if the runway was wet.
Based on that rule, the judge reversed the decision
and ended up reopening the runway.
But it turns out that the rule, it wasn't… it wasn't valid.
They agreed on that, but it was not published
and therefore, it did not actually exist.
And they did not tell the judge that.
The judge had no obligation whatsoever
to examine whether this was an unofficial document
or whether it had been approved or not.
No such document was presented to the judge.
In fact, we didn't even touch this subject.
She was here and knew all the documents that were being given to me.
How can a person who wrote a contract,
or signed a Conduct Adjustment Agreement,
have the power to look at the sky and bring down an airplane?
For me, if the runway hadn't been reopened,
that plane would not have been there, and we wouldn't be here talking.
Today's news…
is an answer to our battle.
The Attorney General who filed the complaint
asked for a sentence of four to 12 years in prison.
This decision now depends on the court.
FEDERAL COURTHOUSE MINISTER JARBAS NOBRE
[suspenseful music playing]
[Rodrigo] Good afternoon, my name is Rodrigo de Grandis,
I'm the Attorney General in charge of this case.
[man at hearing] Each phase of the process has a final assessment.
[various people speaking indistinctly in Portuguese]
[Dario, in English] I was there for all the testimonies of the trial.
On the first day, I broke down.
[man] You flew that aircraft on July 16th, 2007?
Affirmative.
A captain said that he saw the plane would not stop on the Congonhas runway.
I mentioned that to the copilot
and asked him to notify the tower
that the conditions on the runway were very slippery
and to also warn the other aircraft and the other pilots.
If they knew there was a problem,
why did they continue operating that aircraft at that airport?
[music continues]
TAM'S FORMER FLIGHT SAFETY DIRECTOR
I went to all the hearings
of the three defendants that they put on trial.
TAM'S FORMER VP OF OPERATIONS
Knowing that the person answering these questions had a role in the…
ANAC'S FORMER DIRECTOR
…in the outcome that ended my daughter's life
is very difficult.
TWO OF THE INDICTED, ALBERTO FAJERMAN AND MARCO AURÉLIO CASTRO,
REFUSED TO BE INTERVIEWED FOR THIS SERIES.
FEDERAL COURTHOUSE MINISTER JARBAS NOBRE
[Eduardo] We often had the feeling that our loved ones had been murdered.
It wasn't an accident, they were murdered.
ROGERIO'S BROTHER
Only someone being tried and found guilty would bring some comfort.
[speaking indistinctly in Portuguese]
[Dario, in English] I like to be invisible wherever I go, you know?
Suddenly I'm writing a letter to ministries in Brazil,
to ministries abroad, to a senator and everything else, it's…
It was surreal to me.
The person who gave me the strength to…
to do everything I did, was my daughter.
The families believe that justice will finally be served.
The judge is expected to issue a sentence in 2014. We hope for the maximum penalty.
[Rodrigo] I would leave the hearings
convinced that the accusation was very well-founded.
So much so that I was shocked to hear of the acquittal.
-[woman clears throat] -[man clears throat]
MAY 4, 2015 8 YEARS AFTER THE ACCIDENT
[dark music playing]
[man coughs]
[Simone] My mother called me,
and said, "Sweetie, can you believe it?" I said, "I can."
PAULO'S SISTER
"I can believe it."
[reporter 1] The District Attorney's Office indicted three people,
but they were all acquitted.
[reporter 2] To justify the acquittals,
Judge Márcio Assad said that according to the DA's Office's accusations,
it would be possible to hold a huge number of people responsible for the accident.
Márcio Assad Guardia.
Such a brilliant judge with ethics that are truly
admirable.
He literally wrote a book that will leave a legacy.
I think that the feeling of impunity remains, uh…
It remains not only for the family members,
but for those who work in law as well.
If you ask me,
if I'd do it all over again,
I would certainly do the same things I did.
Yes, I would perhaps change other accusations in my life,
but certainly not this one.
[dark music continues]
JUDGE MÁRCIO ASSAD GUARDIA REFUSED TO GIVE A STATEMENT FOR THE SERIES.
[interviewer] Dario, why do you think you were unable to convince the judge?
[music ends]
[deep sigh]
I don't know.
Maybe because the Federal Police report had a different approach.
[dark music resumes]
REPORT
[reporter] The Federal Police report
blames the pilot and copilot for the accident.
[Dario] For us, for the families, this was unacceptable. Unacceptable.
NO RESPONSIBILITY OTHER THAN THE CREW
They were passengers just as much as the rest of the people on that flight.
PART OF THE CREW
As CENIPA itself says, there is no one to blame.
It was a chain of events and, unfortunately, it happened.
[Antonio] The Swiss cheese model places an axis
through several spinning discs with holes in them.
[music quickens]
[Gustavo] Like slices of Swiss cheese.
It compares these holes with certain faults
that can happen in these barriers.
If we get some Swiss cheese with all the holes aligned,
the accident happens.
Blaming the pilot is not honest, it… it borders on cowardice.
The pilot is the last in a series of stages
that we must go through to ensure the safety of an airplane.
AVIATION BLACKOUT
FATIGUE
TWO PILOTS
WEIGHT
SLIPPERY RUNWAY
ESCAPE AREA
LACK OF TRAINING
NO RECALL
THRUST LEVERS
And that ended up being the main cause of the accident.
All of it caused the pilot to make a mistake.
We did everything we could to get this far,
you know, to seek justice.
Uh, unfortunately, it was not the result we hoped for,
but we accept the result of justice,
that is, the acquittal of the three defendants.
This won't bring my daughter back.
It won't bring any of the victims back.
But it would show that people who occupy these positions of responsibility
do, in fact, have this responsibility.
And they must know that they must answer for their actions.
DIRECTOR
[reporter] The director of ANAC scheduled a press conference, but did not show up.
It was her assistant who announced Denise Abreu's resignation.
She sent a letter to the Secretary of Defense, claiming personal reasons
and said that she intends to give further explanations to the president.
The period after
the accident was very difficult.
I had over 90 gallstones.
I started to develop sepsis.
I had emergency surgery. I had two cardiac arrests.
And it took me a while to be able
to rebuild myself emotionally.
Nine months later, I was reborn.
Good evening, my friends.
This Sunday's Hangout is on.
We are here with today's guest,
who might be running for president of our country, Denise Abreu.
[pensive music playing]
[interviewer] You were very critical of Lula, and especially of Dilma.
Not of Lula, never.
Many people say, "You were very critical of the Worker's Party." No.
[slowly] Out with Dilma Rousseff and the Worker's Party.
Congratulations on everything you've been doing.
Count on me for whatever you need.
I am a public servant.
[reporter 1] In 2016, she launched her candidacy
for mayor of São Paulo, but she gave up to support Dória.
And I know how much we should value our salaries,
which are paid for by the people.
The director of the Lighting Department of the City of São Paulo, Denise Abreu,
was fired today by city mayor João Dória.
It may sound like a political speech, but it isn't.
I have no political aspirations for making this speech.
It's just the way I am.
Recordings show that Denise Abreu
tried to hide the fact that, due to lack of maintenance by the city,
a peeled electrical wire caused the death of a man last November.
[reporter 2] Witnesses said that a loose wire electrified the lighting pole.
A farce to hide the fact that the electrical connection
had not been maintained for 30 years.
We can say it was a tragedy waiting to happen, right?
[music ends]
[explosion]
[tragic music playing]
[music becomes optimistic]
JULY 17TH MEMORIAL
[reporter 3] Five years after the accident,
a memorial was built to honor the victims.
The July 17th Memorial is located exactly where the plane crashed.
[reporter 4] 199 lights illuminate the memorial
in the southern area of São Paulo.
For us, this memorial is a sacred place.
[Roberto] And there's that mulberry tree over there, see?
It survived the plane crash, it survived the implosion of the building.
And we insisted for this memorial to be built around it.
To show that life can, let's say,
go on.
[no audible dialogue]
[camera click]
[Simone] I went to live in Buenos Aires.
I lived there for a year and a half, almost two.
I needed to escape that atmosphere of death for a while.
I needed to be reborn, you know?
[camera click]
[Ildercler] I have two beautiful daughters.
God gave me this double honor.
He put a smile on my face again.
[no audible dialogue]
[camera click]
[Roberto] The compensations didn't change anyone's economic status.
I still live in the same old little 500-square-foot apartment.
And live the same old life.
[camera click]
My mother used to say something very simple.
"Let's care about life, because death is certain."
So I think that's what I've tried to do.
[Eduardo] I was a 23-year-old kid, you know?
With AFAVITAM and this whole thing,
I matured ten years in two, just like that, because
not even I knew how much I would absorb and how much I would be able to handle.
[camera click]
[Christophe] Since its beginnings, aviation has progressed
because every time an accident happens,
we try to understand why and we start to solve the problems.
[camera click]
With ABRAPAVAA's work today, we're also making aviation improve
from the perspective of humanitarian assistance.
[Dario] Life goes on.
I recovered.
I think there are families who are still trying to recover from this tragedy.
AFAVITAM still exists.
Every year, we pay tribute to the victims,
both in Porto Alegre and São Paulo.
[optimistic music continues]
And we continue to fight to ensure the space is in good condition.
Because it is a public space,
but it must always be remembered for the tragedy that happened there.
It must be a landmark, at the entrance of that airport
so this doesn't happen again.
[Sarrubbo] If the memorial is deteriorating today,
if it's poorly maintained,
this is a sign that we are already starting to forget.
The airport was privatized,
we want to increase the number of flights, increase traffic…
Man, the memorial is right there.
[car horns honking]
Let's look at the memorial and see the path we have to follow from now on.
And we should remain always vigilant, so that we don't go through this again.
[imperious music playing]
FIFTEEN AIRPORTS AUCTIONED
[reporter 1] Congonhas Airport, in São Paulo,
was auctioned this Thursday…
[reporter 2] …by Spanish company AENA for 2 billion, 450 million reals,
231% above the minimum bid.
AENA paid billions of reals in the privatization auction,
and it needs to generate revenue.
According to AENA, Congonhas Airport will get a new passenger terminal.
The investment will be to expand the Congonhas Airport.
I don't think there's enough space, but they want to expand it.
[reporter 3] An attempt to explain the workings of an airport
swallowed up by a metropolis.
[reporter 4] An island of planes squeezed between houses
and residential buildings.
[Simone] Yeah, when we talk about expanding,
we're not just talking about expanding the runway,
the size of the airport, but also expanding the number of people, right?
[Raul] So if you have more people in a terminal,
you have more people eating sandwiches,
drinking coffee, parking their cars.
You can get all sorts of revenue there.
[reporter 5] There are too many people and planes for just one airport.
[Antonio] It's one plane after another.
I mean, that's absurd. There's no safety.
[Dario] We just want safety.
Am I going to keep using air transport? Sure.
But I want to feel safer every time I get on a plane.
I don't want to get on a… little box of surprises.
Obviously, profit is important.
It is, for sure. Every company has to make a profit.
But… you can't put profit above people's lives.
[music intensifies, then becomes somber]
TWO YEARS AFTER THE ACCIDENT,
TAM REACHED ITS HIGHEST REVENUE TO DATE.
IN 2016, TAM MERGED WITH CHILEAN AIRLINE LAN.
TODAY LATAM IS THE BIGGEST AIRLINE IN LATIN AMERICA.
IN RECENT YEARS, AIRBUS SURPASSED THE TRADITIONAL BOEING
AND BECAME THE WORLD'S BIGGEST PLANE MANUFACTURER.
DUE TO THE STRIKE,
89 AIR TRAFFIC CONTROLLERS WERE INDICTED BY THE MILITARY.
THEIR DEMANDS WERE ONLY PARTIALLY MET.
IT'S ESTIMATED THAT 85% OF AIR TRAFFIC CONTROLLERS IN BRAZIL
ARE IN THE MILITARY.
CLAIMING LACK OF INTEREST, THE BRAZILIAN AIR FORCE
DID NOT ALLOW ANY OFFICERS TO BE INTERVIEWED FOR THIS SERIES.
THE GOL DISASTER RESULTED IN 154 CASUALTIES.
DUE TO THE CONGONHAS TAM TRAGEDY, 199 PEOPLE LOST THEIR LIVES.
THIS SERIES IS DEDICATED TO THEM.
MAY THEY NEVER BE FORGOTTEN.
[music ends]
[melancholic music playing]
[music becomes suspenseful]
[music ends]