Resonance of Failure: The TAM Flight JJ3054 Accident

• Ester Dos Santos Quintino
• Christianne Reiser
• Lucas Martins de Oliveira Mendes
• Moacyr Machado Cardoso Júnior
• Willer Gomes dos Santos
• Guilherme Moreira de Souza

Instituto Tecnológico de Aeronáutica

Evento

XXII SITRAER – Brasília, DF, Brasil, 22 a 24 de outubro de 2025

Volume

Anais do XXII Simpósio de Transporte Aéreo – SITRAER 2025 · ISBN 978-65-272-2024-4 · DOI 10.29327/9786527220244

Editora

Even3 Publicações

Editores

Fabiana Serra de Arruda, Camila Lucena, Giovanna Miceli Ronzani Borille, Evandro José da Silva

Abstract

The TAM Flight JJ3054 accident, which occurred on July 17, 2007, at Congonhas’s Airport in São Paulo, is examined as a case study in the emergence of failures within complex sociotechnical systems. Using the Functional Resonance Analysis Method (FRAM), this research models how normal performance variability and unanticipated interactions among system functions contributed to the accident. Moving beyond linear causality, the FRAM approach enabled the functional reconstruction of key system behaviors, including thrust lever management, braking system activation, degraded runway surface management, time-constrained decision-making, and the influence of organizational and regulatory structures. The analysis reveals how minor, routine performance variations (individually acceptable) can combine non-linearly to generate conditions conducive to systemic failure. Contributing factors such as the dispatch of the aircraft with one thrust reverser inoperative, the lack of runway grooving under wet conditions, and the persistence of outdated standard operating procedures illustrate how latent conditions and real-time adjustments interact dynamically. Rather than resulting from a single failure or human error, the accident emerged from the resonance of functional variabilities across technical, human, environmental, and organizational dimensions. By adopting a systems-oriented perspective, this study reinforces the need for operational models that capture real-world complexity and performance variability. It also highlights the value of FRAM as a methodological tool for anticipating emergent risks in aviation, supporting the development of resilience-informed safety strategies that go beyond compliance and error prevention.

Keywords: FRAM; Complex Sociotechnical Systems; Minimum Equipment List; Aviation