The True Story Behind Netflix's Aviation Disaster Documentary A Tragedy Foretold: Flight 3054

Time​ Magazine

23-04-2025

On July 17, 2007, Brazil endured the worst aviation accident in the country's history: the crash of a TAM Airlines plane, which left 199 people dead. The incident is also considered the biggest aviation tragedy in Latin America and is revisited in the Brazilian documentary series A Tragedy Foretold, releasing on Netflix on April 23 amid a recent uptick in concerns of aviation safety in the U.S.
On the day of the tragic crash, the aircraft—an Airbus A320 operated by TAM—failed to land properly at Congonhas Airport in São Paulo. It overran the runway and collided with a TAM building and a gas station on Washington Luís Avenue, causing an explosion.
When the TAM Airbus A320 tragedy occurred in 2007, Brazil was undergoing what became known as the 'aviation blackout'—a crisis in the country's civil aviation sector between 2006 and 2007, marked by massive delays, flight cancellations, and airport chaos, affecting millions of passengers.
The crisis was caused by a lack of investment in airport infrastructure and air traffic control—the result of years of budget cuts—and by low wages and poor working conditions for air traffic controllers. This led to strikes and work-to-rule protests (when strict adherence to procedures is used to slow down operations), all while passenger numbers were growing without proportional expansion of infrastructure.
The crisis worsened after the crash of Gol Flight 1907 on Sept. 29, 2006, which killed all passengers and crew onboard when it collided with another aircraft en route from Manaus to Brasília. This incident heightened insecurity among aviation professionals. Some air traffic controllers were suspended for investigation over potential operational errors. With no backups available, others had to cover for them, leading to even more strain. Controllers demanded better working conditions and the urgent hiring of more personnel.
The worst accident in Brazil's aviation history
At approximately 6:48 p.m. Brazil local time on July 17, 2007, the TAM Airbus A320—now operating under the name LATAM—was arriving from Salgado Filho Airport in Porto Alegre and attempted to land at Congonhas Airport in São Paulo. The runway was wet and, due to recent renovations, lacked the grooving that helps aircraft brake more effectively. The landing maneuver was unsuccessful: the Airbus overran the runway and crashed into a TAM cargo building located directly across from the airport.
The plane exploded, killing 199 people: 181 passengers, six crew members, and 12 individuals who were on the ground or in the building. The building was later demolished and turned into a memorial for the victims, featuring 199 points of light.
In the documentary series, victims' families recall the day of the accident and the agonizing wait to identify the bodies. Some families were unable to bury their loved ones, as some victims' bodies were completely pulverized in the crash. Others were found as much as 30 days after the accident.
The accident was investigated by three Brazilian agencies. CENIPA, the Center for Investigation and Prevention of Aeronautical Accidents, concluded that a combination of human and operational errors caused the tragedy. According to the report, during landing, the pilots placed only one of the engine thrust levers in the idle position, while the other remained in climb mode. This caused the aircraft's system to interpret that they were attempting to take off again, not brake. A final segment of the cockpit voice recorder captured the pilots noting that only one of the controls was functioning properly.
Other contributing factors included the lack of an audible alert for throttle misconfiguration and flaws in crew training, which relied heavily on online courses. Although he was experienced, the co-pilot had limited hours flying A320 aircraft. Additionally, there was no regulation preventing landings at Congonhas with an inoperative thrust reverser—even on rainy days.
CENIPA, as a preventive agency, did not name those responsible. However, its report contributed to further investigations by the Civil Police and Federal Police, which reached different conclusions on accountability.
Who was held responsible?
Initially, the Civil Police indicted 10 people, including employees of Infraero (the airport authority), the National Civil Aviation Agency (Anac), and TAM Airlines. The State Public Prosecutor's Office added one more name, bringing the total to 11 individuals formally accused.
However, the case did not proceed in state court. It was transferred to the Federal Public Prosecutor's Office, under the argument that it involved a crime against aviation safety, falling under federal jurisdiction. The Federal Police then took over the investigation and ultimately indicted only the two pilots: Kleyber Lima and Henrique Stefanini Di Sacco.
Even so, when the Federal Public Prosecutor's Office formally brought charges, prosecutor Rodrigo de Grandis chose to indict three other people instead: TAM's Director of Flight Safety, Marco Aurélio dos Santos de Miranda e Castro; the company's Vice President of Operations, Alberto Fajerman; and Anac director Denise Abreu.
In 2014, Fajerman was acquitted due to lack of evidence. Denise Abreu and Marco Aurélio were charged with intentional homicide—arguing they allowed the aircraft to operate in inadequate conditions—but in 2015, all three defendants were acquitted.
What changed after the tragedy?
CENIPA's report issued 83 safety recommendations, directed to the International Civil Aviation Organization, Anac, Congonhas Airport, Airbus, and TAM. One major change was the installation of visual and audio warning systems to alert pilots of possible throttle misconfigurations. At the time of the crash, Airbus had already developed the device but had not mandated its installation, as this would have required a costly recall.
At Congonhas Airport, the most notable change was the resurfacing of the runway, now with transverse grooving and a porous friction layer to improve water drainage and reduce the risk of skidding. The usable length of the main runway was reduced to 1,660 meters to allow for safety zones. Regarding pilot training, the National Civil Aviation Agency (Anac) established minimum training standards specifically for braking system failures.
Although Brazil has recorded an increase in air accidents in recent years—especially in 2024, which saw 138 deaths in 40 fatal accidents and was considered the deadliest year for Brazilian aviation since 2014—these figures include various types of aircraft, such as helicopters and ultralights, according to data from the Aeronautical Accident Investigation and Prevention System maintained by the Brazilian Air Force.
In the case of regular commercial aviation—the category to which TAM Flight 3054 belonged—the first fatal accident recorded since the 2007 tragedy occurred in August 2024.
At that time, Flight 2283, an ATR 72-500 operated by Voepass, crashed in Vinhedo, in the state of São Paulo, killing 62 people. Until then, Brazil had gone 17 years without a fatal accident in regular commercial aviation—a figure that reinforces the idea that many of the safety recommendations adopted after the TAM crash had a lasting impact.