@inproceedings{Quintino2025SystemicAnalysisTam,

title = {A Systemic Analysis of the TAM Airlines Flight 3054 Accident: A Hybrid STEP and SWOT Approach},

author = {Ester dos Santos Quintino and Guilherme Moreira and Willer Gomes and Moacyr Cardoso},

url = {https://www.sige.ita.br/edicoes-anteriores/2025/TRABALHOS/Artigos-com-ISSN/A Systemic Analysis of the TAM Airlines Flight 3054 Accident A Hybrid STEP and SWOT Approach.pdf},

issn = {1983-7402},

year  = {2025},

date = {2025-01-01},

booktitle = {Anais do Simp\'{o}sio de Aplica\c{c}\~{o}es Operacionais em \'{A}reas de Defesa (SIGE)},

pages = {309\textendash314},

address = {S\~{a}o Jos\'{e} dos Campos, Brasil},

organization = {Instituto Tecnol\'{o}gico de Aeron\'{a}utica},

abstract = {The crash of TAM Airlines Flight 3054 on July 17, 2007, is one of Brazil’s most significant aviation disasters. While pilot error was initially identified as the primary cause, a deeper analysis reveals that the accident resulted from a complex socio-technical system operating under stress. This study employs a hybrid methodology, combining Sequentially Timed Events Plotting (STEP) and an analysis of Strengths, Weaknesses, Opportunities, and Threats (SWOT), to reconstruct the sequence of events and assess the operational environment. The critical crew error, influenced by human-automation interface flaws, triggered a series of interconnected failures, including compromised safety systems, a contaminated runway, and inadequate infrastructure. The analysis demonstrates that the catastrophic outcome was due to multiple vulnerabilities rather than a single failure. The study proposes multi-level recommendations targeting technical systems, human factors training, airport infrastructure, and regulatory oversight to enhance aviation safety and prevent future incidents.},

keywords = {Safety, STEP, SWOT},

pubstate = {published},

tppubtype = {inproceedings}

}