LAPA flight 3142
Encyclopedia
LAPA Flight 3142 was a scheduled Buenos Aires
Buenos Aires
Buenos Aires is the capital and largest city of Argentina, and the second-largest metropolitan area in South America, after São Paulo. It is located on the western shore of the estuary of the Río de la Plata, on the southeastern coast of the South American continent...

Córdoba
Córdoba, Argentina
Córdoba is a city located near the geographical center of Argentina, in the foothills of the Sierras Chicas on the Suquía River, about northwest of Buenos Aires. It is the capital of Córdoba Province. Córdoba is the second-largest city in Argentina after the federal capital Buenos Aires, with...

 flight operated by the Argentine
Argentina
Argentina , officially the Argentine Republic , is the second largest country in South America by land area, after Brazil. It is constituted as a federation of 23 provinces and an autonomous city, Buenos Aires...

 airline Líneas Aéreas Privadas Argentinas. The service was operated with a Boeing 737-204C
Boeing 737
The Boeing 737 is a short- to medium-range, twin-engine narrow-body jet airliner. Originally developed as a shorter, lower-cost twin-engine airliner derived from Boeing's 707 and 727, the 737 has developed into a family of nine passenger models with a capacity of 85 to 215 passengers...

, registration LV-WRZ, that crashed on at 20:54 local time while attempting to take off
Takeoff
Takeoff is the phase of flight in which an aerospace vehicle goes from the ground to flying in the air.For horizontal takeoff aircraft this usually involves starting with a transition from moving along the ground on a runway. For balloons, helicopters and some specialized fixed-wing aircraft , no...

 from Aeroparque Jorge Newbery
Aeroparque Jorge Newbery
-Accidents and incidents:*On 17 December 1969, an Austral Líneas Aéreas C-46 Commando, lost engine 1 due to fuel exhaustion shortly after take-off. The plane failed to gain height and made a crash landing in a small sport field...

 after it failed to get airborne. The crash resulted in 67 fatalities —65 of them occupants of the aircraft— and at least 40 people injured, some of them in serious condition. The death toll
Death Toll
Death Toll is a 2008 action film starring DMX, Lou Diamond Phillips, Leila Arcieri and Keshia Knight Pulliam, written and produced by Daniel Garcia of the rap group Kane & Abel and directed by Phenomenon...

 makes the accident the second deadliest one in the history of Argentine aviation, behind Austral Líneas Aéreas Flight 2553
Austral Líneas Aéreas Flight 2553
Austral Líneas Aéreas Flight 2553, better known as Austral 2553, was a domestic scheduled Posadas–Buenos Aires service operated with a McDonnell Douglas DC-9-32 that crashed on the lands of Estancia Magallanes, Nuevo Berlín, away from Fray Bentos, Uruguay, on . All 74 passengers and crew perished...

.

Aircraft

The plane involved in the accident was a Boeing 737-204C
Boeing 737
The Boeing 737 is a short- to medium-range, twin-engine narrow-body jet airliner. Originally developed as a shorter, lower-cost twin-engine airliner derived from Boeing's 707 and 727, the 737 has developed into a family of nine passenger models with a capacity of 85 to 215 passengers...

, registration LV-WRZ, production number 20389, line 251, with JT8D-9A engines. It first flew on , and it was delivered by Boeing
Boeing
The Boeing Company is an American multinational aerospace and defense corporation, founded in 1916 by William E. Boeing in Seattle, Washington. Boeing has expanded over the years, merging with McDonnell Douglas in 1997. Boeing Corporate headquarters has been in Chicago, Illinois since 2001...

 to Britannia Airways
Britannia Airways
Britannia Airways was the largest charter airline in the United Kingdom, rebranded as Thomsonfly in 2005. Its main bases were Gatwick, London Luton, Birmingham, Manchester, Newcastle and Glasgow...

 on April 17 of that year. It was listed in the United Kingdom
United Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...

's registry as G-AXNB.

Almost 20 years later, on , the plane was sold to the French
France
The French Republic , The French Republic , The French Republic , (commonly known as France , is a unitary semi-presidential republic in Western Europe with several overseas territories and islands located on other continents and in the Indian, Pacific, and Atlantic oceans. Metropolitan France...

 airline TAT European Airlines
TAT European Airlines
Transport Aérien Transrégional was a French regional airline with its head office on the grounds of Tours Val de Loire Airport in Tours. It was formed in 1968 as Touraine Air Transport by M. Marchais. Air France acquired a minority stake in the airline in 1989. Between 1993 and 1996 the company...

, and registered in France as F-GGPB.

Finally, LAPA took possession of the plane on , and flew it under the Argentine tail number
Tail number
A tail number refers to an identification number painted on an aircraft, frequently on the tail.Tail numbers can represent:* An aircraft registration number * United States military aircraft serials-See also:...

 LV-WRZ. At the time of the accident, it had accumulated 67,864 hours of flying time and 41,851 take-offs and landing
Landing
thumb|A [[Mute Swan]] alighting. Note the ruffled feathers on top of the wings indicate that the swan is flying at the [[Stall |stall]]ing speed...

s. The aircraft was old at the time the accident took place.

Accident

As the aircraft started the take-off run, a warning sounded in the cockpit, indicating that the aircraft was not correctly configured for the maneuver. The crew continued the run, not realising that the flap
Flap (aircraft)
Flaps are normally hinged surfaces mounted on the trailing edges of the wings of a fixed-wing aircraft to reduce the speed an aircraft can be safely flown at and to increase the angle of descent for landing without increasing air speed. They shorten takeoff and landing distances as well as...

s were not at the required take-off position and were instead fully retracted, thus preventing the aircraft from lifting off. The jet overshot the runway, breaking through the airport's perimeter fence, crossed a road, hitting an automobile, and finally collided with road-construction machinery and a highway median
Central reservation
On divided roads, such as divided highways or freeways/motorways, the central reservation , median, parkway , median strip or central nature strip is the area which separates opposing lanes of traffic...

. Fuel spilling over the hot engines and gas leaking from a damaged gas regulation station resulted in a fire that totally destroyed the aircraft.

The Junta de Investigaciones de Accidentes de Aviación Civil
Junta de Investigaciones de Accidentes de Aviación Civil
The Junta de Investigaciones de Accidentes de Aviación Civil is an agency of Argentina that investigates aviation accidents. Its headquarters is in Buenos Aires. The JIAAC has four administrative regions. As of 2011 Gustavo Enrique Graziani is the president of the JIAAC.-See also:* LAPA Flight...

(JIAAC) determined that the pilots failed to configure the aircraft correctly for take-off. The penal prosecution
Criminal law
Criminal law, is the body of law that relates to crime. It might be defined as the body of rules that defines conduct that is not allowed because it is held to threaten, harm or endanger the safety and welfare of people, and that sets out the punishment to be imposed on people who do not obey...

 focused on proving that the company's policies and organization, lacking the Argentine Air Force
Argentine Air Force
The Argentine Air Force is the national aviation branch of the Armed Forces of the Argentine Republic. , it had 14,606 military and 6,854 civilian staff.-History:...

's controls, were the main factors that led to the accident. For instance, it was mentioned that a pilot was allowed to fly without a license by the company. Because of these perceived flaws, some of LAPA's directors and the Air Force staff responsible for monitoring the airline were taken to jury trial
Jury trial
A jury trial is a legal proceeding in which a jury either makes a decision or makes findings of fact which are then applied by a judge...

.

Crew

The captain was Gustavo Weigel (45) and his co-pilot was Luis Etcheverry (31). Both died in the accident. Weigel had 6,500 hours of flying experience, of which 1,710 had been in a Boeing 737, the type of aircraft that was in the accident. The co-pilot had flown 560 of his 4,085 hours in the 737.

With regard to the two pilots, the JIAAC report said that "the records of their flight and simulator
Flight simulator
A flight simulator is a device that artificially re-creates aircraft flight and various aspects of the flight environment. This includes the equations that govern how aircraft fly, how they react to applications of their controls and other aircraft systems, and how they react to the external...

 training showed repeated negative flying characteristics, and if they had been able to move away from these characteristics in the face of difficulties, their poor attitude manifested itself once again in relaxed attitudes such as that seen in the cockpit
Cockpit
A cockpit or flight deck is the area, usually near the front of an aircraft, from which a pilot controls the aircraft. Most modern cockpits are enclosed, except on some small aircraft, and cockpits on large airliners are also physically separated from the cabin...

 of flight 3142".

Even though the aforementioned report stated that "the pilots had fulfilled technical and psychological requirements", and that "their experience, both in general flight, and with this kind of aircraft was suitable for the job they were performing", the lawsuit later determined that Weigel was not fit to fly, since his license had expired.

Even though these personal issues surrounding the pilots had a very significant influence on the accident, the legal investigation performed in the following years centred on proving that the pilots were not entirely to blame, but that the lack of controls by the Air Force and LAPA's organizational culture also played a role in the events leading to the crash.

Flight review

The JIAAC review of the flight reads:


The evening of the accident, the captain arrived at the Aeroparque Jorge Newbery
Aeroparque Jorge Newbery
-Accidents and incidents:*On 17 December 1969, an Austral Líneas Aéreas C-46 Commando, lost engine 1 due to fuel exhaustion shortly after take-off. The plane failed to gain height and made a crash landing in a small sport field...

 one hour before take-off, as usual, in order to perform a regular commercial flight (LAPA 3142), on which 95 passengers and 5 crew members were to be transported to the destination airport Ingeniero Ambrosio Taravella
Ingeniero Ambrosio L.V. Taravella International Airport
Ingeniero Aeronáutico Ambrosio L.V. Taravella International Airport , more commonly known as Pajas Blancas, is located north-northwest away from the center of Córdoba, the capital city of the Córdoba Province...

 in the city of Córdoba
Córdoba, Argentina
Córdoba is a city located near the geographical center of Argentina, in the foothills of the Sierras Chicas on the Suquía River, about northwest of Buenos Aires. It is the capital of Córdoba Province. Córdoba is the second-largest city in Argentina after the federal capital Buenos Aires, with...

.


He arrived before the first officer and had an informal conversation with the flight dispatcher on duty. The aforementioned briefing started with the rest of the flight's crew, and when the first officer arrived, they went back over the weather conditions –which were good– and the NOTAM
NOTAM
NOTAM or NoTAM is the quasi-acronym for a "Notice To Airmen". NOTAMs are created and transmitted by government agencies and airport operators under guidelines specified by Annex 15: Aeronautical Information Services of the Convention on International Civil Aviation...

s for the destination airport as well as for alternative ones. Both pilots controlled the flight plan. Having seen the good weather conditions, the captain selected Aeroparque Jorge Newbery
Aeroparque Jorge Newbery
-Accidents and incidents:*On 17 December 1969, an Austral Líneas Aéreas C-46 Commando, lost engine 1 due to fuel exhaustion shortly after take-off. The plane failed to gain height and made a crash landing in a small sport field...

 as the alternative airport and decided on the fuel requirements for the flight. The first officer went to the aircraft and the captain followed him shortly after.


The whole briefing lasted approximately ten minutes.


There were no unusual incidents during the briefing. There were no comments or attitudes outside the norm from either of the two pilots during the briefing.


According to the dispatcher, the captain looked very well and as energetic as usual and the first officer looked well.
The first officer, the flight commissioner and cabin crew arrived at the aircraft first.


The first officer notified one of the mechanics assisting the aircraft that the total fuel requirement was 8,500 kg
Kilogram
The kilogram or kilogramme , also known as the kilo, is the base unit of mass in the International System of Units and is defined as being equal to the mass of the International Prototype Kilogram , which is almost exactly equal to the mass of one liter of water...

, all to be stored in tanks on the wings. The mechanic corroborated loading fuel into the main tank. In this case, as required by the technical documentation of the time, the fuel was to be moved to the wing tanks. The mechanic started that job when the captain arrived at the aircraft.


Before entering the cockpit, he threw the flight technical record to the floor, showing annoyance, confirming that attitude by later shutting off the fuel transfer faucet between the main tank and the wing tanks, a job that was being performed at that precise moment by the assistant flight mechanic.


During their first four minutes on board, the captain, the co-pilot and the commissioner talked about trivial matters in good spirits, focusing on the commissioner's personal issues. When the commissioner left the cockpit, the conversation changed tone and matter as they discussed a controversial situation about their relationship. The captain said, after a reproach from the co-pilot, that he was "going through bad times", to which the copilot replied that he was also having a bad day.


Without interrupting the conversation and as part of it, the reading of the Procedures Control List (PCL) for the aircraft started, mixed with the personal issues that worried them and that led them to misread the procedure checklist.


This confusing situation, in which the PCL was interspersed with conversation irrelevant to the crew's task, persisted during "push back", engine start and taxiing, up to the moment of take-off, which was delayed by other aircraft waiting ahead of the LAPA flight and heavy arriving traffic.


During this final wait, the three men were smoking in the cockpit and their conversation could be of dubious interpretation.


Take-off started on Runway 13 of the Aeroparque at 20:53 hours, and in spite of overpassing rotation (Vr) and take-off security (V2) speeds, the aircraft did not succeed in taking off, continuing straight along its path uncontrollably, hitting several obstacles and finally impacting an embankment
Earthworks (engineering)
Earthworks are engineering works created through the moving or processing of quantities of soil or unformed rock.- Civil engineering use :Typical earthworks include roads, railway beds, causeways, dams, levees, canals, and berms...

.


The report details: "in its final run after failing to take off, the aircraft hit a Chrysler
Chrysler
Chrysler Group LLC is a multinational automaker headquartered in Auburn Hills, Michigan, USA. Chrysler was first organized as the Chrysler Corporation in 1925....

 Neón car that was travelling on the Rafael Obligado road (Costanera Norte) that crosses the projection of Runway 13. The car's fuel in contact with sparks from the sliding fuselage
Fuselage
The fuselage is an aircraft's main body section that holds crew and passengers or cargo. In single-engine aircraft it will usually contain an engine, although in some amphibious aircraft the single engine is mounted on a pylon attached to the fuselage which in turn is used as a floating hull...

 against the tarmac and the dragged automobile possibly ignited a fire on the left front side of the aircraft, which grew from rupture of the wings which spilled jet fuel
Jet fuel
Jet fuel is a type of aviation fuel designed for use in aircraft powered by gas-turbine engines. It is clear to straw-colored in appearance. The most commonly used fuels for commercial aviation are Jet A and Jet A-1 which are produced to a standardized international specification...

 of type JP-1
JP-1
JP-1 was an early jet fuel, specified in 1944 by the U.S. government . It was a pure kerosene fuel with high flash point and a freezing point of −60 °C...

. Also, as a result of a gas regulator plant being hit, a gas leak developed. The fire moved to the back of the aircraft, covering it entirely."

After impact against the embankment, but before catching fire, a flight attendant
Flight attendant
Flight attendants or cabin crew are members of an aircrew employed by airlines primarily to ensure the safety and comfort of passengers aboard commercial flights, on select business jet aircraft, and on some military aircraft.-History:The role of a flight attendant derives from that of similar...

 attempted to hold and operate a fire extinguisher
Fire extinguisher
A fire extinguisher or extinguisher, flame entinguisher is an active fire protection device used to extinguish or control small fires, often in emergency situations...

, but she didn't succeed because it was already very hot. She also unsuccessfully tried to open the rear right door that was jammed —probably due to deformation. Finally, another flight attendant succeeded in opening the rear left door allowing several passengers to be evacuated before the fire propagated itself. The right side of the fuselage showed an opening, through which a few passengers escaped.

On the doors, preliminary versions of the report added that "the front left slide L1, of grey colour, was found deployed but unpressurised", which means a much greater effort was needed to open the door. The early reports also considered that the absence of a food or drinks trolley in the rear galley of the aircraft helped, since walking distance to the exit was notably reduced.

Fire units from the airport, as well as the Federal Police
Policía Federal Argentina
The Policía Federal Argentina is a police force of the Argentine federal government. The PFA has detachments throughout the country, but its main responsibility is policing the Federal District of Buenos Aires...

, and the Naval Prefecture fought the fire. The evacuation operation was directed by the city's Medical Emergency Attention Service (SAME), which used 15 ambulance
Ambulance
An ambulance is a vehicle for transportation of sick or injured people to, from or between places of treatment for an illness or injury, and in some instances will also provide out of hospital medical care to the patient...

s of their own as well as some from private hospitals. Based on the severity
Triage
Triage or ) is the process of determining the priority of patients' treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. The term comes from the French verb trier, meaning to separate,...

 of their injuries, the casualties were taken to different treatment centres.

Cabin conversation

This aircraft type is equipped with a cockpit voice recorder
Cockpit voice recorder
A cockpit voice recorder , often referred to as a "black box", is a flight recorder used to record the audio environment in the flight deck of an aircraft for the purpose of investigation of accidents and incidents...

 (CVR) that records the conversation in the cockpit. Below is a transcription of the final 90 seconds of the conversation recorded by the CVR, beginning at 30:34 (30 minutes and 34 seconds from the moment the recording started) and running through the attempted take-off and accident.

Pilot: Captain Cop.: Co-pilot Tower: Control tower

30:34–30:57

Pilot.: "Was there a plane behind us?" (heard at very low volume).

Tower.: "Taking off one two?" Sound of parking brakes being released.

Cop./Tower: "We're taking off."

Cop.: "Move it, Adrian, or I'll run over you."

Another voice: "Ok."

30:58 – Sound of engines accelerating starts.

31:00 – Sound of maximum engine acceleration.

31:01 – Alarm begins to sound (Beep, Beep, Beep...).

31:05Pilot: "No, no, no, huh?"

31:12Pilot: "What the hell is that?"

31:16Cop.: "Take off thrust set, speed alive" (spoken in English)

31:20Pilot: "I don't know what's going on, buddy, but everything is ok." (unclear).

31:23Cop.: "Eighty knots." (spoken in English)

31:36Cop.: "V 1."

31:37Cop.: "Rotate." (spoken in English)

31:39Cop.: "V 2."

31:41–31:45 – Continuous mechanical sound of the stick shaker
Stick shaker
A stick shaker is a mechanical device to rapidly and noisily vibrate the control yoke of an aircraft to warn the pilot of an imminent stall...

.

31:45 – Sound of engines decelerating. Cuts out.

31:46.04 – Sound of impact.

31:53Tower: "3142 and..." (end of recording).

Source: Diario Ámbito Financiero
Ámbito Financiero
Ámbito Financiero is an Argentine newspaper founded on December 9, 1976 by economist Julio A. Ramos. It was initially sold in downtown Buenos Aires, covering mainly the daily prices of the U.S. dollar, gold, stocks, etc., and included other editorials....

 and prevac.com.ar

JIAAC investigation

The JIAAC's investigation report was only one of the documents taken into account in the judicial investigation, though it was criticized for focusing solely on blaming the pilots directly.

During the three days after the accident, the United States National Transportation Safety Board
National Transportation Safety Board
The National Transportation Safety Board is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine...

 (NTSB) sent a team to assist the JIAAC in their investigation. This team consisted of an NTSB representative and technicians from Boeing, Pratt & Whitney
Pratt & Whitney
Pratt & Whitney is a U.S.-based aerospace manufacturer with global service operations. It is a subsidiary of United Technologies Corporation . Pratt & Whitney's aircraft engines are widely used in both civil aviation and military aviation. Its headquarters are in East Hartford, Connecticut, USA...

, and the US Federal Aviation Administration
Federal Aviation Administration
The Federal Aviation Administration is the national aviation authority of the United States. An agency of the United States Department of Transportation, it has authority to regulate and oversee all aspects of civil aviation in the U.S...

 (FAA). While in Argentina, these investigators worked with JIAAC personnel, forming teams according to their areas of expertise.

The data from the black box
Black Box (transportation)
The term black box is a placeholder name used casually to refer to a collection of several different recording devices used in transportation: the flight recorders in aircraft, the event recorder in railway locomotives, the event data recorder in automobiles, message case in ships, and other...

, the flight data recorder
Flight data recorder
A flight data recorder is an electronic device employed to record any instructions sent to any electronic systems on an aircraft. It is a device used to record specific aircraft performance parameters...

 (FDR) and the cockpit voice recorder
Cockpit voice recorder
A cockpit voice recorder , often referred to as a "black box", is a flight recorder used to record the audio environment in the flight deck of an aircraft for the purpose of investigation of accidents and incidents...

 (CVR) were read at the NTSB headquarters in Washington. With this information, a computerized animation of the failed take-off attempt was constructed.

Another aspect that was studied and analyzed was the adherence to the maintenance plan in the available technical documentation. The analysis led investigators to believe that the aircraft, its components and its engines complied with the requirements set out in the maintenance plan and the approved operational specifications of the Dirección Nacional de Aeronavegabilidad (National Board of Aeronavigation).

To complete the detailed investigation, the JIAAC technicians reassembled the main components of the aircraft in a hangar
Hangar
A hangar is a closed structure to hold aircraft or spacecraft in protective storage. Most hangars are built of metal, but other materials such as wood and concrete are also sometimes used...

 in the Aeroparque. They also cleaned, identified and analyzed the boards, actuators, electronic equipment, the cockpit pedestal, etc. that were recovered from the accident site, and dismantled the engines of the plane as much as possible given the state of destruction they faced. The technicians inspected the hydraulic system on thrust reversers of both engines, and the braking system of the landing gear
Undercarriage
The undercarriage or landing gear in aviation, is the structure that supports an aircraft on the ground and allows it to taxi, takeoff and land...

, all of which were found to be in sufficient working order.

The investigation concluded that the engines almost certainly functioned until the final impact, though their behaviour at that particular moment could not be precisely determined. Nevertheless, from the reading of the FDR it was observed that both engines had equal thrust and were set to provide thrust for take-off before power was reduced and the thrust reversers were applied. In order to determine if there was a bird strike
Bird strike
A bird strike—sometimes called birdstrike, avian ingestion , bird hit, or BASH —is a collision between an airborne animal and a man-made vehicle, especially aircraft...

, the National Institute for the Investigation of Natural Sciences (Instituto Nacional de Investigaciones de las Ciencias Naturales) performed a study with negative results.

The thrust reversers—which are located behind the engine and direct the exhaust forward to slow the aircraft down quickly after landing (see image)—were found seriously damaged, but the hydraulic mechanism of the left engine was set for reverse thrust, while the right one was set for forward thrust. The investigation was unable to determinate if the thrust reversers were intentionally activated and later deactivated.

It was important for the investigation to establish the position of the mechanical activators on the flaps
Flap (aircraft)
Flaps are normally hinged surfaces mounted on the trailing edges of the wings of a fixed-wing aircraft to reduce the speed an aircraft can be safely flown at and to increase the angle of descent for landing without increasing air speed. They shorten takeoff and landing distances as well as...

, since the fact that they weren't activated was a fundamental cause of the accident. A special investigation was carried out to establish what had happened with the flaps. The extended flaps alter the aerodynamic
Aerodynamics
Aerodynamics is a branch of dynamics concerned with studying the motion of air, particularly when it interacts with a moving object. Aerodynamics is a subfield of fluid dynamics and gas dynamics, with much theory shared between them. Aerodynamics is often used synonymously with gas dynamics, with...

 characteristics of the aircraft, giving the aircraft lift
Lift (force)
A fluid flowing past the surface of a body exerts a surface force on it. Lift is the component of this force that is perpendicular to the oncoming flow direction. It contrasts with the drag force, which is the component of the surface force parallel to the flow direction...

 to get off the ground at a lower speed over a shorter distance than would be possible without flaps. Even if it had been possible to reach the take-off speed without flaps before the end of the runway, it would still have been necessary to have enough runway. This is why in practice, there are no runways that would allow the take-off of medium- to large- size aircraft without flaps.

The main finding within the remains of the plane was that all of the examined flaps' worm gear operators were in the unwound position, indicating that the flaps were not deployed. This tallies with the fact that the flap command in the cockpit was also in the no-flaps position, that the readings at the FDR indicate they were retracted, and that the flap lights were off, indicating that they were not activated.

The alarm sound recorded by the CVR indicated that there was a problem with the departure configurations. The recording showed that at the time of departure the flaps were not in the correct position for lift-off.

A study was performed on the electrical circuitry to determine the position of the electrical breakers on the departure configuration warning alarm. Also, a study was performed on the slat
Leading edge slats
Slats are aerodynamic surfaces on the leading edge of the wings of fixed-wing aircraft which, when deployed, allow the wing to operate at a higher angle of attack. A higher coefficient of lift is produced as a result of angle of attack and speed, so by deploying slats an aircraft can fly at slower...

 indicator lights' filaments.

The indicator lights were found to be off, the only fire alarm was off and the main warning indicators (Master Caution) were found on. The latter could be activated by any one of a long list of possible faults resulting in the destruction of the aircraft.

Causes

According to the investigative commission, the immediate cause of the accident was "that the flight crew of LAPA flight 3142 forgot to extend the wing flaps to initiate take-off, and ignored the alarm that advised them of the error in configuration for take-off."

Contributing factors

The report of the JIAAC cites the following factors as contributing to the accident:
  • Lack of crew discipline, who did not make the logical reaction of aborting take-off and checking for errors when the alarm sounded as the engines started and as it continued to sound until the take-off attempt.
  • Excess conversations irrelevant to the flight, and moments of significant emotional intensity between the pilots that were mixed with the reading of the flight checklist, resulting in the omission of the part of the procedures where flaps for take-off are to be extended.
  • Personal and/or family and/or economic problems or other issues of both pilots that interfered with their operational manner.
  • Insufficient psychological screening, resulting in the inability to detect when the pilots were suffering from personal and/or family and/or other types of problems that influenced their ability as pilots.
  • Knowledge and discussion of very personal and non-work-related affairs among the pilots and with the flight crew that fostered an atmosphere lacking in the necessary focus and concentration for operational tasks.
  • Aggravation of the captain's previous negative in-flight behaviour by his personal situation and interactions within the cockpit before and during the emergency.
  • Previous negative flight characteristics of the first officer that manifested themselves during the reading of the list of control procedures, all occurring in a cockpit whose occupants had their attention on personal issues unrelated to the flight.
  • Lack of immediate recognition or corroboration by the pilots of the relationship between the type of audible alarm and the improper take-off configuration, and the failure to employ the flaps correctly for take-off.
  • Design of the alarm system that did not ensure that the crew respond to the information it was feeding them and allowing them to continue with take-off regardless.

Casualties

The following table shows the casualties incurred by the accident as reported by JIAAC:
Injuries Fatal Major Minor None
Crew 3 2
Passengers 60 15 16 4
Others 2 2 1
Total 65 17 17 6

Criminal proceedings

After the accident, the criminal case remained in the hands of federal judge Gustavo Literas, who, during the first months received the preliminary report of the JIAAC and took testimony from dozens of LAPA mechanics.

At the beginning of March 2000, the judge called 540 people to testify, most of them LAPA pilots, copilots, and flight attendants. From this point the investigation centered on the theory that, in addition to pilot error, the ultimate cause of the accident was structural problems in the management of flight operations. During the first two weeks of March testimony was taken from some 140 people, and by this time almost all the survivors had also given testimony.

On May 14, judge Carlos Liporaci, who replaced judge Literas por licencia, ordered a search of LAPA headquarters and their operations room at Aeroparque, seizing the files of the company's pilots. According to the newspaper Clarín
Clarín (newspaper)
Clarín is the largest newspaper in Argentina, published by the Grupo Clarín media group. It was founded by Roberto Noble on 28 August 1945. It is politically centrist but popularly understood to oppose the Kirchner government...

, the court secretary, Pablo Bertussi, said, "When the accident happened, we took only the files of the pilots of that flight. Now we want to review those of the other pilots of this company."

On May 18, the JIAAC delivered its final report on the accident to the judge. The report was questioned by judicial sources because it focused solely on laying blame on the pilots. Regarding this report, the newspaper La Nación
La Nación
La Nación is an Argentine daily newspaper. The country's leading conservative paper, the centrist Clarín is its main competitor. It is the only newspaper in Argentina still published in broadsheet format.-Overview:...

 said the next day:
Even so, according to judicial sources, the dossier is still one more expert's report, and Judge Gustavo Literas, who is investigating the case, asked the Air Force to send him the files that prompted the report's conclusions. The judge wants all of the allegations to be based upon and supported by documents, according to our sources."

Indictments

The following week, on the 24 May, the judge called for the indictment
Indictment
An indictment , in the common-law legal system, is a formal accusation that a person has committed a crime. In jurisdictions that maintain the concept of felonies, the serious criminal offence is a felony; jurisdictions that lack the concept of felonies often use that of an indictable offence—an...

 of 32 people, including Gustavo Andrés Deutsch, President of LAPA, the former head of the Air Force, Brigadier General Rubén Montenegro (retired); the former head of the National Division of Aeronavigability, Brigadier Juan Baigorria (retired); the former head of the Division of Habilitaciones, Commodore Damián Peterson (retired); the former titular of the National Institute of Aeronautical and Space Medicine, Commodore Diego Lentino (retired); and the former head of the Command of Aerial Regions, Brigadier Major Enrique Dutra. Literas also ordered the seizure of the assets of Deutsch and 11 other LAPA leaders in the amount of 60 million pesos
Argentine peso
The peso is the currency of Argentina, identified by the symbol $ preceding the amount in the same way as many countries using dollar currencies. It is subdivided into 100 centavos. Its ISO 4217 code is ARS...

.

Regarding the progress of the investigation, the morning paper Página/12
Página/12
Página/12 is a newspaper based in Buenos Aires, Argentina.Página/12 was founded on May 25, 1987, by journalist Jorge Lanata in association with writer Osvaldo Soriano and investigative journalist Horacio Verbitsky...

 commented on the following day:

The investigation unveiled the lack of human resources politic in LAPA. "It would have been wider expertise and demand in the test performed to the pilots. We detected negligence and flexibility", explained to Página/12 a high judicial source. None of the inspections of the Air Force passed by Weigel —who died in the accident— were suitable to detect his proven anormal performance. "It's inadmissible that the same psycho-physiological examinations that I underwent while at the military service
Military service
Military service, in its simplest sense, is service by an individual or group in an army or other militia, whether as a chosen job or as a result of an involuntary draft . Some nations require a specific amount of military service from every citizen...

 are still used", said indignated an experimented government official with some grey hairs.


A little less than one month afterward, on 22 June, Gustavo Deutsch—president of LAPA—appeared for his declaration and responded to over 100 questions from the judge and attorneys general. La Nación reported that according to a judicial source, Deutsch "did not reveal useful information to the investigation". Even so, Deutsch was the only LAPA official who responded to the questions, as the others elected not to respond.

By the end of August, near the one-year anniversary of the tragedy, the investigation had accumulated 1600 pages of findings in 80 sections, it had heard 1500 witnesses, and 34 indictments were carried through the judicial process. At this point, the various sources of information had rendered enough evidence to show that, although the direct cause of the accident was human error, the pilot was in no condition to command an airplane; thus, the responsibility also fell partly on company officials and various high-level heads of the Air Force.

In early November 2000, the second session of the Federal Court of Appeal annulled the confiscation of 60 million pesos that the judge had ordered against the LAPA officials.

Formal charges

On 22 December 2000, in a 1200-page resolution, Judge Literas charged four LAPA officials and three members of the Air Force. The LAPA officials were charged with estrago culposo
Culpa
Culpa is a Latin or Spanish word meaning guilt or fault.It may also be referring to:*Mea Culpa, the Latin phrase for "it is my fault"*Culpa , a Cuban film directed by Jorge Molina...

 seguido de muerte
(similar to 'catastrophic criminal negligence
Criminal negligence
In the criminal law, criminal negligence is one of the three general classes of mens rea element required to constitute a conventional as opposed to strict liability offense. It is defined as an act that is:-Concept:...

 leading to death') and included:
  • Gustavo Andrés Deutsch – President.
  • Ronaldo Patricio Boyd – Director general.
  • Fabián Chionetti – Operations manager.
  • Nora Arzeno – Human resources manager.

Likewise, several members of the Air Force were prosecuted for dereliciton of duty in public office:
  • Brigadier Major Enrique Dutra (retired) – Head of the Command of Aerial Regions.
  • Commodore Carlos Petersen (retired) – Director of Empowerment and Promotion.
  • Commodore Diego Lentino (retired) – Director of the National Institute of Aeronautical and Space Medicine.


When the resolution was released, it also called for seizing the assets of LAPA president Gustavo Deutsch in the amount of 40,000,000 pesos
Argentine peso
The peso is the currency of Argentina, identified by the symbol $ preceding the amount in the same way as many countries using dollar currencies. It is subdivided into 100 centavos. Its ISO 4217 code is ARS...

, 500 thousand for Director General Ronaldo Boyd, and 100 thousand for each of the other managers. All of the accused were left at liberty.

With respect to the motive behind accusing the LAPA officials, La Nación drew upon the judicial resolution:

There are by now enough prima facie
Prima facie
Prima facie is a Latin expression meaning on its first encounter, first blush, or at first sight. The literal translation would be "at first face", from the feminine form of primus and facies , both in the ablative case. It is used in modern legal English to signify that on first examination, a...

 elements to sustain that the accused negligently performed those duties and obligations that were assigned to them, consequently creating a dangerous situation that ultimately produced the disaster investigated, from the arrival of commander Gustavo Weigel to the company, allowing the development of his career within it, to the moment of the assembly of the crew that was in charge of flight 3142 on 31 August 1999.


The daily Clarín added that the resolution states that "a large fraction of the pilots were in violation of their annual vacation periods. As for the activities of the directors of the LAPA corporation, there is evidence of sloppy procedure in the areas of security and especially personnel selection."

With respect to the motive behind accusing the military personnel, the judge made the following comment about the Command of Aerial Regiones (CRA) of the Air Force:

The CRA has not yet established a clear policy for the selection of inspectors, nor plans for the initial and periodical instructions of its personnel that would contemplate the minimum requirements to perform their functions in the areas of license handling and operation supervision.

Changing judges

On 21 March 2001, Judge Literas resigned from his post and the case passed into the hands of Judge Claudio Bonadío.

Two years after its inception, the case's file had 110 sections, over a thousand testimonies, and seven accused individuals who awaited the ruling of the Federal Court as to whether they would be brought to jury trial proceedings. The judge also accepted Nora Nouche, the copilot's partner, as a plaintiff
Plaintiff
A plaintiff , also known as a claimant or complainant, is the term used in some jurisdictions for the party who initiates a lawsuit before a court...

 and recognized her as another victim rather than one of the responsible persons.

On 8 November 2001, the case changed hands once again and fell to Judge Sergio Torres.

The trial continues

Roughly eight months later, on 15 July 2002, the second session of the Federal Court of Appeals confirmed the accusations of Deutsch, Boyd, and Chionetti, as well as revoking the accusation against Nora Arzeno. It also revoked the dismissal of Alfredo De Víctor and Valerio Diehl, the predecessors of Chionetti in operations management at LAPA, as well as José María Borsani, head of the Boeing 737 division of LAPA. At the same time, it recognized the lack of merit of flight instructors Vicente Sánchez, Alberto Baigorria, José Héctor García, and Juan Carlos Ossa.

Among the military officials, the Federal Court decided to revoke the accusations levelled initially against Enrique Dutra, Damián Peterson, and Diego Lentino.

La Nación made the following comment about the Court's resolution:


The central point of the resolution of Congressmen Horacio Cattani, Martín Irurzun, and Eduardo Luraschi is the analysis of Weigel's professional background. Beginning with this evaluation, they sustained, "one can affirm the existence of negligent actions of those persons (the accused) who, in one way or another, allowed the pilot (Weigel) to be in command of an airliner".

The judges understood that, taking it as a given that one of the basic principles of aeronautical activity is safety, "one ought not pass over nor minimize the errors committed by the crew during initial exams or follow-ups (skill re-certification exams), whether in flight or in a simulator, which provide observations like those that appeared in the dossier of the deceased pilot (Weigel)."

Thus, they enumerated a long series of errors and lack of attentiveness committed by the pilot during his exams. According to the material contained in the file that was incorporated into the judicial review, it was noted as early as April 1994 that Weigel "appeared slow" and that "he should improve his command of lists and procedures...He passed his pilot exam with the minimum score" and was subsequently certified by his instructors.

In that same year, his file claimed that Weigel needed to improve his in-cockpit coordination and his use of the checklists. "One evaluation shows that he was uninformed about his appropriate role; as a consequence of this, he does not lead well and there is a lack of security and coordination in the cockpit," according to his file.


On 17 October, federal officials requested a renewed accusation against Dutra, Petersen, Lentino, and Arzeno, whose charges the Federal Court had revoked.

The following day, Clarín revealed that federal officials "in a 40-page letter, presented to federal Judge Sergio Torres, stated that at the time of the LAPA accident, they did not have a revised and approved Operations Manual provided by the Command of Aerial Regions" and that "this document was required and should have regulated the organizational and administrative structure of the airline, the minimum equipment that a plane should have, and even the procedures to be followed in the case of an accident."

At the same time, La Nación claimed that "Arzeno was responsible for a little-known fact: Weigel, while he should have not been permitted to fly after his previous actions, also should not have been in command of an airplane on the day of the tragedy because his license was expired."

A little over a year later, on 1 December 2003, the second session of the Federal Court confirmed the accusations against Dutra, Peterson, and Lentino, accusing them of the crimes of "abuse of authority and failure to fulfill the responsibilities of public office." Among the reasons cited by the judges were the lack of controls and the fact that "the evaluations taken of the crew were totally insufficient to present a clear profile of the subjects."

Additionally, it revoked the dismissal of Arzeno and charged him with negligence. The judges, according to the information taken from La Nación, said that "human behavior does not occur in a vacuum, but is rather a reflection of the corporate and regulatory environment in which it takes place. For the Congressmen, there was a "clear relationship" between the courses that Pilot Weigel had not completed, and "the violations that occurred in the cockpit" on that fateful day, a fact that was not caught by the managers who controlled the process.

On 10 September 2004, the Federal official Carlos Rívolo required the accused to stand trial in public jury trial proceedings. The request, roughly 600 pages in length, called for a judgment on Gustavo Deutsch, Ronaldo Boyd, Fabián Chionetti, Nora Arzeno, Valerio Diehl, and Gabriel Borsani for estrago culposo (catastrophic criminal negligence
Criminal negligence
In the criminal law, criminal negligence is one of the three general classes of mens rea element required to constitute a conventional as opposed to strict liability offense. It is defined as an act that is:-Concept:...

). In a similar vein, it requested the judgement of Enrique Dutra, Damián Peterson, and Diego Lentino, asking that they be charged for "failure to fulfill the duties of public office."

Concerning this request, the daily Infobae said that "among other considerations, Rívolo emphasized that the pilot of the destroyed plane, Gustavo Weigel, killed in the accident, had a "regulationally expired" pilot's license and acknowledged that the aviator, before take-off, "had not checked that the doors were closed" and "said that he always forgot to close the doors."

On 9 June 2005, the Federal Court of Appeals rejected the nullification motions that several of the accused had proposed, and it ordered them to jury trial. Infobae commented:

The defense, led by Jorge Sandro, dismissed the fiscal accusation as "incongruent" and declared that the accused had not been given "a clear, precise, and detailed description" of the crimes of which they were accused and therefore were denied "the guarantees of due process and right to defense."

He added that Deutsch and Boyd "did not have the authority of selection, instruction, and control of the pilots and crew members" and Chionetti "adduced that he had gained the relevant authority mere months before the incident."

But Judges Horacio Cattani and Eduardo Luraschi ratified today the nullification of those appeals. "Such questions, in a way, pertain to the nullifying declaration and represent a mere complaint of the defense against the treatment given to the group," they said in a statement.

The Court maintained that from a "simple reading" of the fiscal accusation there emerged a clear description of how the events occurred and the accusations against the directors, in relation "to the errors committed by the pilot and copilot of the destroyed flight as a reflection of the 'recklessness' that incurred disregard of the principle of flight security."

"No doubt remains that, now that this phase of the investigation has come, it is an opportune moment to pose questions during the discussions of the jury trial phase," the statement underscored.


On 5 July 2005, Judge Torres ruled the process complete and elevated all of the accused to jury trial, consequently forming a tribunal to try them. Nine persons ended up being accused: six LAPA officials and three members of the Argentinian Air Force (FAA). Charged with estrago culposo were Gustavo Deutsch (ex-president of LAPA), Ronaldo Boyd (Director General of LAPA), Fabián Chionetti, and Valerio Diehl (Operations Managers of LAPA), Gabriel Borsani (head of the B-737 Line at LAPA) and Nora Arzeno (Human Resources Manager of LAPA). For dereliction of duty in public office, the charged were Enrique Dutra (ex-Commander of Aerial Regions of the FAA), Damián Peterson (ex-Director of Aeronautical Habilitaciones), and Diego Lentino (ex-Director of the national Institute of Aeronautical and Aerospace Medicine).

Infobae described the judicial resolution in the following terms:

In the resolution, the judge reiterated that the determining factors allowing the accident to occur were "the lack of effective control and subsequently taking measures by the responsible persons of the firm LAPA S.A. at the decision-making level, with respect to the aspects relevant to flight security."

In this way he placed responsibility on the airline directors for having completed "in a negligent manner" the responsibilities of their posts, including contracting the pilot Gustavo Weigel, allowing the development of his career path at the business.

The judge highlighted "the constant and permanent contact and direct participation that Deutsch and Boyd had in the politics of advancement in the business" and he reproached them for "the lack of effective control that might have made it possible for the pilots to overcome the errors committed."

The accused face million-dollar asset seizures and charges that have accrued to them from the commercial court that conducted the public examination of the airline.

As for the members of the Air Force, they will be tried for neglecting to observe the law pertaining to content control of the Operations Manual of the airline industry and the norms for training airplane pilots.

Accordingly, the judge reiterated that Lentino was accused of not having completed his principal duty adequately, namely running control checks on the psychophysiological fitness of pilots.

The crime of which the ex-officials stand accused carries a penalty of up to two years of prison, and special incarceration can double the time when the offense is committed while in public office.

The final judgement of the case was delayed by motions filed by the defense of several accused in order to slow the jury trial process, all of which were finally rejected weeks later by the Federal Court in Buenos Aires.

Conclusion

In sum, the blame fell upon the pilot Gustavo Weigel, who died in the accident, and upon those who were in charge of tracking his job performance.

On 23 July 2005, one of the accused, Enrique Dutra, was found dead in a car parked in his garage, in the Cordoban neighborhood of Villa Carlos Paz. It was widely believed to be a suicide
Suicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...

.

On 28 February 2006, the two former members of the Air Force requested that the tribunal dismiss the charges against them due to the statute of limitations
Statute of limitations
A statute of limitations is an enactment in a common law legal system that sets the maximum time after an event that legal proceedings based on that event may be initiated...

. According to their request, which was accepted, the case against them should have been shelved because more than four years passed between the first accusations and the sentencing, and the crime of which they were accused had a maximum sentence of two years. Nevertheless, the complaining part appealed the decision, and the case will be taken to the high court, which will decide on the matter. As for the LAPA officials, they were charged with "estrago culposo" (negligence followed by death) instead, a crime with a maximum sentence of four years of prison, thus they could not yet appeal to the statute of limitation.

The trial at the high court will take place at the "Tribunal Oral Federal Nº 4" starting on 28 March 2007. The court was designated to be composed by judges Leopoldo Bruglia, María Cristina Sanmartino and Horacio Vaccare, but the last one decided to recuse himself after relatives of the victims disputed his impartiality. His colleagues will decide if they accept his resignation.

In film

The film Whisky Romeo Zulu
Whisky Romeo Zulu
Whisky Romeo Zulu is a 2005 Argentine drama film, directed by Enrique Piñeyro and written by Piñeyro and Emiliano Torres. Aqua Films' Verónica Cura was the executive producer and Enrique Piñeyro was the producer....

brought the story of the accident to the silver screen. It starred and was written and directed by Enrique Piñeyro
Enrique Piñeyro (actor)
Enrique Piñeyro is a pilot turned film actor, producer, crash analyst, aeronautical physician, film director, and screenplay writer, working partly in Argentina. Piñeyro and Verónica Cura own Aqua Films, a film production company in Argentina.- Biography :Piñeyro was born in Genoa, Italy, 1956...

, an actor
Actor
An actor is a person who acts in a dramatic production and who works in film, television, theatre, or radio in that capacity...

, doctor
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...

, and former LAPA pilot.

The film is a fictional reproduction of the background of the accident as seen through the eyes of Piñeyro himself, who was actually a LAPA pilot from 1988 to 1999. Piñeyro resigned from his position in June 1999—just two months before the accident—after voicing his concerns about the airline's safety policy. Concerning his motivation for making the film, Piñeyro said:

I was personally interested in recounting how the accident came to occur, not the fact that the pilots forgot about the flaps and the plane blew up, but why they forgot the flaps. And what was the process, because forgetting the flaps was the straw that broke the camel's back in a series of tremendous violations of regulations. I was interested in portraying what isn't apparent about the accident, not just the final link (the pilot). Because all the links that came before were conveniently hidden because they compromised the establishment, the business.

See also

  • Air safety
    Air safety
    Air safety is a term encompassing the theory, investigation and categorization of flight failures, and the prevention of such failures through regulation, education and training. It can also be applied in the context of campaigns that inform the public as to the safety of air travel.-United...

  • Austral Líneas Aéreas Flight 2553
    Austral Líneas Aéreas Flight 2553
    Austral Líneas Aéreas Flight 2553, better known as Austral 2553, was a domestic scheduled Posadas–Buenos Aires service operated with a McDonnell Douglas DC-9-32 that crashed on the lands of Estancia Magallanes, Nuevo Berlín, away from Fray Bentos, Uruguay, on . All 74 passengers and crew perished...

  • Mandala Airlines Flight 091
    Mandala Airlines Flight 091
    On 5 September 2005 , a Jakarta-bound Boeing 737-200 jetliner operated by Mandala Airlines crashed into a heavily-populated residential area seconds after taking off from Polonia International Airport in Medan, Indonesia. There were 143 fatalities.Dozens of houses and cars were destroyed, and at...

  • Northwest Airlines Flight 255
    Northwest Airlines Flight 255
    Northwest Airlines Flight 255 was a flight that originated at MBS International Airport in Saginaw, Michigan, and was scheduled to terminate at John Wayne Airport in Orange County, California, with intermediate stops at Detroit Metropolitan Wayne County Airport in Romulus, Michigan, near Detroit,...

  • Spanair Flight 5022
    Spanair Flight 5022
    Spanair Flight JK 5022, from Barajas Airport in Madrid to Gran Canaria Airport in Gran Canaria, Spain, crashed just after take off from runway 36L of Barajas Airport at 14:24 CEST on 20 August 2008. The aircraft was a McDonnell Douglas MD-82, registration EC-HFP...



External links

The source of this article is wikipedia, the free encyclopedia.  The text of this article is licensed under the GFDL.
 
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