LAPA Flight 3142

Aircraft The aircraft was Boeing 737-204C, registered as LV-WRZ with serial number 20389 and line number 251. It was also powered by two JT8D-9A engines. Crew In command was Captain Gustavo Weigel, aged 45, who had logged 6,500 hours of flying experience, 1700 of which were logged on the Boeing 737. His co-pilot was Luis Etcheverry, aged 31, who had logged about 4,000 hours of flying experience, including 600 on the Boeing 737. Both pilots died in the accident. With regard to the two pilots, the JIAAC report said that "the records of their flight and simulator 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 of flight 3142". Even though the 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", a 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 centered 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. == Accident ==

As the aircraft started its takeoff run, the take-off warning system (TOWS) sounded an alarm indicating that the aircraft was not correctly configured for takeoff. The crew ignored the warning and continued, not realising that the flaps were not at the required takeoff position and were instead fully retracted. The jet overshot the runway, breaking through the airport's perimeter fence, crossed a road, hitting an automobile in the process, and finally collided with road construction machinery and a highway median. Fuel spilling over the hot engines and gas leaking from a damaged gas regulation station resulted in a fire that destroyed the aircraft. The Junta de Investigaciones de Accidentes de Aviación Civil (JIAAC) determined that the pilots failed to configure the aircraft correctly for takeoff. The penal prosecution focused on proving that the company's policies and organization, under negligent supervision of the Argentine Air Force, 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. Analysis The JIAAC review of the flight reads: The report details: After impact against the embankment, but before catching fire, a flight attendant attempted to operate a fire extinguisher, but did not succeed because the cabin had already reached high temperatures. 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 spread. The right side of the fuselage showed an opening, through which a few passengers escaped. Regarding 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 than normal 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, and the Naval Prefecture fought the fire. The evacuation operation was directed by the city's Medical Emergency Attention Service (SAME), which used 15 ambulances of their own as well as some from private hospitals. Based on the severity of their injuries, the casualties were taken to different treatment centres. == JIAAC investigation ==

The Junta de Investigaciones de Accidentes de Aviación Civil 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 (NTSB) sent a team to assist the JIAAC in their investigation. This team consisted of an NTSB representative and technicians from Boeing, Pratt & Whitney, and the US Federal Aviation Administration (FAA). While in Argentina, these investigators worked with JIAAC personnel, forming teams according to their areas of expertise. The data from the flight data recorder (FDR) and the cockpit voice recorder (CVR) was 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 Airworthiness). To complete the detailed investigation, the JIAAC technicians reassembled the main components of the aircraft in a hangar in the Aeroparque. They also cleaned, identified and analyzed the boards, actuators, electronic equipment, the cockpit pedestal, and other flight controls 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 the thrust reversers of both engines and the braking system of the landing gear, all of which were found to be in sufficient working order. Engines & thrust reversers during landing with its thrust reversers deployed and the flaps extended 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, the National Institute for the Investigation of Natural Sciences () 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 determine if the thrust reversers were intentionally activated and later deactivated. Control surfaces are the surfaces that extend behind the wings, thus permitting the airplane to maintain sufficient lift to fly at lower speeds, during takeoff, initial ascent, approach, and landing. It was important for the investigation to establish the position of the mechanical activators on the flaps, since their lack of deployment 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 characteristics of the aircraft, giving the aircraft lift to get off the ground at a lower speed over a shorter distance than would be possible without flaps. This is why in practice there are no runways that 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 finding was supported by the flap command in the cockpit that was also in the no-flaps position, the readings at the FDR indicating the flaps were retracted, and the extinguished flap lights indicating that they were not activated. Other analyses 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 take-off warning system. Also, a study was performed on the slat 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. Conclusion 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, family, 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 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 in the Boeing 737 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: ==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 systemic 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 14 May 2000, Judge Carlos Liporaci, who replaced Judge Literas (who was on leave) ordered a search of LAPA headquarters and their operations room at Aeroparque, seizing the files of the company's pilots. 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 18 May 2000, 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 said the next day: Indictments The following week, on 24 May 2000, the judge called for the indictment 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 Aeronautical Permits, Commodore Damián Peterson (retired); the former head 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. Regarding the progress of the investigation, the morning paper Página/12 commented on the following day: A little less than one month afterward, on 22 June 2000, 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 1,600 pages of findings in 80 sections, it had heard 1,500 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 1,200-page resolution, Judge Literas charged four LAPA officials and three members of the Air Force. The LAPA officials were charged with (similar to 'catastrophic criminal negligence 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 dereliction 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 million pesos, 500,000 for Director General Ronaldo Boyd, and 100,000 for each of the other managers. All of the accused escaped incarceration. With respect to the motive behind accusing the LAPA officials, La Nación drew upon the judicial resolution: 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: Changing judges In March 2001, Judge Literas resigned from his post and the case passed into the hands of Judge Claudio Bonadio. 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 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. Continuation of the trial 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: 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 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, something that was not caught by the managers who controlled the process. 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'." Infobae described the judicial resolution in the following terms: Verdict, initial conclusion, and overturn of convictions At the investigation's conclusion, 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. 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. 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 was taken to the high court, which would decide on the matter. The entire case was considered a case of impunity. == Dramatization ==

The film Whisky Romeo Zulu brought the story of the accident to the silver screen. It starred and was written and directed by Enrique Piñeyro, an actor, doctor, 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: The accident was covered in the 9th episode of the 17th season of Mayday (also known as Air Crash Investigation, Air Emergency, and Air Disasters). The episode is titled "Deadly Discussions". ==See also==