LAPA Flight 3142 encounters a serious problem while taking off from Buenos Aires, Argentina. The resulting investigation reveals a shocking cause.
LAPA Flight 3142 was a scheduled Buenos Aires–Córdoba flight operated by the Argentine airline LÃneas Aéreas Privadas Argentinas.The flight was operated with a Boeing 737-204C, registration LV-WRZ, that crashed on 31 August 1999 at 20:54 local time while attempting to take off from Aeroparque Jorge Newbery and failing to get airborne. The crash resulted in 65 fatalities — 63 of the occupants of the aircraft and 2 on the ground — as well as injuries, some serious, to at least a further 34 people.It remains, as of 2022, the second deadliest aviation incident to occur in Argentina, behind AerolÃneas Argentinas Flight 644 38 years prior.
Aircraft and crew
The aircraft was a Boeing 737-204C, registered in Argentina as LV-WRZ, production number 20389, line 251, with JT8D-9A engines. It first flew on 14 April 1970,and it was delivered by Boeing to Britannia Airways on 17 April of that year. It was registered in the United Kingdom as G-AXNB.
Almost 20 years later, on 1 February 1990, the plane was sold to the French airline TAT European Airlines, and registered in France as F-GGPB.
Finally, LAPA took possession of the plane on 21 December 1996, and flew it under the Argentine tail number LV-WRZ. At the time of the accident, it had accumulated 64,564 hours of flight time and 38,680 take-off/landing cycles. The aircraft was 29 years and 139 days old at the time the accident took place.
The captain of the flight was Captain Gustavo R. Weigel (45) and the co-pilot was Luis Etcheverry (31). The captain had 6,500 hours of flying experience, of which 1,700 had been in a Boeing 737, the type of aircraft that was in the accident. The co-pilot had flown about 600 of his 4,000 hours in the 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 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 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 in the cockpit, indicating that the aircraft was not correctly configured for the maneuver. The crew ignored the warning and continued the takeoff, not realising that the flaps 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 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 take-off. The penal prosecution focused on proving that the company's policies and organization, lacking the Argentine Air Force'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.
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 black box, the flight data recorder (FDR) and the cockpit voice recorder (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 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, 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, 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, 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 determine 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, 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 would allow the take-off of medium- to large- size aircraft without flaps.
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