LAPA Flight 3142
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LAPA Flight 3142 was a scheduled
Buenos Aires Buenos Aires ( or ; ), officially the Autonomous City of Buenos Aires ( es, link=no, Ciudad Autónoma de Buenos Aires), is the capital and primate city of Argentina. The city is located on the western shore of the Río de la Plata, on South ...
Córdoba flight operated by the
Argentine Argentines (mistakenly translated Argentineans in the past; in Spanish (masculine) or (feminine)) are people identified with the country of Argentina. This connection may be residential, legal, historical or cultural. For most Argentines, s ...
airline
Líneas Aéreas Privadas Argentinas Líneas Aéreas Privadas Argentinas ( en, Private Argentine Air Lines), more commonly known by the acronym LAPA (and known as ARG Argentina Línea Privada and AIRG from 2001 to 2002), was an airline based in Buenos Aires, Argentina. At its heyda ...
. 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 Jorge Newbery Airfield ( es, link=no, Aeroparque "Jorge Newbery", ), commonly known as Aeroparque, is an international airport northeast of downtown Buenos Aires, Argentina. The airport covers an area of and is operated by ''Aeropuertos Argen ...
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
Aerolíneas Argentinas Flight 644 Aerolíneas Argentinas Flight 644 was a scheduled flight operated by the Douglas DC-6, registration LV-ADW, on 19 July 1961 which was due to operate a domestic scheduled passenger service between Ministro Pistarini International Airport and Genera ...
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 The Boeing Company () is an American multinational corporation that designs, manufactures, and sells airplanes, rotorcraft, rockets, satellites, telecommunications equipment, and missiles worldwide. The company also provides leasing and product ...
to
Britannia Airways Britannia Airways was a charter airline based in the UK. It was founded in 1961 as Euravia and became the world's largest holiday airline. Britannia's main bases were at London Gatwick, London Stansted, London Luton, Cardiff, Bristol, East Mi ...
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 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 (TAT) by M. Marchais. Air France acquired a minority stak ...
, 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 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 A simulation is the imitation of the operation of a real-world process or system over time. Simulations require the use of models; the model represents the key characteristics or behaviors of the selected system or process, whereas the s ...
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 A cockpit or flight deck is the area, usually near the front of an aircraft or spacecraft, from which a Pilot in command, pilot controls the aircraft. The cockpit of an aircraft contains flight instruments on an instrument panel, and the ...
of flight 3142". Junta de Investigaciones de Accidentes de la Aviación Civil (Argentina). Informe "LAPA 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 Takeoff is the phase of flight in which an aerospace vehicle leaves the ground and becomes airborne. For aircraft traveling vertically, this is known as liftoff. For aircraft that take off horizontally, this usually involves starting with a t ...
run, the
take-off warning system A take-off warning system or TOWS is a set of warning signals required on most commercial aircraft, designed to alert the pilots of potentially-dangerous errors in an aircraft's take-off configuration. There are numerous systems on board an aircraf ...
(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
flap Flap may refer to: Arts, entertainment, and media * ''Flap'' (film), a 1970 American film * Flap, a boss character in the arcade game ''Gaiapolis'' * Flap, a minor character in the film '' Little Nemo: Adventures in Slumberland'' Biology and he ...
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 in the process, and finally collided with road construction machinery and a
highway median The median strip, central reservation, roadway median, or traffic median is the reserved area that separates opposing lanes of traffic on divided roadways such as divided highways, dual carriageways, freeways, and motorways. The term also ap ...
. 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 Junta may refer to: Government and military * Junta (governing body) (from Spanish), the name of various historical and current governments and governing institutions, including civil ones ** Military junta, one form of junta, government led by ...
'' (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 "Argentine Wings" , mascot = , anniversaries = 10 August (anniversary) 1 May (Baptism of fire during the Falklands War) , equipment = 139 aircraft , equipment_label = , battles = * Operation Independence * Operation Soberanía * Falklan ...
'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 A jury trial, or trial by jury, is a Trial, legal proceeding in which a jury makes a decision or Question of law, findings of fact. It is distinguished from a bench trial in which a judge or Judicial panel, panel of judges makes all decisions. ...
.


Flight review

The JIAAC review of the flight reads:
The evening of the accident, the captain arrived at the
Aeroparque Jorge Newbery Jorge Newbery Airfield ( es, link=no, Aeroparque "Jorge Newbery", ), commonly known as Aeroparque, is an international airport northeast of downtown Buenos Aires, Argentina. The airport covers an area of and is operated by ''Aeropuertos Argen ...
one hour before take-off, as usual, in order to perform a regular commercial flight (LAPA 3142), on which 95 passengers and five crew members were to be transported to the destination airport Ingeniero Ambrosio Taravella in the city of Córdoba.
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 A Notice to Airmen/Notice to Air Missions (NOTAM), is a notice filed with an aviation authority to alert aircraft pilots of potential hazards along a flight route or at a location that could affect the flight. NOTAMs are unclassified notices or ...
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 Jorge Newbery Airfield ( es, link=no, Aeroparque "Jorge Newbery", ), commonly known as Aeroparque, is an international airport northeast of downtown Buenos Aires, Argentina. The airport covers an area of and is operated by ''Aeropuertos Argen ...
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 , 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 Embankment may refer to: Geology and geography * A levee, an artificial bank raised above the immediately surrounding land to redirect or prevent flooding by a river, lake or sea * Embankment (earthworks), a raised bank to carry a road, railwa ...
.
The report details:
"In its final run after failing to take off, the aircraft hit a
Chrysler Neon The Chrysler/Dodge/Plymouth Neon is a front-engine, front-wheel drive compact car that was introduced in January 1994 for model year 1995 by Chrysler's Dodge and Plymouth divisions in two- and four-door bodystyles over two generations. Marketed ...
car that was travelling on the Rafael Obligado road that crosses the projection of Runway 13. The car's fuel in contact with sparks from the sliding
fuselage The fuselage (; from the French ''fuselé'' "spindle-shaped") is an aircraft's main body section. It holds crew, passengers, or cargo. In single-engine aircraft, it will usually contain an engine as well, although in some amphibious aircraft t ...
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 A wing is a type of fin that produces lift while moving through air or some other fluid. Accordingly, wings have streamlined cross-sections that are subject to aerodynamic forces and act as airfoils. A wing's aerodynamic efficiency is expresse ...
which spilled
jet fuel Jet fuel or aviation turbine fuel (ATF, also abbreviated avtur) is a type of aviation fuel designed for use in aircraft powered by gas-turbine engines. It is colorless to straw-colored in appearance. The most commonly used fuels for commercial a ...
of type
JP-1 Jet fuel or aviation turbine fuel (ATF, also abbreviated avtur) is a type of aviation fuel designed for use in aircraft powered by gas-turbine engines. It is colorless to straw-colored in appearance. The most commonly used fuels for commercial av ...
. 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 A flight attendant, also known as steward/stewardess or air host/air hostess, is a member of the aircrew aboard commercial flights, many business jets and some government aircraft. Collectively called cabin crew, flight attendants are prima ...
attempted to hold and operate a
fire extinguisher A fire extinguisher is a handheld active fire protection device usually filled with a dry or wet chemical used to extinguish or control small fires, often in emergencies. It is not intended for use on an out-of-control fire, such as one which ha ...
, 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 A galley is a type of ship that is propelled mainly by oars. The galley is characterized by its long, slender hull, shallow draft, and low freeboard (clearance between sea and gunwale). Virtually all types of galleys had sails that could be used ...
of the aircraft helped, since walking distance to the exit was notably reduced. Fire units from the airport, as well as the
Federal Police A law enforcement agency (LEA) is any government agency responsible for the enforcement of the laws. Jurisdiction LEAs which have their ability to apply their powers restricted in some way are said to operate within a jurisdiction. LEAs ...
, 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 Junta may refer to: Government and military * Junta (governing body) (from Spanish), the name of various historical and current governments and governing institutions, including civil ones ** Military junta, one form of junta, government led by ...
'' 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 The National Transportation Safety Board (NTSB) 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 incid ...
(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 is an American aerospace manufacturer with global service operations. It is a subsidiary of Raytheon Technologies. Pratt & Whitney's aircraft engines are widely used in both civil aviation (especially airlines) and military aviat ...
, and the US
Federal Aviation Administration The Federal Aviation Administration (FAA) is the largest transportation agency of the U.S. government and regulates all aspects of civil aviation in the country as well as over surrounding international waters. Its powers include air traffic m ...
(FAA). While in Argentina, these investigators worked with JIAAC personnel, forming teams according to their areas of expertise. The data from the ''
black box In science, computing, and engineering, a black box is a system which can be viewed in terms of its inputs and outputs (or transfer characteristics), without any knowledge of its internal workings. Its implementation is "opaque" (black). The te ...
'', the
flight data recorder A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. The device may often be referred to as a "black box", an outdated name which has b ...
(FDR) and the
cockpit voice recorder A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. The device may often be referred to as a "black box", an outdated name which has b ...
(CVR) were read at the NTSB headquarters in
Washington Washington commonly refers to: * Washington (state), United States * Washington, D.C., the capital of the United States ** A metonym for the federal government of the United States ** Washington metropolitan area, the metropolitan area centered o ...
. 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 A hangar is a building or structure designed to hold aircraft or spacecraft. Hangars are built of metal, wood, or concrete. The word ''hangar'' comes from Middle French ''hanghart'' ("enclosure near a house"), of Germanic origin, from Frankish ...
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 Landing gear is the undercarriage of an aircraft or spacecraft that is used for takeoff or landing. For aircraft it is generally needed for both. It was also formerly called ''alighting gear'' by some manufacturers, such as the Glenn L. Martin ...
, 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 A bird strike—sometimes called birdstrike, bird ingestion (for an engine), bird hit, or bird aircraft strike hazard (BASH)—is a collision between an airborne animal (usually a bird or bat) and a moving vehicle, usually an aircraft. The term ...
, 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 Aerodynamics, from grc, ἀήρ ''aero'' (air) + grc, δυναμική (dynamics), is the study of the motion of air, particularly when affected by a solid object, such as an airplane wing. It involves topics covered in the field of fluid dyn ...
characteristics of the aircraft, giving the aircraft
lift Lift or LIFT may refer to: Physical devices * Elevator, or lift, a device used for raising and lowering people or goods ** Paternoster lift, a type of lift using a continuous chain of cars which do not stop ** Patient lift, or Hoyer lift, mobile ...
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. The main finding within the remains of the plane was that all of the examined flaps'
worm gear A worm drive is a gear arrangement in which a worm (which is a gear in the form of a screw) meshes with a worm wheel (which is similar in appearance to a spur gear). The two elements are also called the worm screw and worm gear. The terminolo ...
operators were in the unwound position indicating that the flaps were not deployed. This tallies with the flap command in the cockpit that 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 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.


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, 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 The Boeing 737 is a narrow-body aircraft produced by Boeing at its Renton Factory in Washington. Developed to supplement the Boeing 727 on short and thin routes, the twinjet retains the 707 fuselage width and six abreast seating with two un ...
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 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 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 ''La Nación'' () is an Argentine daily newspaper. As the country's leading conservative newspaper, ''La Nación''s main competitor is the more liberal '' Clarín''. It is regarded as a newspaper of record for Argentina. Its motto is: "''La Nac ...
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 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 The peso is the monetary unit of several countries in the Americas, and the Philippines. Originating in the Spanish Empire, the word translates to "weight". In most countries the peso uses the same sign, "$", as many currencies named "dollar" ...
. Regarding the progress of the investigation, the morning paper Página/12 commented on the following day:
The investigation highlighted the lack of a human resources policy in LAPA. "There must have been more expertise and thoroughness in pilot's tests. We detected negligence and flexibility," a senior judicial source explained to Página/12. None of the Air Force inspections that Weigel underwent – who died in the accident – served to detect his proven abnormal performance. "It is unacceptable that they continue to do the same psychophysical tests that they did to me when I did my military service," said an outraged grey-haired official.
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 A court of appeals, also called a court of appeal, appellate court, appeal court, court of second instance or second instance court, is any court of law that is empowered to hear an appeal of a trial court or other lower tribunal. In much of t ...
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 seguido de muerte'' (similar to 'catastrophic
criminal negligence In criminal law, criminal negligence is a surrogate state of mind required to constitute a ''conventional'' (as opposed to ''strictly liable'') offense. It is not, strictly speaking, a (Law Latin for "guilty mind") because it refers to an ob ...
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 40,000,000
pesos The peso is the monetary unit of several countries in the Americas, and the Philippines. Originating in the Spanish Empire, the word translates to "weight". In most countries the peso uses the same sign, "$", as many currencies named "dollar" ...
, 500 thousand for Director General Ronaldo Boyd, and 100 thousand 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:
There are by now enough prima facie 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.Procesaron a cuatro directivos de LAPA
''La Nación'', 23 December 2000
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

In March 2001, Judge Literas resigned from his post and the case passed into the hands of Judge
Claudio Bonadio Claudio Bonadio (1 February 1956 – 4 February 2020) was an Argentine judge, who was in charge of Federal Criminal and Correctional Court No. 11 since 1994. In that role he intervened in causes of strong impact, some of which involved important ...
. 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 A plaintiff ( Π in legal shorthand) is the party who initiates a lawsuit (also known as an ''action'') before a court. By doing so, the plaintiff seeks a legal remedy. If this search is successful, the court will issue judgment in favor of the p ...
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.Seis directivos de LAPA irán a juicio
''La Nación'', 16 July 2002
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 that "the evaluations taken of the crew were totally insufficient to present a clear profile of the subjects."Está más cerca el juicio por la tragedia del avión de LAPA
("Judgement draws closer for the tragedy of the LAPA airplane"), ''La Nación'' 2 December 2003
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. 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 In criminal law, criminal negligence is a surrogate state of mind required to constitute a ''conventional'' (as opposed to ''strictly liable'') offense. It is not, strictly speaking, a (Law Latin for "guilty mind") because it refers to an ob ...
). 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."Piden elevar a juicio la causa por el accidente de LAPA
''Infobae'', 11 September 2004
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." However, Judges Horacio Cattani and Eduardo Luraschi ratified 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 (former 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 (former Commander of Aerial Regions of the FAA), Damián Peterson (former Director of Aeronautical Permits), and Diego Lentino (former 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 former 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.


Verdict, initial conclusion, and overturn of convictions

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. 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 A statute of limitations, known in civil law systems as a prescriptive period, is a law passed by a legislative body to set the maximum time after an event within which legal proceedings may be initiated. ("Time for commencing proceedings") In m ...
. 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.– Podría prescribir la causa LAPA para ex miembros de la Fuerza Aérea
Infobae, 28 February 2006
Nevertheless, the complaining part appealed the decision, and the case was 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 took 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. On 2 February 2010, Fabián Chionetti (the Operations manager) and Nora Arzeno (the Human resources manager) were both found guilty of criminal negligence and were both sentenced to three years in prison, while the rest were acquitted of the charges. However, on 11 February 2014, the convictions of Chionetti and Arzeno were overturned by the IV Chamber of the Federal Chamber of Cassation, as the amount of time it took to bring all of the accused people to trial exceeded the legal deadlines. The entire case was considered a case of
impunity Impunity is avoidance of punishment, loss, or other negative consequences for an action. In the international law of human rights, impunity is failure to bring perpetrators of human rights violations to justice and, as such, itself constitutes a d ...
.


In film

The film ''
Whisky Romeo Zulu ''Whisky Romeo Zulu'' is a 2004 Argentine drama film directed by Enrique Piñeyro and written by Piñeyro and Emiliano Torres. Verónica Cura was the executive producer and Enrique Piñeyro was the producer. The drama is based on the experience ...
'' 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:
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.
The accident was covered in the 9th episode of the 17th season of ''
Mayday Mayday is an emergency procedure word used internationally as a distress signal in voice-procedure radio communications. It is used to signal a life-threatening emergency primarily by aviators and mariners, but in some countries local organiza ...
'' also known as ''Air Crash Investigation'', ''Air Emergency'', and ''Air Disasters''. The episode is titled " Deadly Discussions".


See also

*
Austral Líneas Aéreas Flight 2553 Austral Líneas Aéreas Flight 2553 was an Argentinian 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, Urugua ...
*
Delta Air Lines Flight 1141 Delta Air Lines Flight 1141 was a scheduled domestic passenger flight between Dallas/Fort Worth, Texas and Salt Lake City, Utah. On August 31, 1988, the flight, using a Boeing 727-200 series aircraft, crashed during takeoff, resulting in 14 deat ...
*
Mandala Airlines Flight 091 Mandala Airlines Flight 091 was a scheduled domestic passenger flight from Medan to Jakarta, operated by Mandala Airlines with a Boeing 737-200Adv. On September 5, 2005 at 10:15 a.m. WIB (UTC+7), the aircraft stalled and crashed into a heavily ...
*
Northwest Airlines Flight 255 On August 16, 1987 a McDonnell Douglas MD-82, operating as Northwest Airlines Flight 255, crashed shortly after takeoff from Detroit Metropolitan Airport, about 8:46 pm EDT (00:46 UTC August 17), resulting in the deaths of all six crew me ...
*
Spanair Flight 5022 Spanair Flight 5022 was a scheduled domestic passenger flight from Barcelona–El Prat Airport to Gran Canaria Airport, Spain, via Madrid–Barajas Airport that crashed just after take-off from runway 36L at Madrid Airport at 14:24  CES ...


References


External links

*
Final accident report
"
Archive
''
Junta de Investigaciones de Accidentes de Aviación Civil Junta may refer to: Government and military * Junta (governing body) (from Spanish), the name of various historical and current governments and governing institutions, including civil ones ** Military junta, one form of junta, government led by ...
''
Available on
Wikisource Wikisource is an online digital library of free-content textual sources on a wiki, operated by the Wikimedia Foundation. Wikisource is the name of the project as a whole and the name for each instance of that project (each instance usually rep ...
* () * ()
Service history of the airplane
{{DEFAULTSORT:Lapa Flight 3142 Aviation accidents and incidents in Argentina Airliner accidents and incidents caused by pilot error Aviation accidents and incidents in 1999 1999 in Argentina Accidents and incidents involving the Boeing 737 Original August 1999 events in South America