Mayday (2013) s17e09 Episode Script
Deadly Discussions
The plane begins to take off, but instantly it starts shaking.
A business trip to Argentina's capital becomes a nightmare for Marisa Beiro.
I was bracing myself.
Something bad was happening.
What the hell? LAPA flight 3142 is in serious trouble.
The airplane crossed a busy highway, killed people who were in their cars.
Marisa fights for her life.
Then, she fights for justice.
And then, I started researching, asking why it had happened.
The stunning answer leaves a nation in shock.
To me, that was unprecedented.
It's difficult to imagine that someone would do that.
# # It's 8:30 pm at Jorge Newbery Airfield in Buenos Aires, Argentina.
Wind zero-two-zero at five.
Altimeter three-zero-decimal-one-zero.
A Boeing 737, the workhorse of the aviation industry, prepares to taxi.
It is operated by the Argentinean airline LAPA.
We made it.
Marisa Beiro is a cosmetics rep from Cordoba.
I was traveling with eight of my co-workers.
One of them was my best friend and sister-in-law.
She's heading home after a lengthy business trip to the capital with a group of colleagues.
It had been ten days since we left, and it was time to go home.
In fact, we had all arranged with our families to pick us up at the airport.
And we wanted to go back to our kids.
- Jamaica? - No.
- Hey, Captain.
- Hey.
The captain of LAPA flight 3142 is Gustavo Weigel.
He's an experienced pilot who's been flying for more than 20 years.
- Everything OK? - Fine.
Everything's fine.
We're just waiting on our fuel.
First Officer Luis Etcheverry has logged more than 500 hours in the 737.
Total fuel required, 8,500kg, to be transferred to the wings.
Tonight's flight is a short one, 400 miles west from Buenos Aires to the city of Cordoba.
Time in the air should be a little over an hour.
Along with the two pilots, there are three flight attendants and 95 passengers onboard.
I noticed something.
There was no safety card in our seat.
And that stood out to me because I always check the safety card when I board a plane - always.
In 1999, the airline business in Argentina is booming.
Industry deregulation five years earlier has led to rapid growth for budget airlines like LAPA.
One-three-five turn right heading zero-six-zero.
Descend and maintain 5,000, slow to two-two-zero knots and hold.
Come on.
Come on.
It's best to understand LAPA as a low-cost carrier making considerable inroads into a transportation system in a very large country that needed airline transportation.
Austral two-three-six, you're next in line for take-off.
Please proceed to runway and hold.
In Argentina, the commercial airline industry is run by the military.
The Air Force Defence Program was responsible for both civilian and military aviation.
- Before start checklist.
- Before start checklist.
First Officer Etcheverry oversees - some last-minute procedures.
- Cockpit preparations? - Completed.
- The flight attendants prepare the cabin for take-off.
We bought some gossip magazines for the flight.
Some of the girls were flying for the first time, so I gave them chewing gum for the air pressure on the plane.
We were just flipping through magazines, very relaxed.
Ready to taxi, 3142.
3142, ready to taxi.
Charlie-five to runway one-three.
Charlie-five to one-three.
Jorge Newbery is a single runway airport.
And, tonight, departures are running a little behind schedule.
You have an experienced crew in the cabin.
Please let them know if there's anything they can do to make your flight more comfortable.
On behalf of First Officer Etcheverry and myself, we hope you have an enjoyable flight.
You guys should come for dinner in Cordoba.
That sounds good.
What should we bring? You can bring the ice cream.
The relationship between the crew seemed to be very close.
It appeared that they had known each other for a while and that, beyond being co-workers, they were friends.
I was sitting near the door and I noticed the door was half open.
The cockpit door is usually completely closed.
Not this time.
You know, we're seconds away.
You should probably get back there - and strap in.
- Alright, guys.
It's been a pleasure.
See you soon.
Hurry, hurry.
Cleared for take-off, LAPA 3142.
Taking off.
The airplane is on the runway, accelerating, getting faster.
You know, when you can feel how the airplane is getting the amount of velocity necessary for take-off.
As the aircraft lifts off, it is immediately apparent that something is wrong.
The plane begins to take off.
But, instantly, it starts shaking like it was going to fall apart.
Something bad was happening.
I was bracing because my gut told me to.
We all knew something was going wrong.
What the hell? Hurtling forward at 160 knots, the 737 slams violently back to the ground.
(PASSENGERS SCREAMING) There was a clear zone at the end of that runway.
And yet, the aircraft continued to proceed at a relatively high speed.
They're now headed straight for a busy highway and an industrial gas plant.
Stop, stop, stop, stop.
It was very quick.
I just looked at my friends and I braced my head.
No, no, no, no, no.
The airplane crossed a busy highway without warning, killed people who were commuting at that time in their cars.
No! No! No! Everything went dark.
Literally, all dark.
It was like the people around me were no longer there.
I was squeezed between the front seat and the seat behind me that got pushed forward.
I could feel extreme heat all around me.
I was suffocating, and I needed to get out.
But I couldn't release my seatbelt.
Emergency.
LAPA flight 3142 just crashed through the airfield perimeter.
Rescuers race to the site of the crash, but survivors on board don't have much time.
Fire threatens to consume the entire plane.
I felt like I was dying.
And something happened that I still can't explain.
Maybe an angel, or God, I don't know.
But it gently released my seatbelt.
And someone said to me, "Get out.
" As Marisa struggles to escape, she sees that none of her friends have survived.
They were all already dead.
It was instant.
Though badly injured, Marisa is one of the lucky ones.
Many of the evacuation doors could not be used due to the fire.
That meant that many passengers couldn't get out.
The plane was fully engulfed.
People were screaming for help.
I went in and got four of them with some help.
But I saw the bodies burning.
It was terrible.
The crash has killed 60 passengers, three crew members, and two motorists.
It's a disaster unlike anything Buenos Aires has seen before.
It was a major calamity.
It involved automobiles.
It involved a natural gas regulating plant.
There had been a major sustaining fire, so it was a major disaster scene.
News of the crash spreads quickly through the Argentinean Capital.
Because they live and work in Buenos Aires, members of the nation's Accident Investigation Unit are on the scene in minutes, getting a rare glimpse of the immediate aftermath.
It's a lot of smoke.
Hard to see anything.
Horacio Larrosa is a senior investigator.
You try to focus on the job and look for details that, later on, could be harder to find once the rescue teams have finished their work.
So, you have to be paying attention to details and make sure nothing slips.
This was my first experience with a big accident.
Even though we were trained and we were prepared for this type of situation, it's something else to see a catastrophe with so much movement of ambulances, wounded people, police, and all the rest.
It was very complicated.
Neither pilot survived.
OK.
Thank you.
Both Captain Weigel and First Officer Etcheverry are dead.
Any hope of finding out what went wrong lies in the wreckage.
The first thing is doing a visual inspection of the site.
Looking at all of the components, trying to put oneself in the situation.
Which is very difficult, when there is so much damage and fire.
They lift off here, barely get off the ground.
They leave the runway here and finally come to rest here.
Because the destroyed aircraft was American-made, the US National Transportation Safety Board sends a team to assist the Argentines.
Whatever you need, we're here to help.
I was the accredited representative from the United States to the official investigation.
- Rodrigo.
- Hey.
How are ya? It's a case where there was just a tremendous amount of public concern and a great deal of encouragement to try to solve this definitively and quickly.
In any take-off accident, you're looking at a variety of factors.
Some of them relate to engine power.
Were the engines producing a proper amount of power.
When you look at the engines after an accident, there are very clear signs that show if the engine was functioning or not.
Look there and there.
It looks like these blades were spinning.
The type of damage sustained by the rotor blades tells investigators that the engines were working normally when they hit the ground.
There was no engine failure.
Well, would you look at this? But something else related to the engines raises an immediate red flag.
One of the plane's thrust reversers is deployed.
I recall vividly the doors on that thrust reverser appeared to be open.
Thrust reversers are only supposed to deploy on landing.
They help slow the plane down by redirecting engine exhaust.
There are doors that drop down into the exhaust plume, kind of like a reverse gear in a way, that's pushing against the forward motion.
If a reverser were to deploy on take-off, it could cause a catastrophic thrust imbalance.
So, we were very concerned about how those thrust reversers had ended up in that position.
Look here.
The flaps aren't extended.
Investigators study the wings of the downed plane and soon make another discovery.
I was able to observe with some of my colleagues that the aircraft's flaps were apparently not extended.
Let's get this wing piece out of here.
For take-off, 737 pilots must always extend the plane's wing flaps.
The flaps increase the area of the wing and give it extra lift.
Without them, a fully loaded 737 cannot get off the ground.
Investigators need to determine how the flaps ended up in this position.
Did they retract during the crash, or were they not deployed in the first place? When you see something that's out of place such as the flap position, you begin to wonder.
What has happened? Has someone raised the flaps? Or has some electronic or hydraulic intervention made the flaps come up? We need to study the entire system.
So, we had to collect all the evidence, observe everything we could, and try to prove what happened.
With both the reverser doors and the flaps needing more intensive study, the team focuses on searching for the plane's black boxes.
The importance of flight recorders in accident investigation cannot be overemphasized.
They are often the most central pieces of evidence in an investigation.
It's not long before they track them down.
But there's a problem.
Like the thrust reversers, both recorders are badly damaged, and there's no facility in Argentina equipped to analyse them.
They need to go to Washington, 5,200 miles north.
It will cost the investigation valuable time.
There was a good deal of pressure to get back the cockpit voice recorder and the flight recorder information in a timely way.
We had to reassure the public and reassure the media that the investigation was proceeding and was being done quickly.
For now, they're left with one or two intriguing clues and a nation that's demanding answers about why LAPA flight 3142 ended in tragedy.
The wreckage of flight 3142 lies in a busy Buenos Aires neighbourhood.
I don't wanna leave anything behind.
It all goes.
Any of the thousands of pieces of debris could be a valuable clue.
We needed to move the remains to a hangar, where we could spread out all the mechanisms and take detailed pictures and also collect data from the remaining instruments.
At the same time, investigators wonder what the air traffic controller can tell them about the fatal take-off attempt.
Anything out of the ordinary that you can remember? There was a bit of a delay.
We were pretty backed up.
These are all the take-offs that night.
They learn that flight 3142 didn't take off on time.
The controller also reveals that the crew's radio calls were unusual.
Cleared for take-off, 3142.
Taking off.
The first officer sometimes failed to repeat instructions or to give the flight's call sign.
Well, if you can think of anything else, please give me a call.
Sure.
Unfortunately for investigators, the controller can't give them much new information to go on.
Why the LAPA flight went so horribly wrong is still a mystery.
What the hell is that doing there? I have no idea.
When it hurtled off the airfield, the 737 hit an industrial gas plant.
Its proximity to the airport has set off alarm bells.
There was a major question when we looked at the wreckage.
We had a public building with a gas facility in it.
If there's a gas plant this close to the airport, they wonder what other risks the airfield might have presented.
The LAPA crash brought up the question of runway length.
2,100m.
Was the runway long enough for a fully fuelled and loaded 737 to get off the ground safely? We had a performance engineer look at the acceleration, the distances, the performance of the aircraft.
He went out and measured every one of those distances and tried to apply them.
They should have been able to get off the ground.
In the end, we found that the runway was of sufficient length.
Investigators find nothing about the runway that would have made the take-off more difficult.
Even though it was an urban airport with everything involved in that, there were no infrastructure deficiencies.
The team presses on in the search for clues.
OK.
Let's start with the most obvious: Thrust reversers.
Once the wreckage had been removed to the hangar, there was an opportunity to carefully look at some of the external damage on the metal surfaces, particularly of the thrust reversers.
This thing is really beaten up.
They find damage on the thrust reverser that doesn't seem to have come from impact with the ground.
A broken light from the end of the runway provides a clue.
There's nothing else on that plane that could have hit something this low.
Damage to the light and to the thrust reverser confirms that the reverser must have been in the deployed position before impact.
We knew then that one of the thrust reverser doors struck a runway light at the end of the runway.
That was a very elemental thing in confirming that a thrust reverser had been deployed.
The thrust reverser remains a possible culprit.
The other primary suspects are the retracted flaps.
The flaps are very, very important, particularly as they allow the slower speeds for take-off and the slower speeds for landing.
Were the flaps on LAPA 3142 ever extended for take-off? To try to answer that critical question, the team carefully examines the entire flap mechanism - every wire, gear, and screw.
The actuators seem fine.
The part that controls the movement of the flaps is called a jackscrew.
The jackscrew acts much like a jack used to lift a car.
As it turns, it moves a nut that extends or retracts the flaps.
That nut travels along the shaft.
It stops at various places to indicate various degrees of flap extension from a zero position up at one end to a fully extended position at the other.
Studying the jackscrews, they make a crucial find.
We had discovered the nuts on the screw were in the retracted position.
It means the flaps were not extended as the plane raced along the runway.
It's not possible for the screw to move during the accident because that thread and nut are very strong.
It can't slip.
Six out of eight screws were found and they were all in the same position.
The flap lever from the cockpit confirms the finding.
The lever's pretty banged up, but it sure looks like it's in the flaps up position.
It had left a mark with the flap lever in the up position.
So, there was no chance that it had moved during the accident.
All signs are pointing to a baffling conclusion.
It seems the pilots never extended the flaps for take-off.
Taking off.
In light of this evidence, investigators now face an even more difficult question.
How could an attempted take-off be made with the flaps in this position? The 737 cockpit is equipped with systems designed to prevent pilots from attempting to take off without first extending the wing flaps.
Approaching runway one-three, LAPA 3142.
Investigators now wonder, did those systems somehow fail on flight 3142? They examine a cockpit indicator Easy does it.
.
.
that lights up once the flaps are properly extended for take-off.
Perhaps the lights malfunctioned.
If they came on while the flaps were still retracted, that may have fatally misled the pilots.
In order to understand how this might have happened, we had to do a lot of analysis.
When a light is off, the filament is cold and brittle.
In a crash, impact forces usually break cold filaments.
But a hot filament from a burning light can stretch instead.
The tiny bulb soon provides an important clue.
The filament is broken.
They weren't seeing any flap lights.
The light bulb filaments were analysed and we found that they had been off.
Taking off.
The flap indicator did not malfunction.
The lights never came on because the flaps were never extended.
But the pilots, for some reason, began their take-off roll anyway.
Investigators know that the cockpit warning systems have built-in redundancy for added safety.
Along with flap indicator lights, there's also an alarm that sounds if pilots begin take-off without flaps.
The alarm would have gone off as soon as they started moving.
How could the take-off warning system not alert the crew to this condition? We needed to figure out if that system had indeed failed to provide a warning.
In 1987, a Northwest Airlines crew forgot to extend their flaps and crashed on take-off from Detroit, killing 156 people.
Investigators discovered that the alarm designed to warn the crew did not sound because the pilots had pulled a fuse to disable it.
They didn't want the alarm to sound as they taxied to the runway.
Did the pilots of Flight 3142 make the same mistake? Did they deliberately disconnect the configuration warning? Everything's where it should be.
We were able to verify whether the fuse, which is behind the co-pilot, was removed or not.
And it wasn't.
It was fine.
The pilots did not deliberately de-activate the warning.
There must be another explanation for the doomed take-off.
Meanwhile, across Argentina, frustration at the lack of answers about the crash continues to grow.
It was a major disaster for them and they really hadn't had something like that ever before.
When you get home and turn on the TV, the accident is all they're talking about.
But you have to keep your professionalism and try not to be influenced by anything that is said in the media.
(REPORTER SPEAKING IN SPANISH) Can we get the FDR data on the screen? Finally, the crucial black box data arrives from Washington.
Investigators hope it can tell them precisely what was happening as flight 3142 attempted to lift off.
Great.
Let's go to the flap positions and engine performance.
The flight data recorder recorded ten parameters from the 11 expected.
Like we thought, no flaps.
The data confirms their earlier findings.
That was one of the most important parameters.
The flaps were at zero during the whole time on the runway.
No issues with the engine performance.
When we looked at the engine pressure ratios, the EPRS, it just further confirmed the idea that there had been a normal attempted take-off.
The FDR doesn't indicate whether the thrust reversers were deployed or not.
But the engine power data provides a strong indication.
It looks like the reversers were deployed here.
When the thrust reverser is deployed, pilots also increase engine thrust to maximize stopping power and slow the plane.
The data suggests that, at the last moment, in an effort to avert disaster, the pilots deployed their thrust reversers and increased thrust.
The EPR came up and then the EPR came down.
Very clear.
And then, it came back up again, most assuredly by thrust reverse.
Back to full data, please.
The reversers had nothing to do with this accident.
Let's take a look at speed.
The data also shows that the plane had enough speed and runway available to lift off safely.
Rotate.
If the flaps had been extended.
So, here's what the data tells us.
At V-1 they're here, 840m of runway still ahead of them.
By the time you get to V-1, it's no longer safe to try to stop on the runway because you do not have enough runway left to stop.
No flaps.
They stall.
They get the plane back down here, 50m from the end of the runway.
There's no way they could stop in time.
Investigators are left with a puzzling question.
They had until right here to abort their take-off safely.
Why didn't they? What the hell? Why an experienced cockpit crew attempted to take off without first extending their wing flaps is the troubling question at the heart of the 3142 investigation.
No, no, no, no, no, no, no! You find yourself wondering, what happened in this aircraft? What happened in this operation? Why did this action not take place when it is indispensable for flight? Investigators turn to the cockpit voice recorder for answers.
The only possibility was in the voice recorder.
Everything OK? Fine.
Everything's fine.
They begin by listening to what was happening just before take-off.
Just waiting on our fuel.
So, besides him, any other guys you're interested in? Yeah, but you don't know him.
I haven't seen him in a while.
What they hear from the crew is astounding.
The whole thing's getting complicated.
You're breaking my heart.
Not only unexpected, but entirely unprofessional.
They should be running checklists.
What's going on? They're required to have a 'sterile cockpit' it's called.
Once you start the engines, up to 10,000 feet, you talk only about operational procedures.
You don't talk about personal issues.
You don't talk about non-related issues.
And this is to prevent distraction.
You guys should come for dinner in Cordoba.
That sounds good.
What should we bring? - You can bring the ice cream.
- OK.
- Before start checklist.
- Before start checklist.
They're talking about planning a meal together.
They're talking about their romantic lives.
And this is interspersed with the checklist.
Hey.
You know I'm with you in the good times and the bad, moron.
It's a good thing I'm nothing like you.
You're full of it.
You're only with me for the good times.
- Cockpit preparations? - Completed.
The checklists were interrupted and were performed incorrectly.
Dinner.
Boyfriends.
Cockpit preparations? They're not following the normal procedures.
Either one of them could have insisted on it.
Flaps are part of the Before Take-off Checklist.
Do they even do that? - Parking brake? - Set.
Paper? We don't have paper.
I can't even tell what checklists they're looking at.
- Anti-ice? - Off.
- Start levers? - Idle stop.
Ready to taxi, 3142.
3142, ready to taxi.
Charlie-five to runway one-three.
Charlie-five to one-three.
No mention of flaps.
They're starting to taxi.
Approaching runway one-three, LAPA 3142.
Don't smoke all of it.
Give me a puff at least.
Investigators now hear something that cements their view of an irresponsible crew.
Even a puff can make you old and grey.
Thanks.
They're actually smoking in the cockpit.
They were sharing a cigarette, the same cigarette.
The three of them were passing a cigarette, which is prohibited by the company.
They're not supposed to be smoking in the cockpit at all.
We're seconds away.
You should probably head back there and strap in.
Alright, guys.
The reason the crew failed to extend the flaps is now clear.
Hurry, hurry.
They were simply too distracted by their own careless behaviour.
Cleared for take-off, LAPA 3142.
Investigators now wonder if the pilots heard an alarm, warning them of their fatal error as they accelerated down the runway.
Taking off.
One primary question was, do you hear any take-off warning on the recording? (BEEPING) There it is! The sound of the alarm was loud.
It could be heard perfectly in the voice recorder many times.
It was a system alarm that warned that, in this situation, the aircraft could not fly.
It was not capable of a safe take-off.
What's that? What the hell is that? Is it on the left? Incredibly, the pilots seem undisturbed by the warning.
I don't know what the alarm is, my friend.
Everything seems fine.
OK, pause.
How can they ignore that? The captain heard the configuration warning.
He talks about it twice and says he doesn't know what it is.
And yet he proceeds with the take-off.
Play.
- 80 knots.
- Check.
Take-off speed.
They've been listening to that alarm for 36 seconds.
The configuration warning was so loud that you can hardly hear them talking underneath it.
Rotate.
It was designed specifically to warn the pilots not to take off.
The investigative team is now at a loss.
How could a crew forget to perform one of the most basic take-off procedures and then go on to ignore the loud, persistent warning designed to alert them to their serious mistake? I believe they didn't understand the importance of this alarm, which was absolutely critical for take-off.
65 people lost their lives because the crew wasn't paying attention to what they were doing.
The essential question now is how did this crew end up in command of a passenger plane? In seeing the crew's behaviour, it raises questions about the company and about the oversight of the company as well as about the individual.
No.
Stop.
Stop, stop, stop, stop.
What kind of pilot was this guy? One of the standard parts of our investigation was to examine the training records for each of the pilots.
A background check shows Captain Gustavo Weigel had been flying for more than 20 years.
He'd never been in a serious accident before, but his work history suggests he'd been on thin ice for quite a while.
Not exactly a perfect record.
In the case of the captain, there were deficiencies noted over time and over different airplanes that he was slow to respond to emergency situations or critical situations.
'Imprecise cockpit coordination, lack of procedural knowledge.
' Yikes His history is riddled with reports of inadequacies.
You have to wonder why he kept passing his training, why he was promoted.
Beyond his promotions, investigators wonder why LAPA even chose to hire this captain in the first place.
A close look at the company's corporate records offers a possible explanation.
It seems the airline was expanding so quickly it struggled to maintain high standards of pilot training and oversight.
Often, in times of major change, there can be cases where issues such as discipline in the cockpit are not enforced as tightly as they could be if the company was more focused.
They couldn't keep up with their own success.
If an organisation is expanding and extending itself to have many more planes, with more crews managing greater numbers of passengers, it is always a risk factor if it's not well managed.
Everything OK? Fine.
Everything's fine.
No-one is more dismayed by LAPA's failings than Marisa Beiro.
We made it.
She lost eight friends and suffered agonising injuries.
When they took me to the hospital, 60% of my body had been burned.
I had a serious burn in my trachea because of the inhalation of smoke and heat.
Today, you'd never know it looking at me, but if you look at my clinical record, I was at death's door.
For the first five months that I was in hospital, I was not allowed to talk, hear, or watch any news about the crash.
Then, I started researching, following the investigative reports, finding out more about the pilot's life.
I started asking why it happened.
When she finally learns the cause of all her pain, Marisa is horrified.
If the alarm went off and it warned that the flaps weren't configured, why didn't they do something? For their lack of proper oversight, six former managers face charges of criminal negligence causing death.
Marisa advocates on behalf of the victims.
In the end, no-one goes to prison.
My friends couldn't defend themselves in that moment.
I put myself in their place in trying to defend such injustice.
- No, no, no, no, no, no.
- No.
Stop.
Stop, stop, stop! With anger, with rage, wishing I could get an explanation.
Why? No! No! No! (PASSENGERS SCREAMING) In their final report, investigators stress the need for pilots to always comply with the sterile cockpit rule, the rule that restricts crew conversation and helps minimize distractions during key parts of the flight.
They also call for better pilot training to ensure crews can recognise and respond to cockpit alarms.
In the past two decades, Argentina has made great strides in improving aviation safety.
In the big picture of things, the LAPA crash was the initiator of the aeronautical progress that has been made in Argentina.
The final objective of any investigation is to improve the system.
That's what accident investigations do.
There is always a lesson to be learned and communicated in order to improve air safety.
Captioned by Ai-Media ai-media.
tv
A business trip to Argentina's capital becomes a nightmare for Marisa Beiro.
I was bracing myself.
Something bad was happening.
What the hell? LAPA flight 3142 is in serious trouble.
The airplane crossed a busy highway, killed people who were in their cars.
Marisa fights for her life.
Then, she fights for justice.
And then, I started researching, asking why it had happened.
The stunning answer leaves a nation in shock.
To me, that was unprecedented.
It's difficult to imagine that someone would do that.
# # It's 8:30 pm at Jorge Newbery Airfield in Buenos Aires, Argentina.
Wind zero-two-zero at five.
Altimeter three-zero-decimal-one-zero.
A Boeing 737, the workhorse of the aviation industry, prepares to taxi.
It is operated by the Argentinean airline LAPA.
We made it.
Marisa Beiro is a cosmetics rep from Cordoba.
I was traveling with eight of my co-workers.
One of them was my best friend and sister-in-law.
She's heading home after a lengthy business trip to the capital with a group of colleagues.
It had been ten days since we left, and it was time to go home.
In fact, we had all arranged with our families to pick us up at the airport.
And we wanted to go back to our kids.
- Jamaica? - No.
- Hey, Captain.
- Hey.
The captain of LAPA flight 3142 is Gustavo Weigel.
He's an experienced pilot who's been flying for more than 20 years.
- Everything OK? - Fine.
Everything's fine.
We're just waiting on our fuel.
First Officer Luis Etcheverry has logged more than 500 hours in the 737.
Total fuel required, 8,500kg, to be transferred to the wings.
Tonight's flight is a short one, 400 miles west from Buenos Aires to the city of Cordoba.
Time in the air should be a little over an hour.
Along with the two pilots, there are three flight attendants and 95 passengers onboard.
I noticed something.
There was no safety card in our seat.
And that stood out to me because I always check the safety card when I board a plane - always.
In 1999, the airline business in Argentina is booming.
Industry deregulation five years earlier has led to rapid growth for budget airlines like LAPA.
One-three-five turn right heading zero-six-zero.
Descend and maintain 5,000, slow to two-two-zero knots and hold.
Come on.
Come on.
It's best to understand LAPA as a low-cost carrier making considerable inroads into a transportation system in a very large country that needed airline transportation.
Austral two-three-six, you're next in line for take-off.
Please proceed to runway and hold.
In Argentina, the commercial airline industry is run by the military.
The Air Force Defence Program was responsible for both civilian and military aviation.
- Before start checklist.
- Before start checklist.
First Officer Etcheverry oversees - some last-minute procedures.
- Cockpit preparations? - Completed.
- The flight attendants prepare the cabin for take-off.
We bought some gossip magazines for the flight.
Some of the girls were flying for the first time, so I gave them chewing gum for the air pressure on the plane.
We were just flipping through magazines, very relaxed.
Ready to taxi, 3142.
3142, ready to taxi.
Charlie-five to runway one-three.
Charlie-five to one-three.
Jorge Newbery is a single runway airport.
And, tonight, departures are running a little behind schedule.
You have an experienced crew in the cabin.
Please let them know if there's anything they can do to make your flight more comfortable.
On behalf of First Officer Etcheverry and myself, we hope you have an enjoyable flight.
You guys should come for dinner in Cordoba.
That sounds good.
What should we bring? You can bring the ice cream.
The relationship between the crew seemed to be very close.
It appeared that they had known each other for a while and that, beyond being co-workers, they were friends.
I was sitting near the door and I noticed the door was half open.
The cockpit door is usually completely closed.
Not this time.
You know, we're seconds away.
You should probably get back there - and strap in.
- Alright, guys.
It's been a pleasure.
See you soon.
Hurry, hurry.
Cleared for take-off, LAPA 3142.
Taking off.
The airplane is on the runway, accelerating, getting faster.
You know, when you can feel how the airplane is getting the amount of velocity necessary for take-off.
As the aircraft lifts off, it is immediately apparent that something is wrong.
The plane begins to take off.
But, instantly, it starts shaking like it was going to fall apart.
Something bad was happening.
I was bracing because my gut told me to.
We all knew something was going wrong.
What the hell? Hurtling forward at 160 knots, the 737 slams violently back to the ground.
(PASSENGERS SCREAMING) There was a clear zone at the end of that runway.
And yet, the aircraft continued to proceed at a relatively high speed.
They're now headed straight for a busy highway and an industrial gas plant.
Stop, stop, stop, stop.
It was very quick.
I just looked at my friends and I braced my head.
No, no, no, no, no.
The airplane crossed a busy highway without warning, killed people who were commuting at that time in their cars.
No! No! No! Everything went dark.
Literally, all dark.
It was like the people around me were no longer there.
I was squeezed between the front seat and the seat behind me that got pushed forward.
I could feel extreme heat all around me.
I was suffocating, and I needed to get out.
But I couldn't release my seatbelt.
Emergency.
LAPA flight 3142 just crashed through the airfield perimeter.
Rescuers race to the site of the crash, but survivors on board don't have much time.
Fire threatens to consume the entire plane.
I felt like I was dying.
And something happened that I still can't explain.
Maybe an angel, or God, I don't know.
But it gently released my seatbelt.
And someone said to me, "Get out.
" As Marisa struggles to escape, she sees that none of her friends have survived.
They were all already dead.
It was instant.
Though badly injured, Marisa is one of the lucky ones.
Many of the evacuation doors could not be used due to the fire.
That meant that many passengers couldn't get out.
The plane was fully engulfed.
People were screaming for help.
I went in and got four of them with some help.
But I saw the bodies burning.
It was terrible.
The crash has killed 60 passengers, three crew members, and two motorists.
It's a disaster unlike anything Buenos Aires has seen before.
It was a major calamity.
It involved automobiles.
It involved a natural gas regulating plant.
There had been a major sustaining fire, so it was a major disaster scene.
News of the crash spreads quickly through the Argentinean Capital.
Because they live and work in Buenos Aires, members of the nation's Accident Investigation Unit are on the scene in minutes, getting a rare glimpse of the immediate aftermath.
It's a lot of smoke.
Hard to see anything.
Horacio Larrosa is a senior investigator.
You try to focus on the job and look for details that, later on, could be harder to find once the rescue teams have finished their work.
So, you have to be paying attention to details and make sure nothing slips.
This was my first experience with a big accident.
Even though we were trained and we were prepared for this type of situation, it's something else to see a catastrophe with so much movement of ambulances, wounded people, police, and all the rest.
It was very complicated.
Neither pilot survived.
OK.
Thank you.
Both Captain Weigel and First Officer Etcheverry are dead.
Any hope of finding out what went wrong lies in the wreckage.
The first thing is doing a visual inspection of the site.
Looking at all of the components, trying to put oneself in the situation.
Which is very difficult, when there is so much damage and fire.
They lift off here, barely get off the ground.
They leave the runway here and finally come to rest here.
Because the destroyed aircraft was American-made, the US National Transportation Safety Board sends a team to assist the Argentines.
Whatever you need, we're here to help.
I was the accredited representative from the United States to the official investigation.
- Rodrigo.
- Hey.
How are ya? It's a case where there was just a tremendous amount of public concern and a great deal of encouragement to try to solve this definitively and quickly.
In any take-off accident, you're looking at a variety of factors.
Some of them relate to engine power.
Were the engines producing a proper amount of power.
When you look at the engines after an accident, there are very clear signs that show if the engine was functioning or not.
Look there and there.
It looks like these blades were spinning.
The type of damage sustained by the rotor blades tells investigators that the engines were working normally when they hit the ground.
There was no engine failure.
Well, would you look at this? But something else related to the engines raises an immediate red flag.
One of the plane's thrust reversers is deployed.
I recall vividly the doors on that thrust reverser appeared to be open.
Thrust reversers are only supposed to deploy on landing.
They help slow the plane down by redirecting engine exhaust.
There are doors that drop down into the exhaust plume, kind of like a reverse gear in a way, that's pushing against the forward motion.
If a reverser were to deploy on take-off, it could cause a catastrophic thrust imbalance.
So, we were very concerned about how those thrust reversers had ended up in that position.
Look here.
The flaps aren't extended.
Investigators study the wings of the downed plane and soon make another discovery.
I was able to observe with some of my colleagues that the aircraft's flaps were apparently not extended.
Let's get this wing piece out of here.
For take-off, 737 pilots must always extend the plane's wing flaps.
The flaps increase the area of the wing and give it extra lift.
Without them, a fully loaded 737 cannot get off the ground.
Investigators need to determine how the flaps ended up in this position.
Did they retract during the crash, or were they not deployed in the first place? When you see something that's out of place such as the flap position, you begin to wonder.
What has happened? Has someone raised the flaps? Or has some electronic or hydraulic intervention made the flaps come up? We need to study the entire system.
So, we had to collect all the evidence, observe everything we could, and try to prove what happened.
With both the reverser doors and the flaps needing more intensive study, the team focuses on searching for the plane's black boxes.
The importance of flight recorders in accident investigation cannot be overemphasized.
They are often the most central pieces of evidence in an investigation.
It's not long before they track them down.
But there's a problem.
Like the thrust reversers, both recorders are badly damaged, and there's no facility in Argentina equipped to analyse them.
They need to go to Washington, 5,200 miles north.
It will cost the investigation valuable time.
There was a good deal of pressure to get back the cockpit voice recorder and the flight recorder information in a timely way.
We had to reassure the public and reassure the media that the investigation was proceeding and was being done quickly.
For now, they're left with one or two intriguing clues and a nation that's demanding answers about why LAPA flight 3142 ended in tragedy.
The wreckage of flight 3142 lies in a busy Buenos Aires neighbourhood.
I don't wanna leave anything behind.
It all goes.
Any of the thousands of pieces of debris could be a valuable clue.
We needed to move the remains to a hangar, where we could spread out all the mechanisms and take detailed pictures and also collect data from the remaining instruments.
At the same time, investigators wonder what the air traffic controller can tell them about the fatal take-off attempt.
Anything out of the ordinary that you can remember? There was a bit of a delay.
We were pretty backed up.
These are all the take-offs that night.
They learn that flight 3142 didn't take off on time.
The controller also reveals that the crew's radio calls were unusual.
Cleared for take-off, 3142.
Taking off.
The first officer sometimes failed to repeat instructions or to give the flight's call sign.
Well, if you can think of anything else, please give me a call.
Sure.
Unfortunately for investigators, the controller can't give them much new information to go on.
Why the LAPA flight went so horribly wrong is still a mystery.
What the hell is that doing there? I have no idea.
When it hurtled off the airfield, the 737 hit an industrial gas plant.
Its proximity to the airport has set off alarm bells.
There was a major question when we looked at the wreckage.
We had a public building with a gas facility in it.
If there's a gas plant this close to the airport, they wonder what other risks the airfield might have presented.
The LAPA crash brought up the question of runway length.
2,100m.
Was the runway long enough for a fully fuelled and loaded 737 to get off the ground safely? We had a performance engineer look at the acceleration, the distances, the performance of the aircraft.
He went out and measured every one of those distances and tried to apply them.
They should have been able to get off the ground.
In the end, we found that the runway was of sufficient length.
Investigators find nothing about the runway that would have made the take-off more difficult.
Even though it was an urban airport with everything involved in that, there were no infrastructure deficiencies.
The team presses on in the search for clues.
OK.
Let's start with the most obvious: Thrust reversers.
Once the wreckage had been removed to the hangar, there was an opportunity to carefully look at some of the external damage on the metal surfaces, particularly of the thrust reversers.
This thing is really beaten up.
They find damage on the thrust reverser that doesn't seem to have come from impact with the ground.
A broken light from the end of the runway provides a clue.
There's nothing else on that plane that could have hit something this low.
Damage to the light and to the thrust reverser confirms that the reverser must have been in the deployed position before impact.
We knew then that one of the thrust reverser doors struck a runway light at the end of the runway.
That was a very elemental thing in confirming that a thrust reverser had been deployed.
The thrust reverser remains a possible culprit.
The other primary suspects are the retracted flaps.
The flaps are very, very important, particularly as they allow the slower speeds for take-off and the slower speeds for landing.
Were the flaps on LAPA 3142 ever extended for take-off? To try to answer that critical question, the team carefully examines the entire flap mechanism - every wire, gear, and screw.
The actuators seem fine.
The part that controls the movement of the flaps is called a jackscrew.
The jackscrew acts much like a jack used to lift a car.
As it turns, it moves a nut that extends or retracts the flaps.
That nut travels along the shaft.
It stops at various places to indicate various degrees of flap extension from a zero position up at one end to a fully extended position at the other.
Studying the jackscrews, they make a crucial find.
We had discovered the nuts on the screw were in the retracted position.
It means the flaps were not extended as the plane raced along the runway.
It's not possible for the screw to move during the accident because that thread and nut are very strong.
It can't slip.
Six out of eight screws were found and they were all in the same position.
The flap lever from the cockpit confirms the finding.
The lever's pretty banged up, but it sure looks like it's in the flaps up position.
It had left a mark with the flap lever in the up position.
So, there was no chance that it had moved during the accident.
All signs are pointing to a baffling conclusion.
It seems the pilots never extended the flaps for take-off.
Taking off.
In light of this evidence, investigators now face an even more difficult question.
How could an attempted take-off be made with the flaps in this position? The 737 cockpit is equipped with systems designed to prevent pilots from attempting to take off without first extending the wing flaps.
Approaching runway one-three, LAPA 3142.
Investigators now wonder, did those systems somehow fail on flight 3142? They examine a cockpit indicator Easy does it.
.
.
that lights up once the flaps are properly extended for take-off.
Perhaps the lights malfunctioned.
If they came on while the flaps were still retracted, that may have fatally misled the pilots.
In order to understand how this might have happened, we had to do a lot of analysis.
When a light is off, the filament is cold and brittle.
In a crash, impact forces usually break cold filaments.
But a hot filament from a burning light can stretch instead.
The tiny bulb soon provides an important clue.
The filament is broken.
They weren't seeing any flap lights.
The light bulb filaments were analysed and we found that they had been off.
Taking off.
The flap indicator did not malfunction.
The lights never came on because the flaps were never extended.
But the pilots, for some reason, began their take-off roll anyway.
Investigators know that the cockpit warning systems have built-in redundancy for added safety.
Along with flap indicator lights, there's also an alarm that sounds if pilots begin take-off without flaps.
The alarm would have gone off as soon as they started moving.
How could the take-off warning system not alert the crew to this condition? We needed to figure out if that system had indeed failed to provide a warning.
In 1987, a Northwest Airlines crew forgot to extend their flaps and crashed on take-off from Detroit, killing 156 people.
Investigators discovered that the alarm designed to warn the crew did not sound because the pilots had pulled a fuse to disable it.
They didn't want the alarm to sound as they taxied to the runway.
Did the pilots of Flight 3142 make the same mistake? Did they deliberately disconnect the configuration warning? Everything's where it should be.
We were able to verify whether the fuse, which is behind the co-pilot, was removed or not.
And it wasn't.
It was fine.
The pilots did not deliberately de-activate the warning.
There must be another explanation for the doomed take-off.
Meanwhile, across Argentina, frustration at the lack of answers about the crash continues to grow.
It was a major disaster for them and they really hadn't had something like that ever before.
When you get home and turn on the TV, the accident is all they're talking about.
But you have to keep your professionalism and try not to be influenced by anything that is said in the media.
(REPORTER SPEAKING IN SPANISH) Can we get the FDR data on the screen? Finally, the crucial black box data arrives from Washington.
Investigators hope it can tell them precisely what was happening as flight 3142 attempted to lift off.
Great.
Let's go to the flap positions and engine performance.
The flight data recorder recorded ten parameters from the 11 expected.
Like we thought, no flaps.
The data confirms their earlier findings.
That was one of the most important parameters.
The flaps were at zero during the whole time on the runway.
No issues with the engine performance.
When we looked at the engine pressure ratios, the EPRS, it just further confirmed the idea that there had been a normal attempted take-off.
The FDR doesn't indicate whether the thrust reversers were deployed or not.
But the engine power data provides a strong indication.
It looks like the reversers were deployed here.
When the thrust reverser is deployed, pilots also increase engine thrust to maximize stopping power and slow the plane.
The data suggests that, at the last moment, in an effort to avert disaster, the pilots deployed their thrust reversers and increased thrust.
The EPR came up and then the EPR came down.
Very clear.
And then, it came back up again, most assuredly by thrust reverse.
Back to full data, please.
The reversers had nothing to do with this accident.
Let's take a look at speed.
The data also shows that the plane had enough speed and runway available to lift off safely.
Rotate.
If the flaps had been extended.
So, here's what the data tells us.
At V-1 they're here, 840m of runway still ahead of them.
By the time you get to V-1, it's no longer safe to try to stop on the runway because you do not have enough runway left to stop.
No flaps.
They stall.
They get the plane back down here, 50m from the end of the runway.
There's no way they could stop in time.
Investigators are left with a puzzling question.
They had until right here to abort their take-off safely.
Why didn't they? What the hell? Why an experienced cockpit crew attempted to take off without first extending their wing flaps is the troubling question at the heart of the 3142 investigation.
No, no, no, no, no, no, no! You find yourself wondering, what happened in this aircraft? What happened in this operation? Why did this action not take place when it is indispensable for flight? Investigators turn to the cockpit voice recorder for answers.
The only possibility was in the voice recorder.
Everything OK? Fine.
Everything's fine.
They begin by listening to what was happening just before take-off.
Just waiting on our fuel.
So, besides him, any other guys you're interested in? Yeah, but you don't know him.
I haven't seen him in a while.
What they hear from the crew is astounding.
The whole thing's getting complicated.
You're breaking my heart.
Not only unexpected, but entirely unprofessional.
They should be running checklists.
What's going on? They're required to have a 'sterile cockpit' it's called.
Once you start the engines, up to 10,000 feet, you talk only about operational procedures.
You don't talk about personal issues.
You don't talk about non-related issues.
And this is to prevent distraction.
You guys should come for dinner in Cordoba.
That sounds good.
What should we bring? - You can bring the ice cream.
- OK.
- Before start checklist.
- Before start checklist.
They're talking about planning a meal together.
They're talking about their romantic lives.
And this is interspersed with the checklist.
Hey.
You know I'm with you in the good times and the bad, moron.
It's a good thing I'm nothing like you.
You're full of it.
You're only with me for the good times.
- Cockpit preparations? - Completed.
The checklists were interrupted and were performed incorrectly.
Dinner.
Boyfriends.
Cockpit preparations? They're not following the normal procedures.
Either one of them could have insisted on it.
Flaps are part of the Before Take-off Checklist.
Do they even do that? - Parking brake? - Set.
Paper? We don't have paper.
I can't even tell what checklists they're looking at.
- Anti-ice? - Off.
- Start levers? - Idle stop.
Ready to taxi, 3142.
3142, ready to taxi.
Charlie-five to runway one-three.
Charlie-five to one-three.
No mention of flaps.
They're starting to taxi.
Approaching runway one-three, LAPA 3142.
Don't smoke all of it.
Give me a puff at least.
Investigators now hear something that cements their view of an irresponsible crew.
Even a puff can make you old and grey.
Thanks.
They're actually smoking in the cockpit.
They were sharing a cigarette, the same cigarette.
The three of them were passing a cigarette, which is prohibited by the company.
They're not supposed to be smoking in the cockpit at all.
We're seconds away.
You should probably head back there and strap in.
Alright, guys.
The reason the crew failed to extend the flaps is now clear.
Hurry, hurry.
They were simply too distracted by their own careless behaviour.
Cleared for take-off, LAPA 3142.
Investigators now wonder if the pilots heard an alarm, warning them of their fatal error as they accelerated down the runway.
Taking off.
One primary question was, do you hear any take-off warning on the recording? (BEEPING) There it is! The sound of the alarm was loud.
It could be heard perfectly in the voice recorder many times.
It was a system alarm that warned that, in this situation, the aircraft could not fly.
It was not capable of a safe take-off.
What's that? What the hell is that? Is it on the left? Incredibly, the pilots seem undisturbed by the warning.
I don't know what the alarm is, my friend.
Everything seems fine.
OK, pause.
How can they ignore that? The captain heard the configuration warning.
He talks about it twice and says he doesn't know what it is.
And yet he proceeds with the take-off.
Play.
- 80 knots.
- Check.
Take-off speed.
They've been listening to that alarm for 36 seconds.
The configuration warning was so loud that you can hardly hear them talking underneath it.
Rotate.
It was designed specifically to warn the pilots not to take off.
The investigative team is now at a loss.
How could a crew forget to perform one of the most basic take-off procedures and then go on to ignore the loud, persistent warning designed to alert them to their serious mistake? I believe they didn't understand the importance of this alarm, which was absolutely critical for take-off.
65 people lost their lives because the crew wasn't paying attention to what they were doing.
The essential question now is how did this crew end up in command of a passenger plane? In seeing the crew's behaviour, it raises questions about the company and about the oversight of the company as well as about the individual.
No.
Stop.
Stop, stop, stop, stop.
What kind of pilot was this guy? One of the standard parts of our investigation was to examine the training records for each of the pilots.
A background check shows Captain Gustavo Weigel had been flying for more than 20 years.
He'd never been in a serious accident before, but his work history suggests he'd been on thin ice for quite a while.
Not exactly a perfect record.
In the case of the captain, there were deficiencies noted over time and over different airplanes that he was slow to respond to emergency situations or critical situations.
'Imprecise cockpit coordination, lack of procedural knowledge.
' Yikes His history is riddled with reports of inadequacies.
You have to wonder why he kept passing his training, why he was promoted.
Beyond his promotions, investigators wonder why LAPA even chose to hire this captain in the first place.
A close look at the company's corporate records offers a possible explanation.
It seems the airline was expanding so quickly it struggled to maintain high standards of pilot training and oversight.
Often, in times of major change, there can be cases where issues such as discipline in the cockpit are not enforced as tightly as they could be if the company was more focused.
They couldn't keep up with their own success.
If an organisation is expanding and extending itself to have many more planes, with more crews managing greater numbers of passengers, it is always a risk factor if it's not well managed.
Everything OK? Fine.
Everything's fine.
No-one is more dismayed by LAPA's failings than Marisa Beiro.
We made it.
She lost eight friends and suffered agonising injuries.
When they took me to the hospital, 60% of my body had been burned.
I had a serious burn in my trachea because of the inhalation of smoke and heat.
Today, you'd never know it looking at me, but if you look at my clinical record, I was at death's door.
For the first five months that I was in hospital, I was not allowed to talk, hear, or watch any news about the crash.
Then, I started researching, following the investigative reports, finding out more about the pilot's life.
I started asking why it happened.
When she finally learns the cause of all her pain, Marisa is horrified.
If the alarm went off and it warned that the flaps weren't configured, why didn't they do something? For their lack of proper oversight, six former managers face charges of criminal negligence causing death.
Marisa advocates on behalf of the victims.
In the end, no-one goes to prison.
My friends couldn't defend themselves in that moment.
I put myself in their place in trying to defend such injustice.
- No, no, no, no, no, no.
- No.
Stop.
Stop, stop, stop! With anger, with rage, wishing I could get an explanation.
Why? No! No! No! (PASSENGERS SCREAMING) In their final report, investigators stress the need for pilots to always comply with the sterile cockpit rule, the rule that restricts crew conversation and helps minimize distractions during key parts of the flight.
They also call for better pilot training to ensure crews can recognise and respond to cockpit alarms.
In the past two decades, Argentina has made great strides in improving aviation safety.
In the big picture of things, the LAPA crash was the initiator of the aeronautical progress that has been made in Argentina.
The final objective of any investigation is to improve the system.
That's what accident investigations do.
There is always a lesson to be learned and communicated in order to improve air safety.
Captioned by Ai-Media ai-media.
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