MARISA [English Dub]: The plane begins to take off,
but instantly it starts shaking.
NARRATOR: A business trip to Argentina's capital
becomes a nightmare for Marisa Beiró.
MARISA [English Dub]: I was bracing myself. Something bad was happening.
AIR TRAFFIC CONTROLLER: What the hell?
NARRATOR: LAPA Flight 3142 is in serious trouble.
MALCOLM: The airplane crossed a busy highway,
killed people who were in their cars.
NARRATOR: Marisa fights for her life.
Then she fights for justice.
MARISA [English Dub]: And then I started researching,
asking why it had happened.
NARRATOR: The stunning answer leaves a nation in shock.
MALCOLM: To me that was unprecedented.
It's difficult to imagine that someone would do that.
[♪ theme music ]
♪
NARRATOR: It's 8:30 p.m. at Jorge Newbery Airfield
in Buenos Aires, Argentina.
AIR TRAFFIC CONTROLLER: Wind zero-two-zero at five.
Altimeter three-zero-decimal-one-zero.
NARRATOR: A Boeing 737, the workhorse of the aviation industry,
prepares to taxi.
It is operated by the Argentinean airline LAPA.
MARISA: We made it.
NARRATOR: Marisa Beiró is a cosmetics rep from Córdoba.
MARISA [English Dub]: I was traveling with eight of my coworkers.
One of them was my best friend and sister-in-law.
NARRATOR: She's heading home after a lengthy business trip
to the capital with a group of colleagues.
MARISA [English Dub]: 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.
CAPT. WEIGEL: Jamaica? FLIGHT ATTENDANT: No.
FO. ETCHEVERRY: Hey, Captain. FLIGHT ATTENDANT: Hey.
NARRATOR: The captain of LAPA Flight 3142 is Gustavo Weigel.
He's an experienced pilot
who's been flying for more than 20 years.
FLIGHT ATTENDANT: Everything okay?
CAPT. WEIGEL: Fine. Everything's fine.
FO. ETCHEVERRY: We're just waiting on our fuel.
NARRATOR: First officer Luis Etcheverry has logged
more than 500 hours in the 737.
FO. ETCHEVERRY: Total fuel required 8,500 kilograms
to be transferred to the wings.
NARRATOR: Tonight's flight is a short one,
400 miles west from Buenos Aires to the city of Córdoba.
Time in the air should be a little over an hour.
Along with the two pilots, there are three flight attendants
and 95 passengers on board.
MARISA [English Dub]: 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.
NARRATOR: In 1999, the airline industry in Argentina is booming.
Industry deregulation five years earlier
has led to rapid growth for budget airlines like LAPA.
AIR TRAFFIC CONTROLLER: One-three-five turn right heading zero-six-zero.
Descend and maintain 5,000,
slow to two-two-zero knots and hold.
CAPT. WEIGEL: Come on. Come on.
ROBERT: 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.
AIR TRAFFIC CONTROLLER: Austral two-three-six, you're next in line for takeoff.
Please proceed to runway and hold.
NARRATOR: In Argentina, the commercial airline industry
is run by the military.
MALCOLM: The Air Force Defense Program was responsible
for both civilian and military aviation.
CAPT. WEIGEL: Before start checklist.
FO. ETCHEVERRY: Before start checklist.
NARRATOR: First Officer Etcheverry
oversees some last minute procedures.
FO. ETCHEVERRY: Cockpit preparations?
CAPT. WEIGEL: Completed.
NARRATOR: The flight attendants prepare the cabin for takeoff.
MARISA [English Dub]: 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.
FO. ETCHEVERRY: Ready to taxi, 3142.
AIR TRAFFIC CONTROLLER: 3142, ready to taxi Charlie-five to runway one-three.
FO. ETCHEVERRY: Charlie-five to one-three.
NARRATOR: Jorge Newbery is a single runway airport,
and tonight, departures are running
a little bit behind schedule.
CAPT. WEIGEL: 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.
FLIGHT ATTENDANT: You guys should come for dinner in Córdoba.
FO. ETCHEVERRY: That sounds good. What should we bring?
FLIGHT ATTENDANT: You can bring the ice cream.
HORACIO [English Dub]: 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 coworkers they were friends.
MARISA [English Dub]: I was sitting near the door
and I noticed the door was half open.
The cockpit door is usually completely closed.
Not this time.
FO. ETCHEVERRY: You know, we're seconds away.
You should probably get back there and strap in.
FLIGHT ATTENDANT: All right guys, it's been a pleasure. See you soon.
FO. ETCHEVERRY: Hurry, hurry.
AIR TRAFFIC CONTROLLER: Cleared for takeoff, LAPA 3142.
FO. ETCHEVERRY: Taking off.
MARISA [English Dub]: 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 takeoff.
NARRATOR: As the aircraft lifts off, it is immediately apparent
that something is wrong.
MARISA [English Dub]: 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.
AIR TRAFFIC CONTROLLER: What the hell?
NARRATOR: Hurtling forward at 160 knots,
the 737 slams violently back to the ground.
[passengers screaming]
ROBERT: There was a clear zone at the end of that runway,
and yet the aircraft continued to proceed
at a relatively high speed.
NARRATOR: They're now headed straight for a busy highway
and an industrial gas plant.
CAPT. WEIGEL: Stop, stop, stop, stop.
MARISA [English Dub]: It was very quick.
I just looked at my friends and I braced my head.
FO. ETCHEVERRY: No, no, no, no, no.
MALCOLM: The airplane crossed a busy highway without warning,
killed people who were commuting at that time in their cars.
FO. ETCHEVERRY: No! No! No!
[explosion]
MARISA [English Dub]: 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 seat belt.
AIR TRAFFIC CONTROLLER: Emergency. LAPA Flight 3142
just crashed through the airfield perimeter.
NARRATOR: Rescuers race to the site of the crash,
but survivors on board don't have much time.
Fire threatens to consume the entire plane.
MARISA [English Dub]: 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 seat belt.
And someone said to me, "Get out."
NARRATOR: As Marisa struggles to escape,
she sees that none of her friends have survived.
MARISA [English Dub]: They were all already dead. It was instant.
NARRATOR: Though badly injured, Marisa is one of the lucky ones.
HORACIO [English Dub]: Many of the evacuation doors
could not be used due to the fire.
That meant that many passengers couldn't get out.
RESCUER [Archive, English Dub]: 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.
NARRATOR: The crash has killed 60 passengers,
three crew members and two motorists.
It's a disaster unlike anything Buenos Aires has seen before.
ROBERT: 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.
♪
NARRATOR: News of the LAPA 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.
ARGENTINEAN INVESTIGATOR: It's a lot of smoke. Hard to see anything.
NARRATOR: Horacio Larrosa is a senior investigator.
HORACIO [English Dub]: 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.
AUGUSTO [English Dub]: 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.
INVESTIGATOR 2: Neither pilot survived.
ARGENTINEAN INVESTIGATOR: Okay. Thank you.
NARRATOR: Both Captain Weigel and First Officer Etcheverry are dead.
Any hope of finding out what went wrong lies in the wreckage.
AUGUSTO [English Dub]: 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.
ARGENTINEAN INVESTIGATOR: They lift off here, barely get off the ground.
They leave the runway here and finally come to rest here.
NARRATOR: Because the destroyed aircraft was American made,
the U.S. National Transportation Safety Board
sends a team to assist the Argentines.
ROBERT: Whatever you need, we're here to help.
ROBERT: I was the accredited representative
from the United States to the official investigation.
MALCOLM: 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.
ROBERT: In any takeoff 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?
HORACIO [English Dub]: When you look at the engines after an accident,
there are very clear signs that show
if the engine was functioning or not.
ARGENTINEAN INVESTIGATOR: Look there and there.
It looks like these blades were spinning.
NARRATOR: 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.
ARGENTINEAN INVESTIGATOR: Well, would you look at this?
NARRATOR: But something else related to the engines
raises an immediate red flag.
One of the plane's thrust reversers is deployed.
ROBERT: I recall vividly the doors
on that thrust reverser appeared to be open.
NARRATOR: Thrust reversers are only supposed to deploy on landing.
They help slow the plane down by redirecting engine exhaust.
ROBERT: 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.
NARRATOR: If a reverser were to deploy on takeoff,
it could cause a catastrophic thrust imbalance.
ROBERT: So we were very concerned about how
those thrust reversers had ended up in that position.
ARGENTINEAN INVESTIGATOR: Look here. The flaps aren't extended.
NARRATOR: Investigators study the wings of the downed plane
and soon make another discovery.
HORACIO [English Dub]: I was able to observe with some of my colleagues
that the aircraft's flaps were apparently not extended.
ARGENTINEAN INVESTIGATOR: Let's get this wing piece out of here.
NARRATOR: For takeoff, 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 take off on a standard runway.
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?
ROBERT: 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?
ARGENTINEAN INVESTIGATOR: We need to study the entire system.
HORACIO [English Dub]: So we had to collect all the evidence,
observe everything we could and try to prove what happened.
NARRATOR: With both the reverser doors and the flaps
needing more intensive study, the team focuses
on searching for the plane's black boxes.
ROBERT: The importance of flight recorders
in accident investigation cannot be overemphasized.
MALCOLM: They are often the most central pieces of evidence
in an investigation.
NARRATOR: 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 analyze them.
NARRATOR: They need to go to Washington, 5,200 miles north.
It will cost the investigation valuable time.
MALCOLM: 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.
NARRATOR: 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.
NARRATOR: The wreckage of LAPA Flight 3142 lies
in a busy Buenos Aires neighborhood.
ARGENTINEAN INVESTIGATOR: I don't wanna leave anything behind. It all goes.
NARRATOR: Any of the thousands of pieces of debris
could be a valuable clue.
HORACIO [English Dub]: 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.
NARRATOR: At the same time, investigators wonder
what the air traffic controller can tell them
about the fatal takeoff attempt.
INVESTIGATOR 2: Anything out of the ordinary that you can remember?
AIR TRAFFIC CONTROLLER: There was a bit of a delay.
We were pretty backed up.
These are all the takeoffs that night.
NARRATOR: They learn that Flight 3142 didn't take off on time.
The controller also reveals that the LAPA crew's
radio calls were unusual.
AIR TRAFFIC CONTROLLER: Cleared for takeoff, LAPA 3142.
FO. ETCHEVERRY: Taking off.
NARRATOR: The first officer sometimes failed to repeat
instructions or to give the flight's call sign.
INVESTIGATOR 2: Well, if you can think of anything else,
please give me a call.
AIR TRAFFIC CONTROLLER: Sure.
NARRATOR: 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.
ROBERT: What the hell is that doing there?
ARGENTINEAN INVESTIGATOR: I have no idea.
NARRATOR: When it hurtled off the airfield,
the 737 hit an industrial gas plant.
Its proximity to the airport has set off alarm bells.
ROBERT: It was a major question when we looked at the wreckage.
We had a public building with a gas facility in it.
NARRATOR: If there's a gas plant this close to the airport,
they wonder what other risks the airfield might have presented.
ROBERT: The LAPA crash brought up the question of runway length.
ARGENTINEAN INVESTIGATOR: Twenty-one hundred meters.
NARRATOR: Was the runway long enough for a fully fueled
and loaded 737 to get off the ground safely?
ROBERT: 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.
ROBERT: They should have been able to get off the ground.
ROBERT: In the end, we found that the runway was of sufficient length.
NARRATOR: Investigators find nothing about the runway
that would have made the takeoff more difficult.
AUGUSTO [English Dub]: Even though it was an urban airport
with everything involved in that,
there were no infrastructure deficiencies.
NARRATOR: The team presses on in the search for clues.
ROBERT: Okay. Let's start with the most obvious:
thrust reversers.
ROBERT: 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.
ROBERT: This thing is really beaten up.
NARRATOR: 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.
ARGENTINEAN INVESTIGATOR: There's nothing else on that plane
that could have hit something this low.
NARRATOR: Damage to the light and to the thrust reverser
confirms that the reverser must have been
in the deployed position before impact.
ROBERT: 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.
NARRATOR: The thrust reverser remains a possible culprit.
The other primary suspects are the retracted flaps.
ROBERT: The flaps are very, very important, particularly
as they allow the slower speeds for takeoff
and the slower speeds for landing.
NARRATOR: Were the flaps on LAPA 3142 ever extended for takeoff?
To try to answer that critical question,
the team carefully examines the entire flap mechanism --
every wire, gear and screw.
ARGENTINEAN INVESTIGATOR: The actuators seem fine.
NARRATOR: 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.
ROBERT: 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.
NARRATOR: Studying the jackscrews, they make a crucial find.
ROBERT: We had discovered the nuts on the screw
were in the retracted position.
NARRATOR: It means the flaps were not extended
as the plane raced along the runway.
HORACIO [English Dub]: 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.
NARRATOR: The flap lever from the cockpit confirms the finding.
ARGENTINEAN INVESTIGATOR: The lever's pretty banged up,
but it sure looks like it's in the flaps up position.
HORACIO [English Dub]: 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.
NARRATOR: All signs are pointing to a baffling conclusion.
It seems the pilots never extended the flaps for takeoff.
FO. ETCHEVERRY: Taking off.
NARRATOR: In light of this evidence, investigators now face
an even more difficult question.
ROBERT: How could an attempted takeoff be made
with the flaps in this position?
NARRATOR: The 737 cockpit is equipped with systems
designed to prevent pilots from attempting to take off
without first extending the wing flaps.
FO. ETCHEVERRY: Approaching runway one-three, LAPA 3142.
NARRATOR: Investigators now wonder:
Did those systems somehow fail on Flight 3142?
They examine a cockpit indicator...
ARGENTINEAN INVESTIGATOR: Easy does it.
NARRATOR: ... that lights up once the flaps
are properly extended for takeoff.
Perhaps the lights malfunctioned.
If they came on while the flaps were still retracted,
that may have fatally misled the pilots.
AUGUSTO [English Dub]: In order to understand how this might have happened,
we had to do a lot of analysis.
NARRATOR: 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.
ARGENTINEAN INVESTIGATOR: They weren't seeing any flap lights.
HORACIO [English Dub]: The light bulb filaments were analyzed,
and we found that they had been off.
FO. ETCHEVERRY: Taking off.
NARRATOR: 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 takeoff approach 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 takeoff without flaps.
ARGENTINEAN INVESTIGATOR: The alarm would have gone off as soon as they started moving.
ROBERT: How could the takeoff warning system
not alert the crew to this condition?
We needed to figure out if that system
had indeed failed to provide a warning.
NARRATOR: In 1987, a Northwest Airlines crew
forgot to extend their flaps and crashed on takeoff
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?
ARGENTINEAN INVESTIGATOR: Everything's where it should be.
HORACIO [English Dub]: 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.
NARRATOR: The pilots did not deliberately deactivate the warning.
There must be another explanation
for the doomed takeoff.
Meanwhile, across Argentina, frustration
at the lack of answers about the crash continues to grow.
ROBERT: It was a major disaster for them,
and they really hadn't had something like that ever before.
HORACIO [English Dub]: 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.
NEWS ANCHOR: [speaking in Spanish]
ARGENTINEAN INVESTIGATOR: Can we get the FDR data on the screen?
NARRATOR: 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.
ARGENTINEAN INVESTIGATOR: Great. Let's go to
the flap positions and engine performance.
HORACIO [English Dub]: The flight data recorder
recorded 10 parameters from the 11 expected.
ARGENTINEAN INVESTIGATOR: Like we thought -- no flaps.
NARRATOR: The data confirms their earlier findings.
HORACIO [English Dub]: That was one of the most important parameters.
The flaps were at zero during the whole time on the runway.
ARGENTINEAN INVESTIGATOR: No issues with the engine performance.
ROBERT: When we looked at the engine pressure ratios, the EPRs,
it just further confirmed the idea
that there had been a normal attempted takeoff.
NARRATOR: The FDR doesn't indicate whether
the thrust reversers were deployed or not.
But the engine power data provides a strong indication.
ARGENTINEAN INVESTIGATOR: It looks like the reversers were deployed here.
NARRATOR: 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.
ROBERT: The EPR came up and then the EPR came down. Very clear.
And then it came back up again,
most assuredly by thrust reverse.
ARGENTINEAN INVESTIGATOR: Back to full data, please.
The reversers had nothing to do with this accident.
Let's take a look at speed.
NARRATOR: The data also shows that the plane had enough speed
and runway available to lift off safely...
FO. ETCHEVERRY: Rotate.
NARRATOR: ... if the flaps had been extended.
ARGENTINEAN INVESTIGATOR: So here's what the data tells us.
At V-1 they're here, 840 meters of runway still ahead of them.
MALCOLM: 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.
ARGENTINEAN INVESTIGATOR: No flaps. They stall.
They get the plane back down here,
50 meters from the end of the runway.
There's no way they could stop in time.
NARRATOR: Investigators are left with a puzzling question.
ARGENTINEAN INVESTIGATOR: They had until right here
to abort their takeoff safely. Why didn't they?
AIR TRAFFIC CONTROLLER: What the hell?
NARRATOR: Why an experienced cockpit crew attempted to take off
without first extending their wing flaps
is the troubling question
at the heart of the LAPA 3142 investigation.
FO. ETCHEVERRY: No, no, no, no, no, no, no!
AUGUSTO [English Dub]: 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?
NARRATOR: Investigators turn to the
cockpit voice recorder for answers.
HORACIO [English Dub]: The only possibility was in the voice recorder.
FLIGHT ATTENDANT: Everything okay?
CAPT. WEIGEL: Fine. Everything's fine.
NARRATOR: They begin by listening to
what was happening just before takeoff.
FO. ETCHEVERRY: Just waiting on our fuel.
CAPT. WEIGEL: So besides him, any other guys you're interested in?
FLIGHT ATTENDANT: Yes, but you don't know him. I haven't seen him in a while.
NARRATOR: What they hear from the crew is astounding.
FLIGHT ATTENDANT: The whole thing's getting complicated.
CAPT. WEIGEL: You're breaking my heart.
NARRATOR: Not only unexpected, but entirely unprofessional.
ARGENTINEAN INVESTIGATOR: They should be running checklists. What's going on?
MALCOLM: 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.
FLIGHT ATTENDANT: You guys should come for dinner in Córdoba.
FO. ETCHEVERRY: That sounds good. What should we bring?
FLIGHT ATTENDANT: You can bring the ice cream.
FO. ETCHEVERRY: Okay. Before start checklist.
CAPT. WEIGEL: Before start checklist.
MALCOLM: They're talking about planning a meal together.
They're talking about their romantic lives.
And this is interspersed with the checklist.
FO. ETCHEVERRY: 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.
CAPT. WEIGEL: You're full of it. You're only with me for the good times.
FO. ETCHEVERRY: Cockpit preparations?
CAPT. WEIGEL: Completed.
MALCOLM: The checklists were interrupted
and were performed incorrectly.
ARGENTINEAN INVESTIGATOR: Dinner. Boyfriends. Cockpit preparations?
MALCOLM: They're not following the normal procedures.
Either one of them could have insisted on it.
ARGENTINEAN INVESTIGATOR: Flaps are part of the Before Takeoff Checklist.
Do they even do that?
FO. ETCHEVERRY: Parking brake? CAPT. WEIGEL: Set.
FO. ETCHEVERRY: Paper?
CAPT. WEIGEL: We don't have paper.
ARGENTINEAN INVESTIGATOR: I can't even tell
what checklists they're looking at.
FO. ETCHEVERRY: Anti-ice? CAPT. WEIGEL: Off.
FO. ETCHEVERRY: Start levers? CAPT. WEIGEL: Idle stop.
FO. ETCHEVERRY: Ready to taxi, 3142.
AIR TRAFFIC CONTROLLER: 3142, ready to taxi
Charlie-five to runway one-three.
FO. ETCHEVERRY: Charlie-five to one-three.
ARGENTINEAN INVESTIGATOR: No mention of flaps. They're starting to taxi.
FO. ETCHEVERRY: Approaching runway one-three, LAPA 3142.
FLIGHT ATTENDANT: Don't smoke all of it. Give me a puff at least.
NARRATOR: Investigators now hear something that cements
their view of an irresponsible crew.
CAPT. WEIGEL: Even a puff can make you old and gray.
FLIGHT ATTENDANT: Thanks.
ARGENTINEAN INVESTIGATOR: They're actually smoking in the cockpit.
MALCOLM: 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.
FO. ETCHEVERRY: We're seconds away.
You should probably head back there and strap in.
FLIGHT ATTENDANT: All right, guys.
NARRATOR: The reason the crew failed to extend the flaps is now clear.
FO. ETCHEVERRY: Hurry, hurry.
NARRATOR: They were simply too distracted by their own careless behavior.
AIR TRAFFIC CONTROLLER: Cleared for takeoff, LAPA 3142.
NARRATOR: Investigators now wonder if the pilots heard
an alarm warning them of their fatal error
as they accelerated down the runway.
FO. ETCHEVERRY: Taking off.
ROBERT: One primary question was:
Do you hear any takeoff warning on the recording?
[Alarm sounding]
ARGENTINEAN INVESTIGATOR: There it is!
HORACIO [English Dub]: The sound of the alarm was loud.
It could be heard perfectly in the voice recorder many times.
AUGUSTO [English Dub]: It was a system alarm that warned that
in this situation the aircraft could not fly.
It was not capable of a safe takeoff.
CAPT. WEIGEL: What's that? What the hell is that?
FO. ETCHEVERRY: Is it on the left?
NARRATOR: Incredibly, the pilots seem undisturbed by the warning.
CAPT. WEIGEL: I don't know what the alarm is, my friend.
Everything seems fine.
ARGENTINEAN INVESTIGATOR: Okay, pause. How can they ignore that?
MALCOLM: 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 takeoff.
ARGENTINEAN INVESTIGATOR: Play.
FO. ETCHEVERRY: Eighty knots. CAPT. WEIGEL: Check.
ARGENTINEAN INVESTIGATOR: Takeoff speed.
They've been listening to that alarm for 36 seconds.
FO. ETCHEVERRY: V-1.
MALCOLM: The configuration warning was so loud
that you can hardly hear them talking underneath it.
FO. ETCHEVERRY: Rotate.
MALCOLM: It was designed specifically
to warn the pilots not to take off.
NARRATOR: The investigative team is now at a loss.
How could a crew forget to perform one of
the most basic takeoff procedures
and then go on to ignore the loud, persistent warning
designed to alert them to their serious mistake?
HORACIO [English Dub]: I believe they didn't understand
the importance of this alarm,
which was absolutely critical for takeoff.
NARRATOR: Sixty-five 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?
MALCOLM: In seeing the crew's behavior, it raises questions
about the company and about the oversight of the company
as well as about the individual.
CAPT. WEIGEL: No. Stop. Stop, stop, stop, stop.
ARGENTINEAN INVESTIGATOR: What kind of pilot was this guy?
MALCOLM: One of the standard parts of our investigation
was to examine the training records for each of the pilots.
NARRATOR: 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.
ARGENTINEAN INVESTIGATOR: Not exactly a perfect record.
MALCOLM: 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.
ARGENTINEAN INVESTIGATOR: Imprecise cockpit coordination,
lack of procedural knowledge. Yikes.
NARRATOR: His history is riddled with reports of inadequacies.
MALCOLM: You have to wonder why he kept passing his training,
and why he was promoted.
NARRATOR: 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.
MALCOLM: 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.
ARGENTINEAN INVESTIGATOR: They couldn't keep up with their own success.
AUGUSTO [English Dub]: If an organization 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.
FLIGHT ATTENDANT: Everything okay?
CAPT. WEIGEL: Fine. Everything's fine.
NARRATOR: No one is more dismayed by LAPA's failings
than Marisa Beiró.
She lost eight close friends and suffered agonizing injuries.
MARISA [English Dub]: When they took me to the hospital,
60 percent 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.
NARRATOR: When she finally learns the cause of all her pain,
Marisa is horrified.
MARISA [English Dub]: If the alarm went off and it warned that
the flaps weren't configured, why didn't they do something?
NARRATOR: For their lack of proper oversight,
six former LAPA managers
face charges of criminal negligence causing death.
Marisa advocates on behalf of the victims.
MARISA: [Speaking Spanish]
NARRATOR: In the end, no one goes to prison.
MARISA [English Dub]: My friends couldn't defend themselves in that moment.
I put myself in their place in trying to defend such injustice.
FO. ETCHEVERRY: No, no, no, no, no, no.
CAPT. WEIGEL: No. Stop. Stop, stop, stop, stop, stop.
MARISA [English Dub]: With anger, with rage,
wishing I could get an explanation: Why?
FO. ETCHEVERRY: No! No! No!
[passengers screaming]
[explosion]
♪
NARRATOR: 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 recognize and respond to cockpit alarms.
In the past two decades, Argentina has made great strides
in improving aviation safety.
ROBERT: In the big picture of things, the LAPA crash
was the initiator of the aeronautical progress
that has been made in Argentina.
HORACIO [English Dub]: 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.