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00:00The plane begins to take off, but instantly it starts shaking.
00:07A business trip to Argentina's capital becomes a nightmare for Marisa Beyron.
00:13I was bracing myself. Something bad was happening.
00:18The hell?
00:20Lapa Flight 3142 is in serious trouble.
00:24The airplane crossed a busy highway, killed people who were in their cars.
00:30Marisa fights for her life. Then she fights for justice.
00:36And then I started researching, asking why it had happened.
00:41The stunning answer leaves a nation in shock.
00:46To me, that was unprecedented. It's difficult to imagine that someone would do that.
00:54I don't know!
00:56I don't know!
01:04The Mesh
01:15It's 8.30 p.m. at Jorge Newbury Airfield in Buenos Aires, Argentina.
01:26Wind 020 at 5, altimeter 30, decimal 10.
01:31A Boeing 737, the workhorse of the aviation industry, prepares to taxi.
01:37It is operated by the Argentinian airline LAPA.
01:42We made it.
01:44Marisa Beirot is a cosmetics rep from Córdoba.
01:50I was traveling with eight of my co-workers.
01:54One of them was my best friend and sister-in-law.
02:00She's heading home after a lengthy business trip to the capital with a group of colleagues.
02:08It had been 10 days since we left, and it was time to go home.
02:13In fact, we had all arranged with our families to pick us up at the airport.
02:17And we wanted to go back to our kids.
02:23Hey, Captain.
02:26The captain of LAPA Flight 3142 is Gustavo Weigel.
02:32He's an experienced pilot who's been flying for more than 20 years.
02:37Everything okay?
02:39Fine.
02:39Everything's fine.
02:41We're just waiting on our fuel.
02:44First officer, Luis Echeveri, has logged more than 500 hours in the 737.
02:50Total fuel required, 8,500 kilograms to be transferred to the wings.
02:55Tonight's flight is a short one.
02:58400 miles west from Buenos Aires to the city of Córdoba.
03:04Time in the air should be a little over an hour.
03:06Along with the two pilots, there are three flight attendants and 95 passengers on board.
03:19I noticed something.
03:21There was no safety card in our seat.
03:23And that stood out to me because I always check the safety card when I board a plane.
03:28Always.
03:28In 1999, the airline business in Argentina is booming.
03:39Industry deregulation five years earlier has led to rapid growth for budget airlines like LAPA.
03:46135, turn right, heading 060, descend and maintain 5,000, slow to 220 knots and hold.
03:53Come on.
03:54Come on.
03:54It's best to understand LAPA as a low-cost carrier,
04:00making considerable inroads into a transportation system
04:05in a very large country that needed airline transportation.
04:10Astral 236, you're next in line for takeoff.
04:12Please proceed to runway and hold.
04:15In Argentina, the commercial airline industry is run by the military.
04:19The Air Force defense program was responsible for both civilian and military aviation.
04:27Before start checklist.
04:28Before start checklist.
04:29First officer Echeverry oversees some last-minute procedures.
04:33Cockpit preparations completed.
04:36The flight attendants prepare the cabin for takeoff.
04:38We bought some gossip magazines for the flight.
04:45Some of the girls were flying for the first time,
04:48so I gave them chewing gum for the air pressure on the plane.
04:51We were just flipping through magazines, very relaxed.
04:54Ready to taxi, 3-1-4-2.
05:033-1-4-2, ready to taxi Charlie 5 to runway 1-3.
05:07Charlie 5 to 1-3.
05:09Jorge Newbery is a single runway airport.
05:16And tonight, departures are running a little behind schedule.
05:22You have an experienced crew in the cabin.
05:24Please let them know if there's anything they can do
05:26to make your flight more comfortable.
05:27On behalf of first officer Echeverry and myself,
05:31we hope you have an enjoyable flight.
05:34You guys should come for dinner in Cordoba.
05:37That sounds good.
05:38What should we bring?
05:39You can bring me ice cream.
05:43The relationship between the crew seemed to be very close.
05:47It appeared that they had known each other for a while
05:50and that beyond being co-workers, they were friends.
05:56I was sitting near the door,
05:58and I noticed the door was half open.
06:03The cockpit door is usually completely closed.
06:06Well, not this time.
06:07You know, we're seconds away.
06:10You should probably get back there and strap in.
06:13All right, guys.
06:14It's been a pleasure.
06:15See you soon.
06:17Hurry, hurry.
06:17Cleared for takeoff, lap of three, one, four, two.
06:27Taking off.
06:27The airplane is on the runway, accelerating, getting faster.
06:37You know, when you can feel how the airplane is getting the amount of velocity necessary for takeoff.
06:43As the aircraft lifts off, it is immediately apparent that something is wrong.
06:59The plane begins to take off, but instantly it starts shaking like it was going to fall apart.
07:04Something bad was happening.
07:18I was bracing because my gut told me to.
07:20We all knew something was going wrong.
07:22But we already knew that something was wrong.
07:27What the hell?
07:31Hurtling forward at 160 knots,
07:34the 737 slams violently back to the ground.
07:38There was a clear zone at the end of that runway,
07:45and yet the aircraft continued to proceed at a relatively high speed.
07:52They're now headed straight for a busy highway and an industrial gas plant.
07:59Stop, stop, stop, stop.
08:00It was very quick.
08:05I just looked at my friends, and I braced my head.
08:10No, no, no, no, no, no, no.
08:11The airplane crossed a busy highway without warning,
08:15killed people who were commuting at that time in their cars.
08:18No, no, no!
08:22No!
08:23No!
08:30Everything went dark.
08:35Literally all dark.
08:38It was like the people around me were no longer there.
08:44I was squeezed between the front seat and the seat behind me
08:49that got pushed forward.
08:54I could feel extreme heat all around me.
08:56I was suffocating.
08:57And I needed to get out, but I couldn't release my seatbelt.
09:08Emergency.
09:09Lapa Flight 3142 just crashed through the airfield perimeter.
09:13Rescuers race to the site of the crash.
09:16But survivors on board don't have much time.
09:20Fire threatens to consume the entire plane.
09:27I felt like I was dying.
09:30And something happened that I still can't explain.
09:33Maybe an angel or God.
09:35I don't know, but it gently released my seatbelt.
09:38And someone said to me,
09:39Get out.
09:47As Marisa struggles to escape,
09:50she sees that none of her friends have survived.
09:52They were all already dead.
09:58It was instant.
10:06Though badly injured, Marisa is one of the lucky ones.
10:09Many of the evacuation doors could not be used due to the fire.
10:20That meant that many passengers couldn't get out.
10:25The plane was fully engulfed.
10:27People were screaming for help.
10:29I went in and got four of them with some help.
10:31But I saw the bodies burning.
10:32It was terrible.
10:33The crash has killed 60 passengers,
10:41three crew members,
10:42and two motorists.
10:44It's a disaster unlike anything Buenos Aires has seen before.
10:50It was a major calamity.
10:52It involved automobiles.
10:54It involved a gas, natural gas regulating plant.
10:57There had been a major sustaining fire.
11:00So, it was a major disaster scene.
11:12News of the Lapa crash spreads quickly
11:14through the Argentinian capital.
11:18Because they live and work in Buenos Aires,
11:22members of the nation's accident investigation unit
11:24are on the scene in minutes,
11:27getting a rare glimpse of the immediate aftermath.
11:30It's a lot of smoke.
11:32Hard to see anything.
11:34Horacio Narroza is a senior investigator.
11:41You try to focus on the job
11:43and look for details that later on
11:45could be harder to find
11:47once the rescue teams have finished their work.
11:50So, you have to be paying attention to details
11:52and make sure nothing slips.
11:54This was my first experience with a big accident.
12:04Even though we were trained
12:05and we were prepared for this type of situation,
12:08it's something else to see a catastrophe
12:10with so much movement of ambulances,
12:12wounded people, police, and all the rest.
12:15It was very complicated.
12:17Neither pilot survived.
12:25Okay.
12:27Both Captain Weigel
12:28and First Officer Echeverry are dead.
12:32Any hope of finding out what went wrong
12:35lies in the wreckage.
12:36The first thing is doing a visual inspection of the site,
12:42looking at all of the components,
12:44trying to put oneself in the situation,
12:46which is very difficult
12:48when there is so much damage and fire.
12:54They lift off here,
12:56barely get off the ground.
12:58They leave the runway here
12:59and finally come to rest here.
13:09Because the destroyed aircraft was American-made,
13:13the U.S. National Transportation Safety Board
13:16sends a team to assist the Argentines.
13:20Whatever you need, we're here to help.
13:22I was the accredited representative
13:24from the United States
13:26to the official investigation.
13:28Rodrigo?
13:29It's a case where
13:30there was just a tremendous amount
13:32of public concern
13:33and a great deal of encouragement
13:36to try to solve this
13:37definitively and quickly.
13:40In any take-off accident,
13:42you're looking at a variety of factors.
13:45Some of them relate to engine power,
13:48where the engine's producing
13:49a proper amount of power.
13:52When you look at the engines
13:58after an accident,
13:58there are very clear signs
14:01that show if the engine
14:02was functioning or not.
14:05Look there and there.
14:08Looks like these blades are spinning.
14:10The type of damage
14:11sustained by the rotor blades
14:13tells investigators
14:14that the engines were working normally
14:16when they hit the ground.
14:18There was no engine failure.
14:20But something else related to the engines
14:26raises an immediate red flag.
14:29One of the plane's thrust reversers
14:32is deployed.
14:32I recall vividly the doors
14:36on that thrust reverser
14:38appeared to be open.
14:41Thrust reversers are only supposed
14:42to deploy on landing.
14:44They help slow the plane down
14:46by redirecting engine exhaust.
14:49There are doors that drop down
14:51into the exhaust plume,
14:54kind of like a reverse gear in a way
14:57that's pushing against
14:58the forward motion.
15:00If a reverser were to deploy
15:02on takeoff,
15:04it could cause
15:05a catastrophic thrust imbalance.
15:07So we were very concerned
15:09about how those thrust reversers
15:12had ended up in that position.
15:16Look here.
15:18The flaps aren't extended.
15:21Investigators study the wings
15:23of the downed plane
15:24and soon make another discovery.
15:30I was able to observe
15:32with some of my colleagues
15:33that the aircraft's flaps
15:35were apparently not extended.
15:39Let's get this wing piece out of here.
15:41For takeoff,
15:43737 pilots must always extend
15:45the plane's wing flaps.
15:48The flaps increase the area of the wing
15:50and give it extra lift.
15:53Without them,
15:53a fully loaded 737
15:55cannot get off the ground.
15:59Investigators need to determine
16:00how the flaps ended up
16:02in this position.
16:04Did they retract during the crash?
16:06Or were they not deployed
16:08in the first place?
16:11When you see something
16:12that's out of place,
16:14such as the flap position,
16:16you begin to wonder,
16:18what has happened?
16:19Has someone raised the flaps?
16:21Or has some electronic
16:23or hydraulic intervention
16:24made the flaps come up?
16:27We need to study
16:28the entire system.
16:33So we had to collect
16:34all the evidence,
16:36observe everything we could,
16:38and try to prove
16:39what happened.
16:39With both the reverser doors
16:45and the flaps
16:45needing more intensive study,
16:48the team focuses on searching
16:50for the plane's black boxes.
16:52The importance of flight recorders
16:55and accident investigation
16:57cannot be overemphasized.
16:59They are often
17:00the most central pieces
17:02of evidence
17:02in an investigation.
17:05It's not long
17:06before they track them down.
17:09But there's a problem.
17:11Like the thrust reversers,
17:13both recorders
17:14are badly damaged,
17:15and there's no facility
17:17in Argentina
17:17equipped to analyze them.
17:19They need to go to Washington,
17:215,200 miles north.
17:24It will cost the investigation
17:26valuable time.
17:28There was a good deal
17:30of pressure
17:30to get back
17:31the cockpit voice recorder
17:32and the flight recorder
17:33information
17:34in a timely way.
17:36We had to reassure
17:37the public
17:38and reassure the media
17:39that the investigation
17:40was proceeding
17:41and was being done
17:42quickly.
17:44For now,
17:45they're left with
17:46one or two
17:47intriguing clues.
17:49And a nation
17:50that's demanding answers
17:51about why
17:52Lapa Flight 3142
17:54ended in tragedy.
18:04The wreckage
18:06of Lapa Flight 3142
18:08lies in a busy
18:09Buenos Aires neighborhood.
18:11I don't want to leave
18:12anything behind.
18:14It all goes.
18:16Any of the thousands
18:17of pieces of debris
18:18could be a valuable clue.
18:25We needed to move
18:26the remains to a hangar
18:28where we could spread out
18:29all the mechanisms
18:30and take detailed pictures
18:31and also collect data
18:33from the remaining instruments.
18:39At the same time,
18:40investigators wonder
18:41what the air traffic controller
18:43can tell them
18:44about the fatal
18:44takeoff attempt.
18:47Anything out of the ordinary
18:49that you can remember?
18:51There was a bit of a delay.
18:52We were pretty backed up.
18:55These are all
18:56the takeoffs that night.
18:59They learned that
19:00Flight 3142
19:02didn't take off on time.
19:05The controller also reveals
19:07that the Lapa crew's
19:08radio calls
19:09were unusual.
19:10Cleared for takeoff,
19:12Lapa 3142.
19:15Taking off.
19:16The first officer
19:17sometimes failed
19:18to repeat instructions
19:20or to give the flight's
19:21call sign.
19:24Well, if you can think
19:26of anything else,
19:26please give me a call.
19:28Sure.
19:29Unfortunately for investigators,
19:31the controller can't give them
19:33much new information
19:34to go on.
19:35Why the Lapa flight
19:38went so horribly wrong
19:39is still a mystery.
19:46What the hell
19:46is that doing there?
19:49I have no idea.
19:51When it hurtled
19:52off the airfield,
19:54the 737
19:54hit an industrial
19:56gas plant.
19:58Its proximity
19:59to the airport
19:59has set off
20:00alarm bells.
20:01There was a major question
20:04when we looked
20:05at the wreckage.
20:06We had a public building
20:07with a gas facility
20:09in it.
20:10If there's a gas plant
20:12this close to the airport,
20:13they wonder
20:14what other risks
20:15the airfield
20:16might have presented.
20:17The Lapa crash
20:18brought up the question
20:20of runway length.
20:212,100 meters.
20:23Was the runway
20:24long enough
20:25for a fully fueled
20:26and loaded 737
20:27to get off
20:28the ground safely?
20:29We had a performance
20:33engineer
20:33look at
20:34the acceleration,
20:36the distances,
20:36the performance
20:37of the aircraft.
20:39He went out
20:39and measured
20:40every one
20:41of those distances
20:42and tried
20:42to apply them.
20:44They should have
20:44been able
20:44to get off the ground.
20:46In the end,
20:47we found that
20:47the runway
20:48was of its
20:49sufficient length.
20:51Investigators
20:52find nothing
20:53about the runway
20:54that would have
20:54made the take-off
20:55more difficult.
20:57We know
20:58that it's
20:58an urban airport
20:59even though
21:00it was an
21:01urban airport
21:02with everything
21:02involved in that,
21:04there were no
21:04infrastructure deficiencies.
21:12The team
21:13presses on
21:14in the search
21:14for clues.
21:16Okay,
21:17let's start
21:18with the most obvious.
21:20Thrust reversers?
21:21Once the wreckage
21:23had been removed
21:24to the hangar,
21:26there was an opportunity
21:27to carefully look
21:28at some of the
21:30external damage
21:31on the metal surfaces,
21:33particularly of the
21:34thrust reversers.
21:36This thing
21:36is really beaten up.
21:39They find damage
21:41on the thrust reverser
21:42that doesn't seem
21:43to have come
21:44from impact
21:44with the ground.
21:47A broken light
21:49from the end
21:49of the runway
21:50provides a clue.
21:51There's nothing
21:55else on that plane
21:55that could have
21:56hit something
21:56this low.
21:58Damage to the light
21:59and to the thrust
22:00reverser confirms
22:01that the reverser
22:02must have been
22:03in the deployed
22:04position before impact.
22:06We knew then
22:08that one of the
22:09thrust reverser doors
22:10struck runway light
22:11at the end
22:12of the runway.
22:13That was a very
22:14elemental thing
22:15in confirming
22:15that a thrust reverser
22:17had been deployed.
22:18The thrust reverser
22:20remains a possible
22:22culprit.
22:24The other primary
22:25suspects are
22:26the retracted flaps.
22:28The flaps are
22:29very, very important,
22:31particularly as
22:32they allow
22:33the slower speeds
22:34for take-off
22:35and the slower
22:37speeds for landing.
22:39Were the flaps
22:40on Lapper 3142
22:41ever extended
22:42for take-off?
22:44To try to answer
22:45that critical question,
22:47the team
22:48carefully examines
22:49the entire
22:50flap mechanism,
22:51every wire,
22:52gear and screw.
22:55Activators
22:55seem fine.
22:57The part that
22:58controls the
22:59movement of the
22:59flaps is called
23:00a jack screw.
23:02The jack screw
23:03acts much like
23:04a jack used
23:05to lift a car.
23:07As it turns,
23:08it moves a nut
23:09that extends
23:10or retracts
23:11the flaps.
23:13That nut
23:14travels along
23:15the shaft.
23:17It stops at
23:18various places
23:19to indicate
23:20various degrees
23:21of flap extension,
23:24from a zero
23:25position up
23:25at one end
23:26to a fully
23:27extended position
23:28at the other.
23:31Studying the
23:32jack screws,
23:33they make
23:34a crucial find.
23:36We had discovered
23:37the nuts on the
23:38screw were in
23:39the retracted
23:40position.
23:41It means
23:42the flaps
23:43were not
23:43extended
23:44as the plane
23:45raced along
23:45the runway.
23:51It's not
23:52possible for
23:52the screw
23:53to move
23:53during the
23:54accident,
23:55because that
23:55thread and
23:56nut are very
23:57strong.
23:58It can't
23:58slip.
23:59Six out of
24:00eight screws
24:01were found,
24:01and they were
24:02all in the
24:03same position.
24:03The flap lever
24:08from the
24:09cockpit
24:09confirms the
24:10finding.
24:13The lever's
24:14pretty banged up,
24:14but it sure
24:15looks like
24:15it's in the
24:15flap's up
24:16position.
24:22It had
24:22left a mark
24:23with the flap
24:24lever in the
24:24up position,
24:25so there was
24:26no chance
24:27that it had
24:27moved during
24:28the accident.
24:32All signs
24:33are pointing
24:33to a baffling
24:34conclusion.
24:36It seems
24:37the pilots
24:37never extended
24:38the flaps
24:39for takeoff.
24:40Taking off.
24:42In light
24:42of this
24:43evidence,
24:44investigators
24:44now face
24:45an even
24:45more difficult
24:46question.
24:48How could
24:48an attempted
24:49takeoff be
24:49made with
24:50the flaps
24:51in this
24:51position?
24:58The 737
25:01cockpit is
25:02equipped with
25:03systems designed
25:04to prevent
25:05pilots from
25:05attempting to
25:06take off
25:06without first
25:07extending the
25:08wing flaps.
25:10Approaching
25:10runway 13,
25:11Lapa 3142.
25:14Investigators
25:15now wonder,
25:16did those
25:16systems somehow
25:17fail on
25:18flight 3142?
25:21They examine
25:22a cockpit
25:23indicator that
25:24lights up once
25:25the flaps are
25:26properly extended
25:27for takeoff.
25:28perhaps the
25:30lights malfunctioned.
25:33If they came
25:34on while the
25:34flaps were
25:35still retracted,
25:36that may have
25:37fatally misled
25:38the pilots.
25:43In order to
25:43understand how
25:44this might have
25:45happened, we
25:46had to do a
25:47lot of
25:47analysis.
25:52When a
25:52light is off,
25:54the filament
25:54is cold and
25:55brittle.
25:56In a crash,
25:57impact forces
25:58usually break
25:59cold filaments.
26:01But a hot
26:02filament from a
26:03burning light
26:03can stretch
26:04instead.
26:06The tiny bulb
26:08soon provides
26:09an important
26:09clue.
26:11The filament
26:12is broken.
26:13They weren't
26:14seeing any
26:15flap lights.
26:15the lightbulb
26:20filaments were
26:20analyzed, and
26:22we found that
26:22they had been
26:23off.
26:26Taking off.
26:27The flap
26:28indicator did
26:29not malfunction.
26:31The lights
26:32never came on
26:33because the flaps
26:34were never
26:34extended.
26:36But the
26:37pilots, for
26:38some reason,
26:39began their
26:39takeoff role
26:40anyway.
26:45Investigators
26:45know that the
26:46cockpit warning
26:47systems have
26:48built-in
26:48redundancy for
26:49added safety.
26:51Along with
26:52flap indicator
26:53lights, there's
26:54also an alarm
26:55that sounds if
26:56pilots begin
26:57takeoff without
26:58flaps.
27:00The alarm
27:01would have gone
27:01off as soon as
27:02they started
27:02moving.
27:03How could
27:05the takeoff
27:06warning system
27:07not alert
27:09the crew
27:10to this
27:11condition?
27:12We needed
27:12to figure out
27:13if that
27:14system had
27:15indeed failed
27:16to provide
27:17a warning.
27:20In 1987,
27:22a Northwest
27:23Airlines crew
27:24forgot to
27:24extend their
27:25flaps and
27:26crashed on
27:26takeoff from
27:27Detroit,
27:29killing 156
27:30people.
27:33Investigators
27:34discovered that
27:34the alarm
27:35designed to
27:36warn the
27:36crew did
27:37not sound
27:38because the
27:40pilots had
27:40pulled a fuse
27:41to disable
27:42it.
27:43They didn't
27:44want the
27:44alarm to
27:45sound as
27:45they taxied
27:46to the
27:46runway.
27:49Did the
27:50pilots of
27:51Flight 3142
27:52make the
27:53same mistake?
27:55Did they
27:55deliberately
27:56disconnect
27:56the
27:57configuration
27:57warning?
27:59Everything's
28:00where it
28:00should be.
28:03we were
28:05able to
28:06verify
28:06whether the
28:07fuse,
28:07which is
28:08behind the
28:08co-pilot,
28:09was removed
28:10or not.
28:11And it
28:12wasn't.
28:13It was
28:13fine.
28:15The pilots
28:16did not
28:17deliberately
28:18deactivate the
28:19warning.
28:20There must
28:20be another
28:21explanation for
28:22the doomed
28:22takeoff.
28:23meanwhile,
28:30across
28:30Argentina,
28:31frustration
28:32at the
28:32lack of
28:33answers
28:33about
28:34the
28:34crash
28:34continues
28:35to
28:35grow.
28:37It was
28:37a major
28:38disaster
28:38for them
28:39and they
28:39really
28:39hadn't
28:39had
28:40something
28:40like
28:40that
28:41ever
28:41before.
28:41When you
28:49get home
28:49and turn
28:50on the
28:50TV,
28:51the
28:51accident
28:52is all
28:52they're
28:53talking
28:53about.
28:54But you
28:55have to
28:55keep your
28:55professionalism
28:56and try
28:57not to
28:57be
28:58influenced
28:58by anything
28:59that is
28:59said
28:59in the
29:00media.
29:00The
29:00system
29:01came
29:01from the
29:02accident
29:03of the
29:03Lapa,
29:03in a
29:04certain
29:05collapse.
29:05Can we
29:11get the
29:11FDR data
29:11on the
29:12screen?
29:14Finally,
29:15the
29:15crucial
29:15black
29:16box
29:16data
29:17arrives
29:17from
29:18Washington.
29:19Investigators
29:20hope it
29:21can tell
29:21them
29:21precisely
29:22what
29:22was
29:22happening
29:23as
29:24Flight
29:243142
29:25attempted
29:26to
29:26lift
29:26off.
29:28Great.
29:29Let's
29:30go to
29:30the
29:30flat
29:30positions
29:31in
29:31engine
29:31performance.
29:32The
29:37flight
29:38data
29:38recorder
29:39recorded
29:3910
29:40parameters
29:40from
29:41the
29:4111
29:41expected.
29:43Like
29:43we
29:44thought,
29:44no
29:45flaps.
29:46The
29:47data
29:47confirms
29:48their
29:48earlier
29:49findings.
29:53That
29:54was one
29:54of the
29:55most
29:55important
29:55parameters.
29:57The
29:57flaps
29:57were at
29:58zero
29:58during
29:59the
29:59whole
29:59time
30:00on
30:00the
30:00runway.
30:00No
30:02issues
30:02with
30:02the
30:02engine
30:02performance.
30:04When
30:04we
30:04looked
30:04at
30:05the
30:05engine
30:05pressure
30:06ratios,
30:06the
30:06EPRS,
30:07it
30:08just
30:08further
30:08confirmed
30:09the
30:09idea
30:09that
30:10there
30:10had
30:10been
30:10a
30:11normal
30:11attempt
30:12to
30:12take
30:12off.
30:13The
30:13FDR
30:14doesn't
30:15indicate
30:15whether
30:15the
30:16thrust
30:16reversers
30:16were
30:17deployed
30:17or
30:17not.
30:19But
30:19the
30:19engine
30:19power
30:20data
30:20provides
30:21a
30:21strong
30:21indication.
30:22Looks
30:23like
30:23the
30:23reversers
30:24were
30:24deployed
30:24here.
30:26When
30:26the
30:26thrust
30:27reverser
30:27is
30:27deployed,
30:28pilots
30:28also
30:29increase
30:30to
30:31maximize
30:32stopping
30:32power
30:33and
30:33slow
30:33the
30:33plane.
30:35The
30:36data
30:36suggests
30:37that
30:37at
30:37the
30:37last
30:38moment,
30:39in
30:39an
30:39effort
30:39to
30:40avert
30:40disaster,
30:41the
30:41pilots
30:42deployed
30:42their
30:42thrust
30:43reversers
30:43and
30:44increased
30:44thrust.
30:47The
30:48EPR
30:48came up
30:49and then
30:50the EPR
30:50came down.
30:51Very
30:52clear.
30:53And then
30:53it came
30:53back up
30:54again,
30:55most
30:55assuredly
30:56by
30:56thrust
30:57reverse.
30:58Back
30:58to full
30:59data,
30:59please.
31:00The
31:06reversers
31:06had
31:06nothing
31:07to do
31:07with
31:07this
31:07accident.
31:09Let's
31:10take a
31:10look at
31:10speed.
31:12The
31:12data also
31:13shows that
31:14the plane
31:14had enough
31:15speed and
31:16runway
31:16available to
31:17lift off
31:17safely.
31:18Rotate.
31:19If the
31:20flaps had
31:20been
31:21extended.
31:26So,
31:27here's what
31:28the data
31:28tells us.
31:28At
31:30V1,
31:31they're
31:32here.
31:33840
31:34meters of
31:34runway
31:35still ahead
31:35of them.
31:36By the
31:37time you
31:37get to
31:37V1,
31:38it's no
31:39longer safe
31:39to try
31:40to stop
31:40on the
31:40runway
31:40because
31:41you do
31:42not have
31:42enough
31:43runway
31:43left to
31:44stop.
31:45With
31:45no
31:45flaps,
31:47they
31:47stall,
31:48they get
31:48the plane
31:49back down
31:49here.
31:5150 meters
31:52from the
31:52end of the
31:52runway,
31:53there's no
31:53way they
31:53could stop
31:54in time.
31:54investigators
31:57are left
31:57with a
31:58puzzling
31:58question.
31:59They had
31:59until right
32:00here to
32:01abort their
32:01takeoff
32:02safely.
32:04Why didn't
32:05they?
32:07The hell?
32:07why an
32:18experienced
32:18cockpit
32:19crew
32:19attempted
32:20to take
32:20off
32:20without
32:21first
32:21extending
32:22their
32:22wing
32:22flaps
32:23is the
32:24troubling
32:24question
32:25at the
32:25heart
32:26of the
32:26Lapper
32:263142
32:27investigation.
32:33You find
32:36yourself
32:37wondering
32:37what
32:38happened
32:38in this
32:38aircraft?
32:39What
32:40happened
32:40in this
32:40operation?
32:42Why did
32:43this
32:43action
32:44not take
32:44place
32:45when it
32:45is
32:46indispensable
32:46for
32:47flight?
32:50Investigators
32:50turned to
32:51the cockpit
32:51voice recorder
32:52for answers.
32:56The only
32:57possibility
32:58was in
32:59the voice
32:59recorder.
33:00Everything
33:01okay?
33:02Fine.
33:03Everything's
33:04fine.
33:04They begin
33:05by listening
33:05to what
33:06was
33:06happening
33:06just
33:07before
33:07takeoff.
33:08Just waiting
33:08on our
33:09fuel.
33:12So besides
33:12him,
33:13any other
33:13guys you're
33:14interested in?
33:15Yes,
33:15but you don't
33:16know him.
33:17I haven't
33:17seen him
33:17in a while.
33:19What they
33:19hear from
33:20the crew
33:20is astounding.
33:22The whole
33:22thing's getting
33:23complicated.
33:25You're breaking
33:25my heart.
33:27Not only
33:27unexpected,
33:28but entirely
33:29unprofessional.
33:31They should be
33:31running
33:32checklists.
33:32What's going
33:33on?
33:33They're
33:34required to
33:35have a
33:36sterile
33:36cockpit,
33:37it's called.
33:38Once you
33:38start the
33:38engines up
33:39to 10,000
33:40feet, you
33:41talk only
33:42about
33:42operational
33:43procedures.
33:44You don't
33:44talk about
33:45personal
33:46issues.
33:46You don't
33:47talk about
33:47non-related
33:49issues.
33:49This is to
33:50prevent
33:50distraction.
33:52You guys
33:52should come
33:52for dinner
33:52in Cordoba.
33:54That sounds
33:55good.
33:55What should
33:56we bring?
33:57You can
33:57bring me
33:57ice cream.
33:59Okay.
34:01Before
34:01start
34:01checklist.
34:03Before
34:03start
34:03checklist.
34:05They're
34:05talking about
34:06planning a
34:06meal together.
34:07They're
34:07talking about
34:08their romantic
34:09lives, and
34:10this is
34:10interspersed
34:11with the
34:11checklist.
34:12Hey, you
34:13know I'm
34:13with you in
34:13the good
34:13times and
34:14the bad
34:14moron.
34:16It's a good
34:16thing I'm
34:17nothing like
34:17you.
34:19You're
34:19full of it.
34:20You're only
34:21with me for
34:21the good
34:21times.
34:24Cockpit
34:24preparations.
34:26Completed.
34:26The
34:27checklists
34:27were
34:27interrupted
34:28and were
34:28performed
34:28incorrectly.
34:30Dinner,
34:31boyfriends,
34:32cockpit
34:33preparations?
34:34They're not
34:35following the
34:35normal procedures.
34:37Either one
34:37of them
34:37could have
34:38insisted on
34:38it.
34:39Flaps
34:40are part
34:40of the
34:40before
34:40takeoff
34:41checklist.
34:42Do
34:42they even
34:42do
34:42that?
34:44Parking
34:44brake.
34:45What's up?
34:46Paper.
34:48We don't
34:48have paper.
34:49I can't
34:50even tell
34:50what
34:50checklist
34:51they're
34:51looking at.
34:52Anti-ice.
34:53Off.
34:54Start
34:55levers.
34:56That'll
34:57stop.
34:58Ready to
34:59taxi.
34:593-1-4-2.
35:013-1-4-2.
35:02Ready to
35:03taxi.
35:03Charlie
35:035 to
35:04runway
35:041-3.
35:06Charlie
35:075 to
35:071-3.
35:09No
35:10mention
35:10of flaps.
35:12They're
35:12starting
35:12to
35:12taxi.
35:15Approaching
35:16runway
35:161-3.
35:17Lapa
35:183-1-4-2.
35:22Don't
35:22smoke
35:23all
35:23of it.
35:23Give
35:23me a
35:24puff
35:24at
35:24least.
35:24Investigators
35:26now hear
35:27something that
35:28cements their
35:28view of an
35:29irresponsible
35:30crew.
35:31You're
35:31going to
35:31puff can
35:32make you
35:32all look
35:32great.
35:37Thanks.
35:39They're
35:39actually
35:40smoking in
35:40the cockpit.
35:42They were
35:42sharing a
35:43cigarette,
35:43the same
35:44cigarette.
35:44Three of
35:45them were
35:45passing a
35:45cigarette,
35:46which is
35:46prohibited
35:47by the
35:47company.
35:47They're
35:47not supposed
35:48to be
35:48smoking in
35:48the
35:48cockpit
35:49at all.
35:50We're
35:50seconds away.
35:51You should
35:51probably head
35:51back there
35:51and strap
35:52in.
35:52Right,
35:53guys?
35:53The reason
35:54the crew
35:54failed to
35:55extend the
35:56flaps is
35:57now clear.
35:58Very
35:59very.
36:00They were
36:00simply too
36:01distracted by
36:02their own
36:02careless
36:03behavior.
36:05Clear for
36:06takeoff,
36:06lap of
36:063-1-4-2.
36:07Investigators
36:08now wonder if
36:09the pilots
36:09heard an
36:10alarm,
36:12warning them
36:12of their
36:12fatal error
36:13as they
36:14accelerated
36:14down the
36:15runway.
36:15Taking
36:16off.
36:16one primary
36:18question was
36:19do you
36:20hear any
36:22takeoff
36:23warning on
36:24the
36:24recording?
36:28There it
36:29is.
36:33The sound
36:34of the
36:35alarm was
36:35loud.
36:36It could
36:37be heard
36:37perfectly in
36:38the voice
36:38recorder
36:39many times.
36:40It was
36:45a system
36:45alarm that
36:46warned that
36:47in this
36:47situation the
36:48aircraft could
36:49not fly.
36:50It was not
36:51capable of a
36:52safe takeoff.
36:55What's that?
36:56What the hell
36:56is that?
36:58Is it in the
36:58left?
37:00Incredibly,
37:01the pilots seem
37:02undisturbed by
37:03the warning.
37:04I don't know
37:05what the alarm
37:05is, my friends.
37:07Everything seems
37:07fine.
37:09Okay, pause.
37:10How can
37:12they ignore
37:12that?
37:13The captain
37:13heard the
37:14configuration
37:15warning.
37:16He talks
37:16about it twice
37:17and says he
37:18doesn't know
37:18what it is,
37:19and yet he
37:20proceeds with
37:21the takeoff.
37:22Play.
37:2380 knots.
37:25Check.
37:26Takeoff
37:27speed.
37:28They've been
37:28listening to
37:28that alarm
37:29for 36
37:29seconds.
37:31V1.
37:32The
37:33configuration
37:33warning was
37:34so loud that
37:36you can hardly
37:37hear them
37:37talking underneath
37:38it.
37:39Rotate.
37:40It was designed
37:40specifically to
37:41warn the pilots
37:42not to take
37:43off.
37:45The investigative
37:46team is now
37:47at a loss.
37:49How could a crew
37:50forget to perform
37:51one of the most
37:52basic takeoff
37:53procedures,
37:54and then go on
37:55to ignore the
37:56loud, persistent
37:57warning designed
37:58to alert them to
37:59their serious
38:00mistake?
38:00takeoff?
38:01I believe they
38:05didn't understand
38:06the importance
38:06of this alarm,
38:08which was
38:08absolutely critical
38:10for takeoff.
38:1265 people
38:14lost their
38:15lives because
38:16the crew
38:16wasn't paying
38:17attention to
38:18what they were
38:18doing.
38:21The essential
38:22question now
38:23is how did
38:24this crew
38:25end up in
38:26command of a
38:26passenger plane?
38:27In seeing the
38:30crew's behavior,
38:31it raises
38:32questions about
38:33the company
38:33and about the
38:35oversight of the
38:35company, as well
38:36as about the
38:37individual.
38:38Stop it.
38:38Stop, stop, stop,
38:39stop.
38:46What kind of pilot
38:47was this guy?
38:49One of the
38:49standard parts of
38:50our investigation
38:51was to examine the
38:52training records for
38:53each of the pilots.
38:55A background
38:56check shows
38:57Captain Gustavo
38:58Weigel had been
38:59flying for more
39:00than 20 years.
39:02He'd never been
39:03in a serious
39:03accident before,
39:05but his work
39:06history suggests
39:07he'd been on
39:07thin ice for
39:08quite a while.
39:10Not exactly a
39:11perfect record.
39:13In the case of
39:14the captain,
39:15there were
39:15deficiencies noted
39:16over time and
39:18over different
39:18airplanes that he
39:20was slow to
39:20respond to
39:21emergency
39:23situations or
39:24critical
39:24situations.
39:26Imprecise
39:27cockpit
39:27coordination,
39:29lack of
39:29procedural
39:30knowledge,
39:32yikes.
39:34His history
39:35is riddled
39:36with reports
39:36of inadequacies.
39:38You have to
39:39wonder why he
39:40kept passing
39:40his training
39:41and why he
39:42was promoted.
39:44Beyond his
39:45promotions,
39:46investigators wonder
39:47why Lapper
39:48even chose to
39:49hire this
39:50captain in the
39:50first place.
39:51A close
39:53look at the
39:54company's
39:54corporate records
39:55offers a
39:56possible
39:56explanation.
39:58It seems
39:59the airline
40:00was expanding
40:00so quickly,
40:02it struggled
40:03to maintain
40:03high standards
40:04of pilot
40:05training and
40:06oversight.
40:08Often in
40:09times of
40:09major change,
40:11there can be
40:11cases where
40:12issues such
40:13as discipline
40:14in the
40:14cockpit are
40:15not enforced
40:16as tightly
40:17as they could
40:17be if the
40:18company was
40:18more focused.
40:19they couldn't
40:20keep up with
40:21their own
40:21success.
40:26If an
40:27organization is
40:28expanding and
40:29extending itself
40:30to have many
40:31more planes
40:32with more
40:33crews managing
40:34greater numbers
40:34of passengers,
40:35it is always
40:37a risk factor
40:37if it's not
40:38well managed.
40:41Everything okay?
40:43Fine.
40:43Everything's fine.
40:46No one is
40:46more dismayed
40:47by Lapper's
40:48failings than
40:49Marisa Beyreau.
40:52She lost
40:53eight friends
40:53and suffered
40:55agonizing injuries.
40:59When they took
41:00me to the
41:00hospital,
41:0260% of my
41:03body had been
41:03burned.
41:05I had a
41:05serious burn
41:06in my trachea
41:06because of the
41:07inhalation of
41:08smoke and
41:08heat.
41:13Today,
41:13you'd never
41:14know it
41:14looking at me,
41:16but if you
41:16look at my
41:16clinical record,
41:17heard, I
41:18was at
41:18death's
41:19door.
41:23For the
41:26first five
41:26months that I
41:27was in
41:28hospital, I
41:29was not
41:29allowed to
41:29talk, hear,
41:31or watch any
41:31news about
41:32the crash.
41:33Then I
41:34started
41:34researching,
41:36following the
41:36investigative
41:37reports,
41:38finding out
41:39more about
41:39the pilot's
41:40life.
41:41I started
41:41asking why
41:42it happened.
41:48When she
41:49finally learns
41:50the cause of
41:51all her pain,
41:52Marisa is
41:53horrified.
41:57If the
41:58alarm went
41:58off and it
41:59warned that
42:00the flaps
42:00weren't
42:01configured,
42:02why didn't
42:02they do
42:03something?
42:05For their
42:06lack of
42:06proper oversight,
42:08six former
42:08LAPA managers
42:09faced charges
42:10of criminal
42:11negligence
42:11causing death.
42:13Marisa advocates
42:15on behalf of
42:15the victims.
42:22In the
42:22end, no
42:24one goes
42:24to prison.
42:27My friends
42:27couldn't defend
42:28themselves in
42:29that moment.
42:30I put myself
42:31in their place
42:32in trying to
42:32defend such
42:34injustice.
42:34No, no, no,
42:35no, no, no,
42:35no, no, no.
42:36Stop, stop,
42:37stop, stop, stop,
42:38stop.
42:39With anger,
42:40with rage,
42:41wishing I could
42:42get an
42:42explanation.
42:44Why?
42:49In their final
42:58report,
42:58investigators
42:59stress the
43:00need for
43:00pilots to
43:01always comply
43:02with the
43:02sterile cockpit
43:03rule.
43:05The rule that
43:06restricts crew
43:07conversation
43:07and helps minimize distractions during key parts of the flight.
43:13They also call for better pilot training
43:15to ensure crews can recognize and respond to cockpit alarms.
43:21In the past two decades, Argentina has made great strides in improving aviation safety.
43:27In the big picture of things, the Lapa crash was the initiator
43:32of the aeronautical progress that has been made in Argentina.
43:37The final objective of any investigation is to improve the system.
43:46That's what accident investigations do.
43:49There is always a lesson to be learned and communicated
43:53in order to improve air safety.