Estado: | Accident investigation report completed and information captured |
Fecha: | martes 31 agosto 1999 |
Hora: | 20:54 |
Tipo: | Boeing 737-204C |
Operador: | LAPA - Líneas Aéreas Privadas Argentinas |
Registración: | LV-WRZ |
Numéro de série: | 20389/251 |
Año de Construcción: | 1970-04-14 (29 years 5 months) |
Horas Totales de la Célula: | 67864 |
Ciclos: | 41851 |
Motores: | 2 Pratt & Whitney JT8D-9A |
Tripulación: | Fatalidades: 3 / Ocupantes: 5 |
Pasajeros: | Fatalidades: 60 / Ocupantes: 95 |
Total: | Fatalidades: 63 / Ocupantes: 100 |
Víctimas en Tierra: | Fatalidades: 2 |
Daños en la Aeronave: | Destruido |
Consecuencias: | Written off (damaged beyond repair) |
Ubicación: | Buenos Aires-Jorge Newbery Airport, BA (AEP) ( Argentina)
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Elevación del lugar del accidente: | 5 m (16 feet) amsl |
Fase: | Despegue (TOF) |
Naturaleza: | Vuelo Doméstico Programado |
Aeropuerto de Salida: | Buenos Aires-Jorge Newbery Airport, BA (AEP/SABE), Argentina |
Aeropuerto de Llegada: | Córdoba-Ingeniero Ambrosio L.V. Taravella International Airport, CD (COR/SACO), Argentina |
Número de Vuelo: | 3142 |
Descripción:LAPA flight 3142 was scheduled to depart from Buenos Aires-Jorge Newbery Airport at 20:36 for a 1 hour and 15 minute flight to Córdoba, Argentina.
The first officer and cabin crew were the first to arrive at the Boeing 737-200. The first officer notified one of the mechanics that the total fuel requirement was 8,500 kg, all to be stored in the wing tanks. The mechanic noticed there was still some fuel in the central tank and commenced transferring the fuel from the central to the wing tanks. At that moment the captain boarded the flight.
He threw his paperwork on the ground, showing annoyance, confirming that attitude by later shutting off the fuel transfer between the main tank and the wing tanks.
During their first four minutes on board, the captain, the co-pilot and the purser talked about trivial matters in good spirits, focusing on the purser's personal issues. When the purser left the cockpit, the conversation changed tone as they discussed a controversial situation about the family problems of the captain. The captain said that he was "going through bad times", to which the copilot replied that he was also having a bad day.
Without interrupting the conversation, the crew began working the checklists, mixed with the personal issues that worried them and that led them to misread the checklist. In the process they omitted to select the flaps to the appropriate takeoff position.
This confusing situation, in which the checklist procedure was mixed with conversation irrelevant to the crew's task, persisted during push back, engine start and taxiing, up to the moment of take-off, which was delayed by other aircraft waiting ahead of the LAPA flight and heavy arriving traffic.
During this final wait, the crew members were smoking in the cockpit and continued their conversation.
Take-off was started on runway 13 at 20:53 hours. During the takeoff roll the Take-off warning system sounded because the flaps had not been selected. The crew ignored the warning and continued the takeoff. After passing Vr, the pilot attempted to rotate the aircraft. The stick shaker activated as the aircraft entered a stall. It successively impacted the ILS antenna, the perimeter fence, a waiting shelter for buses, two automobiles, two excavators and an embankment where it stopped. Immediately a fire erupted.
Three flight crew members, 60 passengers and two persons inside an automobile were killed.
Probable Cause:
CAUSAS:
La JIAAC considera como causa inmediata del accidente que la tripulación de vuelo del LAPA 3142 olvidó extender los flaps para iniciar el despegue y desestimó la alarma sonora que avisaba sobre la falta de configuración para esa maniobra.
Fueron factores contribuyentes:
- Falta de disciplina de los tripulantes que no ejecutaron la lógica reacción de abortar el despegue y comprobación de la falla ante la alarma sonora que comenzó a escucharse al dar motor y continuó sonando hasta el intento de rotación.
- Exceso de conversaciones ajenas al vuelo y por momentos de intensidad emocional importante entre los pilotos, que se mezclaron con el desarrollo de las listas de control de procedimientos, llegándose a omitir la parte de estas últimas donde se debía cumplimentar la extensión de flaps para despegue. Problemas personales y/o familiares y/o económicos y/o de otra índole de ambos pilotos, que incidieron en su comportamiento operacional.
- Insuficiencia del sistema de control psíquico, que no permitió detectar cuando los pilotos estaban sufriendo problemas personales y/o familiares y/o de otro tipo que influían sobre s capacidad operativa al disminuir su estabilidad psíquica.
- Conocimiento y trato de cuestiones muy personales y extralaborales entre los pilotos e incluso con la comisario de abordo, que facilitó el ambiente de escasa seriedad y concentración en las tareas operacionales.
- Antecedentes de características de vuelo negativas del comandante que afloraron ante su situación personal y de relación en la cabina antes y durante la emergencia.
- Antecedentes de características de vuelo del copiloto, que se manifestaron durante el cumplimiento de las listas de control de procedimiento en una cabina donde sus componentes participaban de una atención totalmente dispersa en intereses particulares ajenos al vuelo.
- No reconocimiento ni comprobación inmediata de ambos pilotos, de la relación entre el tipo de alarma sonora intermitente que indica falla en la configuración para despegue, con la ausencia de colocación de flaps en la posición para la maniobra.
- Diseño del sistema de alarma de configuración para el despegue que no permite, en este tipo de aeronave, una comprobación simple, por parte de las tripulaciones, que asegure la escucha periódica de este tipo de alarma intermitente.
Accident investigation:
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Investigating agency: | JIAAC Argentina |
Status: | Investigation completed |
Duration: | 260 days (9 months) | Accident number: | 25/00 | Download report: | Final report
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Fuentes:
» JIAAC Informe final LAPA 3142
Fotos
accident date:
31-08-1999type: Boeing 737-204C
registration: LV-WRZ
accident date:
31-08-1999type: Boeing 737-204C
registration: LV-WRZ
accident date:
31-08-1999type: Boeing 737-204C
registration: LV-WRZ
accident date:
31-08-1999type: Boeing 737-204C
registration: LV-WRZ
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Buenos Aires-Jorge Newbery Airport, BA to Córdoba-Ingeniero Ambrosio L.V. Taravella International Airport, CD as the crow flies is 647 km (405 miles).
Accident location: Exact; deduced from official accident report.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.