“Pray. You still have to make it to the hospital.” Those were the first few words Marisa Beiró heard from a paramedic. Her boots were melted into her own skin and 65% of her body surface was severely burnt. Behind her, the wreck of the fuselage was still in flames.
On the 31st August 1999 at 8.54pm a Boeing 737 LAPA flight, with final destination Córdoba, failed to take off from Jorge Newbery Airport in Buenos Aires. The plane overshot the runway, crashed into the fence, then crossed Av. Rafael Obligado, hitting a car that was on the road, before ending on a golf course where it exploded and burst into flames.
Sixty-seven people died that night, among them some of the 100 passengers and crew on the plane, and the couple in the car the plane hit. A further 34 were injured, half of them seriously.
Why did this happen?
Once in the air, planes stabilise: at cruising altitude, a plane could lose an engine without passengers even noticing. But taking off and landing are more complex manoeuvres.
Minutes before the attempted take off, an alarm went off, the sound supposed to inform the pilot that the flaps were retracted. The flaps are the hinged surfaces on the back of the wings, and as they are extended the plane slows down. But as the flaps were retracted, the plane was unable to take off, even though the minimum flight speed had been reached.
Captain Gustavo Weigel and co-pilot Luis Etcheverry (both of whom died in the accident) ignored the alarm and prepared for takeoff.
The problem was the plane had reached the point of no return (the maximum speed in which a pilot can stop the aircraft without it over-running the runway) when Weigel decided to abort the flight, making the accident irreversible.
Cherchez la femme, crime investigators say. In aircraft disasters it all comes down to the cockpit voice recorder (CVR), a device designed to record every conversation in the flightdeck.
The tape recovered from the black box revealed that the crew members held conversations that were completely foreign to the procedures, and although this may sound as something that would have little or nothing to do with an accident of such dimension, it would later be pointed as one of the main causes for the crash. But not the most important one.
Why two experienced pilots would ignore an alarm just like that, had yet to be determined.
The investigation was led by the JIAAC (Civil Aviation Accidents Board of Investigations). Members of JIAAC were joined by a team of investigators from the US National Transportation Safety Board, who worked alongside the JIAAC to determine what had gone wrong.
The report issued by the commission was damming: “The flight crew of LAPA flight 3412 forgot to extend the wing flaps to initiate take-off, and ignored the alarm that advised them of the error.”
Then came a long list with contributing factors which included: Lack of discipline of the crew who carried on inappropriate conversations during take off, who would even engage them on an emotional or sentimental state; the design of the alarm system did not ensure the crew responded to the information, allowing them to take off regardless; insufficient psychological testing to determine if pilots were in a fit mental state to fly; previous negative characteristics of the first officer that manifested themselves during the reading of the list of control procedures, all occurring in a cockpit whose occupants had their attention on personal issues unrelated to the flight.
The conclusions drawn by the commission opened a Pandora’s box, leading to questions regarding the entire national aviation system, putting those anxious to file the crash in the drawer labelled ‘pilot error’ in a very awkward position.
If the two pilots had no skills and got bad results in the simulator, why were they hired to fly a commercial flight? If their behaviour in the cockpit or even the psychological state test showed they weren’t able to shoulder their responsibility flying a plane, who was monitoring? Ultimately, who was supposed to check that a private company like LAPA would do everything within their power to match the national safety standards?
The answer was none other than the Argentine air force, which controls commercial flights in Argentina, and the LAPA executives.
Justice works slowly in Argentina, so on 20th February 2008 – eight-and-a-half years after the accident – the trial started on the Tribunal Oral Federal No 4. That day, 65 empty chairs were lined up in front of the building, representing those who died on board, while a group of victims’ families demanded the truth come out.
Currently, six former members of LAPA and two members of the Argentine air force are taking turns to take the stand.
LAPA president Gustavo Andrés Deutsch, vice-president Ronaldo Patricio Boyd, operation managers Fabián Chionetti and Valerio Diehl, human resources manager Nora Arzeno, and Gabriel Borsani, the head of line B-737, all face charges of ‘catastrophic criminal negligence leading to death’.
As for the air force members, former director of Empowerment and Promotion, Commodore Carlos Petersen, and former director of the National Institute of Aeronautical and Space Medicine, Commodore Diego Lentino are being prosecuted for neglecting duty in public office.
The trial is expected to last until December, and a list of over 1,200 witnesses will have been called to give their statement.
In Spanish it’s lento pero seguro, in German langsam aber sicher, in English it’s slowly but surely. Almost every language has an expression to transmit that intangible something. That awaited thing that no matter how long it could take, it will definitely arrive. And one would wait. For a long time were bureaucracy was taking over, evidence was lost, judges and investigators were threatened, the idea of justice seemed like a blurred utopia. Now as the trial continues, there seems to be something to hold on to: hope.