Investigation Summary
The investigation into Flight 3142 revealed one of the most significant breakdowns of the 'sterile cockpit' rule in aviation history. The Cockpit Voice Recorder (CVR) captured the Captain and First Officer engaging in nearly continuous conversation about personal, family, and professional grievances from the moment they entered the cockpit until the crash. This distraction led them to misread and skip vital items on the Pre-Takeoff Checklist, specifically the setting of the flaps to the required 5 or 15 degrees. When the throttles were advanced for takeoff, the Take-off Warning System (TOWS) sounded an intermittent horn, indicating the aircraft was not configured correctly. The crew ignored this alarm for 35 seconds, continuing the roll until they reached rotation speed. Upon attempting to rotate, the aircraft immediately entered a stall, vibrating the control column (stick shaker) and failing to climb. The aircraft struck an ILS antenna, a perimeter fence, a bus shelter, two cars, and two excavators before impacting an embankment.
Final Conclusions
The JIAAC determined the immediate cause was the crew's failure to extend the flaps and their dismissal of the configuration alarm. Contributing factors included a lack of professional discipline, an excess of non-pertinent conversation of high emotional intensity, and personal problems affecting the pilots' operational stability. The investigation also criticized the airline's culture and the regulatory body's failure to detect the pilots' history of negative performance characteristics.
Video Analysis
LAPA Flight 3142: The 1999 Buenos Aires Boeing 737 Takeoff Accident — Analysis of the 1999 crash at Jorge Newbery Airport caused by the crew's failure to deploy flaps. The investigation focuses on the breakdown of cockpit discipline and the ignored configuration warning siren.
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Airframe & Maintenance
Crew Experience
Captain
Gustavo Weigel. Records showed repeated negative flying characteristics; a later lawsuit determined his license had expired.
First Officer
Luis Etcheverry. Records showed repeated negative flying characteristics.
Systems & Failure Modes
Take-off Warning System (TOWS)
An intermittent horn designed to alert the crew if the throttles are advanced while the flaps, trim, or brakes are not in the correct takeoff configuration.
Stick Shaker
A mechanical device that rapidly vibrates the control yoke to provide a tactile warning to the pilots that the aircraft is approaching an aerodynamic stall.
Flaps
High-lift devices on the wings that must be extended to a specific setting (usually 5 or 15 degrees on a 737-200) to allow the aircraft to lift off at a safe speed.
Interesting Facts
- 01The takeoff configuration warning sounded for 35 seconds and was ignored by the crew.
- 02The aircraft struck a Chrysler Neon car on the Rafael Obligado road, which contributed to the initial fire.
- 0363 people on board (3 crew and 60 passengers) and 2 people on the ground were killed in the accident.
- 04The Captain had a history of negative flight characteristics that had not been properly addressed by the airline.
- 05While the JIAAC found the crew met technical requirements at the time, a subsequent judicial investigation determined Captain Weigel's license had expired.
- 06The aircraft was a Boeing 737-200 manufactured in 1970 with over 67,000 airframe hours.
Safety Actions & Advisories
Cockpit Discipline Reform
The investigation led to a renewed emphasis on the 'Sterile Cockpit Rule' in Argentine aviation, strictly prohibiting non-essential conversation during critical phases of flight.
Psychological Monitoring
Recommendations were made to improve the 'psychic control system' for pilots to detect personal or emotional instability that could impair operational capacity.
Alarm System Design Review
The JIAAC criticized the design of the takeoff configuration alarm system for not allowing crews to easily perform periodic checks to ensure the alarm is audible and recognizable.
Known Controversies & Unanswered Questions
Judicial Investigation vs. JIAAC Report
Reference ↗The official JIAAC report was criticized by judicial investigators for focusing almost exclusively on pilot error while allegedly downplaying systemic failures within LAPA's management and the Argentine Air Force's regulatory oversight.