Buenos Aires-Aeroparque-Jorge Newbery

Region:

Swearingen SA227 Metro III

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

14004

Captain / Total hours on type:

2000.00

Aircraft flight hours:

2630

Aircraft flight cycles:

2419

Circumstances:

The twin engine aircraft departed Lincoln-Estancia La Nueva Airport on a private flight to Buenos Aires, carrying one passenger and one pilot. While descending to Buenos Aires-Aeroparque-Jorge Newbury Airport, the pilot was unable to intercept the ILS for runway 13 because of an excessive speed of 260 knots and a too high angle of descent. In such conditions, he could not configure the aircraft for approach and landing (flaps) in accordance with the information in the BE 300 flight manual. He completed a left turn at a speed of 228 knots and descended below the glide before initiating a second turn to the right when control was lost. The aircraft entered a dive and crashed onto two houses located in Nordelta, about 26 km northwest of the airport. The aircraft and two houses were destroyed and both occupants were killed, among them Gustavo Andres Deutsch aged 78 who was the former owner of the defunct airline LAPA.

Probable cause:

The accident resulted from the combination of immediate triggers and failures in the aeronautical system's defenses, including:
- Prevailing weather conditions at the scene of the accident;
- Pilot-in-command experienced difficulties in managing aircraft control and flight path during an instrument approach;
- The probability of overload of work of the pilot in command as a result of the operational demands presented by the situation;
- The execution of the operation by a single pilot (single pilot operation), taking into account the age of the pilot; and
- Deficiencies in pilot-in-command certification denying the value of CE-6 as a defense barrier for the aeronautical system (CE-6 is a Critical Element of ICAO Annex 19 regarding responsibilities in issuing licenses).

Final Report:

Crash of a Swearingen SA227AC Metro III in Buenos Aires

Date & Time: Dec 15, 2006 at 1820 LT

Type of aircraft:

Operator:

Registration:

LV-WRA

Flight Phase:

Flight Type:

Positioning

Survivors:

Site:

Buenos Aires-Ezeiza-Ministro Pistarini

Schedule:

Buenos Aires - Buenos Aires

MSN:

AC-429

YOM:

1981

Location:

Country:

Region:

Piper PA-31-350 Navajo Chieftain

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

2666

Captain / Total hours on type:

1556.00

Copilot / Total flying hours:

1465

Copilot / Total hours on type:

1232

Aircraft flight hours:

34587

Circumstances:

The crew was performing a positioning flight from Buenos Aires-Ezeiza-Ministro Pistarini Airport to Buenos Aires-Aeroparque-Jorge Newbury Airport. Before departure, the captain switched off the Stall Alarm System for unknown reasons. Shortly after takeoff from runway 17, the climb gradient was small and landing gear were retracted at a very low altitude. The left wing stalled and struck the runway surface. Out of control, the aircraft impacted ground, slid for few dozen metres, overran the runway and came to rest in a field. Both pilots were uninjured while the aircraft was damaged beyond repair.

Probable cause:

Loss of control shortly after rotation due to the premature retraction of the landing gear and a takeoff completed with a low climb gradient in the second segment.

Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain in Las Primaveras

Date & Time: Mar 12, 2003 at 1940 LT

Type of aircraft:

Operator:

Federal Aviation

Registration:

LV-MML

Flight Phase:

Flight Type:

Survivors:

Site:

Schedule:

Mendoza – Buenos Aires

MSN:

31-7852133

YOM:

1978

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

4364

Captain / Total hours on type:

52.00

Copilot / Total flying hours:

1109

Copilot / Total hours on type:

142

Circumstances:

The twin engine airplane departed Mendoza-El Plumerillo on a ferry flight to Buenos Aires-Aeroparque-Jorge Newbury Airport with two pilots on board. After takeoff, the crew was cleared to climb to 7,000 feet then to proceed to the east via airway W9. About 20 minutes into the flight, after being cleared to descend to FL55, the crew noticed smoke in the cabin. Assuming the smoke was coming from under the panel instruments, the crew used the fire extinguisher put smoke continued to spread in the cabin. The crew informed ATC about his situation, reduced his altitude and attempted an emergency landing. The crew lowered the landing gear but completed a flapless landing in an open field. The aircraft rolled for few dozen metres before coming to a halt, bursting into flames. Both pilots evacuated safely while the aircraft was consumed by fire.

Probable cause:

A fire broke out in flight, probably in the electrical wiring, for reasons that investigations were unable to determine.

Final Report:

Crash of a Boeing 737-204C in Buenos Aires: 65 killed

Date & Time: Aug 31, 1999 at 2054 LT

Type of aircraft:

Boeing 737-200

Operator:

Registration:

LV-WRZ

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Schedule:

Buenos Aires – Córdoba

MSN:

20389

YOM:

1970

Flight number:

MJ3142

Location:

Country:

Region:

Swearingen SA227 Metro III

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

6500

Captain / Total hours on type:

1710.00

Copilot / Total flying hours:

4085

Copilot / Total hours on type:

560

Aircraft flight hours:

67864

Aircraft flight cycles:

41851

Circumstances:

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:

The JIAAC considers as an immediate cause of the accident that the flight crew of the LAPA 3142 forgot to extend the flaps for takeoff and dismissed the alarm sound that warned about the lack of configuration for that maneuver.
The contributing factors were:
- Lack of discipline of the crew that did not execute the logical reaction of aborting the takeoff and verification of the failure when the alarm began to sound when adding engine power and continued sounding until the rotation attempt.
- Excess of conversations foreign to the flight and for moments of important emotional intensity between the pilots, that were mixed with the execution of the check lists, arriving at omitting the part of these last ones where the extension of flaps for takeoff had to be completed.
- Personal and/or family and/or economic and/or other problems of both pilots, which affected their operational behavior.
- Insufficiency of the psychic control system, which did not allow to detect when the pilots were suffering personal and/or family problems and/or of another type that influenced their operational capacity when diminishing their psychic stability.
- Knowledge and treatment of very personal and extra-occupational issues among the pilots and even with the onboard commissioner, who facilitated the atmosphere of scarce seriousness and concentration in the operational tasks.
- Background of negative flight characteristics of the commander that surfaced before his personal situation and relationship in the cockpit before and during the emergency.
- Background of flight characteristics of the co-pilot, which manifested themselves during compliance with the procedural checklists in a cockpit where its components participated with a completely dispersed attention to particular interests outside the flight.
- No immediate recognition or verification of both pilots, of the relationship between the type of intermittent audible alarm that indicated failure in the configuration for takeoff, with the absence of flaps in the position for this maneuver.
- Design of the take-off configuration alarm system that does not allow, in this type of aircraft, a simple check by the crews to ensure periodic listening to this type of intermittent alarm.

Final Report:

Crash of a Swearingen SA227AC Metro III in Santa Fe

Date & Time: Jun 3, 1998 at 0722 LT

Type of aircraft:

Operator:

Air Tango

Registration:

LV-WIL

Flight Phase:

Landing (descent or approach)

Flight Type:

Cargo

Survivors:

Site:

Landing (descent or approach)

Schedule:

Buenos Aires – Santa Fe – Posadas

MSN:

AC-537

YOM:

1983

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

While descending to Santa Fe-Sauce Viejo Airport by night, the crew was informed about poor weather conditions at destination. The visibility was estimated to be 30 metres in foggy conditions, well below minimums. As the crew elected to attempt an approach, he as cleared for and ILS approach to runway 03. On short final, the aircraft descended below the MDA and struck the ground 430 metres short of runway threshold. On impact, it lost its undercarriage and slid for another 180 metres before coming to rest. Both pilots escaped uninjured while the aircraft was damaged beyond repair.

Probable cause:

It was determined that the crew descended below the established minima during an instrument approach until the aircraft impacted terrain. The following contributing factors were identified:
- Inadequate flight planning, since there was reduced visibility at Sauce Viejo Airport from 01:00 hrs,
- Inappropriate request from the captain who attempted to make an approach in below minima weather conditions,
- Erroneous decision of the captain, knowing the meteorological conditions, to continue the approach below the decision height.

Crash of a Douglas DC-9-32 near Nuevo Berlin: 74 killed

Date & Time: Oct 10, 1997 at 2210 LT

Type of aircraft:

Douglas DC-9

Operator:

Registration:

LV-WEG

Flight Phase:

Flight

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Plain, Valley

Schedule:

Posadas - Buenos Aires

MSN:

47446

YOM:

1969

Flight number:

AU2553

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

9238

Captain / Total hours on type:

177.00

Copilot / Total flying hours:

2910

Copilot / Total hours on type:

1384

Aircraft flight hours:

56854

Aircraft flight cycles:

54800

Circumstances:

The aircraft departed Posadas-Libertador General José de San Martín Airport at 2118LT on a regular scheduled flight to Buenos Aires, carrying 69 passengers and five crew members. While cruising at an altitude of 35,000 feet, weather conditions deteriorated with cumulonimbus reported till 49,000 feet, stormy weather, icing conditions and severe turbulences with winds up to 80 km/h and an OAT of -59° C. The crew modified his route and entered the Montevideo FIR without contacting Montevideo ATC. At 2204LT, the aircraft entered an area with severe icing conditions and three minutes later, the copilot (pilot-in-command) initiated a descent without prior permission. Meanwhile, the captain contacted Ezeiza Control, requesting permission to descend. Ezeiza Control radioed that the flight was over Uruguay territory and that they needed to contact Montevideo Control for permission. At 2209:17, Montevideo ATC cleared the crew to descend to FL257, an altitude reached at 2210:25. During the descent the first officer complained that his airspeed indicator did not seem to be working correctly. Descending through FL300, the first officer extended the slats. The pilots were trained to extend slats when recovering from approach to stall situations at 10,000 - 12,000 feet. However, the actual airspeed at the time of extension was higher than permitted. This exceeded the design limit, causing an asymmetry. The aircraft entered an uncontrolled descent and crashed in a near vertical attitude in an open field located about 21 km east of Nuevo Berlin. The aircraft disintegrated on impact and all 74 occupants were killed. At the point of impact, a cratere of 10 metres deep by 30 metres wide was found. The accident was not survivable. It was reported that that the airspeed suddenly increased from 200 knots to 450 knots in four seconds, probably after the Pitot tubes got iced.

Probable cause:

The immediate cause of the accident was likely that at an altitude of 30,000 feet, the first officer, who was the pilot-in-command, found himself in flight conditions which induced him to extend the slats. This manoeuvre was completed at a speed much higher than the limit of the structural design of the slats, and their extension caused an asymmetry and a subsequent loss of control from which a recovery was not possible. The copilot's interpretation as to the need to extend the slats would have been a result of erroneous indications of low speed (IAS), caused by blockage of the Pitot tubes which resulted from icing conditions while cruising in clouds with an extreme OAT of -59° C. It was not possible to determine if the obstruction was caused by the crew by not activating the heating system via the selector switch, or failure of that system.
The following contributing factors were identified:
a) No indication of Mach number on the speed indicators installed in the accident aircraft within its flight envelope, with air speeds below 250 KIAS.
b) Lack of crew training in flight instrument failures and upset recovery.
c) Lack of crew training in the recovery of approach to stall in the DC-9 aircraft in "clean configuration" in accordance with the procedures specified in the FCOM, section 5, 10-0-0, code 30.
d) Lack of instruction and pilot training in crew resource management (CRM).
e) Absence of a warning light Pitot/Stall-Heater OFF on the annunciator panel.
f) Deficiency in operational procedures.

Final Report:

Crash of a Cessna 402B II off Buenos Aires: 6 killed

Date & Time: Jun 2, 1995 at 1900 LT

Type of aircraft:

Cessna 402

Operator:

Registration:

LV-MIU

Flight Phase:

Flight Type:

Charter/Taxi (Non Scheduled Revenue Flight)

Survivors:

Site:

Lake, Sea, Ocean, River

Schedule:

Buenos Aires - Paraná

MSN:

402B-1332

YOM:

1978

Location:

Country:

Region:

Servicios Aéreos Facchini

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

After takeoff from Buenos Aires-Aeroparque-Jorge Newbury Airport runway 13, while climbing, the crew declared an emergency following an engine failure and was cleared to return. While completing a 180 turn, the crew lost control of the aircraft that crashed in the sea about 2,700 metres short of runway 31, three minutes after departure. A passenger survived while six other occupants were killed, all members of the corporate of LAER.

Probable cause:

Engine failure for unknown reasons.

Crash of a Rockwell Sabreliner 40R in Buenos Aires

Date & Time: Dec 21, 1994 at 0422 LT

Type of aircraft:

Rockwell Sabreliner 40

Operator:

Registration:

N747E

Flight Phase:

Flight Type:

Cargo

Survivors:

Site:

MSN:

282-22

YOM:

1964

Location:

Country:

Region:

Rockwell Aero Commander 500

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Circumstances:

During the takeoff roll by night, after V1 speed, the crew elected to rotate but the aircraft failed to respond. The captain abandoned the takeoff procedure and initiated an emergency braking maneuver. Unable to stop within the remaining distance, the aircraft overran, lost its undercarriage and came to rest few dozen metres further. Both pilots escaped uninjured and the aircraft was damaged beyond repair.

Probable cause:

It was determined that the total weight of the aircraft was above MTOW and the CofG was out of permissible limits.

Crash of a Rockwell Aero Commander 500B in Buenos Aires: 2 killed

Date & Time: Jun 2, 1994

Type of aircraft:

Operator:

Rent-a-Plane

Registration:

LV-GXR

Flight Phase:

Flight Type:

Cargo

Survivors:

Site:

MSN:

500-0962-17

YOM:

1960

Location:

Country:

Region: