LAM Mozambique Flight 470 - Great Disasters

Published April 18, 2021

Statistically, flying is the safest way to travel; tens of thousands of flights take place every day without incident.That is thanks not only to meticulous design, construction, and maintenance of aircraft, but also to the skill and training of the pilots in charge.

After all, every time you get on a plane, you place your life in their hands.

Stock image. Source: Unsplash

On the 29th of November, 2013, LAM Mozambique Airlines Flight 470 left Maputo International Airport in Mozambique, bound for Quatro de Fevereiro Airport in Luanda, Angola. The Embraer E190 twinjet plane, carrying 6 crew and 27 passengers, departed at 11:26 Central Africa Time, or 9:26 UTC, and was due to arrive at 14:10 West Africa Time, or 13:10 UTC.

The captain was Herminio dos Santos Fernandes, a 49-year-old with more than 9,000 total flight hours, including 2,519 on the Embraer E190. His co-pilot, 24 year old Grácio Gregório Chimuquile had 1,400 hours experience, with just over a hundred hours on the E190.

A little under an hour into the flight, the pilots were contacted by the Air Traffic Controller at Gaborone Area Control Centre; they were asked to give the aircraft registration number, and an estimate for when they would reach a point known as AGRAM. This is the boundary between the Gaborone Flight Information Area and the Luanda Flight Information Area, in other words, where they would have to switch from one traffic controller to another. They gave this information promptly.

About an hour later, at 11:17 UTC, Gaborone ATC contacted them again; “Mozambique 470 you can continue with Luanda 8888, 5565 good day”.

There was no response.

After trying to raise the aircraft again, and again failing to get a response, the Gaborone flight controller contacted his opposite number in Luanda, perhaps assuming that the pilots had simply switched early.

“LUANDA, Gabs, just advice if you are in contact with Mozambique 470, he is not talking to me, are you in contact there?”

Although Luanda’s response was inaudible, the two flight controllers did not speak about the flight again until 13:05 UTC – five minutes before the plane was supposed to be landing at Luanda – when Luanda Area Control Centre advised that they had still not heard from the LAM flight.

The Senior Air Traffic Controller was informed of the missing flight, and they checked with other area controllers without success.

Source: Base map from Wikimedia Commons

Searching for the plane was complicated somewhat because of the region where it disappeared; close to the borders of Botswana, Namibia, Angola and Zambia. Most of Namibia lies to the west of Botswana, but a narrow strip extends along the top of its eastern neighbour. Above this strip, Angola to the west meets Zambia to the east.

Early reports optimistically stated that the plane might have landed in Rundu, a Namibian city on the border with Angola, and Namibian authorities in the Eastern Kavango and Zambezi regions were informed, launching a search and rescue operation, however their efforts were hampered by the remoteness of the area, incoming bad weather and darkness.

Meanwhile, villagers in Botswana reported to local authorities that they had heard explosions.

The following morning, at around 7am local time, the plane was located in the Bwabwata National Park area, part of that narrow strip of Namibia north of Botswana. Namibia Police Force deputy commissioner Willy Bampton told reporters,

“Botswana officials informed us that they saw smoke in the air and they thought the crash happened in their country, but when they came to the border they realised that it was in Namibia… The plane has been completely burnt to ashes and there are no survivors,”

A Bwabwata game ranger named Shinonge also spoke to reporters, telling them;

“The bodies are scattered all over the place. It’s a horrible sight.”

An investigation team was quickly dispatched; this would include representatives from Mozambique, the country where the plane was registered and where the operator was based; Brazil, where the Embraer was designed and manufactured; Botswana, the country which controlled the flight region the plane had been in; Angola, as the flight’s final destination, and the USA, where the plane’s powerplant – engines and propellers – were manufactured. The team was led by the Directorate of Aircraft Accident Investigation (or DAAI) in Namibia – the country where the crash actually occurred.

The location of the crash made things difficult for the investigators. Firstly, just reaching it was difficult; it was only accessible with all-terrain vehicles, as it was in an area of savannah, a long way from any settlements. Dense vegetation also made it difficult to effectively survey the area from the ground.

And, because it was part of the national park, it was an important ecological area, with animals like elephants, lions and wild dogs freely roaming in the area. This meant it would be necessary for investigators to work quickly, so that the area could be cleaned up and made safe.

Bwabwata National Park. Source: Wikimedia Commons

Modern technology would prove invaluable; a remotely piloted aircraft, or drone, was used to take high-resolution aerial photographs, which could then be merged to provide a photographic map. This allowed the investigators to clearly see where various pieces of wreckage had ended up, including pieces that may easily have been missed in a ground search. Drone imagery was also used during the clean-up, allowing workers to see their progress as they returned the area to its original condition.

From the crash site and the position of the wreckage, investigators could quickly establish some facts. The plane had been on course for its destination when it came down, wings level, at a nose down angle of about -8°; two parallel pits in the ground indicated the point of impact, where the engines had dug into the earth.

Investigators particularly look for the so-called “four corners” of the aircraft; the nose, the tail, and the two wingtips. If there is an in-flight breakup, it’s likely that one or more of these extremities will come off while the plane is still in the air, and they will therefore fall further away from the rest of the wreckage. Finding all four corners relatively close to each other, as they did in this case, means that the plane was intact until it hit the ground.

Debris was carried forward for about 487 metres from the initial point of impact. According to aviation safety analyst Todd Curtis, speaking on the television documentary series Mayday or Air Crash Investigation:

“When I see a wreckage trail that’s that long and the aircraft is that disintegrated, it says that there was both a high vertical speed as it hit the ground and a high forward speed to allow the wreckage to spread over such a wide area, and that usually indicates that there was a very high speed – not necessarily an out of control high speed – impact with the ground.”

However, the landing gear was found retracted; the trunnions (the structural component attaching them to the undercarriage) were “relatively intact”, and the tyres were unpunctured, with no evidence of rolling. The flight control surfaces- the “flaps” and “slats” on the wing which the pilot uses to control the plane, particularly during take-off and landing – were found retracted, as they would be during normal flight, and damage to the turbine blades showed that the engines were running at the time of impact. That meant that there had been no attempt at a landing.

At the same time, the evidence suggested that the plane hadn’t been out of control. Dennis Jones, an investigator from the American NTSB who was part of the team, said:

“There was no big crater in the ground, so that suggested to me that there was some sense of controllability.”

In other words, it looked as if the plane had simply flown into the ground. The question was, why?

Fortunately, the plane was equipped with both a Flight Data Recorder (or FDR) and a Cockpit Voice Recorder (CVR) – and both had been retrieved from the wreckage. They had been sent to Washington DC for analysis, but this would take a couple of weeks.

That didn’t mean that the investigators had nothing to do, though. The process of investigating a plane crash can be quite neatly summarised with a quote from the fictional detective, Sherlock Holmes:

“When you have eliminated all which is impossible, then whatever remains, however improbable, must be the truth.”

Therefore, even if one theory seems likely at the outset, investigators will go through all other possibilities, to ensure that they reach the correct solution, and there were other leads that they could follow while they waited for the FDR and CVR data.

The plane had been cruising at a flight level of 380 or 38,000 feet, as normal, until they reached a point called EXEDU; this is a mandatory reporting point in the Gaborone Flight Information Region, and it lies 72 nautical miles south of the point AGRAM, mentioned earlier, where the flight would cross from the Gaborone area into the Luanda Flight Information Region.

From here, a replay of radar data showed a sudden descent, beginning at 11:09:07 UTC. Just over six minutes later, the target was lost as it descended past 6,600ft above sea level; it would make impact with the ground fifteen seconds later, at 3,390 above sea level. This is a very fast descent, beyond that which would be used in normal circumstances.

A minute and a half later, Gaborone air traffic control called the flight, telling them to switch to Luanda – and, of course, got no reply.

This information obviously raised further questions. If it took more than six minutes for the plane to reach the ground, that should have been plenty of time for the pilots to make a distress call, but none had been received.

The natural assumption would be that something catastrophic had happened, rendering the pilots unable to make a call. However, as investigators worked through the possibilities, they found no evidence supporting this idea. Although bad weather would later hamper the search, meteorological data showed that the weather at the time and height of the flight had been fine. Documentation showed that the plane’s weight and balance had been correctly calculated, and would not have contributed to a crash. Analysis of the wreckage showed no sign of any kind of explosion – the damage had been caused at the point of impact, and the soot patterns showed that the fire had happened after it had hit the ground. Maintenance records showed that the plane, just one year old, showed no signs of any issues. According to Curtis;

“There were no major system failures that had been repaired recently, no deferred maintenance that would have affected any major systems, and in fact [it] had a fairly intense inspection, roughly a day before the event. Nothing that said that the airplane itself was in anything other than top shape when it took off.”

The plane involved in the crash, photographed December 2012. Source: Wikimedia Commons

With no evidence of any external factors or issues with the plane itself, investigators looked at the human factor. Both pilots had valid licenses and medical certificates, and sufficient experience to fly the Embraer. Captain dos Santos Fernandes was much more experienced than his co-pilot Chimuquile, but it is normal practice within the air industry to pair up pilots in this way, so that younger pilots can learn from their elders, and the older pilots benefit from a fresher perspective. Their duty time was within regulations, and they had both had sufficient rest time prior to the flight – the captain had in fact been on leave the day before.

The recovery operation specifically aimed to locate remains of the pilots for forensic testing, but it proved impossible to detect any alcohol or drug impairment, due to the fragmentation and degradation of the remains.

Although there had only been 33 people on the plane, a team from the National Forensic Science Institute of Namibia (NFSI) had to test over a thousand pieces in order to identify the remains. According to the report, “The high degree of fragmentation of the bodies of the victims of the crash was indicative of the forces exerted at the time of impact.” In addition, the remains had lain out in the heat for some time before they could be retrieved – average daytime temperatures in Namibia in November exceed 30°C or 86°F.

Nevertheless, the team was able to identify remains belonging to all the victims, whether by appearance, dental records, or DNA; some were repatriated in accordance with the wishes of the families. Unidentified remains were buried in Windhoek, Namibia, the following April.

The other human factor was, of course, the air traffic controller. Like the pilots, he had all the right qualifications- a valid ATC license, medical certificate, and English language proficiency. However, for six minutes the plane had been on his radar, making an unplanned descent – why hadn’t he noticed it?

Quite simply, he was too busy. At the time of the crash, the entire Gaborone flight information region- the entire upper airspace of Botswana – was manned by just one controller. Normally, the area should have been separated into an East sector and a West sector, each under their own controller. Instead, he was operating both.

Reports of conflicting traffic in the East sector meant that he was looking at that region while the doomed flight, in the West sector, made its descent.

In addition, because the descent had happened around the time that the plane was expected to move out of his area and into Luanda’s control, he was not alarmed by the fact that it disappeared from his radar.

The plane had been equipped with an Emergency Location Transmitter or ELT, which should have initiated an alert when it crashed, but the impact severed a vital cable, and meant it was unable to transmit. Therefore, with ATC’s attention elsewhere, nobody realised that the crash had even happened until much later.

Eventually, it was the data on the flight recorders that made the sequence of events horribly clear.

Jones told Air Crash Investigation what they heard on the cockpit voice recorder:

“It was just a routine flight until the first officer excused himself to go to the lavatory. From that point on… just quiet.It sounded like normal things going on. All of a sudden you hear knocking on the door. There was no response. And then the knocking started becoming more repetitive.
Then we heard the ground proximity warning system saying “pull up”. That was the first sense that we knew the airplane was even heading down.”

At first, investigators wondered if this might be a case of what they call “subtle incapacitation”. At normal cruising level, there isn’t naturally enough oxygen to sustain human life; if, somehow, the air supply to the cockpit was interrupted, the captain may have suffered hypoxia, and thus been unable to let Chimuquile back in when he tried to return to the cockpit. However, closer analysis of the voice recorder indicated that dos Santos Fernandes was still breathing, and making inputs to the plane’s controls.

“We can hear clicking sounds, seemed as though the pilot that was on the flight deck was operating some mechanism. We couldn’t tell exactly but it sounded like rotating the dials, probably associated with the autopilot, but we didn’t know, we just can hear clicking sounds going on… We can hear movement, so this seemed to be someone who’s conscious.”

In addition, the cockpit door had an electromechanical lock, which requires a code to open from outside. As an authorised member of the crew, Chimuquile knew the code, but was unable to use it to open the door and instead resorted to knocking. Inside the cockpit, dos Santos Fernandes had access to an override which prevented the door from being opened with that code.

Curtis added;

“What they didn’t hear was even more unusual. They didn’t hear a single word coming out of the mouth of the captain. Not a word to the first officer, not a word on the radio, not even a word to himself. There was silence on his side.”

Edited stock image. Sources: Unsplash, Unsplash

This seemed to indicate a most disturbing possibility; that the crash was caused by deliberate action on the part of the captain. This is not a conclusion that any crash investigator wants to come to lightly, so all of the evidence had to be reviewed to be sure, but everything added up the same way.Analysis of the flight data recorder lined up with the cockpit voice recorder’s evidence.At 1:53:31 hours into the flight the CVR picked up the clicking sounds mentioned; these sounds lined up with the Flight Data Recorder outputs showing the altitude selection changing from FL380 to 4,288 ft at 11:06:36, then to 1,888 ft at 11:06:52, and then to 592 ft at 11:07:08. This final setting would take them well below ground level in this area. Other actions followed; reducing the power, turning off the autothrottle, leaving the throttles at idle. These actions would be consistent with normal descent procedures, however, at 11:10:54, the speed brake handle was activated, opening the spoiler panels. Because the flight data recorder monitors the actual position of the handle, this absolutely had to have been done manually, and this was not part of normal procedures.This action would increase the plane’s vertical speed. It went from a normal descent rate of 5000 feet per minute to a maximum of just over 10,000 feet per minute. This is essentially as fast as a plane can descend without breaking apart.

Investigators conducted several flight simulation tests to be sure, and those backed up the available evidence; the only way these inputs could have been made was if the captain had deliberately made them. In addition, it would have been possible to recover the plane from its descent even right towards the end when the ground proximity warnings began.

According to Curtis,

“The inputs he was making shows that the captain had a very very thorough knowledge of the aerodynamics of the aircraft, the behaviour of the systems, the effect of which was to have a very smooth very consistent descent from cruise all the way into the ground.”

Head of the Civil Aviation Institute, Joao Abreau, told a press conference,

“During these actions you can hear low and high-intensity alarm signals and repeated beating against the door with demands to come into the cockpit.”

Now, the pressing question was why? Why would an experienced captain direct his plane into the ground, killing not only himself but also five colleagues and twenty seven passengers?

Looking into dos Santos Fernandes’ background and work history, the investigators found no red flags, no warning signs of any depression. He had undergone a routine medical check-up and psychological evaluation in August; this raised no concerns, aside from advising him to change his eating patterns and exercise regularly, which is advice most of us hear on a regular basis.

However, his personal history revealed significant stressors. He had been separated from his wife for ten years, but divorce proceedings had not gone through; his youngest daughter had undergone heart surgery “not [a] long time ago”, and, perhaps most tellingly, his eldest son had died almost exactly a year before in a car crash which was believed to be itself suicidal. Dos Santos Fernandes had not attended his son’s funeral.

Human Performance Investigator Malcolm Brenner also appeared on the Air Crash Investigation program, saying:

“What we do know is that it took about two minutes until the captain locked the door, and then it took about an additional minute before he initiated the descent, so during that time you have to assume that he was thinking about life, about whether he’d want to do something like this… the anniversary of the son’s death would have been about the time of this accident, just a few days before, so certainly it would have been on his mind.”

Investigator Jones said,

“It’s really impossible for me to answer what the effect his life circumstances had on his decision at that moment during that flight. It’s impossible to know from the evidence we have whether this was a deliberate act that was concocted well before the flight or whether it was something that happened during the flight.”

There were two ways in which this tragedy could have been prevented – and one was, in fact, already in place, just not enforced.

LAM’s Manual of Flight Operation contains the following (translated from Portuguese):

“A pilot can only leave the Flight Deck when the aircraft is above 10 000 feet, for physiological reason or when carrying out his operational task. He or she shall, for that matter, first call a cabin attendant who will remain in the Flight Deck until his return. At the moment of the pilot’s exit, the other (pilot) shall lock the door, to only re-open it for the return of the absent pilot”

This policy put LAM ahead of most of the aviation industry, and above international minimum standards. However, when Chimuquile left to go to the toilet, he didn’t call a flight attendant into the cockpit beforehand. I have no doubt that this oversight was one he bitterly regretted in those last minutes.

The other way to prevent this would have been for someone to realise the state of mind that the captain was in, and prevent him from taking the controls in the first place – but, as mentioned, he had passed his medical check-ups without raising any concerns. It is not so easy to look into the minds of others, and continuing societal stigma over mental health issues mean that people are often discouraged from talking about them, or seeking help.

However, I haven’t got to the worst part of this tragedy yet. Remember the date of the crash? The 29th of November, 2013. The preliminary report, giving the cause as suicide by pilot, was issued on the 21st of December that year.

And fifteen months after that, pilot Andreas Lubitz locked his captain out of their cockpit, and directed their Airbus 320 into a mountainside in the Alps. That crash killed 150 people, and garnered worldwide attention.

Much of the media attention in that case focused on the fact that Lubitz had consulted over 40 doctors, and had concealed the fact that he had been declared unfit to fly from his employers at Germanwings. His actions also seemed to be pre-planned, as he had practiced similar altitude adjustments on a previous flight without actually bringing the plane down.

However, Germanwings had not at that time implemented a “more than one person in the cockpit” rule, which would have likely prevented Lubitz from carrying out his plan. If more attention had been paid to LAM flight 470, if procedures had been updated and enforced, those 150 lives could have been saved. However, coverage of the crash in Namibia was scarce, and thus there was little pressure on management to make those changes.

Aviation Safety Analyst Tom Kok told the Air Crash Investigation filmmakers,

“If an accident happens in the first world, it’s being picked up by many more media houses sometimes than when it happens in Africa. It might have had a much bigger impact and led perhaps quicker to measures from the international aviation community to address these aviation mental health issues… The world woke up to this issue after Germanwings because it became a bigger focus of press attention than the accident in Mozambique [sic] unfortunately. But ever since we are working as an industry to put into place a much better aviation mental health package, a system which will hopefully help us prevent these kind of accidents in the future.”

Stock image. Source: Unsplash

Pilots are just as human as the rest of us, and none of us are exempt from mental health issues. In fact, the pressure and responsibility that a commercial pilot bears on a daily basis adds to their level of stress – it definitely takes a certain kind of attitude to deal with that.

But talking about mental health issues such as depression and suicide is still taboo in many parts of the world, and people in high-pressure positions often feel that they must hide anything that may be perceived as a weakness, or risk losing their livelihood.

And so, the pressure on them can build until they feel that they are at a breaking point.

Some might suggest that, if a pilot was sufficiently determined, the presence of another person in the cockpit would not make any difference; they could overpower them. However, while I’m not a psychologist, I don’t think that is likely.

What stands out to me about the way in which dos Santos Fernandes and, later, Lubitz, carried out their actions is that they were somewhat distanced from the consequences. Waiting until they were alone, setting the autopilot to bring the plane down, and then simply waiting. It’s very non-confrontational; there’s a locked door which means they don’t have to face their colleague – and neither made any response to the increasingly desperate knocking they heard.

Kevin Hines, who survived a suicide attempt jumping off the Golden Gate Bridge and is now an activist in suicide prevention, has said that he openly cried on the bus there, and for forty minutes walking back and forth over the bridge, hoping for someone to intervene.

“I desperately wanted someone to say, are you okay? I would have told them everything.”

And, one of the key pieces of suicide prevention advice is to remove opportunity; to take away medication, sharp objects or weapons which might be used. In this case, and in Germanwings 9525, the weapon was a commercial jetliner – and the mere presence of another person on the flight deck would have, at the very least, substantially reduced the opportunity to use it in that way.

If you have suicidal thoughts, or if you are concerned about someone you know, please seek help. The International Association for Suicide Prevention can direct you to crisis centres in your area, and provides a range of helpful resources. Visit iasp.info.

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