LAM Mozambique Flight 470: The Forgotten Tragedy
On 29 November 2013, LAM Mozambique Flight 470 slammed into the ground in the Bwabwata National Park in Namibia. All 33 people on board the plane are killed. Investigators looking into the crash discover the cause of the crash to be so unbelievable that it is beyond belief.
11:26 am (Maputo time): Maputo, Mozambique
An Embraer ERJ-190–100 aircraft takes off from Maputo International Airport. The flight is operating LAM Mozambique Flight 470, a flight bound for Luanda, Angola. They are scheduled to land in Luanda in about four hours.
In command of the aircraft is 49-year-old Captain Herminio dos Santos Fernandes. He has over 9000 flight hours, of which about 2500 hours are on the aircraft type.
Assisting him is 24-year-old First Officer Grácio Chimuquile. He has over 1100 flight hours of which 100 hours are on the aircraft type.
In the cabin, there are 27 passengers and 4 cabin crew, all of whom are headed to Luanda. The flight is rather empty for the route between the two cities with Portuguese heritage.
12:18 pm (Gaborone time): Gaborone FIR
LAM Mozambique Flight 470 enters the flight information region (FIR) of Gaborone, Botswana over waypoint ENMIT. From here until waypoint AGRAM, the aircraft will be under the jurisdiction of Botswana controllers.
The weather along the path is desirable with only scattered clouds at 3000ft above ground level which is way below the cruising altitude of LAM Mozambique Flight 470.
The controller at the Gaborone Area Control Centre (ACC) cleared the flight to maintain FL380 (38,000ft) and to report when at waypoint AGRAM. The crew of LAM Mozambique Flight 470 acknowledged and repeated the controller’s clearance per procedures.
Also, the controller requested an estimate of when the aircraft would be at waypoint AGRAM and the registration number of the aircraft. The crew responded that they would arrive at waypoint AGRAM in about an hour and that the registration number of the aircraft was C9-EMC.
50 minutes later, at Gaborone ACC, the controller was swamped by his workload. He was handling conflicting traffic in his sector. He was so engrossed to the point where he did not notice something peculiar…
An hour after the previous transmission, the controller transmitted to the aircraft, “Mozambique 470, you can continue with Luanda 8888, 5565 good day.” There was no response.
The controller called the aircraft again on frequency but silence was the only reply.
Confused and alarmed by the unexpected silence, he called Luanda ACC, inquiring if they have heard from the crew of LAM Mozambique Flight 470. It is unknown what the controllers in the Luanda ACC reply.
Air accident investigators from Botswana, Namibia and Angola checked their radar to look for signs of LAM Mozambique Flight 470. The Namibians spot the aircraft on their radar. The aircraft initially flew at FL380 as assigned but had started to descend abruptly at a vertical speed of about 10,000ft/min. The aircraft vanished from the Namibian radar at an altitude of about 6000ft.
2:40 pm (Namibia time): Namibia
Hours after LAM Mozambique Flight 470 vanished, the Namibian authorities received information of a low-flying aircraft and rising smoke in the Bwabwata National Park. They confirmed with controllers in Botswana to confirm that an aircraft was missing in the Gaborone FIR.
The Namibian air traffic controller on duty immediately started a search and rescue operation. However, due to bad weather, the search was called off until the next morning.
At 9 am the following morning, the inevitable reality had been proven true. The plane had slammed into the ground in the Bwabwata National Park on the Caprivi Strip, a panhandle of Namibia, near Divundu, Namibia. All 33 people on board are killed by the crash.
Investigators from the Directorate of Aircraft Accident Investigations (DAAI) of Namibia was immediately dispatched to investigate the crash. Assisting them are American investigators from the National Transportation Safety Board, Brazilians from Centro de Investigação e Prevenção de Acidentes Aeronáuticos (CENIPA) and Embraer.
The black boxes were recovered and subsequently sent to the NTSB laboratory in Washington for analysis.
Arriving at the crash site, they begin examining the wreckage. They notice that the aircraft had slammed into the ground and slid across the ground for 400 metres, disintegrating in the process. A post-crash fire had ensued. At the start of the wreckage were two identical depressions in the ground. Investigators realized that this was the depressions the engines had left behind during the first impact of the aircraft with the ground as the distance between the depression was consistent with the distance between the engines of the aircraft. Based on the depressions, the investigators determined that the plane impacted the ground with its wings level.
The investigators begin to rule out possible causes of the crash based on the wreckage and available information.
Could the plane have been attempting to make an emergency landing? The lack of puncture and roll marks on the landing gears suggests that an attempt at an emergency landing was extremely unlikely.
Could the engines have failed? Based on the marks left on the turbines of the engines, the engines were rotating in a high energy state on impact.
Could the aircraft have suffered a mechanical failure? Investigators discover that the aircraft had been inspected the day before the crash. Hence, a mechanical failure was unlikely to have caused the crash.
Investigators have now reached a dead end. Their only hope now is to obtain crucial information from the black boxes.
The investigators have received news that the black boxes have been analyzed by the laboratory in Washington and that data download was successful.
Investigators listen to the CVR and simultaneously look at the FDR data. What they discover is shocking.
The first one hour and fifty minutes of the flight was uneventful, with the pilots talking about politics for most of this part of the flight.
One hour and fifty minutes into the flight, Captain Fernandez asks First Officer Graćio if he needed to go to the lavatory. He added that he had control of the aircraft if needed.
First Officer Graćio responded, “No problem.” He closes the door behind him as he goes to the lavatory, leaving Captain Fernandez alone in the cockpit. This violated LAM Mozambique company procedures, which dictate that two people must be in the cockpit at all times.
With First Officer Graćio out of the cockpit, Captain Fernandez is free to do as he wills. He turns the altitude preselect knob in three increments, bringing down the selected altitude for the aircraft to fly at down from 38,000ft down to 4288ft, and then to 1288ft, and finally down further to 592ft, below ground level in the area. This is corroborated by the cockpit voice recorder (CVR), which captured sounds of a knob being rotated in the cockpit, and the flight data recorder (FDR), which captured the reduction in preselected altitude of the aircraft.
The autothrottle system was then disabled by him. The autopilot vertical mode was automatically changed from altitude hold mode to flight management computer flight level change and then to flight level change.
The autothrottle system was then manually re-engaged by Captain Fernandez. The throttles were manually retarded. This was due to autopilot being in flight level change mode and due to the preselected altitude being lower than current aircraft altitude.
The autothrottle was then disengaged manually by Captain Fernandez. The fact that the autothrottle was disengaged manually was confirmed by the MASTER CAUTION warning not sounding in the CVR nor was it in the FDR.
The throttles were then advanced forward and then retarded back to idle. This action was done manually by Captain Fernandez.
At this point, someone is heard knocking on the door. This is determined to be First Officer Graćio. First Officer Graćio is left locked out of the cockpit as Captain Fernandez had disabled the code to open the door.
The speed mode of the autopilot transitioned from auto to manual.
The speed brakes were manually commanded to open the spoiler panels by Captain Fernandez. It would stay in this position until the crash. Besides adding drag to an aircraft, the speed brakes also reduce the lift of an aircraft. As a result, the vertical speed of the aircraft increased dramatically.
The autopilot vertical mode then changed to over-speed mode.
25 seconds before the crash, the Ground Proximity Warning System (GPWS) sounded a cautionary alarm in the cockpit. The warning is designed to warn pilots of an impending danger of impact with terrain.
13 seconds later, the GPWS sounded a warning in the cockpit. This sounded when the aircraft is in an impending danger of collision with terrain that is more critical.
The GPWS then sounds an alarm asking Captain Fernandez to pull up of the lethal descent. He never does.
2 seconds later, the plane slams into the ground in the Bwabwata National Park in Namibia. After the initial impact, the wreckage slid for more than 400 metres before coming to rest. All 33 people on board the plane are killed instantly.
Investigators are shocked. Captain Fernandez had plenty of opportunity to get out of the lethal descent that he put the aircraft in. Why didn’t he? Why did he leave First Officer Graćio locked out of the cockpit?
In the CVR recording, Captain Fernandez can be heard breathing and is manipulating the controls of the aircraft. This rules out a decompression as a factor in the accident. This is corroborated by the FDR which recorded that the cabin pressure was at an optimum level.
Having ruled out almost all other possibilities, the investigators are left with one very disturbing option: pilot suicide. This is backed up by the CVR and FDR. While this may seemingly be a wild theory, this was not the first time this happened.
For instance, in 1994, Royal Air Maroc Flight 630 crashed into the ground near Douar Izounine, Morocco about 17 nautical miles from Agadir, Morocco. All 44 people on board the flight were killed instantly. The investigation found that the captain had disconnected the autopilot and put the aircraft into a steep dive.
In 1997, Silkair Flight 185 plunged into the Musi River in Indonesia, killing all 104 onboard the flight. The official investigation by KNKT Indonesia could not determine a cause for the crash. However, the NTSB found that there was circumstantial evidence that the captain committed suicide. Meanwhile, a Los Angeles court found that a malfunctioning rudder caused the crash.
However, to prove that Captain Fernandez had deliberately crashed the aircraft, the investigators need to find a motive.
The investigators decide to interview family and friends to look into the potential motives of Captain Fernandez committing suicide.
From the interviews, they discover that Captain Fernandez had experienced some life events in his life that was of interest to the investigators. For instance, he had separated from his wife 10 years before and the proceedings were still taking place. His son had died almost exactly a year before the crash in a car accident that was a suicide. He did not attend his son’s funeral. His youngest daughter had just undergone heart surgery in a South African hospital not long before the crash. These life events caused Captain Fernandez to be depressed.
Finally, investigators had a complete picture of the events that led to the crash. Captain Fernandez and First Officer Graćio were flying in the skies above Namibia when Captain Fernandez asks First Officer Graćio if he wanted to go to the toilet. He agrees and leaves Captain Fernandez in the cockpit alone, in violation of procedures. Captain Fernandez put the aircraft in a lethal descent, ignoring First Officer Graćio’s futile attempts to enter the cockpit. The controller on duty did not notice the abrupt descent as a result of preoccupation.
Ultimately, the effects of these factors are clear. The aircraft slammed into Bwabwata National Park, killing all 33 onboard the aircraft.
In its final report, the DAAI Namibia concluded that First Officer Graćio had left Captain Fernandez alone in the cockpit against procedure. If First Officer Graćio had not done so, the aircraft might not have crashed. Captain Fernandez then put the plane into the lethal descent, killing all 33 onboard the aircraft. The DAAI recommends that the Mozambique Civil Aviation Authority ensure that the two-person in the cockpit rule is adhered to at all time and that the International Civil Aviation Authority (ICAO) research on methods of mitigating threats to aviation safety from each side of the cockpit door.
The following is a statement from the final report of the DAAI Namibia which sums up all that has been mentioned above:
Probable cause/s: The inputs to the auto flight systems by the person believed to be the Captain, who remained alone on the flight deck when the person believed to be the co-pilot requested to go to the lavatory, caused the aircraft to departure from cruise flight to a sustained controlled descent and subsequent collision with the terrain. Contributing factors: The non-compliance to company procedures that resulted in a sole crew member occupying the flight compartment.
The tale of LAM Mozambique Flight 470 is a cautionary tale about how pilots should follow established procedures as they help ensure safety is not compromised.
But that was not the end of the story.
The crash of LAM Mozambique Flight 470 was soon forgotten by the aviation community as the crash was obscure.
In 2015, Germanwings Flight 9525 crashed into the French Alps more than 54 nautical miles from Nice, France. All 150 people on board are killed instantly. The investigation by the BEA France discovered that the first officer had locked the captain out of the cockpit and put the plane into a lethal descent into the French Alps.
After the Germanwings crash, the aviation industry finally took action to prevent a similar disaster from happening. The lessons that should have been learned from the tale of LAM Mozambique Flight 470 could have prevented the crash of Germanwings Flight 9525.
With the aviation industry continuing to carry an ever-increasing amount of passengers as time passes, we can only hope that the changes have been implemented.
In memory of the 33 people who died on board LAM Mozambique Flight 470.
I was inspired to write this article after reading articles by Admiral_Cloudberg. I highly recommend reading his series on plane crashes as they are very interesting. Thank you!