Copa Airlines Flight 201
An Copa Airlines Boeing 737-204 identical to the one involved in the crash
|Date||June 6, 1992|
|Summary||Spatial disorientation due to instrument malfunction.|
|Site||Darién Gap, Panama
|Aircraft type||Boeing 737-204 Advanced|
|Flight origin||Tocumen International Airport|
|Destination||Alfonso Bonilla Aragón Int'l Airport|
Copa Airlines Flight 201 was a regularly scheduled passenger flight from Tocumen International Airport in Panama City, Panama to Alfonso Bonilla Aragón International Airport in Cali, Colombia. On 6 June 1992, the Boeing 737-204 Advanced operating the route flipped, disintegrated in mid-air and crashed into the Darien Gap 29 minutes after takeoff, killing all 47 people on board. The in-flight break-up was caused by faulty instrument readings and several other contributing factors, including incomplete training.
Flight 201 was particularly disturbing to the public because it was the deadliest accident in Panamanian aviation history, and also the first fatal crash of Copa Airlines in its 45-year history.
- 1 Aircraft and crew
- 2 Crash
- 3 Nationalities of the victims
- 4 Examination and investigation
- 5 Aftermath
- 6 Media coverage
- 7 See also
- 8 References
- 9 External links
Aircraft and crew
The aircraft was a 12 year-old twin-engined Boeing 737-204 Advanced, tail number HP-1205CMP piloted by Captain Rafael Carlos Chial, 53, and First Officer Cesareo Tejada. The flight attendants on the flight were Iris Karamañites, Flor Díaz, Vanessa Lewis, Xenia Guzmán and Ramón Bouche. Copa 201 was carrying 40 passengers and 7 crew. The jet was manufactured in 1980 and entered service with Britannia Airways bearing tail number G-BGYL. The aircraft was acquired by Copa Airlines as a result of the leasing agreement that both companies had in the 1990s, and the aircraft still bore a hybrid Britannia/Copa livery (still wore Britannia stripes, but with "Copa" titles on the forward fuselage and tail, and the Panamanian flag on the middle part of the fuselage) at the time of the accident.
Flight 201 took off from runway 21L at Tocumen International Airport in Panama City, at 20:37 local time for a scheduled passenger flight to Cali, Colombia with 40 passengers and seven crew members. Among the passengers were Colombian merchants conducting business in Panama. At 20: 47 PM, about 10 minutes after takeoff, Capt. Chial contacted Panama City air traffic control, requesting weather information. The controller reported that there was an area of very bad weather at 30–50 miles from their position.
At 20:48, Capt. Chial made another radio contact requesting permission from Panama City ATC to fly a different route due to severe weather, taking the plane over Darién Province. Some minutes later, at 20:54 PM, Panama City control center received a third message from Capt. Chial, who reported problems with the airplane and requesting permission to turn back to Tocumen, which was granted.
However, two minutes later and meanwhile flying in an altitude of 25,000 feet, flight 201 entered a steep dive at an angle of 80 degrees to the right and began to roll uncontrollably towards the ground. Despite the attempts of Capt. Chial and Co-pilot Tejada to level off, the airplane continued its steep dive until it exceeded the speed of sound and started to break apart at 10,000 feet. Most of the bodies had their clothes torn off and were thrown away. Flight 201 crashed into a jungle area within the Darien Gap at 486 knots (560 miles per hour), instantly killing everyone on board.
At 20:57 PM, Tocumen air traffic control tried unsuccessfully to make contact with flight until it received a radio message from an KLM DC-10 aircraft that was approaching the airport, reporting that they intercepted an distress signal from flight 201’s transponder in an area between the Colombian border and Darien Province, several kilometers away from their position. After several unsuccessful attempts to contact the lost plane, Tocumen ATC finally declared a full emergency in the airport, and informed the Colombian ATC center at Bogota about the missing plane. At dawn the next day, search aircraft were sent to Flight 201's last known position.
After eight hours, searchers spotted the first pieces of wreckage in the jungle of the Darien Gap. Because of the remoteness of the area and the difficulty of access, it took rescue personnel 12 hours to reach the site. During the initial response, two soldiers from the US Southern Command military based in Panama that were helping in the rescue efforts died of asphyxiation, when the rope they were using to descend from a helicopter towards the crash site strangled them.
Because the bodies of the victims and various parts of the aircraft’ fuselage were scattered in a radius of 10 km, the recovery process was extensively difficult. After investigators reached the crash site, the investigations to find the causes of the crash began.
Nationalities of the victims
The aircraft was carrying 47 people: 40 passengers and a crew of seven. Fatalities included 36 Colombians, eight Panamanians, two Americans and one Italian.
The crash killed 4 Colombian traders who boarded the flight back to Cali, along with an employee of Carvajal Ltd. who was traveling with his wife and daughter.
Examination and investigation
Initially, the team was concerned about the cause of the crash, because it bore some similarities to the crash of United Airlines Flight 585, which happened a year earlier in Colorado, United States. This crash also involved a Boeing 737-200. In that case, investigators were considering the possibility of a serious design flaw in the Power Control Unit (PCU) of the 737 rudder system, which was causing uncommanded deflections, but it was not officially confirmed until four years later, after the incident of Eastwind Airlines Flight 517.
The cockpit voice recorder was recovered and flown to Panama City, then to the United States, for analysis by the National Transportation Safety Board. However, NTSB analysts discovered that the tape was broken due to a maintenance error. Crash investigators had better luck with the flight data recorder, which showed the plane was in a high-speed dive before breaking up.
The trouble was later traced to a faulty wiring harness in the Attitude indicator (AI) instruments that were fractured due to damage by overstress, which caused an intermittent short circuit. As a consequence, the indicator led Capt. Chial to believe he was banking left, thereby prompting him to bank right. This reaction rolled the aircraft to almost 80 degrees and caused it to go into a steep dive, with no chance for recovery.
Also, the switch of the captain's AI was found at the scene of the accident in the position of both in Vertical Gyro (VG-1). Investigators determined that the switch was moved from the normal position to VG-1, causing the crew to experience intermittent attitude errors on their instruments.
Specifically, the investigation team found that the backup AI (Stand-by) was probably available to the pilots during the intermittent failure of the instruments systems (the post-impact damage of the emergency indicator showed that it was operating on impact with the ground), but due to an ineffective cross-checking procedure done by the pilots, the backup AI was not used correctly to identify the problem and select a reliable source of attitude information.
Another factor contributing to the crash was that the Copa Airlines’ ground training simulator program was ineffective, as it did not present enough information relating to the differences between aircraft and crew resource management in order to give to the cabin crew knowledge to overcome intermittent attitude indicator errors and to maintain control of an aircraft with an VG auxiliary font. Moreover, on the accident aircraft, the pilots were trying to apply what they had learned in the simulator relating to this issue, but due to the movement of the AI’s switch to the position on both in VG-1 and the insufficient information during the training; the reference from VG-2 was lost and the pilots were unable to identify the problem as a consequence.
Other factor contributing to the crash was the non-standard cabin configurations between aircraft in the fleet of the company, which caused confusion to the pilots about determining the setting of the AI switches, basing on the aircraft was being operated at the time.
The possibility of rudder deflection in flight was discarded as a possible cause of the accident, but it was registered on the Boeing 737 rudder issues as an "accident with suspicious rudder deflection".
In the morning of the next day, Colombian radio stations were reporting that some residents of Tucutí and other villages nearby to the crash site said that on the night of the accident they felt a very strong explosion, meanwhile others said that they saw a burning object that was falling from the sky towards the jungle.
However, these reports were eventually dismissed by the head of Panama's civil aviation authority, Sosimo Guardia.
Initial theories of the crash
After the first analysis to flight 201's wreckage were made, investigators raised several theories of possible causes of the crash.
The first theory established that the doomed flight was brought down by a bomb by paramilitary groups, due to the fact that the route in which the 737 was flying through was used by suspected paramilitary groups and Colombian guerrillas linked to drug trafficking. However, this theory was ruled out after bomb experts found no traces of explosives on the wreckage.
The second theory established that flight 201 suffered a mid-air collision with another aircraft. This theory was also dismissed after search teams found no wreckage traces of another airplane in the area.
Because some bodies were partially burnt, like some parts of the fuselage, another theory was raised and established that the plane suffered a short circuit in the electrical system, which caused a catastrophic in-flight fire as a consequence. This theory was also ruled out after investigators analyzed the electrical system of the airplane and found no evidence of short circuits.
Speculation about the pilots
During the investigation, it was speculated that the first officer Tejada was in charge of the flight at the time of the dive, and that captain Chial was eating (which was confirmed in the autopsy that was performed to him), and was not wearing his seat belt. Although a food tray was found in the wreckage, it is unknown whether the captain was having dinner at the passenger cabin or in the cockpit.
Furthermore, it was also speculated that the first officer was watching the malfunctioning AI instead of the backup AI, which led him to bank the Boeing 737 more to the right until it reached 80 degrees, and probably causing the autopilot to disconnect and the unrecoverable dive. This is also unknown due to the breaking down of the cockpit voice recorder' tape.
Delays during the investigation
A special team consisting of personnel from Copa Holdings, Boeing, Pratt & Whitney and the NTSB worked together with Panamanian civil aviation authorities on the investigation, which lasted one year. However, the investigations were interrupted by political changes in Panama due to the reestablishment of democracy by the government of Guillermo Endara after the fall of the military dictatorship lead by Manuel Antonio Noriega in December 1989. As a consequence, the researches about the crash were exchanged via personal communication with those involved in the investigations.
The delivery of the final report made by Panamanian authorities about the crash of flight 201 to the NTSB and the United Nations' ICAO agency was expected to occur by December 1993, just one year after the accident. However, because of the political changes that Panama was passing through during the 1990s, the delivery of the report was delayed until 1998. These delays and interruptions of the investigations were an major embarrassment for the Panamanian government and caused the public opinion to demand explanations.
Response from Copa Airlines
In the wake of the disaster, Copa gave flights to Panama City to the families of the victims, and the main executive members of Copa Holdings declared a permanent emergency meeting session at the airline's main headquarters in Panama City.
Copa Airlines had to strengthen its training program for flight crews: in particular, for pilots learning to fly different types of aircraft, and in several skills such as overcome intermittent Attitude Indicator (AI) errors and the ability to maintain control of the aircraft during instrument failures in adverse weather conditions. Copa also had to reconfigure the operations of its fleet until it became one of the most modern and safest airlines in the Americas.
As of September 2010, Flight 201 was still used as a valid flight number on the same flight path, which is operated by an Embraer E-190. However, the airline followed standard aviation procedures and no longer uses CM200 and CM201 flight numbers for the Panama-Cali route, respectively.
The accident remains as the deadliest plane crash in Panamanian aviation and Copa Airlines' history as of June 2014.
As a result of the accident, the relatives of those who perished in the crash filed forty-nine wrongful death lawsuits against Lucas Aerospace, one of the part suppliers of the Boeing 737. The case was settled out of court for an undisclosed amount.
On 1993, one of the relatives of Clariza Bernal Luna, one of the US passengers that were on the flight, filled a lawsuit against Copa Airlines in a Texas federal court; alleging that the airline had sold a ticket to the passenger through a travel agency in Houston, although the airline has no operations center in Texas. The case was eventually dismissed by the court on March 30, 1994.
A year after the crash, the story of the crash of Flight 201 and its investigation was featured in a WGBH, BBC, and NDR documentary. It was screened in the United States in the PBS NOVA series as Mysterious Crash of Flight 201 on 30 November 1993, and in the United Kingdom in the Horizon series as Air Crash - The Deadly Puzzle on 14 February 1994.
- List of accidents and incidents on commercial airliners grouped by location
- Boeing 737 rudder issues
- "HP-1205CMP COPA Boeing 737-204(A) - cn 22059 / ln 631 - Planespotters.net". planespotters.net. Retrieved 2008-09-06.
- "NOVA: The Mysterious Crash Of Flight 201". The Internet Movie Database. Retrieved 2010-07-28.
- "47 Killed in Crash of Panama Airliner". Los Angeles Times. Retrieved 2012-08-16.
- El Tiempo (June 11, 2012). "Explosión en avion: fallecen 47 personas". Retrieved June 11, 2012.
- "Official: Ill-fated plane was caught in electrical storm". New Straits Times. 9 June 1992.
- "Panama Plane Wreckage Found". Manila Standard. 9 June 1992.
- "Jungle hampers crash site efforts". The Victoria Advocate. 9 June 1992.
- "47 are killed in crash of Panama jet". The Spokesman-Review. 8 June 1992.
- ABC Hemeroteca (June 8, 1992). "Un Boeing 737 panameño se estrella en la selva con 47 personas a bordo". Retrieved August 26, 2013.
- "Safety slurs are refuted by USAir official". Reading Eagle. 28 January 1995.
- BFI Database
- PlaneCrashInfo.Com - COPA Flight 201 Entry
- Airliners.Net - Pictures of the plane when it was owned by Britannia Airways
- MyAviation.Net - Picture of the plane when it was owned by Copa Airlines
- Accident description at the Aviation Safety Network
- AirDisaster.Com - COPA Flight 201 Entry