Copa Airlines Flight 201
A 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.
Aircraft and crew
The aircraft was a 12-year-old twin-engined Boeing 737-204 Advanced, registration 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 as 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 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 the severe weather ahead. The new route would take 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 made a request to turn back to Tocumen, which was granted.
However, two minutes later and while flying at 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 while accelerating towards the ground. Despite the attempts by Capt. Chial and the 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 from the aircraft. Flight 201 crashed into a jungle area within the Darien Gap at 486 knots (560 miles per hour), instantly killing everyone still on board.
At 20:57 PM, Tocumen air traffic control tried unsuccessfully to make contact with flight until it received a radio message from a KLM DC-10 aircraft that was approaching the airport, reporting that they intercepted a 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’s fuselage were scattered in a radius of 10 km, the recovery process was extensively difficult. After investigators reached the crash site, the investigation to find the cause 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.
Examination and investigation
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 flight 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.
Another factor contributing to the crash was the non-standard cockpit configurations between aircraft in the fleet of the company, which caused confusion to the pilots about determining the setting of the AI switches, based on the aircraft that was being operated at the time.
Despite bearing some similarities to other incidents related to the Boeing 737 during the 1990s (such as United Airlines Flight 585), the possibility of rudder deflection in flight was discarded as a possible cause of the crash. However, Flight 201 was registered on the category of "accidents related to 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, Zosimo Guardia.
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.
The accident remains as the deadliest plane crash in Panamanian aviation and Copa Airlines' history as of July 2015.
As a result of the accident, the relatives of those who perished in the crash filed 49 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.
In 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
- Korean Air Cargo Flight 8509
- "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.
- 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