COPA Airlines 1992

1. REPORT ON
FLIGHT ACCIDENT
OCCUR DUE TO
INSTRUMENT FAILURE
Submitted by:-
ROSHAN SAH (1NT13AE052)

2. Accident summary:-
Date:- 06 June 1992
Site:- Darian Gap, Panama
Coordinate:- 7°58’59.09”N 77°56’0.16’’W
Passenger:- 40
Crew:- 7
Fatalities:-47(all)
Aircraft type:- Boeing 737-204 Advanced
Operator:- Copa Airlines
Registration:- HP-1205CMP
Flight origin:- Tocumen International Airport
Destination:- Alfonso Bonilla Aragon International Airport
Cause of Accident:- Spatial distortion due to Instrument Malfunction
Introduction:-
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 take-off, killing all
47 people on board. The in-flight break-up was caused by faulty

3. 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 (and to date, only) fatal crash in the history of
Copa Airlines.
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 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.
Crash:-
Flight 201 took off from runway 21L at Tocumen International
Airport in Panama City at 20:37 (8:37 p.m.) 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 (8:47 p.m.), 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 (50-80 kilometres) from their
position.

4. At 20:48 (8:48 p.m.), 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 (8:54 p.m.), Panama City control centre received a third
message from Capt. Chial, who reported problems with the
aeroplane 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 (7,620 metres), 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 (3,048
metres). 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,
900 kilometres per hour), instantly killing everyone still on
board.
At 20:57 (8:57 p.m.), 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
kilometres 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 centre 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

5. 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 (6.2
miles), the recovery process was extensively difficult. After
investigators reached the crash site, the investigation to find the
cause of the crash began.
Detail about Instrument
Fig:- Attitude Indicator
An attitude indicator (AI), also known as gyro
horizon or artificial horizon or attitude director
indicator (ADI, when it has a Flight Director), is
an instrument used in an aircraft to inform the pilot of the
orientation of the aircraft relative to Earth's horizon. It
indicates pitch(fore and aft tilt) and bank (side to side tilt) and is
a primary instrument for flight in instrument meteorological
conditions.

6. Attitude indicators are also used on manned spacecraft, where
they indicate the craft's yaw angle (nose left or right) as well as
pitch and roll, relative to a fixed-space inertial reference frame
The essential components of the indicator are:-
 "miniature airplane", horizontal lines with
a dot between them representing the
actual wings and nose of the aircraft.
 the center horizon bar separating the two
halves of the display, with the top half
usually blue in color to represent sky and
the bottom half usually dark to represent
earth.
 degree indices marking the bank angle.
They run along the edge of the dial. On a
typical indicator, there is a zero angle of
bank index, there may be 10 and 20
degree indices, with additional indices at
30, 60 and 90 degrees.
If the symbolic aircraft dot is above the horizon line (blue
background) the aircraft is nose up. If the symbolic aircraft dot
is below the horizon line (brown background) the aircraft is
nose down. The fact that the horizon moves up and down and
turns, while the symbolic aircraft is fixed relative to the rest of
the instrument panel, tends to induce confusion in trainees
learning to use the instrument; a standard mental corrective
provided by flight instructors is "Fly the little airplane, not the
horizon."
A 45 degree bank turn is made by placing the indicator
equidistant between the 30 and 60 degree marks. A 45 degree
bank turn is usually referred to as a steep turn.
The pitch angle is relative to the horizon. During instrument
flight, the pilot must infer the total performance by using other
instruments such as the airspeed indicator, altimeter,vertical
speed indicator, directional gyro, turn rate indicator, and power

7. instruments, e.g. an engine tachometer. "Performance =
Attitude + Power
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 over-stress, 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

8. 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".