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1992 crash of Copa Airlines 737 in South America in storm encounter

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1992 crash of Copa Airlines 737 in South America in storm encounter

Old 18th Oct 2012, 02:48
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1992 crash of Copa Airlines 737 in South America in storm encounter

Having Googled this accident, it seems the 737 penetrated a thunderstorm and lost control hitting the deck vertically. The official accident investigation report would be most instructive in the context of a simulator instruction subject. Google links are too brief to obtain useful information and I wondered if someone could send me the link to the official report on the accident? Thanks in advance.

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Old 18th Oct 2012, 14:25
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Copa 201 /6Jun92

The _investigation_ of Copa 201 was interrupted by political changes in Panama. Recall this was at a time prior to the web -- so information was mostly exchanged via personal communication with participants. During that decade, the Boeing-coordinator [D.R.] was available at later accidents -- so his recollections helped fill-in some of the wiring issues with the V/G [Both-on-One selector]. At the USA's ntsb, Hauter followed the investigation [see the Nova program]. Note the similarities with the Waldo Lynch upset (proximity near cells, one-pilot out-of-seat, V/G display). Also note the design weakness of the Both-on-One switch-logic [contrasted against the better Right-on-Aux design].

== Edit, there was an earlier thread discussing LOST ATTitude input to an Autopilot or ADI. See message #25, http://www.pprune.org/rumours-news/3...blished-2.html

Here are my notes [prior to release of a Spanish AAR]:

Copa Flt 201 / 6Jun92 2100 EST [date from NTSB file and Flt Int'l. ] B737-204, HP-1205, [ msn 22059 / ff. Jan.15.1980 Official registration was HP-1205CMP, N1205 doesn't exist for a 737. HP-1205CMP was leased from Britannia AW on Apr.10.1992, only 7 weeks before the crash.(Jan R)], all killed sob = 47 = 7+40, in flight structural failure; rudder system inspection alert [per RAeS "Aerospace" Jun93, pg 31 table entry].

telecom' 7/12/93: NTSB's Tom Haueter had went to site. Over Darien Jungle on the Panamanian-Colombian border; aircraft was outside of thunderstorm, upset and over-speed led to inflight breakup; he stated that no info from CVR tape was available, but FDR data was good. Panamanian investigation report expected shortly [that was in Dec '93 but AAR still not released by Aug'95], and NTSB will distribute the Panamanian's report for the USA readers.

Marian Marzynski (produced TV's NOVA, "Mysterious Crash of Flight 201" broadcast 30Nov93 on PBS ) stated FL250, WX avoided, No CVR data, FDR OK, suspect bad gyro-Attitude display (possible gyro switched from faulted-"Both On One").

Flt Int'l reported 80 degrees nose down at 10000 feet.

NTSB-OPI sent "factual" rpt from US NTSB, sent 8Aug95, but full AAR not published yet. USA-NTSB examined "wire segment with detached connector reported to be the wire for the pitch signal from vertical amplifier to ADI. . . . fractured wire elements were heavily necked down indicative of ductile tensile overstress separations . . . fracture of the wire was just outside the crimp position in the connector . . ."

Aug'95 T Haueter explained that a change in the Panamanian government led to a sweep-out of investigators employed by govt. T Haueter expects AAR will conclude ADIs were switched to BOTH ON ONE, with a erroneous signal then feeding both main attitude displays. TH says that investigators did conclude that a specific component was identified as defective (wire-connector), and that distorted signal from VG.]

Included in MM's film about the Copa 201 investigation was a segment in which the team re-examined the specific wire fractures, reviewed MM's film of their initial examination, then concluded that they were distracted by specific wire damage that seemed unrelated to their initially hypothesized failure sequence.

So, the Copa CVR was INOP -- no record of cockpit conversation. There was recovered the OVHD Panel with the Gyro Switch in "Both-on-One" (but no one was sure if the Indians had found it in that state). [DR claims that relays in the E&E bay verified Both-on-One selection.]

From examination of the wreckage (wire bundle), USA's NTSB metallurgist (Marx) concluded that fractured wire elements "were heavily necked down indicative of ductile tensile overstress separations. Microscopic examination inside the mating connector disclosed 18 wire elements displaying similar fracture features ... no evidence of electrical arcing inside the connector or at wire elements." That wire segment "reported to be the wire for the pitch signal from vertical amplifier to ADI." (Quoted from Marx's rpt).

Jun'96, Bob MacIntosh: Panamanian investigative agency has NOT yet released the official AAR on Copa 201. Purported pressure from ICAO, insiders believe that the Panamanians WILL complete an AAR (but the delay is an embarrassment). Official AAR may come from Panama within the next year.

= = = = Spanish-language AAR = = = =

Boeing 737-204, accident at Cerca de Tucuti, Darien, Panama, on 6Jun92 (ICAO Ref 0122/92). _Aircraft Accident Digest_, Volume #39, “1992” [cover shows a year-date of publication as 2003], ICAO Circular 296-AN/170, pgs 168-193. Report released by the Directorate of Civil Aviation, Panama; this report appears in Spanish (no English translation offered), ICAO’s “AAD” offered _no_ date as to when this report was actually released by the Directorate.

From Section 3, Conclusiones:

“R. Un corto circuito intermitente fue encontrado en el embobinado del sincronizador de tonel del Giro Vertical, el cual era causado por un alambre pinchado contra la armadura. La perdida de voltaje hacia el sincronizador de tonel causaria al respective Indicador Direccional de Actitud que se congelara o se trabara en posicion.”

“S. El interruptor del giro vertical se encontro en la escena del accidente en la posicion de ambos en VG-1, (both on VG-1). Se determino que el interruptor del giro vertical fue movido de la posicion NORMAL a la de ambos on VG-1 (both on VG-1) ya sea antes del despeque o durante el vuelo, mas probablemente durante el vuelo, y que la tripulacion de vuelo detecto un error intermitente de actitud en sus instrumentos de vuelo.”

“T. El Primer Oficial pudo haber sido el piloto volando al momento de iniciarse la indicacion de error de actitud, debido a que le Capitan fue encontrado en la aeronave accidentada sin indicios de tener el cinturon de seguridad puesto, y se encontro tambien una bandeja de comida en la cabina de vuelo.”

“V. Lo mas probable es que el indicador de actitud de Emergencia (Stand-by) estaba disponible a la tripulacion de vuelo durante la falla intermitente del sistema primario del Capitan, ya que el dano post-impacto presentado por el indicador de emergencia (Stand-by) indicaba que estaba operando al momento del impacto con el suelo.”

“W. El indicador de actitud de emergencia (stand-by) no fue utilizado exitosamente para identificar el error de actitud en los instrumentos primaries de vuelo y mantener el control del vuelo debido a que el procedimiento de entrenamiento y de simulador de la compania era llevado a cabo en una configuracion de cabina distinta a la de la aeronave accidentada, y este entrenamiento introdujo un elemento de confusion.”

“X. La estandarizacion de las cabinas de la flota es un factor en este accidente, debido a que la tripulacion de vuelo repitio acciones anteriores aprendidas en el simulador para seleccionar una fuente alterna de guia que hubiera sido apropiada para algunas aeronaves de COPA con una fuente VG auxiliary, pero en la aeronave accidentada, el movimiento del interruptor de VG a la posicion de ambos en VG-1 (both on VG-1) resulto en la perdida de referencia procedente de VG-2, y en mayor confusion.”

Section 3.1 “Causas”

Las causas probables de este accidente incluyen:

“a) perdida de control de la aeronave debido a que la tripulacion de vuelo siguio informacion falso proveniente de un indicador de actitud que operaba de manera intermitente.”

“b) la falta de horizonte visible al nivel de vuelo de crucero, debido a las condiciones nocturnas y al mal tiempo proximo.”

“c) verificacion cruzada insuficiente entre los sistemas primaries de indicacion de actitud y el indicador de actitud de emergencia (stand-by) para identificar el error de actitud inter mitente, y para seleccionar una fuente confiable (correcta) de informacion de actitud.”

“d) configuraciones de cabina no estandarizadas entre las aeronaves de la flota de la compania, lo cual requirio que la tripulacion determinara la manera de colocar los interruptores en base a la aeronave que estaba siendo operada en el momento.”

“e) entrenamiento de tripulacion en tierra y en simulador incompleto, ya que no presentaba “direrencias entre aeronaves” y “manejo de recursos de tripulacion” en detalle suficiente para brindarle a la tripulacion concimiento para superar los errors intermitentes en la indicacion de actitud y para mantener el control de la aeronave.”

Last edited by IGh; 19th Oct 2012 at 23:03. Reason: Added link to earlier discussion on ATT-switching
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Old 19th Oct 2012, 01:59
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Thanks very much IGh. Presumably the standby ADI worked normally so it makes you wonder about the company training that the pilot did not immediately use the standby ADI within seconds of realising the primary ADI was giving erroneous info. Having made that comment I realise it is wide open to criticism that this Ppruner has yet to read the final accident report.
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