Aeroperú Flight 603 Explained

Occurrence Type:Accident
Aeroperú Flight 603
Image Upright:1.2
Type:Crashed into ocean following instrument failure
Site:Pacific Ocean, northwest off Lima, Peru
Coordinates:-11.8167°N -128°W
Aircraft Type:Boeing 757-23A
Origin:Miami International Airport
Miami, Florida, United States
Stopover0:Mariscal Sucre International Airport (former)
Quito, Ecuador
Last Stopover:Jorge Chavez International Airport
Lima, Peru
Destination:Arturo Merino Benítez International Airport
Santiago, Chile
Operator:Aeroperú
Iata:PL603
Icao:PLI603
Callsign:AEROPERU 603
Tail Number:N52AW
Occupants:70
Passengers:61
Crew:9
Fatalities:70
Survivors:0

Child:yes
Accused:Eleuterio Chacaliaza, four others
Convicted:Eleuterio Chacaliaza
Verdict:
Charges:Negligent homicide
Sentence:Chacaliaza:
2-year suspended sentence

Aeroperú Flight 603 (PL603/PLI603) was a scheduled passenger flight from Miami International Airport in Miami, Florida, to Arturo Merino Benítez International Airport in Santiago, Chile, with stopovers in Quito, Ecuador, and Lima, Peru. On October 2, 1996, the Boeing 757-23A aircraft flying the final leg of the flight crashed into the Pacific Ocean. There were no survivors among 70 people on board.

Flying over water, at night, with no visual references, the pilots were unaware of their true altitude, and struggled to control and navigate the aircraft. The investigation determined that the air data computers were unable to show correct airspeed and altitude on cockpit displays because a maintenance worker had failed to remove tape covering the pitot-static system ports on the aircraft exterior.

Overview

Aircraft

The aircraft, a Boeing 757-23A was delivered new from Boeing on December 2, 1992, to Ansett Worldwide. It was leased to Aeroméxico on 27 September 1993 and then sub-leased to Aeroperú on April 1, 1994. The lease transferred back to Ansett in February 1995, and Aeroperú continued to operate the aircraft until it crashed.[1] [2]

Crew

The captain was 58-year-old Eric Schreiber Ladrón de Guevara, who had logged almost 22,000 flight hours (including 1,520 hours on the Boeing 757).[3] The first officer was 42-year-old David Fernández Revoredo, who had logged almost 8,000 flight hours, with 719 of them on the Boeing 757.

Accident

On October 1, 1996, Aeroperú Flight 603 from Miami International Airport had landed at the Lima Airport. There were 180 passengers on the first leg of the flight on a Boeing 757. Of those, 119 had exited the plane, and the remaining passengers were transferred to another Boeing 757.

This aircraft took off 42 minutes after midnight (05:42 UTC) on October 2, and the crew immediately discovered that their basic flight instruments were behaving erratically, and reported receiving contradictory serial emergency messages from the flight management computer, including the altitude and airspeed indicator, rudder ratio, mach speed trim, overspeed, underspeed and flying too low. The crew declared an emergency and requested an immediate return to the airport.[4]

The pilots incorrectly believed that they could figure out the actual aircraft altitude by asking the controller, but neither the pilots nor the controller realized that the altitude information displayed on the controller's screen was sent from the aircraft's Mode C Transponder. As the transponder was receiving the same erroneous altitude information being displayed on the aircraft's altimeter, the altitude on the controller's display was also incorrect.[4]

Faced with a lack of reliable basic flight instrument readings, constant contradictory warnings from the aircraft's flight computer (some of which were valid and some of which were not) and believing that they were at a safe altitude,[3] the crew decided to begin descent for the approach to the airport. Since the flight was at night over water, no visual references were available to convey to the pilots their true altitude or to aid their descent. As a consequence of the pilots' inability to precisely monitor the aircraft's airspeed or vertical speed, they experienced multiple stalls, resulting in rapid loss of altitude with no corresponding change on the altimeter. While the altimeter indicated an altitude of approximately 9700feet, the aircraft's true altitude was much lower.

The air traffic controller instructed a Boeing 707 to take off and to help guide the 757 in to land, but it was too late. The 757's left wingtip clipped the water approximately 25 minutes after the emergency declaration, tearing off a part of the left wing. The pilots desperately clawed for altitude and managed to get the 757 airborne again for 19 seconds, but due to the damage to the left wing the aircraft rolled over and slammed into the water near-inverted.[5] All 70 passengers and crew died.[6] [7]

Passengers

About half of the passengers on the flight were Chileans returning to Chile.[8] [9]

Nation Number
Chile30
Colombia1
Ecuador2
Italy2
Mexico6
New Zealand1
Peru20
Spain1
United Kingdom2
United States4
Venezuela1
Total 70

Of the passengers, 21 originated from Miami; all of the originating passengers were Chilean. An additional 10 passengers had boarded in Quito. The remaining passengers had boarded in Lima.[10]

Aftermath

After the accident, Aeroperú changed the number of its evening Miami-Lima-Santiago Boeing 757 service to Flight 691.[11]

Search, rescue, and recovery

After the crash, recovery crews found nine bodies floating, but 61 bodies had sunk with the aircraft.

Investigation

The Commission of Accident Investigations (CAI) of the Director General of Air Transport (DGAT) of Peru wrote the final accident report.[12]

The chief Peruvian accident investigator, Guido Fernández Lañas, was the uncle of the co-pilot, David Fernández. There were some reservations about the potential conflict of interest, but the National Transportation Safety Board-appointed investigator, Richard Rodriguez, determined that Fernández Lañas could properly investigate the accident.[4]

The Peruvian Navy collected the floating wreckage. After the Peruvian authorities asked for assistance, the United States Navy provided equipment to locate the underwater wreckage of the Boeing 757 and retrieve its flight data recorder and cockpit voice recorder.[4]

Later investigation into the accident revealed that adhesive tape had been accidentally left over some or all of the static ports (on the underside of the fuselage) after the aircraft was cleaned and polished, eventually leading to the crash. Employee Eleuterio Chacaliaza had left the tape on by mistake.[13]

The static ports are vital to the operation of virtually all of those flight instruments that provide basic aerodynamic data such as airspeed, altitude and vertical speed, not only to the pilots but also to the aircraft's computers, which provide additional functions, such as warnings when flight characteristics approach dangerous levels. The blockage of all of the static ports is one of the few common-failure modes resulting in total failure of multiple basic flight instruments and as such is regarded as one of the most serious faults that can occur within the avionics systems.[14]

The design of the aircraft did not incorporate a system of maintenance covers for the static ports. Such covers are commonly employed in aviation for blocking access to critical components when the aircraft is not in operation and are generally a bright color and carry flags (which may have "remove before flight" markings). Instead, the design of the aircraft and the relevant maintenance procedure called for the use of adhesive tape to cover the ports.[14]

As a result of the blocked static ports, the basic flight instruments relayed false airspeed, altitude and vertical speed data. Because the failure was not in any of the instruments, but rather in a common supporting system, thereby defeating redundancy, the erroneous altimeter data was also broadcast to air traffic control, which was attempting to provide the pilots with basic flight data. This led to extreme confusion in the cockpit as the pilots were provided with some data (altitude) which seemed to correlate correctly with instrument data (altimeter) while the other data provided by ATC (approximate airspeed) did not agree. Although the pilots were quite cognizant of the possibility that all of the flight instruments were providing inaccurate data, the correlation between the altitude data given by ATC and that on the altimeter likely further compounded the confusion. Also contributing to their difficulty were the numerous cockpit alarms that the computer system generated, which conflicted both with each other and with the instruments. This lack of situational awareness was revealed by the cockpit voice recorder transcript.[15] That the flight took place at night and over water, thus not giving the pilots any visual references, was also identified as a major factor.[14] The official accident report concluded that the flight crew, distracted by the conflicting warnings, did not heed the radar altimeter reading after descending through 2500feet.

Legal settlement

Mike Eidson, an American attorney, represented 41 passengers and crew in a lawsuit contending that the aircraft's manufacturer, Boeing, bore responsibility for the disaster, as the company ought to have foreseen the misuse of its products.[4] [16] The suit was filed against Boeing in federal court in Miami in May 1997. According to the complaint, the flightdeck errors were caused by careless maintenance by Aeroperú and negligence and defective design by Boeing. Boeing argued that it was not at fault, and that responsibility for the accident lay with the employee who did not remove the tape from the static ports, and the aircraft's pilot for not noticing the tape still applied by visual check. Richard Rodriguez of the NTSB said that it was understandable that Schreiber did not find the tape because the maintenance worker had used duct tape instead of the brightly colored tape that he was supposed to use. In addition, Rodriguez said that the pitot-static ports were high above the ground, meaning that Schreiber could not have seen the tape against the fuselage.[4] After extensive litigation, the parties agreed to transfer the case against Boeing and Aeroperú to an international arbitration in Santiago, for a determination of the damages. The defendants agreed to not contest liability in Chile.[16]

On December 13, 1999, family members of the flight's passengers received one of the largest compensations stemming from an aviation accident outside the United States aboard a non-U.S. carrier, averaging nearly $1 million per victim.[4] Mayday stated that the manner of the crash resulting in the passengers' drowning was responsible for the large settlements.[4]

Criminal prosecution

Chacaliaza was convicted in Peru for negligent homicide and given a two-year suspended sentence in 1998.[17] Four other defendants were acquitted. Chacaliaza said he would appeal the ruling, claiming that sabotage brought down the plane and that he had removed the adhesive tape.[18]

Peruvian air accident investigator Guido Fernández criticized the ruling, stating that the maintenance worker was relatively uneducated and had little understanding of what he did. Fernández argued that his supervisors bore more responsibility, yet Chacaliaza was the one prosecuted by the system.[4]

In popular culture

See also

Similar events

External links

Notes and References

  1. Web site: N52AW Aeroperú Boeing 757-200 . 2020-05-15 . www.planespotters.net.
  2. Web site: AeroPeru N52AW (Boeing 757 - MSN 25489) (Ex XA-SKR XA-SME). www.airfleets.net. Airfleets aviation. 2020-05-15.
  3. Web site: ACCIDENT OF THE BOEING 757-200 AIRCRAFT OPERATED BY EMPRESA DE TRANSPORTE AÉREO DEL PERÚ S.A. AEROPERÚ . live . https://web.archive.org/web/20121202020838/http://www.skybrary.aero:80/bookshelf/books/1719.pdf . 2012-12-02 . 2018-12-29 . Accident Investigation Board, Directorate General of Air Transport, Ministry of Transportation and Communications . SKYbrary.
  4. "Flying Blind", Mayday [documentary TV series] - Posted on the official verified YouTube channel of Wonder Documentaries, a part of Little Dot Studios Network, a subsidiary of All3Media. At 3:04 the narrator states "Most [passengers] are Chileans on their way home." The portion where Richard Rodriguez speaks of how he accepted Guido Fernandez's participation is at 33:20/51:42. The part where Rodriguez discusses his view on how Schrieber missed the tape is at 45:28/51:42. Eidson speaks about the manner of death at 49:09/51:42 (the Mayday narrator stating that the manner of death caused the large settlement was around 48:30). The part where Fernandez discusses his view of the maintenance worker's culpability is at 46:10/51:42. Rodriguez, Guido Fernandez, and Eidson are shown directly speaking in the documentary.
  5. Web site: r/CatastrophicFailure - Aeroperu 603 CVR Recording from 1996, in which a 757's flight computers are deprived of critical information and fail over the ocean at night, resulting in 70 deaths 30 minutes later.. 18 February 2017. 2021-07-04.
  6. Web site: Case Study: Aero Peru 603. code7700.com. 2020-05-15.
  7. News: 1996-10-03. 70 on Peru Jet Believed Dead After Crash In the Pacific. The New York Times. Associated Press. 2020-05-15. 0362-4331.
  8. News: October 2, 1996. Searchers comb Pacific for more bodies after Peruvian crash. 11 June 2009. CNN. There were 30 Chileans,[...].
  9. Web site: October 3, 1996. Murieron 70 personas en un avión peruano que cayó al mar. 70 people died in a Peruvian plane that fell into the sea. dead. https://web.archive.org/web/20110708162152/http://edant.clarin.com/diario/96/10/03/E-04401d.htm. 2011-07-08. 11 June 2009. Clarín Digital. es. Integraban la lista 30 chilenos,[...].
  10. Web site: 2 October 1996. CRONICA. CHRONICLE. dead. https://web.archive.org/web/20010513232451/http://www.copesa.cl/DE/1996/_Des1996/10_02/cronica.html. 13 May 2001. 11 June 2009. Consorcio Periodístico de Chile S.A.. es.
  11. Volando (Aeroperú's inflight magazine), Issue 17, July–August 1997
  12. Book: Walters. James M.. Aircraft Accident Analysis: Final Reports. Sumwalt III. Robert L.. 2000-02-16. McGraw Hill Professional. 978-0-07-137984-7. 98. Robles, Ricardo, Presidente, Commission of Accident Investigations (CAII), Director General of Air Transport (DGAT) of Peru. 1996. Final report, Boeing 757-200 Accident, Aeroperu, 2 October 1996. Lima, Peru.. Robert L. Sumwalt (U.S. government official). 11 May 2011. Google Books.
  13. News: 22 January 1998. World News Briefs; $29 Million for Victims Of 1996 Peru Air Crash. The New York Times. Reuters. 11 June 2009. 0362-4331.
  14. Book: Casey, Steven. The Atomic Chef, Caught on Tape. Aegean Publishing Company. 2006. 9780963617866. Santa Barbara. 131.
  15. Web site: Close-Up: Aeroperu 603 Voice Recorder Transcription (English Translation). avweb.com. 28 April 1997. 26 May 2015.
  16. Web site: December 13, 1999. Aeroperu Crash Victims Win Landmark Award. live. https://web.archive.org/web/20200205140254/https://www.colson.com/press-releases/aeroperu-crash-victims-win-landmark-award/ . 2020-02-05 . June 1, 2009. Colson Hicks Eidson. Law Firm Colson Hicks Eidson Attorneys.
  17. Web site: DEUDOS DEL ACCIDENTE AEROPERU PIDEN MAYOR REPARACION CIVIL. 1998-08-11. cdn.preterhuman.net. es. DEBT OF THE AIRCRAFT ACCIDENT REQUEST GREATER CIVIL REPAIR. 2020-05-15.
  18. News: AEROPERÚ INDEMNIZA VÍCTIMAS DE ACCIDENTE. 1998-01-22. El Tiempo. es. AIRPORT INDEMNIFIES VICTIMS OF ACCIDENT. 2020-05-15.
  19. Flying Blind. Mayday. Discovery Channel Canada / National Geographic Channel. 1. 4. 2003.
  20. Who's Flying the Plane?. Mayday. Discovery Channel Canada / National Geographic Channel. 6. 3. 2007.
  21. News: Step inside the cockpit of six real-life air disasters. New York Post. January 26, 2014. March 26, 2018.