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Aeroperú Flight 603

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1996 aviation accident

Aeroperú Flight 603
N52AW, the aircraft involved in the accident, photographed in Miami in January 1996
Accident
Date2 October 1996 (1996-10-02)
SummaryCrashed into ocean following instrument obstruction
SitePacific Ocean, 89 km (55 mi) northwest off Lima, Peru
11°49′S 77°51′W / 11.817°S 77.850°W / -11.817; -77.850
Aircraft
Aircraft typeBoeing 757-23A
OperatorAeroperú
IATA flight No.PL603
ICAO flight No.PLI603
Call signAEROPERU 603
RegistrationN52AW
Flight originMiami International Airport
Miami, Florida, United States
1st stopoverMariscal Sucre International Airport (former)
Quito, Ecuador
Last stopoverJorge Chavez International Airport
Lima, Peru
DestinationArturo Merino Benítez International Airport
Santiago, Chile
Occupants70
Passengers61
Crew9
Fatalities70
Survivors0
AccusedEleuterio Chacaliaza, four others
ConvictedEleuterio Chacaliaza
ChargesNegligent homicide
Verdict
SentenceChacaliaza:
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.

Background

Aircraft

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

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). 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.

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.

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, 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 9,700 feet (3,000 m), 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. All 70 passengers and crew died.

Passengers

About half of the passengers on the flight were Chileans returning to Chile.

Nation Number
Chile 30
Colombia 1
Ecuador 2
Italy 2
Mexico 6
New Zealand 1
Peru 20
Spain 1
United Kingdom 2
United States 4
Venezuela 1
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.

Aftermath

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

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.

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.

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.

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.

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.

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.

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. 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. The official accident report concluded that the flight crew, distracted by the conflicting warnings, did not heed the radar altimeter reading after descending through 2,500 feet (760 m).

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. 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. 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.

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. Mayday stated that the manner of the crash resulting in the passengers' drowning was responsible for the large settlements.

Criminal prosecution

Chacaliaza was convicted in Peru for negligent homicide and given a two-year suspended sentence in 1998. 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.

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.

In popular culture

See also

Similar events

Notes

  1. 11 passengers and 9 crew

References

  1. ^ "ACCIDENT OF THE BOEING 757-200 AIRCRAFT OPERATED BY EMPRESA DE TRANSPORTE AÉREO DEL PERÚ S.A. AEROPERÚ" (PDF). Accident Investigation Board, Directorate General of Air Transport, Ministry of Transportation and Communications. Archived (PDF) from the original on 2 December 2012. Retrieved 29 December 2018 – via SKYbrary.
  2. "N52AW Aeroperú Boeing 757-200". www.planespotters.net. Retrieved 15 May 2020.
  3. "AeroPeru N52AW (Boeing 757 - MSN 25489) (Ex XA-SKR XA-SME)". www.airfleets.net. Airfleets aviation. Retrieved 15 May 2020.
  4. ^ "Flying Blind", Mayday - 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 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. "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. Retrieved 4 July 2021.
  6. "Case Study: Aero Peru 603". code7700.com. Retrieved 15 May 2020.
  7. "70 on Peru Jet Believed Dead After Crash In the Pacific". The New York Times. Associated Press. 3 October 1996. ISSN 0362-4331. Retrieved 15 May 2020.
  8. "Searchers comb Pacific for more bodies after Peruvian crash". CNN. 2 October 1996. Retrieved 11 June 2009. There were 30 Chileans,
  9. "Murieron 70 personas en un avión peruano que cayó al mar" [70 people died in a Peruvian plane that fell into the sea]. Clarín Digital (in Spanish). 3 October 1996. Archived from the original on 8 July 2011. Retrieved 11 June 2009. Integraban la lista 30 chilenos,
  10. "CRONICA" [CHRONICLE]. Consorcio Periodístico de Chile S.A. (in Spanish). 2 October 1996. Archived from the original on 13 May 2001. Retrieved 11 June 2009.
  11. Volando (Aeroperú's inflight magazine), Issue 17, July–August 1997
  12. Walters, James M.; Sumwalt III, Robert L. (16 February 2000). Aircraft Accident Analysis: Final Reports. McGraw Hill Professional. p. 98. ISBN 978-0-07-137984-7. Retrieved 11 May 2011 – via Google Books. 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.
  13. "World News Briefs; $29 Million for Victims Of 1996 Peru Air Crash". The New York Times. Reuters. 22 January 1998. ISSN 0362-4331. Retrieved 11 June 2009.
  14. ^ Casey, Steven (2006). The Atomic Chef, Caught on Tape. Santa Barbara: Aegean Publishing Company. p. 131. ISBN 9780963617866.
  15. "Close-Up: Aeroperu 603 Voice Recorder Transcription (English Translation)". avweb.com. 28 April 1997. Retrieved 26 May 2015.
  16. ^ "Aeroperu Crash Victims Win Landmark Award". Colson Hicks Eidson. Law Firm Colson Hicks Eidson Attorneys. 13 December 1999. Archived from the original on 5 February 2020. Retrieved 1 June 2009.
  17. "DEUDOS DEL ACCIDENTE AEROPERU PIDEN MAYOR REPARACION CIVIL" [DEBT OF THE AIRCRAFT ACCIDENT REQUEST GREATER CIVIL REPAIR]. cdn.preterhuman.net (in Spanish). 11 August 1998. Retrieved 15 May 2020.
  18. "AEROPERÚ INDEMNIZA VÍCTIMAS DE ACCIDENTE" [AIRPORT INDEMNIFIES VICTIMS OF ACCIDENT]. El Tiempo (in Spanish). 22 January 1998. Retrieved 15 May 2020.
  19. "Flying Blind". Mayday. Season 1. Episode 4. 2003. Discovery Channel Canada / National Geographic Channel.
  20. "Who's Flying the Plane?". Mayday. Season 6. Episode 3. 2007. Discovery Channel Canada / National Geographic Channel.
  21. "Step inside the cockpit of six real-life air disasters". New York Post. 26 January 2014. Retrieved 26 March 2018.

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Aviation accidents and incidents in Peru
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Aviation accidents and incidents in 1996 (1996)
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