ASN Aircraft accident Boeing 737-204 Advanced HP-1205CMP Tucutí
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Status:Accident investigation report completed and information captured
Date:Saturday 6 June 1992
Time:21:00
Type:Silhouette image of generic B732 model; specific model in this crash may look slightly different
Boeing 737-204 Advanced
Operator:COPA Panama - Compañía Panameña de Aviación
Registration: HP-1205CMP
MSN: 22059/631
First flight: 1980-01-15 (12 years 5 months)
Total airframe hrs:45946
Cycles:17845
Engines: 2 Pratt & Whitney JT8D-15
Crew:Fatalities: 7 / Occupants: 7
Passengers:Fatalities: 40 / Occupants: 40
Total:Fatalities: 47 / Occupants: 47
Aircraft damage: Destroyed
Aircraft fate: Written off (damaged beyond repair)
Location:13 km (8.1 mls) SW of Tucutí (   Panama)
Phase: En route (ENR)
Nature:International Scheduled Passenger
Departure airport:Panama City-Tocumen International Airport (PTY/MPTO), Panama
Destination airport:Cali-Alfonso Bonilla Aragón Airport (CLO/SKCL), Colombia
Flightnumber: 201
Narrative:
A Boeing 737-204 aircraft, operated by COPA Panama, was destroyed when it crashed near Tucutí, Panama. All 40 passengers and seven crew members were killed.
COPA Flight 201 took off from runway 21L at Panama City-Tocumen International Airport at 20:36. Destination of the flight was Cali, Colombia. The flight intercepted Airway A321 and climbed to the cruising altitude of FL250. At 20:46 the flight contacted the Panama City controller and requested weather information.
The controller reported that there was an area of very bad weather at 30-50 miles. Last radio contact was at 20:48 when the crew reported reaching FL250.
During the flight there was an intermittent failure of the main attitude indicator due to a short circuit. This was not noticed by the flight crew, who attempted to adjust the aircraft attitude based on the false information from the attitude indicator.
They lost control of the aircraft which entered a steep descent and started to disintegrate at FL100, and impacting the ground 80 degrees nose down.

Probable Cause:

The probable causes of this accident include:
a) loss of control of the aircraft because the flight crew followed false information from an attitude indicator that operated intermittently.
b) lack of visible horizon during cruise flight due to night and approaching bad weather.
c) insufficient cross-checking between the primary and emergency (stand-by) attitude indicators to identify intermittent attitude errors and to select a reliable source of (correct) attitude information.
d) non-standard cabin configurations between aircraft in the fleet of the company, which required the crew to determine how to set the switches based on the aircraft was being operated at the time.
e) incomplete ground crew training simulator, as it did not present "differences between aircraft" and "crew resource management" in sufficient detail to give the crew knowledge to overcome intermittent attitude indicator errors and to maintain control of the aircraft.

Classification:
ADI issues
Loss of control

Sources:
» Final Report released by the Directorate of Civil Aviation, Panama


Photos

photo of Boeing-737-204-G-BGYL
accident date: 06-06-1992
type: Boeing 737-204
registration: G-BGYL
 

Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Panama City-Tocumen International Airport to Cali-Alfonso Bonilla Aragón Airport as the crow flies is 695 km (434 miles).
Accident location: Exact; as reported in the official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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Boeing 737-200

  • 1114 built
  • 54th loss
  • 32nd fatal accident
  • 16th worst accident (at the time)
  • 33rd worst accident (currently)
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 Panama
  • The worst accident
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