AeroPeru Flight 603
Encyclopedia
Aeroperú
Flight 603 was a scheduled flight from Jorge Chávez International Airport
in Lima, Peru
(SPIM), to Comodoro Arturo Merino Benítez International Airport
in Santiago
, Chile
(SCEL), which crashed
on October 2, 1996.
The pilots struggled to navigate the aircraft after the failure of all the plane's instruments. With the pilots unaware of their true altitude, the plane's wing hit the water and it crashed shortly afterward. The cause of the instrument failure was a maintenance worker's failure to remove tape covering the static ports
necessary to provide correct instrument data to the cockpit.
airliner
crew discovered that their basic flight instruments
were behaving erratically and reported receiving contradictory serial emergency messages from the onboard computer, such as rudder ratio
, mach speed trim
, overspeed, underspeed
and flying too low
. The crew declared an emergency and requested an immediate return to the airport.
Faced with the lack of reliable basic flight instruments, 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, pilot Eric Schreiber and copilot David Fernández decided to cautiously begin descent for the approach to the airport. Since the flight was at night over water, no visual references could be made to convey to the pilots their true altitude or aid the pilots in the descent. Also, 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, the aircraft's true altitude was in fact much lower.
The air traffic control
ler had a Boeing 707
take off to help guide the 757 back to land. Before the 707 could reach the 757, the 757's wingtip struck the water approximately twenty-five minutes after emergency declaration, making the pilots realize the true altitude of the airliner; the pilots struggled with the controls and managed to get airborne again for twenty seconds, but the aircraft crashed inverted into the water. All nine crew members and sixty-one passengers died. It is unclear whether the pilots noticed the radar altimeter after passing through 2,500 feet, as no statement was made in the report.
After the crash recovery crews found nine bodies floating; the rest of the bodies sank with the airliner.
Of the passengers, 21 originated from Miami; all of the originating passengers were Chilean.
The Peruvian accident investigator, Guido Fernández, was the uncle of the co-pilot, David Fernández, but, despite originally holding some reservations about the potential conflict of interest, the National Transportation Safety Board
-appointed investigator, Richard Rodriguez, determined that he 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 and black boxes
of the Boeing 757.
Later investigation into the accident revealed that masking tape was accidentally left over some or all of the static ports
(on the underside of the fuselage
) after the aircraft was cleaned, eventually leading to the crash. Employee Eleuterio Chacaliaza left the tape on by mistake.
The static ports are critical 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 altimeter also relayed the false altitude information to the Air Traffic Controller, who 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 can be seen in the CVR transcript. The fact that the flight took place at night and over water, thus not giving the pilots any visual references, was also a major factor.
. Boeing argued that it was not at fault, and that responsibility for the accident lay with the aircraft's pilot for not finding the tape. Richard Rodriguez of the NTSB said that it was understandable that Schreiber did not find the tape because the maintenance worker used duct tape instead of the bright tape that he was supposed to use. In addition, Rodriguez said that the pitot-static ports were high above the ground. Therefore Schreiber did not see 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, Chile, for a determination of the damages. The defendants agreed not to contest liability in Chile.
On December 13, 1999, family members of the flight's passengers received one of the largest cash awards stemming from an aviation accident outside the United States aboard a non-U.S. carrier
. The episode "Flying Blind" from Mayday
(Air Crash Investigation, Air Emergency) stated that the manner of the crash resulting in the passengers' drowning was responsible for the large settlements.
After the accident, Aeroperú changed the number of its evening Miami-Lima-Santiago Boeing 757 service to Flight 691. The Flight 603 incident contributed to the eventual demise of Aeroperú, which was already plagued with financial and management difficulties. The airline folded in 1999.
Peruvian justice sentenced Chacaliaza for negligent homicide; it did not sentence any other staff members of the airline. Guido Fernandez criticized the move; he argued that Chacaliaza, who was relatively uneducated, had little understanding of what he did, and that his supervisors had more responsibility.
(Air Crash Investigation, Air Emergency). The cockpit voice recording of the incident became part of the script of a play called Charlie Victor Romeo
.
Aeroperu
Aeroperú was the former national flag carrier of Peru, and from 1993 to 2000 was a subsidiary of AeroMéxico. Its headquarters were in Miraflores, Lima. It went bankrupt in 1999...
Flight 603 was a scheduled flight from Jorge Chávez International Airport
Jorge Chávez International Airport
Jorge Chávez International Airport , known as Aeropuerto Internacional Jorge Chávez in Spanish, is Peru's main international and domestic airport. It is located in Callao, 11 kilometers from the Historic Centre of Lima and 17 km from Miraflores. Callao is the port city now fully...
in Lima, Peru
Peru
Peru , officially the Republic of Peru , is a country in western South America. It is bordered on the north by Ecuador and Colombia, on the east by Brazil, on the southeast by Bolivia, on the south by Chile, and on the west by the Pacific Ocean....
(SPIM), to Comodoro Arturo Merino Benítez International Airport
Comodoro Arturo Merino Benítez International Airport
Comodoro Arturo Merino Benítez International Airport , also known as Pudahuel Airport and Santiago International Airport, located in Pudahuel, north-west of downtown Santiago, is Chile's largest aviation facility and the busiest international air passenger gateway to the country...
in Santiago
Santiago, Chile
Santiago , also known as Santiago de Chile, is the capital and largest city of Chile, and the center of its largest conurbation . It is located in the country's central valley, at an elevation of above mean sea level...
, Chile
Chile
Chile ,officially the Republic of Chile , is a country in South America occupying a long, narrow coastal strip between the Andes mountains to the east and the Pacific Ocean to the west. It borders Peru to the north, Bolivia to the northeast, Argentina to the east, and the Drake Passage in the far...
(SCEL), which crashed
Aviation accidents and incidents
An aviation accident is defined in the Convention on International Civil Aviation Annex 13 as an occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, in which a...
on October 2, 1996.
The pilots struggled to navigate the aircraft after the failure of all the plane's instruments. With the pilots unaware of their true altitude, the plane's wing hit the water and it crashed shortly afterward. The cause of the instrument failure was a maintenance worker's failure to remove tape covering the static ports
Pitot-static system
A pitot-static system is a system of pressure-sensitive instruments that is most often used in aviation to determine an aircraft's airspeed, Mach number, altitude, and altitude trend. A pitot-static system generally consists of a pitot tube, a static port, and the pitot-static instruments...
necessary to provide correct instrument data to the cockpit.
Overview
On October 2, 1996, shortly after takeoff just past midnight, the Boeing 757Boeing 757
The Boeing 757 is a mid-size, narrow-body twin-engine jet airliner manufactured by Boeing Commercial Airplanes. Passenger versions of the twinjet have a capacity of 186 to 289 persons and a maximum range of , depending on variant and cabin configuration...
airliner
Airliner
An airliner is a large fixed-wing aircraft for transporting passengers and cargo. Such aircraft are operated by airlines. Although the definition of an airliner can vary from country to country, an airliner is typically defined as an aircraft intended for carrying multiple passengers in commercial...
crew discovered that their basic flight instruments
Flight instruments
Flight instruments are the instruments in the cockpit of an aircraft that provide the pilot with information about the flight situation of that aircraft, such as height, speed and altitude...
were behaving erratically and reported receiving contradictory serial emergency messages from the onboard computer, such as rudder ratio
Rudder ratio
Rudder ratio refers to a value that is monitored by the computerized flight control systems in modern aircraft. The ratio relates the aircraft airspeed to the rudder deflection setting that's in effect at the time. As an aircraft accelerates the deflection of the rudder needs to be reduced...
, mach speed trim
Mach number
Mach number is the speed of an object moving through air, or any other fluid substance, divided by the speed of sound as it is in that substance for its particular physical conditions, including those of temperature and pressure...
, overspeed, underspeed
Stall (flight)
In fluid dynamics, a stall is a reduction in the lift coefficient generated by a foil as angle of attack increases. This occurs when the critical angle of attack of the foil is exceeded...
and flying too low
Ground Proximity Warning System
A ground proximity warning system is a system designed to alert pilots if their aircraft is in immediate danger of flying into the ground or an obstacle. The United States Federal Aviation Administration defines GPWS as a type of terrain awareness warning system...
. The crew declared an emergency and requested an immediate return to the airport.
Faced with the lack of reliable basic flight instruments, 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, pilot Eric Schreiber and copilot David Fernández decided to cautiously begin descent for the approach to the airport. Since the flight was at night over water, no visual references could be made to convey to the pilots their true altitude or aid the pilots in the descent. Also, 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, the aircraft's true altitude was in fact much lower.
The air traffic control
Air traffic control
Air traffic control is a service provided by ground-based controllers who direct aircraft on the ground and in the air. The primary purpose of ATC systems worldwide is to separate aircraft to prevent collisions, to organize and expedite the flow of traffic, and to provide information and other...
ler had a Boeing 707
Boeing 707
The Boeing 707 is a four-engine narrow-body commercial passenger jet airliner developed by Boeing in the early 1950s. Its name is most commonly pronounced as "Seven Oh Seven". The first airline to operate the 707 was Pan American World Airways, inaugurating the type's first commercial flight on...
take off to help guide the 757 back to land. Before the 707 could reach the 757, the 757's wingtip struck the water approximately twenty-five minutes after emergency declaration, making the pilots realize the true altitude of the airliner; the pilots struggled with the controls and managed to get airborne again for twenty seconds, but the aircraft crashed inverted into the water. All nine crew members and sixty-one passengers died. It is unclear whether the pilots noticed the radar altimeter after passing through 2,500 feet, as no statement was made in the report.
After the crash recovery crews found nine bodies floating; the rest of the bodies sank with the airliner.
Nationalities of passengers
Most of the passengers on Flight 603 were Chileans returning to Chile.| Country | Passengers | Crew | Total |
|---|---|---|---|
| 30 | 0 | 30 | |
| 1 | 0 | 1 | |
| 2 | 0 | 2 | |
| 2 | 0 | 2 | |
| 6 | 0 | 6 | |
| 1 | 0 | 1 | |
| 11 | 9 | 20 | |
| 1 | 0 | 1 | |
| 2 | 0 | 2 | |
| 4 | 0 | 4 | |
| 1 | 0 | 1 | |
| Total | 61 | 9 | 70 |
Of the passengers, 21 originated from Miami; all of the originating passengers were Chilean.
Reporting
Some very early reports initially stated that the crashed flight flew on a New York City to Lima route; the agencies later corrected reports, stating that the flight was flying from Lima to Santiago.Investigation
The Commission of Accident Investigations (CAI) of the Director General of Air Transport (DGAT) of Peru wrote the final accident report.The Peruvian accident investigator, Guido Fernández, was the uncle of the co-pilot, David Fernández, but, despite originally holding some reservations about the potential conflict of interest, the National Transportation Safety Board
National Transportation Safety Board
The National Transportation Safety Board is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine...
-appointed investigator, Richard Rodriguez, determined that he could properly investigate the accident.
The Peruvian Navy
Peruvian Navy
The Peruvian Navy is the branch of the Peruvian Armed Forces tasked with surveillance, patrol and defense on lakes, rivers and the Pacific Ocean up to 200 nautical miles from the Peruvian littoral...
collected the floating wreckage. After the Peruvian authorities asked for assistance, the United States Navy
United States Navy
The United States Navy is the naval warfare service branch of the United States Armed Forces and one of the seven uniformed services of the United States. The U.S. Navy is the largest in the world; its battle fleet tonnage is greater than that of the next 13 largest navies combined. The U.S...
provided equipment to locate the underwater wreckage and black boxes
Flight recorder
A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of an aircraft accident or incident. For this reason, flight recorders are required to be capable of surviving the conditions likely to be encountered in a severe aircraft...
of the Boeing 757.
Later investigation into the accident revealed that masking tape was accidentally left over some or all of the static ports
Pitot-static system
A pitot-static system is a system of pressure-sensitive instruments that is most often used in aviation to determine an aircraft's airspeed, Mach number, altitude, and altitude trend. A pitot-static system generally consists of a pitot tube, a static port, and the pitot-static instruments...
(on the underside of the fuselage
Fuselage
The fuselage is an aircraft's main body section that holds crew and passengers or cargo. In single-engine aircraft it will usually contain an engine, although in some amphibious aircraft the single engine is mounted on a pylon attached to the fuselage which in turn is used as a floating hull...
) after the aircraft was cleaned, eventually leading to the crash. Employee Eleuterio Chacaliaza left the tape on by mistake.
The static ports are critical 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 altimeter also relayed the false altitude information to the Air Traffic Controller, who 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 can be seen in the CVR transcript. The fact that the flight took place at night and over water, thus not giving the pilots any visual references, was also a major factor.
Legal settlement
In November 1996, Mike Eidson, a Miami attorney from Colson Hicks Eidson, said in an interview that many of the passengers survived the initial impact and drowned afterwards. Eidson represented 41 passengers and crew in a lawsuit contending that the aircraft's manufacturer, Boeing, bore responsibility for the disaster, as the company had to foresee the misuse of its products. The suit was filed against Boeing in federal court in Miami in May, 1997. According to the complaint, the control panel errors were caused by careless maintenance by Aeroperú and negligence and defective design by BoeingBoeing
The Boeing Company is an American multinational aerospace and defense corporation, founded in 1916 by William E. Boeing in Seattle, Washington. Boeing has expanded over the years, merging with McDonnell Douglas in 1997. Boeing Corporate headquarters has been in Chicago, Illinois since 2001...
. Boeing argued that it was not at fault, and that responsibility for the accident lay with the aircraft's pilot for not finding the tape. Richard Rodriguez of the NTSB said that it was understandable that Schreiber did not find the tape because the maintenance worker used duct tape instead of the bright tape that he was supposed to use. In addition, Rodriguez said that the pitot-static ports were high above the ground. Therefore Schreiber did not see 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, Chile, for a determination of the damages. The defendants agreed not to contest liability in Chile.
On December 13, 1999, family members of the flight's passengers received one of the largest cash awards stemming from an aviation accident outside the United States aboard a non-U.S. carrier
Airline
An airline provides air transport services for traveling passengers and freight. Airlines lease or own their aircraft with which to supply these services and may form partnerships or alliances with other airlines for mutual benefit...
. The episode "Flying Blind" from Mayday
Mayday (TV series)
Mayday, also known as Air Crash Investigation in the United Kingdom, Australia and Asia and Air Emergency and Air Disasters in the United States, is a Canadian documentary television programme produced by Cineflix investigating air crashes, near-crashes and other disasters...
(Air Crash Investigation, Air Emergency) stated that the manner of the crash resulting in the passengers' drowning was responsible for the large settlements.
After the accident, Aeroperú changed the number of its evening Miami-Lima-Santiago Boeing 757 service to Flight 691. The Flight 603 incident contributed to the eventual demise of Aeroperú, which was already plagued with financial and management difficulties. The airline folded in 1999.
Peruvian justice sentenced Chacaliaza for negligent homicide; it did not sentence any other staff members of the airline. Guido Fernandez criticized the move; he argued that Chacaliaza, who was relatively uneducated, had little understanding of what he did, and that his supervisors had more responsibility.
Dramatization
The accident was featured in the episode "Flying Blind" from MaydayMayday (TV series)
Mayday, also known as Air Crash Investigation in the United Kingdom, Australia and Asia and Air Emergency and Air Disasters in the United States, is a Canadian documentary television programme produced by Cineflix investigating air crashes, near-crashes and other disasters...
(Air Crash Investigation, Air Emergency). The cockpit voice recording of the incident became part of the script of a play called Charlie Victor Romeo
Charlie Victor Romeo
Charlie Victor Romeo is a 1999 play whose script consists of almost-verbatim transcripts from six real-life aviation accidents and incidents. "Charlie Victor Romeo," or CVR, derived from the NATO phonetic alphabet, is aviation lingo for cockpit voice recorder...
.
See also
- Lists of accidents and incidents on commercial airliners
- Pitot-static systemPitot-static systemA pitot-static system is a system of pressure-sensitive instruments that is most often used in aviation to determine an aircraft's airspeed, Mach number, altitude, and altitude trend. A pitot-static system generally consists of a pitot tube, a static port, and the pitot-static instruments...
- Birgenair Flight 301Birgenair Flight 301Birgenair Flight 301 was a flight chartered by Turkish-managed Birgenair partner Alas Nacionales from Puerto Plata in the Dominican Republic to Frankfurt, Germany via Gander, Canada and Berlin, Germany...
- Spatial disorientationSpatial disorientationSpatial disorientation is the inability to correctly interpret aircraft attitude, altitude or airspeed, in relation to the Earth or point of reference. Spatial disorientation is a condition in which an aircraft pilot's perception of direction does not agree with reality...
- Air France Flight 447Air France Flight 447Air France Flight 447 was a scheduled airline flight from Rio de Janeiro-Galeão to Paris-Roissy involving an Airbus A330-200 aircraft that crashed into the Atlantic Ocean on 1 June 2009, killing all 216 passengers and 12 aircrew. The investigation is still ongoing, and the cause of the...
External links
- "In reply refer to: A-96-141." National Transportation Safety BoardNational Transportation Safety BoardThe National Transportation Safety Board is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine...
. November 15, 1996. - AvWeb - AeroPeru 603 Cockpit Voice Recorder transcript (English)
- Youtube - AeroPeru 603 Cockpit Voice Recorder Original Audio Parte 1
- Youtube - AeroPeru 603 Cockpit Voice Recorder Original Audio Parte 2
- Youtube - AeroPeru 603 Cockpit Voice Recorder Original Audio Parte 3
- AvWeb - AeroPeru 603 Alarms activity from the CVR
- "Computer failure puzzling in Peruvian crash." CNNCNNCable News Network is a U.S. cable news channel founded in 1980 by Ted Turner. Upon its launch, CNN was the first channel to provide 24-hour television news coverage, and the first all-news television channel in the United States...
. October 3, 1996. - "Searchers comb Pacific for more bodies after Peruvian crash," CNNCNNCable News Network is a U.S. cable news channel founded in 1980 by Ted Turner. Upon its launch, CNN was the first channel to provide 24-hour television news coverage, and the first all-news television channel in the United States...
. October 2, 1996. - List of passengers
- News and Comment on the Aeroperu B757 Accident - University of Bielefeld