Thursday, 9th of January, 2003
TANS Perú Flight 222, a domestic scheduled passenger flight from Chiclayo-Capitan FAP Jose Abelardo Quiñones Airport (CIX / SPHI) , Peru to Chachapoyas Airport (CHH / SPPY) , Peru, operated with a Fokker F-28 Fellowship 1000, registration OB-1396, crashed into a mountain while on approach near Chachapoyas, Peru.
The aircraft was completely destroyed. The five crew members and 41 passengers perished. (46 fatalities)
The crash of Flight 222 is the ninth deadliest aviation accident in Peru’s history. It is also the sixth worst accident involving the Fokker F-28.
TANS Flight 222 departed Lima for a scheduled flight to Chachapoyas with an intermediate stop at Chiclayo. It departed Chiclayo at 08:17 and climbed to its assigned cruising altitude of FL190, which was reached approx. ten minutes after takeoff. The F-28 followed the V-3 airway, heading 075deg until 08:32. The crew then turned to the left heading 060deg, maintaining FL190 until 08:36. The flight then descended to FL130. After reaching that altitude five minutes later, the crew extended the speedbrakes in order to decelerate from 280 knots to 210 knots. Fifty seconds later, with the speedbrakes still extended, the crew turned to a heading of 135deg, aligning the plane with Chachapoyas’ runway 13. The turn was accomplished in 45 seconds with a 30deg bank angle course change in 45 seconds. Shortly afterwards the Fellowship struck Cerro Coloque at an altitude of 10350 feet. Rescue workers found the wreckage two days after the crash.
Until 1995 this F-28 was used as the Peruvian Presidential plane.
“PROBABLE MAJOR CAUSES:
1.- PROBABLE MAJOR CAUSE
The probable cause of the accident of the aircraft Fokker F-28, MK1000, OB-1396 of the company TANS-PERU, is the Impact Against the Ground without Loss of Control – CFIT (Controlled Flight Into Terrain) caused by complacency (overconfidence) and lack of effective communication between the technical crew, which leads to the total loss of situational awareness.
2.- PROBABLE SECONDARY CAUSES
2.1 Failure to comply with the Standard Operating Procedures. The transcript of the CVR indicates that the Technical Crew is not alert, nor does it make any operational indications such as breafing or checklist on the descent to the Chachapoyas aerodrome.
2.2 Lack of Crew Resource Management – CRM (Crew Resource Management) There is no formal operational communication, at the CVR hearing it denotes a lot of informality and many misplaced comments for a professional technical operation.
2.3 Loss of Situational Awareness. From the audition of the CVR it can be inferred that the crew due to complacency (overconfidence) did not comply with the rules and procedures established for the operation of this route and airport. The alert situation of the Technical Crew was not adequate for the operation phase.
3.- TAXPAYER FACTORS
3.1 Death of the Co-pilot’s father, 4 days before the date of carrying out the flight, could contribute as a causative agent of stress, fatigue and depression, and may influence his professional performance.
3.2 The delay in payments and / or bonuses of the crew could have caused a stress situation, which in the short, medium or long term contributes to fatigue, therefore decrease in professional performance, which would affect the safety of the crew. flight.
3.3 Organizational system and operational scope. The constant changes of the management personnel cause a labor instability within the company, a situation that could be a stress agent that affects human performance in any field.
4.- CONTRIBUTING HUMAN ERRORS
The following Human Errors were observed in the analysis of the performance of this flight:
1) Deficient judgment
2) Poor planning
3) Inadequate monitoring
4) Poor visual perspective
5) Poor visual perception
6) Operational compliance
7) Procedures omitted
8] Disorientation due to loss of situational awareness”