Aeroperú Flight 603
Aeroperú Flight 603 was a scheduled flight from Miami International Airport in Miami, Florida (KMIA) to Comodoro Arturo Merino Benítez International Airport in Santiago, Chile (SCEL), with stopover in Peru. On 2 October 1996, the Boeing 757-23A aircraft flying the final leg of the flight crashed, killing all 70 people aboard.
N52AW, the Boeing 757 involved in the accident
|Date||2 October 1996|
|Summary||Instrument failure due to static port obstruction caused by maintenance error; controlled flight into water|
near Pasamayo, Huaral, Peru
|Aircraft type||Boeing 757-23A|
|IATA flight No.||PL603|
|ICAO flight No.||PLI603|
|Call sign||Aeroperu 603|
|Flight origin||Miami International Airport|
Miami, Florida, U.S.
|Stopover||Jorge Chávez Int'l Airport|
|Destination||Comodoro Arturo Merino Benítez International Airport|
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 static ports on the aircraft exterior. Flying at night over water with no visual references, the pilots struggled to control and navigate the aircraft, unaware of their true altitude. The crash resulted after its left wing and no. 1 engine hit the surface of the Pacific Ocean.
The aircraft, a Boeing 757-23A was delivered new from Boeing on 2 December 1992, to Ansett Worldwide. It was leased to Aeroméxico on 27 September 1993 and then sub-leased to Aeroperú on 1 April 1994. The lease transferred back to Ansett in February 1995, and Aeroperú continued to operate the airframe until it crashed.
Passengers and crewEdit
The captain was 58-year-old Eric Schreiber Ladrón de Guevara, who had logged almost 22,000 flight hours, and the first officer was 42-year-old David Fernández Revoredo, who had logged almost 8,000 flight hours.(pp4-7)
On 1 October 1996, Aeroperú Flight 603 from Miami International Airport had landed at the Lima Airport. One-hundred eighty passengers were on the first leg of the flight on a similar Boeing 757. One-hundred nineteen had disembarked, and the remaining passengers were transferred to another Boeing 757 after maintenance checks.
The aircraft took off 42 minutes after midnight (05:42 UTC) on 2 October,(p10) and straight away, the Boeing 757 airliner crew discovered that their basic flight instruments were behaving erratically and reported receiving contradictory serial emergency messages from the flight management computer, including 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 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,(pp22-23) the crew decided to 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 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, the aircraft's true altitude was in fact much lower.
The air traffic controller had instructed a Boeing 707 to take off and help guide the 757 back in to land, but before the 707 could do so, the 757's left wingtip struck the water, approximately 25 minutes after the emergency declaration. By the time they realized they were too low, it was too late; the pilots struggled with the controls and managed to get airborne again for 17 seconds, but the aircraft crashed inverted into the water. All 70 passengers and crew died.
Search, rescue, and recoveryEdit
After the crash, recovery crews found 9 bodies floating; the rest of the bodies had sunk with the aircraft.
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, 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. The fact 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.
The "probable causes" stated the following:
In accordance with the facts presented above, the analyses performed and the conclusions set out, this Aviation Accident Investigation Board has determined that the probable causes of the aviation accident which befell the BOEING 757 AIRCRAFT with REGISTRATION N52AW on 2 October 1996 are as follows:
a.- PROBABLE PRINCIPAL CAUSE ERROR OF THE MAINTENANCE STAFF INCLUDING THE CREW
It can be deduced from the investigation carried out that the maintenance staff did not remove the protective adhesive tape from the static ports. This tape was not detected during the various phases of the aircraft's release to the line mechanic, its transfer to the passenger boarding apron and, lastly, the inspection by the crew responsible for the flight (the walk-around or pre-flight check), which was carried out by the pilot-in-command, ERIC SCHREIBER, according to the mechanic responsible for the aircraft on the day of the accident.
b. - CONTRIBUTING CAUSES
b.1) PERSONAL ERROR OF THE CREW
The pilot-in-command, Mr ERIC SCHREIBER LADRÓN DE GUEVARA, made a personal error by not complying with the procedure for GPWS alarms and not noticing the readings of the radio altimeters in order to discard everything which he believed to be fictitious.
b.2) PERSONAL ERROR INCLUDING THE CREW
The co-pilot, Mr DAVID FERNÁNDEZ REVOREDO, made a personal error by not being more insistent, assertive and convincing in alerting the pilot-in-command much more emphatically to the ground proximity alarms.— PROBABLE CAUSES, ACCIDENT OF THE BOEING 757-200 AIRCRAFT OPERATED BY EMPRESA DE TRANSPORTE AÉREO DEL PERÚ S.A. AEROPERÚ 
Mike Eidson, a Miami 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[vague] 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 compensations stemming from an aviation accident outside the United States aboard a non-U.S. carrier, averaging nearly $1 million per victim. Eidson stated that the manner of the crash resulting in the passengers' drowning was responsible for the large settlements.
Aeroperú as a wholeEdit
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. As a result of the crash of Flight 603 and the large amount of money paid for the settlements[not in citation given] (which had aggravated the already existing financial issues even further), Aeroperú declared bankruptcy and ceased all operations in March 1999.
Chacaliaza was convicted in Peru for negligent homicide and given a two-year suspended sentence in August 1998. Peruvian air accident investigator Guido Fernández criticized the move; he argued that Chacaliaza, who was relatively uneducated, had little understanding of what he did, and that his supervisors ultimately bore more responsibility for the crash.
In popular cultureEdit
- The events of Flight 603 were featured in "Flying Blind", a Season 1 (2003) episode of the Canadian TV series Mayday (called Air Emergency and Air Disasters in the U.S. and Air Crash Investigation in the UK and elsewhere around the world). The flight was also included in a Mayday Season 6 (2007) Science of Disaster special titled "Who's Flying the Plane?"
- The cockpit voice recording (CVR) of the incident was incorporated into the script of a play called Charlie Victor Romeo, by the Lower East Side theater company in New York, in 1999.
- Ranter, Harro. "ASN Aircraft accident Boeing 757-23A N52AW Lima, Peru". aviation-safety.net. Retrieved 2019-06-04.
- "Flying Blind", Mayday [documentary TV series]
- "Searchers comb Pacific for more bodies after Peruvian crash." CNN. October 2, 1996. Retrieved on 11 June 2009.
- "Murieron 70 personas en un avión peruano que cayó al mar." Clarín Digital. October 3, 1996. Retrieved on 11 June 2009.
- "CRONICA" (Archive). Consorcio Periodístico de Chile S.A. 2 October 1996. Retrieved on 11 June 2009.
- "ACCIDENT OF THE BOEING 757-200 AIRCRAFT OPERATED BY EMPRESA DE TRANSPORTE AÉREO DEL PERÚ S.A. AEROPERÚ" (PDF). www.skybrary.aero. Retrieved 2018-12-29.
- Walters, James M. and Sumwalt III, Robert L.. "Aircraft Accident Analysis: Final Reports." McGraw-Hill Professional, 2000. p. 98. Retrieved from Google Books on 11 May 2011. ISBN 0-07-135149-3, ISBN 978-0-07-135149-2. "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."
- "World News Briefs; $29 Million for Victims Of 1996 Peru Air Crash," The New York Times. 22 January 1998. Retrieved on 11 June 2009.
- Casey, Steven. The Atomic Chef, Caught on Tape. Aegean Publishing Company, 2006: Santa Barbara. p. 131 ISBN 9780963617866
- "Close-Up: Aeroperu 603 Voice Recorder Transcription (English Translation)". avweb.com. Retrieved 26 May 2015.
- "Aeroperu Crash Victims Win Landmark Award." Colson Hicks Eidson. December 13, 1999. Retrieved on June 1, 2009.
- Volando (Aeroperú's inflight magazine), Issue 17, July–August 1997
- "Information about Aeroperú". Aero Transport Data Bank. Retrieved 29 December 2018.
- "World Airline Directory". Flight International. 21 March 2000: 55. Retrieved 29 December 2018.
- http://cdn.preterhuman.net/texts/computing/gopher-archive/gopher.rcp.net.pe/noticias/andina/1998/agosto/11 DEUDOS DEL ACCIDENTE AEROPERU PIDEN MAYOR REPARACION CIVIL
- "Flying Blind". Mayday. Season 1. Episode 4. 2003. Discovery Channel Canada / National Geographic Channel.
- "Who's Flying the Plane?". Mayday. Season 6. Episode 3. 2007. Discovery Channel Canada / National Geographic Channel.
- "Step inside the cockpit of six real-life air disasters". New York Post. January 26, 2014. Retrieved March 26, 2018.
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- Final Report (unofficial English translation) (Archive Alternative of archive) hosted at SKYbrary
- Original report, in Spanish, by the Accident Investigation Board, Directorate General of Air Transport, Ministry of Transportation and Communications
- "In reply refer to: A-96-141." National Transportation Safety Board. November 15, 1996. (Archive)
- AvWeb - AeroPeru 603 Cockpit Voice Recorder transcript (English) (Archive)
- AvWeb - AeroPeru 603 Cockpit Voice Recorder transcript (Spanish) (Archive)
- on YouTube
- on YouTube
- on YouTube
- "Computer failure puzzling in Peruvian crash." CNN. October 3, 1996.
- "Searchers comb Pacific for more bodies after Peruvian crash," CNN. October 2, 1996. (Archive)
- List of passengers (Archive Alternative of archive)
- News and Comment on the Aeroperu B757 Accident - University of Bielefeld