Accident Fokker F-28 Fellowship 1000 OB-1396, Thursday 9 January 2003
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Date:Thursday 9 January 2003
Time:08:45
Type:Silhouette image of generic F28 model; specific model in this crash may look slightly different    
Fokker F-28 Fellowship 1000
Owner/operator:Transportes Aéreos Nacionales de la Selva - TANS
Registration: OB-1396
MSN: 11100
Year of manufacture:1975
Engine model:Rolls-Royce Spey 555-15
Fatalities:Fatalities: 46 / Occupants: 46
Other fatalities:0
Aircraft damage: Destroyed, written off
Category:Accident
Location:near Chachapoyas -   Peru
Phase: Approach
Nature:Passenger - Scheduled
Departure airport:Chiclayo-Capitan FAP Jose Abelardo Quiñones Airport (CIX/SPHI)
Destination airport:Chachapoyas Airport (CHH/SPPY)
Investigating agency: CIAA
Confidence Rating: Accident investigation report completed and information captured
Narrative:
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 ROOT CAUSES:
1.- PROBABLE MAIN CAUSE.
The probable cause of the accident of the aircraft Fokker F-28, MK1000, OB-1396 of the company TANS-PERU, is the Impact Into Terrain 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 Lack of compliance with Standard Operating Procedures. The CVR transcript shows that the Technical Crew was not alert, nor did they make any operational indication such as breafing or check list about the descent to the Chachapoyas airfield.
2.2 Lack of Crew Resource Management (CRM) There is no formal operational communication, in the CVR hearing there is a lot of informality and many comments out of place for a professional technical operation.
2.3 Loss of Situational Awareness. From the CVR hearing it can be extracted 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 alertness of the Technical Crew was not adequate for the operation phase.
3.- CONTRIBUTING FACTORS
3.1 Death of the Co-Pilot's father, 4 days before the date of the flight, could contribute as a stress, fatigue and depression agent, which could influence his professional performance.
3.2 The delay in the crew's payments and/or bonuses could have caused a stressful situation, which in the short, medium or long term contributes to fatigue, thus decreasing professional performance, which would affect flight safety.
3.3 Organizational system and operational environment. The constant changes of management personnel cause labor instability within the company, a situation that could be an agent of stress 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) Poor judgment
2) Poor planning
3) Inadequate monitoring
4) Poor visual perspective
5) Poor visual perception
6) Operational complacency
7) Omitted procedures
8) Disorientation due to loss of situational awareness

METAR:

13:00 UTC / 08:00 local time:
SPPY 091300Z VRB02KT 9999 BKN015 SCT100 13/12 Q1028 PP000 TMN:12.5=

14:00 UTC / 09:00 local time:
SPPY 091400Z VRB03KT 9999 BKN018 SCT100 15/12 Q1028 PP000=

Accident investigation:
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Investigating agency: CIAA
Report number: CIAA-ACCID-001-2003
Status: Investigation completed
Duration: 2 months
Download report: Final report

Sources:


Statistics

  • 7th worst accident in 2003
  • 6th worst accident of this aircraft type
  • 6th worst accident of this aircraft type at the time

Location

Images:


photo (c) via W. Fischdick; Miami International Airport, FL (MIA); August 1991

Revision history:

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