Fokker F-28 Fellowship 1000 – OB-1396

Incident Overview

Date: Thursday 9 January 2003

Aircraft Type: Fokker F-28 Fellowship 1000

Owner/operator: Transportes Areos Nacionales de la Selva – TANS

Registration Number: OB-1396

Location: near Chachapoyas – ÿ Peru

Phase of Flight: Approach

Status: Destroyed, written off

Casualties: Fatalities: 46 / Occupants: 46

Component Affected: The aircraft’s flight control system, navigation system, and overall operational procedures.The aircraft’s flight control system, navigation system, and overall operational procedures.

Investigating Agency: CIAACIAA

Category: Accident

On TANS Flight 222, a scheduled flight to Chachapoyas, the aircraft experienced a significant descent and subsequent impact into terrain, resulting in the loss of the aircraft and its occupants. The flight began with a climb to FL190, then a left turn to 060deg, maintaining FL190, followed by a descent to FL130, and finally, a rapid deceleration to FL130, culminating in a 10350-foot altitude loss. The aircraft was subsequently steered to a heading of 135deg, aligning with the runway 13 approach. A brief, but significant, turn occurred with a 30-degree bank angle, and shortly thereafter, the aircraft executed a rapid descent to FL130. The initial impact into terrain occurred at an altitude of 10350 feet, followed by a subsequent rescue operation, revealing the wreckage two days after the incident. The aircraft, a F-28, was previously used as a Peruvian Presidential plane, and its history indicates a potential for complacency and lack of effective communication, contributing to the accident.On TANS Flight 222, a scheduled flight to Chachapoyas, the aircraft experienced a significant descent and subsequent impact into terrain, resulting in the loss of the aircraft and its occupants. The flight began with a climb to FL190, then a left turn to 060deg, maintaining FL190, followed by a descent to FL130, and finally, a rapid deceleration to FL130, culminating in a 10350-foot altitude loss. The aircraft was subsequently steered to a heading of 135deg, aligning with the runway 13 approach. A brief, but significant, turn occurred with a 30-degree bank angle, and shortly thereafter, the aircraft executed a rapid descent to FL130. The initial impact into terrain occurred at an altitude of 10350 feet, followed by a subsequent rescue operation, revealing the wreckage two days after the incident. The aircraft, a F-28, was previously used as a Peruvian Presidential plane, and its history indicates a potential for complacency and lack of effective communication, contributing to the accident.

Description

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

Primary Cause

Complacency and lack of effective communication between the technical crew, leading to total loss of situational awareness.Complacency and lack of effective communication between the technical crew, leading to total loss of situational awareness.

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