CM201
1992-JUN-06 · Darién Gap, near Tucutí, Panama

Copa Airlines — Flight CM201

Copa Airlines Flight 201 disintegrated in mid-air and crashed into the Darién Gap after the flight crew became spatially disoriented due to a faulty Attitude Director Indicator (ADI). A short circuit in a wiring harness caused the Captain's ADI to freeze intermittently. Confused by the readings, the crew inadvertently switched both pilots' displays to the same malfunctioning gyroscope. While attempting to navigate around severe weather, the pilots misread their instruments and rolled the aircraft into a steep, high-speed dive that exceeded the airframe's structural limits.

Aircraft
Boeing 737-204 Advanced
Registration
HP-1205CMP
Phase
Cruise
Cause
Human Factors (Operational)
Souls on Board
47
Fatalities
47
Origin → Dest
Tocumen International Airport, Panama City, Panama → Alfonso Bonilla Aragón International Airport, Cali, Colombia
Report
Final

Investigation Summary

The investigation revealed a critical failure in both hardware and training. The primary cause was a short circuit in the wiring harness of the Vertical Gyro (VG-1), which provided pitch and roll data to the Captain's ADI. This short caused the indicator to stop updating, effectively freezing the horizon display. When the crew noticed a discrepancy, they attempted to troubleshoot using a selector switch. Investigators found the ADI selector switch in the 'Both on VG-1' position in the wreckage. Due to inconsistencies between the aircraft's cockpit configuration and the flight simulators used by Copa, the Captain mistakenly selected this mode, which fed the faulty VG-1 data to both his and the First Officer's displays. This left both pilots with identical, incorrect information. As the aircraft actually began to bank, the frozen instruments suggested it was level, leading the pilots to apply further control inputs that exacerbated the roll. The aircraft eventually reached a bank angle of 80 degrees and entered a vertical dive, reaching speeds that caused a mid-air structural breakup at approximately 10,000 feet.

Final Conclusions

The Panamanian investigation, supported by the NTSB, concluded the crash was caused by the crew's inability to identify and compensate for a malfunctioning attitude indicator. Contributing factors included the intermittent short circuit in the VG-1 wiring, inadequate simulator training that failed to prepare the crew for instrument switching logic, and a lack of cockpit standardization across the Copa fleet. The crew also failed to utilize the standby ADI, which was found to be functional at the time of impact.

Photographic Evidence (1)

Miami 26.4.92 This plane crashed on 6th June 1992 on flight 201 with the loss of 40 passengers and 7 crew. copyright © 1992 Chris Chennell
© ChrisChen76 · Wikimedia Commons

Video Analysis

Shocking Investigation of Copa Flight 201 Crash | Air Disasters — A look into how a faulty gyroscope and a series of pilot errors led to the mid-air breakup of Copa Flight 201 over the Panamanian jungle.

If playback is blocked, the owner has disabled embedding — use the link above.

Airframe & Maintenance

Airframe Hours
45,946
Cycles
17,845
Engines
Pratt & Whitney JT8D-15

Crew Experience

Captain

Total hours
7,000

Rafael Carlos Chial, age 53.

First Officer

Total hours
475

Cesareo Tejada, age 25. He was the pilot flying at the time of the accident.

Systems & Failure Modes

i

Attitude Director Indicator (ADI)

The primary flight instrument showing the aircraft's pitch and roll; a short circuit caused the Captain's unit to freeze.

i

Vertical Gyro (VG)

The sensor providing orientation data to the ADIs; the crew mistakenly slaved both ADIs to the same failing gyro (VG-1).

i

Flight Data Recorder (FDR)

Recorded unprecedented rapid banking movements, which were later determined to be the result of the faulty gyro signal rather than actual aircraft movement.

Interesting Facts

  • 01The accident remains the deadliest aviation disaster in Panamanian history.
  • 02The 47 fatalities included 36 Colombians, 8 Panamanians, 2 Americans, and 1 Italian.
  • 03The Cockpit Voice Recorder (CVR) was found to be useless because the tape was broken and improperly spliced during maintenance, causing it to record over the accident data with a previous flight.
  • 04The aircraft was leased from Britannia Airways only two months prior to the accident.
  • 05The wreckage was found scattered over a 10-kilometer radius in the dense, remote jungle of the Darién Gap.
  • 06The standby ADI was found to have been functioning correctly until impact, but the crew failed to cross-check it.

Safety Actions & Advisories

Simulator Training Enhancement

Copa Airlines overhauled its ground training program to ensure pilots were better trained on Crew Resource Management (CRM) and instrument failure recognition.

Fleet Standardization

The airline moved to standardize cockpit configurations across its fleet to prevent confusion regarding instrument switching logic.

Known Controversies & Unanswered Questions

Mid-air Collision Theory

Reference ↗

Early in the investigation, authorities considered a collision with a drug-smuggling aircraft flying without a transponder, but this was debunked after no other wreckage was found and FDR data pointed to instrument failure.

Location

Darién Gap, near Tucutí, Panama · 7.9831, -77.9334

Case File History

  1. New evidenceUpdated investigation summary, findings and event timeline.
  2. New evidenceUpdated event timeline and findings.

Related Cases

Case ID · copa-201-1992Last updated · Filed

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