Investigation Summary
The investigation revealed a significant breakdown in cockpit discipline and situational awareness. At the time of the accident, a trainee pilot was in the right seat while the regular first officer was in the passenger cabin. As the aircraft penetrated a severe storm cell, which had been detected on radar 190 miles in advance, the crew encountered heavy hail that obscured forward visibility. The captain took manual control but the trainee pilot failed to monitor the flight instruments. Consequently, neither pilot noticed the aircraft's descent rate exceeding 1,500 feet per minute. Although the Ground Proximity Warning System (GPWS) sounded, the crew did not abort the descent in time to avoid impacting the swampy terrain.
Final Conclusions
The CIAA determined the primary cause was the crew's decision to continue the approach into severe weather rather than diverting or holding. Contributing factors included the failure to maintain a stabilized approach, the loss of situational awareness due to total loss of visibility in the hailstorm, and the failure of the trainee pilot to monitor instruments while the captain was flying manually.
Photographic Evidence (1)
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Octavio Pérez Palma Garreta; Fatality.
First Officer
Jorge Luis Pinto Panta; was in the passenger cabin at the time of the crash. Fatality.
Trainee Pilot
Gonzalo Chirinos Delgado; was in the right seat during the accident. Fatality.
Systems & Failure Modes
GPWS
The Ground Proximity Warning System alerted the crew to the excessive descent rate, but the warning was not acted upon in time.
Weather Radar
The onboard radar had detected the storm cell approximately 190 miles in advance, yet the crew chose to penetrate the core.
Interesting Facts
- 01The aircraft was a 24-year-old Boeing 737-200 originally delivered to South African Airways in 1981 and leased from Safair only two months prior to the accident.
- 02A trainee pilot was occupying the co-pilot's seat while the actual first officer was in the cabin.
- 03The crash site was looted by locals who stole parts of the wreckage, including the flight data recorder, which was later recovered for a $500 reward.
- 04The aircraft flew through a hailstorm for the final 32 seconds of the flight.
- 05Most fatalities occurred in the forward section of the aircraft.
Safety Actions & Advisories
Crew Resource Management Training
The investigation highlighted the need for stricter adherence to CRM procedures, particularly regarding the monitoring of instruments by the non-flying pilot during manual flight.