Runaway Attitude Indicator Leads to Loss of Control and Crash (HP-1205CMP)

Accident Overview

An aircraft departed Panama City-Tocumen Airport runway 21L at 2036 local time, bound for Cali, Colombia. While cruising at flight level 250 (FL250), the crew was informed of poor weather conditions 30–50 miles ahead. Shortly thereafter, an intermittent failure of the main attitude indicator occurred due to a short circuit. The flight crew did not notice the malfunction and attempted to adjust the aircraft's attitude based on the false information from the faulty indicator. This resulted in a loss of control, and the aircraft entered a steep descent. At FL100, the aircraft began to disintegrate, ultimately impacting the ground 80° nose down. The wreckage was located in jungle terrain approximately 13 km southwest of Tucití. All 47 occupants on board were killed.

Probable Cause

The official investigation identified the following findings:

• Loss of control because the flight crew followed false information from an intermittently operating attitude indicator.
• Lack of visible horizon during cruise flight due to night conditions and approaching bad weather.
• Insufficient cross-checking between primary and emergency (standby) attitude indicators to identify intermittent attitude errors and select a reliable source of correct attitude information.
• Non-standard cabin configurations between aircraft in the company's fleet, which required the crew to determine switch settings based on the specific aircraft being operated.
• Incomplete ground crew training in the simulator, which did not present differences between aircraft and crew resource management in sufficient detail to give the crew knowledge to overcome intermittent attitude indicator errors and maintain control.