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American Airlines 965

Accident Case Study

That the pilots made multiple errors of procedure and judgement is without a doubt.

The most alarming fact, however, was their lack of situational awareness. Knowing they are flying into a valley in mountainous terrain argues for a very deliberate approach to getting the FMS programmed and heightened awareness of distance from the airport.


 

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Figure: American Airlines Flight 965 Flight Track, from May Day.

Accident Report

  • Date: 20 DEC 1995
  • Time 21:38:
  • Type: Boeing 757-223
  • Operator: American Airlines
  • Registration: N651AA
  • Fatalities: 8 of 8 crew, 159 of 163 passengers
  • Aircraft Fate: Destroyed
  • Phase: Approach
  • Airport: (Departure) Miami International Airport, FL (MIA/KMIA), United States of America
  • Airport: (Destination) Cali-Alfonso Bonilla Aragón Airport (CLO/SKCL), Colombia

Narrative

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Figure: Approximate Track of Flight 965, from Flight Safety Digest, Figure 1.

At about 18:34 EST, American Airlines Flight 965 took off from Miami for a flight to Cali. At 21:34, while descending to FL200, the crew contacted Cali Approach.

The aircraft was 63nm out of Cali VOR (which is 8nm South of the airport)) at the time. Cali cleared the flight for a direct Cali VOR approach and report at Tulua VOR. Followed one minute later by a clearance for a straight in VOR DME approach to runway 19 (the Rozo 1 arrival).

The crew then tried to select the Rozo NDB (Non Directional Beacon) on the Flight Management Computer (FMC). Because their Jeppesen approach plates showed 'R' as the code for Rozo, the crew selected this option. But 'R' in the FMC database meant Romeo. Romeo is a navaid 150nm from Rozo, but has the same frequency. The aircraft had just passed Tulua VOR when it started a turn to the left (towards Romeo). This turn caused some confusion in the cockpit since Rozo 1 was to be a straight in approach. 87 Seconds after commencing the turn, the crew activated Heading Select (HDG SEL), which disengaged LNAV and started a right turn. The left turn brought the B757 over mountainous terrain, so a Ground Proximity (GPWS) warning sounded. With increased engine power and nose-up the crew tried to climb. The spoilers were still activated however. The stick shaker then activated and the aircraft crashed into a mountain at about 8900 feet (Cali field elevation being 3153 feet).

Probable Cause

  1. The flight crew's failure to adequately plan and execute the approach to runway 19 at SKCL and their inadequate use of automation;
  2. Failure of the flight crew to discontinue the approach into Cali, despite numerous cues alerting them of the inadvisability of continuing the approach;
  3. The lack of situational awareness of the flight crew regarding vertical navigation, proximity to terrain, and the relative location of critical radio aids;
  4. Failure of the flight crew to revert to basic radio navigation at the time when the FMS-assisted navigation became confusing and demanded an excessive workload in a critical phase of the flight.
  5. The flight crew's ongoing efforts to expedite their approach and landing in order to avoid potential delays;
  6. The flight crew's execution of the GPWS escape manoeuvre while the speed brakes remained deployed;
  7. FMS logic that dropped all intermediate fixes from the display(s) in the event of execution of a direct routing;
  8. FMS-generated navigational information that used a different naming convention from that published in navigational charts.

References

Colombia Aeronautica Civil, Controlled Flight Into Terrain, American Airlines Flight 965, Boeing 757-223, N651AA, Near Cali, Colombia, December 20, 1995 (Prepared by University of Bielefeld, Germany

Flight Safety Foundation, "Boeing 757 CFIT Accident at Cali, Columbia, Becomes Focus of Lessons Learned," Flight Safety Digest, May-June 1998

May Day: Lost, Cineflix, Episode 4, Season 2, 20 February 2005 (American Airlines 965)

Revision: 20121015
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