American Airlines Flight 965

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American Airlines Flight 965
Summary
Date December 20, 1995
Type Controlled flight into terrain
Site Buga, Colombia
Passengers 155
Crew 8
Injuries 4
Fatalities 159
Survivors 4
Aircraft type Boeing 757-223
Operator American Airlines
Tail number N651AA
Flight origin Miami International Airport
Destination Alfonso Bonilla Aragón International Airport

American Airlines Flight 965, a Boeing 757 registered N651AA, was a scheduled flight from Miami International Airport in Miami, Florida to Alfonso Bonilla Aragón International Airport in Cali, Colombia, which crashed into a mountain in Buga, Colombia on December 20, 1995, killing 155 passengers and 8 crew members.[1] The crash was the first U.S.-owned 757 accident and, at the time, the deadliest air disaster involving a U.S. carrier since the downing of Pan Am Flight 103 seven years before. Four passengers and a dog survived the crash.[2]

Contents

[edit] Flight history

At that time, Flight 965 mainly carried people returning to Colombia for the Christmas holiday, vacationers, and businesspeople.[3] A winter storm in the northeast United States caused the airline to delay the departure of the airliner for thirty minutes to allow for connecting passengers to board the flight. Seasonal congestion caused the aircraft to take off two hours late.[4]Some other passengers booked on Flight 965 missed the flight due to missed connections.[1]

Nicholas Tafuri served as the captain and Donnie R. Williams served as the first officer. Pedro Pablo Calle served as the chief flight attendant.[4]

Due to an attack by anti-government guerrillas in 1992, Cali's air traffic controllers had no radar to monitor the 757 as the pilots flew the approach using the area's radio instruments and airport's instrument approach system. Cali's approach uses several radio beacons to guide pilots around the mountains and canyons that surround the city. The airplane's flight management system already had these beacons programmed in, and should have, in theory, told the pilots exactly where to turn, climb, and descend, all the way from Miami to the terminal in Cali.

Since the wind was calm, Cali's controllers asked the pilots if they wanted to fly a straight-in approach to runway 19 rather than coming around to runway 01. The pilots agreed, hoping to make up some time. The pilots then erroneously cleared the approach waypoints from their navigation computer. When the controller asked the pilots to check back in over Tuluá, north of Cali, it was no longer programmed into the computer, and so they had to pull out their maps to find it. In the meantime, they extended the aircraft's spoilers to slow it down and expedite its descent.

An American Airlines Boeing 757, similar to N651AA, the aircraft used for Flight 965
An American Airlines Boeing 757, similar to N651AA, the aircraft used for Flight 965

By the time they found Tuluá's coordinates, they had already passed over it. In response to this, they attempted to program the navigation computer for the next approach waypoint, Rozo. However, the Rozo NDB was identified as R on their charts. Colombia had duplicated the identifier for the Romeo NDB near Bogotá, and the computer's list of stored waypoints did not include the Rozo NDB as "R", but only under its full name "ROZO". In cases where a country allowed duplicate identifiers, it often listed them with the largest city first. By picking the first "R" from the list, the captain caused the autopilot to start flying a course to Bogotá, resulting in the airplane turning east in a wide semicircle. By the time the error was detected, the aircraft was in a valley running roughly north-south parallel to the one they should have been in. The pilots had put the aircraft on a collision course with a 3,000-meter mountain.[5] The air traffic controller believed that some of the requests of the pilots did not make sense, but did not know enough non-aviation English to convey this.[6]

[edit] The crash

Nine seconds before the plane hit the mountain, the Ground Proximity Warning System activated, announcing an imminent terrain collision and sounding an alarm. The captain and first officer attempted to climb clear of the mountain, but the spoilers reduced the climb rate and the aircraft hit the mountain near its peak. Research has shown that the aircraft would probably have cleared the terrain if the crew had immediately retracted the spoilers when they were notified by the GPWS.

[edit] Legal aftermath

American Airlines settled numerous lawsuits brought against it by the families of the victims of the accident. American Airlines filed a "third-party complaint" lawsuit for contribution against Jeppesen and Honeywell, who made the navigation computer database and failed to include the coordinates of Rozo under the identifier "R"; the case went to trial in United States District Court for the Southern District of Florida in Miami. At the trial, American admitted that it bore some legal responsibility for the accident. Honeywell and Jeppesen each contended that they had no legal responsibility for the accident. In June 2000, the jury found that Jeppesen was 17 percent at fault for the crash, Honeywell was 8 percent at fault, and American Airlines was 75 percent at fault.[7]

The flight route designation of the Miami to Cali route is now Flight 921 as a Boeing 737-800. Rozo NDB "R" has been replaced by Palma NDB "PL".

[edit] Crash investigation and final report

The crash was investigated by Aeronautica Civil (civil aviation authority) of the Republic of Colombia,[8] with assistance from the U.S. National Transportation Safety Board (U.S. NTSB) as well as other parties, including the U.S. Federal Aviation Administration, Allied Pilots Association, American Airlines, Boeing Commercial Airplane Group and Rolls Royce Engines.

The Aeronautica Civil prepared a final report of its investigation in September 1996, which was released through the U.S. NTSB.[9]

In its report, the Aeronautica Civil determined the following probable causes of the accident:

  1. The flightcrew's failure to adequately plan and execute the approach to runway 19 at SKCL and their inadequate use of automation.
  2. Failure of the flightcrew 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 flightcrew regarding vertical navigation, proximity to terrain, and the relative location of critical radio aids.
  4. Failure of the flightcrew 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.

In addition, the Aeronautica Civil determined that there were the following contributing factors to the accident:

  1. The flightcrew's ongoing efforts to expedite their approach and landing in order to avoid potential delays.
  2. The flightcrew's execution of the GPWS escape maneuver while the speedbrakes remained deployed.
  3. FMS logic that dropped all intermediate fixes from the display(s) in the event of execution of a direct routing.
  4. FMS-generated navigational information that used a different naming convention from that published in navigational charts.

The Aeronautica Civil's report also included a variety of safety-related recommendations to the following parties (number of individual recommendations in parentheses)[8]:

[edit] Dramatization

This accident was featured in the episode "Lost" (a.k.a. "Crash on the Mountain") from the Mayday television series (also known as Air Crash Investigation and Air Emergency).

[edit] Notable passengers

  • Francisco Ferre Malaussena, Mariana Gomez de Ferre, and Felipe Antonio Ferre Gomez, the son, daughter-in-law, and grandson of Miami's former mayor Maurice Ferre.[10][11]
  • Paris Kanellakis, a computer scientist at Brown University, died with wife Maria-Teresa Otoya and children Alexandra and Stephanos.[10]
  • The survivors included Gonzalo Dussan Monroy, Michelle Dussan [12][10], Mercedes Ramirez, and Mauricio Reyes. Gonzalo "Gonzalito" Dussan, Jr., Michelle Dussan's brother and Gonzalo Dussan's son, was initially found alive but died on the operating table due to internal injuries.[4]

[edit] See also

[edit] References

  1. ^ a b "American Airlines jet crashes in the Andes," CNN
  2. ^ "Did mistakes by crew doom flight to Cali?," The Seattle Times
  3. ^ Family members await crash news. CNN. Retrieved on 2008-03-29.
  4. ^ a b c "Lost," Mayday
  5. ^ AOPA "Lessons from Cali" Article
  6. ^ The AA965 Cali accident. Georgia Institute of Technology. Retrieved on 2008-03-29.
  7. ^ Failure Knowledge Database. shippai.jst.go.jp. Retrieved on 2008-03-19.
  8. ^ a b Aeronautica Civil's Final Report
  9. ^ NTSB Report Summary. NTSB. Retrieved on 2008-03-29. “Note: passenger number on NTSB summary is 156, vs. 155 on final report”
  10. ^ a b c "The List of the 164 People on Flight 965," The New York Times
  11. ^ "CONGRESSIONAL RECORD—Extensions of Remarks," U.S. Government Printing Office
  12. ^ "NEW JERSEY DAILY BRIEFING;Crash Survivor Goes Home," The New York Times

[edit] External links

Coordinates: 3°50′45.2″N, 76°06′17.1″W

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