| Status: | Final |
| Date: | 20 DEC 1995 |
| Time: | 21:38 |
| Type: | Boeing 757-223 |
| Operator: | American Airlines |
| Registration: | N651AA |
| C/n / msn: | 24609/390 |
| First flight: | 1991-08-12 (4 years 4 months) |
| Total airframe hrs: | 13782 |
| Cycles: | 4922 |
| Engines: | 2 Rolls Royce RB211-535E4B |
| Crew: | Fatalities: 8 / Occupants: 8 |
| Passengers: | Fatalities: 151 / Occupants: 155 |
| Total: | Fatalities: 159 / Occupants: 163 |
| Airplane damage: | Destroyed |
| Airplane fate: | Written off (damaged beyond repair) |
| Location: | Buga (Colombia)
 |
| Phase: | Approach (APR) |
| Nature: | International Scheduled Passenger |
| Departure airport: | Miami International Airport, FL (MIA/KMIA), United States of America |
| Destination airport: | Cali-Alfonso Bonilla Aragón Airport (CLO/SKCL), Colombia |
| Flightnumber: | 965 |
Narrative: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: "Aeronautica Civil determines that the probable causes of this accident were:
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.
Contributing to the cause of the accident were:
1. The flight crew's ongoing efforts to expedite their approach and landing in order to avoid potential delays;
2. The flight crew's execution of the GPWS escape manoeuvre while the speed brakes 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."
Events:
Sources:
» Aircraft Accident Report controlled flight into terrain American Airlines Flight 965 Boeing 757-223, N651AA near Cali, Colombia December 20, 1995 / Aeronautica Civil of the Republic of Colombia
» Improvements needed in FMS Human Factors / R.N. Aarons, Business & Commercial Aviation Nov. 1996 (144, 146, 160)
»
Boeing 757 CFIT Accident at Cali, Colombia, Becomes Focus of Lessons Learned (Flight Safety Foundation - Flight Safety Digest, May-June 1998)Sample newspaper article from Newspaperarchive.com
Follow-up / safety actions
April 2000, American Airlines sued both Jeppesen (for furnishing AA with a database that hid a critical checkpoint) and Honeywell (that made the plane's flight management computer) over a December 1995 accident near Cali, Bogota.
NTSB issued 17 Safety Recommendations
| Issued: 16-OCT-1996 | To: FAA | A-96-090 |
| Evaluate the effects of automatically stowing the speedbrakes on existing airplanes when high power is commanded and determine the desirability of incorporating automatic speedbrake retraction on these airplanes for windshear and terrain escape maneuvers, or other situations demanding maximum thrust and climb capability. (Closed - Acceptable Action) |
| Issued: 16-OCT-1996 | To: FAA | A-96-091 |
| Require that newly certified transport-category aircraft include automatic speedbrake retraction during windshear and ground proximity warning system escape maneuvers, or other situations demanding maximum thrust and climb capability. (Closed - Unacceptable Action) |
| Issued: 16-OCT-1996 | To: FAA | A-96-092 |
| Evaluate the Boeing commercial airplane group procedure for guarding the speedbrake handle during periods of deployment, and require airlines to implement the procedure if it increases the speed of stowage or decreases the likelihood of forgetting to stow the speedbrakes in an emergency situation. (Closed - Acceptable Action) |
| Issued: 16-OCT-1996 | To: FAA | A-96-093 |
| Evaluate the terrain avoidance procedures of air carriers operating transport category aircraft to ensure that the procedures provide for the extraction of maximum escape performance and ensure that those procedures are placed in procedural sections of the approved operations manuals. (Closed - Acceptable Action) |
| Issued: 16-OCT-1996 | To: FAA | A-96-094 |
| Require that all transport-category aircraft present pilots with angle-of-attack info in a visual format, and that all air carriers train their pilots to use the info to obtain maximum possible airplane climb performance. (Closed - Unacceptable Action) |
| Issued: 16-OCT-1996 | To: FAA | A-96-095 |
| Develop a controlled flight into terrain training program that includes realistic simulator exercises comparable to the successful windshear and rejected takeoff training programs and make training in such a program mandatory for all pilots operating under 14 CFR 121. (Open - Acceptable Response) |
| Issued: 16-OCT-1996 | To: FAA | A-96-096 |
| Require all flight management system (FMS)-equipped aircraft, that are not already capable of so doing, to be modified so that those fixes between the airplane\'s position and the one towards which the airplane is proceeding are retained in the FMS control display unit and FMS-generated flightpath following the execution of a command to the FMS to proceed direct to a fix. (Closed - Reconsidered) |
| Issued: 16-OCT-1996 | To: FAA | A-96-097 |
| Inform pilots of flight management system (FMS)-equipped aircraft of the hazards of selecting navigation stations which common identifiers when operating outside of the United States and that verification of the correct identity and coordinates of FMS-generated waypoints data is required at all times. (Closed - Acceptable Action) |
| Issued: 16-OCT-1996 | To: FAA | A-96-098 |
| Develop and implement standards to portray instrument approach criteria, including terminal environment info and navigational aids, on FMS-generated displays that match, as closely as possible, the corresponding info on instrument approach charts. (Closed - Acceptable Action) |
| Issued: 16-OCT-1996 | To: FAA | A-96-099 |
| Until such time as common standards are developed for flight management system (FMS)-generated displays and instrument approach charts, require the Jeppesen Sanderson Company to inform airlines operating FMS-equipped aircraft of each difference in the naming and/or portrayal of navigation info on FMS-generated and approach chart info, and require airlines to inform their pilots of these differences. (Closed - Acceptable Action) |
| Issued: 16-OCT-1996 | To: FAA | A-96-100 |
| Require pilots operating under 14 CFR Part 121 to have open and easily accessible the approach and navigation charts applicable to each phase of flight before each phase is reached. (Closed - Acceptable Alternate Action) |
| Issued: 16-OCT-1996 | To: FAA | A-96-101 |
| Examine the effectiveness of the enhanced ground proximity warning equipment and if found effective, require all transport-category aircraft to be equipped with enhanced ground proximity warning equipment that provides pilots with an early warning of terrain. (Closed - Acceptable Action) |
| Issued: 16-OCT-1996 | To: FAA | A-96-102 |
| Require that all approach and navigation charts graphically present terrain info. (Closed - Acceptable Alternate Action) |
| Issued: 16-OCT-1996 | To: FAA | A-96-103 |
| Require that approach charts to airports that do not have radar coverage available at the time of the publication of the chart prominently state, on the chart, that radar coverage is unavailable. (Closed - Reconsidered) |
| Issued: 16-OCT-1996 | To: FAA | A-96-104 |
| Review, with the International Civil Aviation Organization (ICAO) member states, the naming conventions used for standard instrument departures (SIDs) and standard terminal arrival route (STARs), and urge member states with SIDs and STARs that do not follow the ICAO naming convention to rename them in accordance with the ICAO recommendation. (Closed - Acceptable Action) |
| Issued: 16-OCT-1996 | To: FAA | A-96-105 |
| Develop, with air traffic authorities of member states of the International Civil Aviation Organization, a program to enhance controllers\' fluency in common English-language phrases and interaction skills sufficient to assist pilots in obtaining situational awareness about critical features of the airspace, particularly in non-radar environments. (Closed - Acceptable Action) |
| Issued: 16-OCT-1996 | To: FAA | A-96-106 |
| Revise Advisory Circular 120-51b to include specific guidance on methods to effectively train pilots to recognize cues that indicate that they have not obtained situational awareness, and effective measures to obtain that awareness. (Closed - Acceptable Action) |
Show all AD's and Safety Recommendations
Photos
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Miami International Airport, FL to Cali-Alfonso Bonilla Aragón Airport as the crow flies is 2494 km (1558 miles).
Books
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