Flugunfall 20 DEC 1995 einer Boeing 757-223 N651AA - Buga
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Status:Accident investigation report completed and information captured
Datum:Mittwoch 20 Dezember 1995
Zeit:21:38
Flugzeugtyp:Silhouette image of generic B752 model; specific model in this crash may look slightly different
Boeing 757-223
Fluggesellschaft:American Airlines
Kennzeichen: N651AA
Werknummer: 24609/390
Baujahr: 1991-08-12 (4 years 4 months)
Betriebsstunden:13782
Anzahl Zyklen der Zelle:4922
Triebwerk: 2 Rolls-Royce RB211-535E4B
Besatzung:Todesopfer: 8 / Insassen: 8
Fluggäste:Todesopfer: 151 / Insassen: 155
Gesamt:Todesopfer: 159 / Insassen: 163
Sachschaden: Zerstört
Konsequenzen: Written off (damaged beyond repair)
Unfallort:Buga (   Kolumbien)
Flugphase: Annäherung (APR)
Betriebsart:Internationaler Linienflug
Flug von:Miami International Airport, FL (MIA/KMIA), USA
Flug nach:Cali-Alfonso Bonilla Aragón Airport (CLO/SKCL), Kolumbien
Flugnummer:AA965
Unfallbericht:
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:

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."

Accident investigation:

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Investigating agency: Aerocivil Colombia
Status: Investigation completed
Duration: 256 days (9 months)
Accident number: final report
Download report: Final report

Informationsquelle:
» 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)


Sicherheitsempfehlungen
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

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Fotos

photo of Boeing-757-223-N651AA
photo of Boeing-757-223-N651AA
Flight path depiction
photo of Boeing-757-223-N651AA
accident date: 20-12-1995
type: Boeing 757-223
registration: N651AA
 

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).
Accident location: Exact; as reported in the official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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