
Détails:
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."
» 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)
Flight path depiction
accident date: 20-12-1995
type: Boeing 757-223
registration: N651AA
| Statuts: | Accident investigation report completed and information captured |
| Date: | mercredi 20 décembre 1995 |
| Heure: | 21:38 |
| Type/Sous-type: |  Boeing 757-223 |
| Compagnie: | American Airlines |
| Immatriculation: | N651AA |
| Numéro de série: | 24609/390 |
| Année de Fabrication: | 1991-08-12 (4 years 4 months) |
| Heures de vol: | 13782 |
| Cycles: | 4922 |
| Moteurs: | 2 Rolls-Royce RB211-535E4B |
| Equipage: | victimes: 8 / Ã bord: 8 |
| Passagers: | victimes: 151 / Ã bord: 155 |
| Total: | victimes: 159 / Ã bord: 163 |
| Dégats de l'appareil: | Détruit |
| Conséquences: | Written off (damaged beyond repair) |
| Lieu de l'accident: | Buga ( Colombie)
|
| Élévation des lieux de l'accident: | 2712 m (8898 feet) amsl |
| Phase de vol: | En approche (APR) |
| Nature: | Transport de Passagers Intern. |
| Aéroport de départ: | Miami International Airport, FL (MIA/KMIA), Etats-Unis d'Amérique |
| Cali-Alfonso Bonilla Aragón Airport (CLO/SKCL), Colombie | |
| Numéro de vol: | AA965 |
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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|
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)
Opérations de secours
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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Photos
Flight path depiction
accident date: 20-12-1995
type: Boeing 757-223
registration: N651AA
Plan
Ce plan montre l'aéroport de départ ainsi que la supposée destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre Miami International Airport, FL et Cali-Alfonso Bonilla Aragón Airport est de 2494 km (1558 miles).
Accident location: Exact; as reported in the official accident report.
La distance entre Miami International Airport, FL et Cali-Alfonso Bonilla Aragón Airport est de 2494 km (1558 miles).
Accident location: Exact; as reported in the official accident report.
Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.
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