American Airlines Flight 965
N651AA, the aircraft involved in the accident, taxiing at Mexico City International Airport in July 1995, five months before the accident
|Date||December 20, 1995|
|Summary||Controlled flight into terrain caused by navigational error and pilot error|
|Site||near Buga, Valle del Cauca, Colombia |
|Aircraft type||Boeing 757-223|
|Flight origin||Miami International Airport, Miami, Florida, United States|
|Destination||Alfonso Bonilla Aragón Int'l Airport, Cali, Colombia|
American Airlines Flight 965 was a regularly scheduled flight from Miami International Airport in Miami, Florida, to Alfonso Bonilla Aragón International Airport in Cali, Colombia. On December 20, 1995, the Boeing 757-200 flying this route (registration N651AA) crashed into a mountain in Buga, Colombia, killing 151 out of the 155 passengers and all eight crew members. The crash was the first U.S.-owned 757 accident and is currently the deadliest aviation accident to occur in Colombia. It was also the deadliest accident involving a Boeing 757 at that time, but was surpassed by Birgenair Flight 301 which crashed seven weeks later with 189 fatalities. Flight 965 was the deadliest air disaster involving a U.S. carrier since the bombing of Pan Am Flight 103 in 1988. Five passengers, all seated within two rows of each other, survived the initial impact, but one died two days later of his injuries. In addition to the four human survivors, a dog who had been in a carrier in the cargo hold at the time of the crash, survived the incident.
The aircraft was a Boeing 757-223 registered N651AA. Its first flight was on August 12, 1991, and was the 390th Boeing 757 built. The aircraft was powered by two Rolls-Royce RB211 engines.
At that time, Flight 965 mainly carried people returning to Colombia for the Christmas holiday, vacationers and businesspeople. 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, so Flight 965 pushed back from Gate D33 in Miami at 5:14 pm, and then taxied to runway 27R, but seasonal congestion caused the 757 to take off at 6:35 pm, 1 hour 21 minutes late.
The cockpit crew consisted of Captain Nicholas Tafuri, age 57, and First Officer Don Williams, age 39. Both pilots were considered to be highly skilled airmen. Captain Tafuri had more than 13,000 hours of flying experience and First Officer Williams had almost 6,000 hours. The cabin crew consisted of Purser Pedro Pablo Calle and Flight Attendants Magdalena Borrero, Rosa Cabrejo, Teresa Delgado, Gilberto Restrepo, and Margaret "Maggie" Villalobos. All cabin crew personnel were born in Colombia and were veterans from Braniff International Airways who had moved to Eastern Air Lines and then to American Airlines, when the routes were transferred from one airline to the other. They had voluntarily chosen the flight, as a prerogative awarded by seniority, to spend Christmas time with their families in Bogotá.
Cali's air traffic controllers had no functional radar to monitor the 757, as it had been blown up in 1992 by the terror group FARC. 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 whether they wanted to fly a straight-in approach to runway 19 rather than coming around to runway 01. The pilots agreed to approach straight-in, 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 speed brakes to slow it down and expedite its descent.
By the time the pilots 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-metre (9,800 ft) mountain. The air traffic controller, Nelson Rivera Ramírez, believed that some of the requests of the pilots did not make sense, but did not know enough non-aviation English to convey this.
Twelve seconds before the plane hit the mountain, named El Diluvio (The Deluge), the Ground Proximity Warning System activated, announcing an imminent terrain collision and sounding an alarm. Within a second of this warning the first officer disengaged the autopilot, and the captain attempted to climb clear of the mountain; however, neither pilot had remembered to disengage the previously deployed speed brakes, which reduced the rate of climb. At 9:41:28 pm Eastern Standard Time it struck trees at about 2,700 metres (8,900 ft) above mean sea level (MSL) on the east side of the mountain. The crash was 9.7 kilometres (6 mi) south of Tuluá VOR and 45 kilometres (28 mi) north of the approach end of runway 19 at Alfonso Bonilla Aragon International Airport. During the investigations, it was found that neither the Boeing fixed-base simulator nor the flight management system simulator could be backdriven with the data obtained directly from the accident airplane's flight data recorder. Because the 757 flight simulators could not be backdriven during the tests, it could not be determined with precision whether the airplane would have missed the mountain/tree tops if the speedbrakes had been retracted during the climb attempt. However, the final report stated that if the flightcrew had retracted the speedbrakes one second after initiating the escape maneuver, the airplane could have been climbing through a position that was 46 metres (150 ft) above the initial impact point. Because the airplane would have continued to climb and had the potential to increase its rate of climb, it might well have cleared the trees at the top of the mountain.
Crash investigation and final report
The crash was investigated by the Special Administrative Unit of Civil Aeronautics (Aeronáutica Civil) of the Republic of Colombia, 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 Aeronáutica Civil prepared a final report of its investigation in September 1996, which was released through the U.S. NTSB.
In its report, the Aeronáutica Civil determined the following probable causes of the accident:
- The flight crew's failure to adequately plan and execute the approach to runway 19 at SKCL and their inadequate use of automation.
- Failure of the flightcrew to discontinue the approach into Cali, despite numerous cues alerting them of the inadvisability of continuing the approach.
- The lack of situational awareness of the flightcrew regarding vertical navigation, proximity to terrain, and the relative location of critical radio aids.
- Failure of the flightcrew to revert to basic radio navigation at the time when the Flight management system (FMS)-assisted navigation became confusing and demanded an excessive workload in a critical phase of the flight.
In addition, the Aeronáutica Civil determined that the following factors contributed to the accident:
- The flight crew's ongoing efforts to expedite their approach and landing in order to avoid potential delays.
- The flight crew's execution of the GPWS escape maneuver while the speedbrakes remained deployed.
- FMS logic that dropped all intermediate fixes from the display(s) in the event of execution of a direct routing.
- FMS-generated navigational information that used a different naming convention from that published in navigational charts.
The Aeronáutica Civil's report also included a variety of safety-related recommendations to the following parties (number of individual recommendations in parentheses):
Investigators later labeled the accident a non-survivable event.
Scavengers took engine thrust reversers, cockpit avionics, and other components from the crashed 757, using Colombian military and private helicopters to go to and from the crash site. Many of the stolen components re-appeared as unapproved aircraft parts on the black market in Greater Miami parts brokers. In response, the airline published a 14-page list stating all of the parts missing from the crashed aircraft. The list included the serial numbers of all of the parts.
In 1997 U.S. District Judge Stanley Marcus ruled that the pilots had committed "willful misconduct"; the ruling applied to American Airlines, which represented the dead pilots. The judge's ruling was subsequently reversed in June 1999 by the U.S. Court of Appeals in Atlanta, which also overturned the jury verdict and declared that the judge in the case was wrong in issuing a finding of fault with the pilots, a role which should have been reserved for the jury only.
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, which 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 Airlines 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 30 percent at fault for the crash, Honeywell was 10 percent at fault, and American Airlines was 60 percent at fault.
As of November 2017, American Airlines still operates the Miami-Cali route, but as American Airlines Flight 921 and using a Boeing 737-800.
- Paris Kanellakis, a computer scientist at Brown University, died with his wife and two children.
In popular culture
- The events of Flight 965 were featured in "Lost", a Season 2 (2004) episode of the Canadian TV series Mayday (called Air Emergency and Air Disasters in the U.S. and Air Crash Investigation in the UK and elsewhere around the world). The episode was broadcast with the title "Crash on the Mountain" in the United Kingdom, Australia and Asia.
- The accident was also featured on Why Planes Crash on MSNBC, in an episode titled "Sudden Impact".
- The episode "Disastrous Descents" of the TV series Aircrash Confidential produced by WMR Productions and IMG Entertainment, featured the accident.
- Air Inter Flight 148
- Air New Zealand Flight 901
- Prinair Flight 277
- Crew resource management
- Ground proximity warning system (GPWS)
- List of accidents and incidents involving commercial aircraft
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Note: passenger number on NTSB summary is 156, vs. 155 on final report
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|Pre-crash photo taken from Airliners.net|
- Final Accident Report - AA965 - Special Administrative Unit of Civil Aeronautics - Prepared for the World Wide Web by Peter Ladkin of Bielefeld University (Alt, Alt #2, Archive, Archive of Alt #2)
- (in Spanish) Final Accident Report - AA965 (Archive) - Special Administrative Unit of Civil Aeronautics - Translation by Captain José Bestene Mattar and Maria Isabel Bobrez Orozco
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- Cockpit voice recording transcript