CASE STUDY #1: AMERICAN FLIGHT 965
Mario D. Ochoa
A Graduate Paper Submitted in Partial Fulfillment of the Requirements for the Completion of MSA 608 Aviation and Aerospace Accident Investigation and Safety Systems and for the Degree of Master of Science in Aeronautics
Embry-Riddle Aeronautical University
Daytona Beach, Florida
American Airlines (AA) Flight 965 out of Miami International crashed on December 20, 1995 in enroute to Cali, Columbia at approximately 9:42 PM Eastern Standard Time (EST). The airplane was a regularly scheduled flight out of Miami and a Boeing 757-233 with 163 passengers and crew on board (Cali Press Release NTSB, 1995). The airplane crashed approximately 33 miles northeast of Cali on its approach to the airport, when it struck a mountain while descending for the approach. The crash occurred under visual meteorological conditions (VMC), at night, and with no significant weather. The accident occurred near the town of Buga, Columbia around the summit of El Deluvio at approximately 8,900 feet sea level. WHY DID THE ACCIDENT HAPPEN?
AA Flight 965 accident happened due to a serious of "operational errors" leading to the catastrophe on the summit of El Deluvio. These errors, which individually were not causal, but interacted in a way that caused the accident when linked together, formed the "accident chain" (Bovier, 1997). In Dr. Diehl's Accident Model, it takes hundreds of hazards to lead to tens of incidents that eventually cause an accident (Hunt, 2005). In this accident, AA Flight 965 had many critical events, particular in the realm of crew resource management (CRM) and situational awareness (SA). These two realms are what affected the outcome of AA Flight 965 on its final minutes in flight and led to the "causation factor" of the accident.
The captain, non-flying crew member on the controls at the time of the accident, and the first officer, flying crew member, both had thousand of hours of flight time and thousands of hours in type aircraft. The last seven minutes of the flight (as reported by the handling investigation agency - Aeronautica Civil of the Government of Columbia) is the critical time that affected the outcome of AA Flight 965. The crew was originally going to fly the precision Instrument Landing System (ILS) approach into Cali, called Cali ILS Runway 01. The crew was offered the non-precision approach, Very high frequency approach Omnidirectional Range with Distance Measuring Equipment (VOR DME) Runway 19 by Air Traffic Control (ATC). This would allow the crew to basically fly a "straight-in" approach to Cali via the current route inbound. Executing this would allow the crew to save flight time and land sooner at the airport and not have to pass Cali to turn around and execute the Cali ILS Runway 01 approach Aeronautica Civil, 1996). In reality, after the captain accepted the approach from ATC at Cali, the captain made a critical error in flight planning. The captain input the wrong waypoint into the Flight Management System (FMS) and started a series of errors immediately following for the next seven minutes the last for AA Flight 965 (Bovier, 1997). By only confirming to the first officer that he had put the required waypoint into the FMS, the proper input was to be the "ROZO" non-directional beacon (NDB), the captain in reality made an input of "R" ("Romeo" waypoint) which led the automatic pilot with the Flight Management Computer (FMC) and all its components fly the aircraft to Bogota, Columbia. This course was due east of the desired course direction, heading 093 degrees, and should have been noticed by either crewmember if they had correct SA. By not recognizing the required input of "R-O-Z-O" into the FMS, the crew allowed the aircraft to turn in the wrong direction. Typing in on the letter "R" in the FMS led to this critical mistake (Aeronautica Civil, 1996).
The next few and systemic critical...
References: Aeronautica Civil of the Republic of Columbia. (1996). Aircraft Accident Report, Controlled Flight Into Terrain, American Airlines Flight 96, Boeing 757-233, N651AA, Near Cali, Columbia, December 20, 1995. Santaf, de Bogota, D.C., Columbia.
American 757 Crashes. (1996, January 3-9). Flight International. Retrieved October 1, 2005 from http://www.rvs.uni-bielefeld.de/publications/Incidents/DOCS/ComAndRep/ Cali/cali-Flreports.html
Cali Press Release - NTSB. (1995). Factual Data: NTSB, Washington D.C. 20694, December 28, 1995. Retrieved October 1, 2005 from http://www.rvs.uni-bielefeld.de/publications /Incidents/DOCS/ComAndRep/Cali/cali-prelimreport.html
Endsley, M. R. (1988). Design and evaluation for situation awareness and enhancement. In the Proceedings of the Human Factors Society 32nd Annual Meeting (pp. 97-101). Santa Monica, CA: Human Factors Society.
Hunt, D.B. (2005). Session #1: Topic#3, Aviation Safety, 31 August 2005, Instructor. MSA 608 Aviation and Aerospace Accident Investigation and Safety Systems. Daytona Beach: Embry-Riddle Aeronautical University
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