American Airlines Flight 965
Encyclopedia
American Airlines
American Airlines
American Airlines, Inc. is the world's fourth-largest airline in passenger miles transported and operating revenues. American Airlines is a subsidiary of the AMR Corporation and is headquartered in Fort Worth, Texas adjacent to its largest hub at Dallas/Fort Worth International Airport...

 Flight 965, a Boeing 757
Boeing 757
The Boeing 757 is a mid-size, narrow-body twin-engine jet airliner manufactured by Boeing Commercial Airplanes. Passenger versions of the twinjet have a capacity of 186 to 289 persons and a maximum range of , depending on variant and cabin configuration...

 registered , was a scheduled flight from Miami International Airport
Miami International Airport
Miami International Airport , also known as MIA and historically Wilcox Field, is the primary airport serving the South Florida area...

 in Miami
Miami, Florida
Miami is a city located on the Atlantic coast in southeastern Florida and the county seat of Miami-Dade County, the most populous county in Florida and the eighth-most populous county in the United States with a population of 2,500,625...

, Florida
Florida
Florida is a state in the southeastern United States, located on the nation's Atlantic and Gulf coasts. It is bordered to the west by the Gulf of Mexico, to the north by Alabama and Georgia and to the east by the Atlantic Ocean. With a population of 18,801,310 as measured by the 2010 census, it...

 to Alfonso Bonilla Aragón International Airport
Alfonso Bonilla Aragón International Airport
-Cargo airlines:-Accidents and incidents :*On 3 May, Douglas C-47B FAC-1126 of SATENA was damaged beyond repair in an accident at Palmaseca Airport.*On 21 January 1974, a Vickers Viscount of Aeropesca Colombia was hijacked and diverted to Cali....

 in Cali
Calì
Calì, also written in English as Cali, is an Italian surname, widespread mainly in the Ionian side of Sicily.For the surname Calì is assumed the origin of the Greek word kalos , or from its Sanskrit root kali, "time."The surname refers to:...

, Colombia
Colombia
Colombia, officially the Republic of Colombia , is a unitary constitutional republic comprising thirty-two departments. The country is located in northwestern South America, bordered to the east by Venezuela and Brazil; to the south by Ecuador and Peru; to the north by the Caribbean Sea; to the...

, which crashed into a mountain in Buga
Buga, Valle del Cauca
Buga formally Guadalajara de Buga is a city and municipality in the Valle del Cauca department of Colombia. It is famous for its Basilica del Señor de los Milagros, which houses an image of Christ called El Señor de los Milagros .-History:Guadalajara de Buga is one of the oldest cities in...

, Colombia
Colombia
Colombia, officially the Republic of Colombia , is a unitary constitutional republic comprising thirty-two departments. The country is located in northwestern South America, bordered to the east by Venezuela and Brazil; to the south by Ecuador and Peru; to the north by the Caribbean Sea; to the...

 on December 20, 1995, killing 151 passengers and 8 crew members. The crash was the first U.S.-owned 757 accident and the highest death toll of any accident in Colombia. It is also the highest death toll of any accident involving a Boeing 757 at that time. It was surpassed by Birgenair Flight 301
Birgenair Flight 301
Birgenair Flight 301 was a flight chartered by Turkish-managed Birgenair partner Alas Nacionales from Puerto Plata in the Dominican Republic to Frankfurt, Germany via Gander, Canada and Berlin, Germany...

 which crashed in 1996 with 189 fatalities. Flight 965 was the deadliest air disaster involving a U.S. carrier since the downing of Pan Am Flight 103
Pan Am Flight 103
Pan Am Flight 103 was Pan American World Airways' third daily scheduled transatlantic flight from London Heathrow Airport to New York's John F. Kennedy International Airport...

 in 1988. Four passengers survived the crash, all of whom were seated within 2 rows of each other.

The Colombian Special Administrative Unit of Civil Aeronautics
Special Administrative Unit of Civil Aeronautics
The Special Administrative Unit of Civil Aeronautics is a government agency of the Colombian Ministry of Transport. It is the agency in charge of regulating civil aviation, the aviation industry, and of managing the Colombian airspace. Aerocivil is also in charge of managing and controlling all of...

 investigated the accident and determined it was caused by navigational errors by the flight crew.

Flight history

At that time, Flight 965 mainly carried people returning to Colombia for the Christmas
Christmas
Christmas or Christmas Day is an annual holiday generally celebrated on December 25 by billions of people around the world. It is a Christian feast that commemorates the birth of Jesus Christ, liturgically closing the Advent season and initiating the season of Christmastide, which lasts twelve days...

 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 Boeing 757 to take off two hours late. Some other passengers booked on Flight 965 missed the flight due to missed connections.

The cockpit crew consisted of Captain Nicholas Tafuri and First Officer Donald Williams. The cabin crew consisted of Purser Pedro Calle and Flight Attendants Magdalena Borrero, Rosa Cabrejo, Teresa Delgado, Gilberto Restrepo, and Margaret Villalobos.

Cali's air traffic controllers had no functional radar
Radar
Radar is an object-detection system which uses radio waves to determine the range, altitude, direction, or speed of objects. It can be used to detect aircraft, ships, spacecraft, guided missiles, motor vehicles, weather formations, and terrain. The radar dish or antenna transmits pulses of radio...

 to monitor the 757 as the pilots flew the approach using the area's radio navigation aids and the airport's instrument approach system. 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
Flight management system
A flight management system is a fundamental part of a modern airliner's avionics. An FMS is a specialized computer system that automates a wide variety of in-flight tasks, reducing the workload on the flight crew to the point that modern aircraft no longer carry flight engineers or navigators. A...

 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 if they wanted to fly a straight-in approach to runway 19 rather than coming around to runway 01. The pilots agreed, 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
Tuluá
Tuluá is a city located in the heart of the Cauca Valley, Colombia Valle del Cauca, Colombia. A major industrial and commercial center, it is the region's fourth largest city after Cali, the department capital, Buenaventura and Palmira. Founded around 1741 by Juan de Lemos y Aguirre, it has a...

, 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 they 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
Non-directional beacon
A non-directional beacon is a radio transmitter at a known location, used as an aviation or marine navigational aid. As the name implies, the signal transmitted does not include inherent directional information, in contrast to other navigational aids such as low frequency radio range, VHF...

 was identified as R on their charts. Colombia had duplicated the identifier for the Romeo NDB near Bogotá
Bogotá
Bogotá, Distrito Capital , from 1991 to 2000 called Santa Fé de Bogotá, is the capital, and largest city, of Colombia. It is also designated by the national constitution as the capital of the department of Cundinamarca, even though the city of Bogotá now comprises an independent Capital district...

, 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-meter (9,800 feet) mountain. The air traffic controller believed that some of the requests of the pilots did not make sense, but did not know enough non-aviation English
English language
English is a West Germanic language that arose in the Anglo-Saxon kingdoms of England and spread into what was to become south-east Scotland under the influence of the Anglian medieval kingdom of Northumbria...

 to convey this.

Crash

Twelve seconds before the plane hit the mountain, the Ground Proximity Warning System
Ground Proximity Warning System
A ground proximity warning system is a system designed to alert pilots if their aircraft is in immediate danger of flying into the ground or an obstacle. The United States Federal Aviation Administration defines GPWS as a type of terrain awareness warning system...

 activated, announcing an imminent terrain collision and sounding an alarm. The captain and first officer attempted to climb clear of the mountain, but the deployed speed brakes reduced the rate of climb and the aircraft hit the mountain near its summit. Research has shown that the aircraft would probably have cleared the terrain if the crew had immediately retracted the speed brakes when the GPWS alarm sounded.

Aftermath

Scavengers took engine thrust reversers, cockpit avionics, and other components from the crashed 757. The scavengers used Colombian military and private helicopters to go to and from the crash site. Many of the stolen unapproved aircraft part
Unapproved aircraft part
Unapproved aircraft parts are aircraft parts not approved by civil aviation authorities for installation on type certified aircraft.The Federal Aviation Administration defines a "standard part" as a part produced in accordance with government regulations, and it defines an "approved part" as a...

s re-appeared on the black market in Greater Miami parts brokers. In a 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 deceased pilots. The judge's ruling was subsequently reversed in June 1999 by the U.S. 11th Circuit 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
Jeppesen
Jeppesen is an American company that specializes in navigational information, operations management solutions and flight training products and services...

 and Honeywell
Honeywell
Honeywell International, Inc. is a major conglomerate company that produces a variety of consumer products, engineering services, and aerospace systems for a wide variety of customers, from private consumers to major corporations and governments....

, who 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
United States District Court for the Southern District of Florida
The United States District Court for the Southern District of Florida is the federal United States district court with jurisdiction over the southern part of the state of Florida....

 in Miami
Miami, Florida
Miami is a city located on the Atlantic coast in southeastern Florida and the county seat of Miami-Dade County, the most populous county in Florida and the eighth-most populous county in the United States with a population of 2,500,625...

. At the trial, American 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.

The flight route designation of the Miami to Cali route is now Flight 921 as a Boeing 737-800
Boeing 737
The Boeing 737 is a short- to medium-range, twin-engine narrow-body jet airliner. Originally developed as a shorter, lower-cost twin-engine airliner derived from Boeing's 707 and 727, the 737 has developed into a family of nine passenger models with a capacity of 85 to 215 passengers...

. Rozo NDB "R" has been replaced by Palma NDB "PL".

An improved ground proximity warning system
Ground Proximity Warning System
A ground proximity warning system is a system designed to alert pilots if their aircraft is in immediate danger of flying into the ground or an obstacle. The United States Federal Aviation Administration defines GPWS as a type of terrain awareness warning system...

, called enhanced ground proximity warning system, was introduced in 1996, which could have prevented the accident.

Since 2002, all planes with more than six passengers are required to have an advanced terrain awareness warning system. No aircraft fitted with a TAWS/EGPWS suffered a controlled flight into terrain
Controlled flight into terrain
Controlled flight into terrain describes an accident in which an airworthy aircraft, under pilot control, is unintentionally flown into the ground, a mountain, water, or an obstacle. The term was coined by engineers at Boeing in the late 1970s...

 accident until July 28, 2010 when Airblue Flight 202
Airblue Flight 202
Airblue Flight 202 was a scheduled domestic passenger flight which crashed on 28 July 2010 near Islamabad, the capital of Pakistan, killing all 146 passengers and six crew on board. It is the deadliest air accident to occur in Pakistan to date...

 crashed into the Margalla Hills, Pakistan.

Crash investigation and final report

The crash was investigated by the Special Administrative Unit of Civil Aeronautics
Special Administrative Unit of Civil Aeronautics
The Special Administrative Unit of Civil Aeronautics is a government agency of the Colombian Ministry of Transport. It is the agency in charge of regulating civil aviation, the aviation industry, and of managing the Colombian airspace. Aerocivil is also in charge of managing and controlling all of...

 (Aeronáutica Civil) of the Republic of Colombia, with assistance from the U.S. National Transportation Safety Board
National Transportation Safety Board
The National Transportation Safety Board is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine...

 (U.S. NTSB) as well as other parties, including the U.S. Federal Aviation Administration
Federal Aviation Administration
The Federal Aviation Administration is the national aviation authority of the United States. An agency of the United States Department of Transportation, it has authority to regulate and oversee all aspects of civil aviation in the U.S...

, Allied Pilots Association, American Airlines
American Airlines
American Airlines, Inc. is the world's fourth-largest airline in passenger miles transported and operating revenues. American Airlines is a subsidiary of the AMR Corporation and is headquartered in Fort Worth, Texas adjacent to its largest hub at Dallas/Fort Worth International Airport...

, Boeing Commercial Airplane Group
Boeing Commercial Airplanes
Boeing Commercial Airplanes designs, assembles, markets and sells large commercial jet aircraft and provides product-related maintenance and training to customers worldwide...

 and Rolls Royce Engines
Rolls-Royce plc
Rolls-Royce Group plc is a global power systems company headquartered in the City of Westminster, London, United Kingdom. It is the world’s second-largest maker of aircraft engines , and also has major businesses in the marine propulsion and energy sectors. Through its defence-related activities...

.

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:
  1. The flightcrew's failure to adequately plan and execute the approach to runway 19 at SKCL and their inadequate use of automation.
  2. Failure of the flightcrew 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 flightcrew regarding vertical navigation, proximity to terrain, and the relative location of critical radio aids.
  4. Failure of the flightcrew 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.


In addition, the Aeronáutica Civil determined that there were the following contributing factors to the accident:
  1. The flightcrew's ongoing efforts to expedite their approach and landing in order to avoid potential delays.
  2. The flightcrew's execution of the GPWS escape maneuver while the speedbrakes 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.


The Aeronáutica Civils report also included a variety of safety-related recommendations to the following parties (number of individual recommendations in parentheses):
  • U.S. FAA (17)
  • International Civil Aviation Organization
    International Civil Aviation Organization
    The International Civil Aviation Organization , pronounced , , is a specialized agency of the United Nations. It codifies the principles and techniques of international air navigation and fosters the planning and development of international air transport to ensure safe and orderly growth...

     (3)
  • American Airlines
    American Airlines
    American Airlines, Inc. is the world's fourth-largest airline in passenger miles transported and operating revenues. American Airlines is a subsidiary of the AMR Corporation and is headquartered in Fort Worth, Texas adjacent to its largest hub at Dallas/Fort Worth International Airport...

     (2)


Investigators later labeled the accident a Nonsurvivable event.

Dramatization

This incident was featured on the television series Air Crash Investigation in the episode "Lost", known in some countries as "Crash on the Mountain".

Notable passengers

  • Francisco Ferre Malaussena, Mariana Gomez de Ferre, and Felipe Antonio Ferre Gomez, the son, daughter-in-law, and grandson of former Miami mayor Maurice Ferre
    Maurice Ferre
    Maurice A. Ferre is a former six-term Mayor of Miami. Ferre was the first United States mayor born in Puerto Rico and the first Hispanic Mayor of Miami. He was an unsuccessful candidate in the 2010 elections for the U.S...

    .
  • Paris Kanellakis
    Paris Kanellakis
    Paris Christos Kanellakis was a computer scientist.Kanellakis was born in Greece as the only child of General Eleftherios and Mrs. Argyroula Kanellakis. In 1976, he received a diploma in Electrical Engineering from the National Technical University of Athens...

    , a computer scientist at Brown University
    Brown University
    Brown University is a private, Ivy League university located in Providence, Rhode Island, United States. Founded in 1764 prior to American independence from the British Empire as the College in the English Colony of Rhode Island and Providence Plantations early in the reign of King George III ,...

    , died with wife María Teresa Otoya and children Alexandra and Stephanos.
  • The survivors are Gonzalo Dussan Monroy, Michelle Dussan, Mercedes Ramirez, and Mauricio Reyes. Gonzalo "Gonzalito" Dussan, Jr., Michelle Dussan's brother and Gonzalo Dussan's son, was initially found alive but died on the operating table due to internal injuries. Gonzalo Dussan did not receive insurance benefits from the death of his companion and the mother of his children, Nancy Delgado, as Delgado and Dussan were not legally married. Ramirez is a central character in Exit Row: The True Story of an Emergency Volunteer, a Miraculous Survivor and the Crash of Flight 965 by Tammy L. Kling.
  • Crews found a small brown dog alive, inside a carrier in the cargo hold. The dog was adopted by the Red Cross team in Cali, Colombia, for a few weeks (they re-named him "Milagro", which is Spanish for "miracle"), then an American Airlines employee who had worked the crash recovery in Cali adopted the dog and brought it to the United States.


The U.S. encountered difficulty while trying to distinguish Americans from non-Americans, as many passengers held dual citizenships.

See also

  • Air Safety
    Air safety
    Air safety is a term encompassing the theory, investigation and categorization of flight failures, and the prevention of such failures through regulation, education and training. It can also be applied in the context of campaigns that inform the public as to the safety of air travel.-United...

  • Crew Resource Management
    Crew Resource Management
    Crew resource management or Cockpit resource management is a procedure and training system in systems where human error can have devastating effects. Used primarily for improving air safety, CRM focuses on interpersonal communication, leadership, and decision making in the cockpit...

  • Enhanced Ground Proximity Warning System (EGPWS)
  • Lists of accidents and incidents on commercial airliners


External links

The source of this article is wikipedia, the free encyclopedia.  The text of this article is licensed under the GFDL.
 
x
OK