American Airlines Flight 965

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[1]) crashed into a mountain in Buga, Colombia, killing 151 out of the 155 passengers and all eight crew members.[2]

American Airlines Flight 965
Wreckage of N651AA at the crash site
Accident
DateDecember 20, 1995
SummaryControlled flight into terrain caused by navigational error and pilot error
Sitenear Buga, Valle del Cauca, Colombia
3°50′45.2″N 76°06′17.1″W
Aircraft
Aircraft typeBoeing 757-223
OperatorAmerican Airlines
IATA flight No.AA965
ICAO flight No.AAL965
Call signAMERICAN 965
RegistrationN651AA
Flight originMiami International Airport, Miami, Florida, United States
DestinationAlfonso Bonilla Aragón Int'l Airport, Cali, Colombia
Occupants163
Passengers155
Crew8
Fatalities159
Injuries4
Survivors4 (5 initially)

The crash was the first U.S.-owned 757 accident and is currently the deadliest aviation accident to occur in Colombia.[3][4] It was also the deadliest accident involving a Boeing 757 at that time,[5] but was surpassed by Birgenair Flight 301 which crashed seven weeks later with 189 fatalities.[6] Flight 965 was the deadliest air disaster involving a U.S. carrier since the bombing of Pan Am Flight 103 in 1988.[7]

The Colombian Special Administrative Unit of Civil Aeronautics investigated the accident and determined it was caused by navigational errors by the flight crew.[8]

Aircraft
N651AA, the aircraft involved, photographed in July 1995, five months before the accident

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.[9][10]

Flight history

Departure

At that time, Flight 965 mainly carried people returning to Colombia for the Christmas holiday, vacationers and businesspeople.[11] 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, and seasonal congestion caused further delay. Flight 965 took off at 6:35 pm EST (23:35 UTC), nearly two hours late.[8]:2[12][13]

The cockpit crew consisted of Captain Nicholas Tafuri, age 57, and First Officer Donald (Don) Williams, age 39.[14] Both pilots were considered to be highly skilled airmen. Captain Tafuri had more than 13,000 hours of flying experience (including 2,260 hours on the Boeing 757/767) and First Officer Williams had almost 6,000 hours, with 2,286 of them on the Boeing 757/767. The cabin crew consisted of Purser Pedro Pablo Calle[13] and Flight Attendants Magdalena Borrero, Rosa Cabrejo, Teresa Delgado, Gilberto Restrepo, and Margaret "Maggie" Villalobos.[14] 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.[15]

Going off-course

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.[16] 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.[13]

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.[8]

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 Non-directional beacon (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. In other words, the "ROZO" waypoint should have been at the top of the FMS, as it was the nearest one, but in the case of Flight 965, it was not. Only several other waypoints that began with "R" were displayed. 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. The pilots then attempted to correct this by turning back to the south. 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.[17] 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.[18]

Crash

Twelve seconds before the plane hit the mountain, named El Diluvio (The Deluge),[15] the Ground Proximity Warning System (GPWS) 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. Within 2 seconds of the GPWS activation, take-off power was selected, and in the next second, pitch was increased to 20.6 degrees upwards, causing activation of the stick shaker.[19]

However, neither pilot had remembered to disengage the previously deployed speed brakes, which were fully extended and significantly reduced the rate of climb. At 9:41:28 pm Eastern Standard Time, the aircraft struck trees at about 2,720 metres (8,920 ft) above mean sea level (MSL) on the east side of the 2,700 metres (9,000 ft) tall mountain. The last record on the flight recorded indicated that the plane was flying at 187 knots and with a pitch attitude of almost 28 degrees. The crash was 9.7 kilometres (6.0 mi; 5.2 nmi) south of Tuluá VOR and 28 kilometres (17 mi; 15 nmi) north of the approach end of runway 19 at Alfonso Bonilla Aragon International Airport.[8] Initially the aircraft cleared the summit, but struck the trees with the tail and crashed shortly after the summit.

Five passengers, all seated within two rows of each other, survived the initial impact, but one died two days later of his injuries.[20] 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 accident.

Crash investigation and final report

The crash was investigated by the Special Administrative Unit of Civil Aeronautics (Spanish: Aeronáutica Civil) of the Republic of Colombia,[8] 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.

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 (FDR). 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.[8] 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.

The Aeronáutica Civil prepared a final report of its investigation in September 1996, which was released through the U.S. NTSB.[21]

In its report, the Aeronáutica Civil determined the following probable causes of the accident:

  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 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 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:

  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 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 Civil's report also included a variety of safety-related recommendations to the following parties (number of individual recommendations in parentheses):[8]

Investigators later labeled the accident a non-survivable event, citing the impact forces and subsequent destruction of the aircraft.[8]:15,55[13]

Aftermath

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.[22] 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.[23]

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.[24] 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.[25]

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.[26]

An enhanced ground proximity warning system was introduced in 1996,[27] which could have prevented the accident.[28][29]

Since 2002, aircraft capable of carrying more than six passengers are required to have an advanced terrain awareness warning system.[30][31]

As of November 2020, American Airlines still operates the Miami-Cali route, but as American Airlines Flight 921 and using a Boeing 737-800.[32]

Notable passengers

The U.S. government encountered difficulty while trying to distinguish Americans from non-Americans, as many passengers held dual citizenships.[33]

  • The events of Flight 965 were featured in "Lost", a Season 2 (2004) episode of the Canadian TV series Mayday[13] (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 a 2015 episode titled "Sudden Impact".
  • The 2018 episode "Disastrous Descents" of the TV series Aircrash Confidential, produced by WMR Productions and IMG Entertainment, featured the accident.
  • A new possible cause for the accident is suggested in the Fact Not Fiction Films' feature-length documentary 'American 965' completed in January 2021. The investigative documentary is directed and produced by former British Airways Captain Tristan Loraine and due for release in 2021.[34][35][36]

See also

References
  1. "FAA Registry (N651AA)". Federal Aviation Administration.
  2. "American Airlines jet crashes in the Andes". CNN. December 21, 1995. Retrieved May 6, 2009.
  3. Ranter, Harro. "ASN Aircraft accident Boeing 757-223 N651AA Buga". aviation-safety.net. Aviation Safety Network. Retrieved February 1, 2019.
  4. Ranter, Harro. "Colombia air safety profile". aviation-safety.net. Aviation Safety Network. Retrieved February 1, 2019.
  5. Ranter, Harro. "Boeing 757". aviation-safety.net. Aviation Safety Network. Retrieved February 1, 2019.
  6. Ranter, Harro. "ASN Aircraft accident Boeing 757-225 TC-GEN Puerto Plata, Dominican Republic". aviation-safety.net. Aviation Safety Network. Retrieved February 1, 2019.
  7. Acohido, Byron (January 18, 1997). "American Airlines jet crashes in the Andes". The Seattle Times. Retrieved May 6, 2009.
  8. "Controlled Flight Into Terrain, American Airlines Flight 965, Boeing 757-223, N651AA, Near Cali, Colombia, December 20, 1995" (PDF). Special Administrative Unit of Civil Aeronautics. Retrieved January 4, 2020.
  9. "American Airlines N651AA (Boeing 757 - MSN 24609)". www.airfleets.net. Airfleets aviation. Retrieved January 4, 2020.
  10. "N651AA American Airlines Boeing 757-200". www.planespotters.net. Retrieved January 4, 2020.
  11. "Family members await crash news". CNN. Retrieved March 29, 2008.
  12. "Cali Accident Report". sunnyday.mit.edu. Retrieved May 30, 2019.
  13. "Lost". Mayday. Season 2. Episode 5. 2004. Discovery Channel Canada / National Geographic Channel.
  14. "The List of the 164 People on Flight 965." Associated Press at The New York Times. Saturday December 23, 1995. Retrieved on May 6, 2009.
  15. Escobar, Jaime; Restrepo, Andrés. "16o ANIVERSARIO DEL ACCIDENTE DEL VUELO 965 DE AMERICAN AIRLINES. CERRO EL DILUVIO, BUGA VALLE. Parte 1" [16th ANNIVERSARY OF THE AMERICAN AIRLINES FLIGHT 965 ACCIDENT. CERRO EL DILUVIO, BUGA VALLE. Part 1]. Spotting in SKCL/CLO (in Spanish). Retrieved October 31, 2015.
  16. Mickolus, Edward F.; Simmons, Susan L. (1997). Terrorism, 1992–1995: A Chronology of Events and a Selectively Annotated Bibliography. ABC-CLIO. p. 904. ISBN 978-0-313-30468-2.
  17. "AOPA "Lessons from Cali" Article". Archived from the original on February 14, 2006. Retrieved February 14, 2006.
  18. "The AA965 Cali accident". Georgia Institute of Technology. Archived from the original on June 16, 2007. Retrieved March 29, 2008.
  19. https://www.skybrary.aero/index.php/B752,_vicinity_Cali_Colombia,_1995
  20. Sider, Don (January 8, 1996). "Miracle on the Mountain". People. Retrieved June 22, 2009.
  21. "NTSB Report Summary". National Transportation Safety Board. Archived from the original on February 13, 2009. Retrieved March 29, 2008. Note: passenger number on NTSB summary is 156, vs. 155 on final report
  22. Bajak, Frank. "'BOGUS PARTS' PLAGUE AIRLINES : SUBSTANDARD COMPONENTS PUT PUBLIC AT RISK." Associated Press at Daily News. December 8, 1996. Retrieved on June 8, 2009.
  23. Bajak, Frank. "BLACK MARKET OF THE SKIES SUBSTANDARD AIRPLANE PARTS POSE RISK" Associated Press at the Columbus Dispatch. Sunday December 8, 1996. Insight 5B.
  24. Wald, Matthew L. "American Airlines Ruled Guilty Of Misconduct in '95 Cali Crash." The New York Times. Friday September 12, 1997. Retrieved on August 24, 2009.
  25. "Cali Crash Case Overturned". CBS News. CBS. Associated Press. June 16, 1999. Retrieved August 30, 2009.
  26. "Crash of American Airlines Boeing in Failure Knowledge Database". Hatamura Institute for the Advancement of Technology. Retrieved April 15, 2011.
  27. Enhanced Ground Proximity Warning System (EGPWS) – Honeywell Aerospace Engineering Archived October 2, 2011, at the Wayback Machine
  28. "Accident Overview". lessonslearned.faa.gov. Federal Aviation Administration. Retrieved June 16, 2020.
  29. Phillips, Don (May 5, 1996). "Cali Crash Questions Safety of Automated Flight". Los Angeles Times. Retrieved June 16, 2020.
  30. "Installation of Terrain Awareness and Warning System (TAWS) Approved for Part 23 Airplanes, Advisory Circular 23-18" (PDF). Federal Aviation Administration, U.S. Department of Transportation. June 14, 2000. Retrieved May 4, 2020.
    Note: Original text copied from U.S. FAA Circular AC23-18
  31. "Sec. 121.354 – Terrain awareness and warning system". Federal Aviation Administration. Retrieved May 4, 2020.
  32. "Flight history for American Airlines flight AA921". Flightradar24. Flightradar24. Retrieved June 16, 2020.
  33. "Number of survivors reported drops to 4 Finding how many Americans on board difficult, official says." Associated Press. December 23, 1995.
  34. "American 965 documentary website". www.american965.com. Retrieved September 9, 2020.
  35. "American 965 IMDb page". www.imdb.com. Retrieved September 9, 2020.
  36. "New documentary American 965 raises serious doubts about investigation into 1995 American Airlines 965 crash with vital evidence ignored". www.filmindustry.network. Retrieved January 9, 2021.
External image
Pre-crash photo taken from Airliners.net
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