American Airlines Flight 965

American Airlines Flight 965

Wreckage of N651AA at the crash site
Accident
Date	December 20, 1995
Summary	Controlled flight into terrain caused by navigational error and pilot error
Site	near Buga, Valle del Cauca, Colombia 3°50′45.2″N 76°06′17.1″W / 3.845889°N 76.104750°W / 3.845889; -76.104750Coordinates: 3°50′45.2″N 76°06′17.1″W / 3.845889°N 76.104750°W / 3.845889; -76.104750
Aircraft
Aircraft type	Boeing 757-223
Operator	American Airlines
IATA flight No.	AA965
ICAO flight No.	AAL965
Call sign	AMERICAN 965
Registration	N651AA
Flight origin	Miami International Airport, Miami, Florida, United States
Destination	Alfonso Bonilla Aragón Int'l Airport, Cali, Colombia
Occupants	163
Passengers	155
Crew	8
Fatalities	159
Injuries	4
Survivors	4 (5 initially)

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 of the 155 passengers and all eight crew members.^[2]

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 30 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 R. 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.

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.^[15] 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 (FMS) 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, 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.^[16] 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.^[17]

Crash[]

Twelve seconds before the plane hit the mountain, named El Diluvio (the Deluge),^[18] 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 two seconds of the warning, take-off power was selected, and in the next second, pitch was increased to 20.6° upwards, causing activation of the stick shaker.^[19] The stick shaker mechanically vibrates the control yoke (the "stick") to warn the flight crew of an aerodynamic stall.

Crucially, when take-off power was selected 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 EST, the aircraft struck trees at about 2,720 metres (8,920 ft) above mean sea level on the east side of the 2,700-metre-tall (9,000 ft) mountain. The last record on the flight data recorder indicated that the plane was flying at 187 kn (346 km/h; 215 mph) and with a pitch attitude of almost 28°. The crash was 9.7 km (6.0 mi; 5.2 nmi) south of Tuluá VOR and 28 km (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,^[21] a dog, which 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 (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 investigations revealed 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, whether the airplane would have missed the mountain/tree tops if the speedbrakes had been retracted during the climb attempt could not be determined with precision,^[8] but 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 m (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.^[22]

In its report, the Aeronáutica Civil determined these 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 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 flight management system-assisted navigation became confusing and demanded an excessive workload in a critical phase of the flight

In addition, the Aeronáutica Civil determined that these factors contributed to the accident:

1. The flight crew's ongoing efforts to expedite their approach and landing to avoid potential delays
2. The flight crew's execution of the ground proximity warning system 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 involved parties (number of individual recommendations in parentheses):^[8]

• U.S. FAA (17)
• International Civil Aviation Organization (3)
• American Airlines (2)

Investigators later labeled the accident a nonsurvivable event, citing the impact forces and subsequent destruction of the aircraft.^{[8]:15,55[13]}

A possible cause for the accident not considered in investigations is suggested in the Fact Not Fiction Films' feature-length documentary American 965 completed in January 2021 and released on 9 July 2021. A design flaw in aircraft that has existed for decades is suggested as a possible cause: air supply on modern aircraft, which comes from the engines, is not filtered, and aircraft have no contaminated air warnings systems fitted.^[23] This contaminated air can then reduce cognitive function. The investigative documentary was directed and produced by former British Airways Captain Tristan Loraine.^[24][25][26]

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 reappeared as unapproved aircraft parts on the black market in Greater Miami parts brokers.^[27] 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.^[28]

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.^[29] 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.^[30]

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% at fault for the crash, Honeywell was 10% at fault, and American Airlines was 60% at fault.^[31]

An enhanced ground proximity warning system (EGPWS) that could have prevented the accident was introduced in 1996.^[32][33][34]

Since 2002, aircraft capable of carrying more than six passengers are required to have an advanced terrain awareness warning system.^[35][36]

As of August 2021 American Airlines continued to operate the Miami-Cali route, as American Airlines Flight 921, operated by Boeing 737-800 aircraft.^[37]

Notable passengers[]

• Paris Kanellakis, a computer scientist at Brown University, died with his wife and two children.^[14]

The U.S. government encountered difficulty while trying to distinguish Americans from non-Americans, as many passengers held dual citizenships.^[38]

In popular culture[]

• The events of Flight 965 were featured in "Lost", a season-two (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 documentary film released in 2021, American 965, directed and produced by a former British Airways captain, suggests a different possible cause for the accident.^[23]

See also[]

• Air Inter Flight 148
• Air New Zealand Flight 901, another accident involving a navigation error
• Crew resource management
• List of accidents and incidents involving commercial aircraft
• Prinair Flight 277
• Air China Flight 129
• 1961 Ndola United Nations DC-6 crash, another CFIT accident that was the result of multiple pilot errors
• Alitalia Flight 404, a DC-9 that crashed due to failure of the glide slope indicator and multiple pilot errors
• Trigana Flight 267
• Santa Barbara Airlines Flight 518
• Thai Airways International Flight 311
• IFO 21
• Intercontinental de Aviación Flight 256
• Garuda Indonesia Flight 152, a CFIT accident where multiple pilot errors, ATC errors, and a major navigational error combined with GPWS failure to kill 234 people

References[]

External links[]

External image
Pre-crash photo taken from Airliners.net

• Special Administrative Unit of Civil Aeronautics
  • Final Accident Report – AA965
    • Text version of final report – Prepared for the World Wide Web by Peter Ladkin of Bielefeld University (Alt, Alt #2, Archive, Archive of Alt #2 Alt Archive)
    • Appendices – The people who prepared them for the World Wide Web used to scan photocopies of them
  • (in Spanish) Final Accident Report – AA965 (Archive, Alt Archive) – Translation by Captain José Bestene Mattar and Maria Isabel Bobrez Orozco
• "At least four of 164 passengers survive U.S. jet crash in Colombia," CNN
• Zarrella, John. "Tearful relatives head to Colombia," CNN. December 22, 1995.
• "More survivors pulled from wreckage of U.S. jet," CNN. December 21, 1995.
• Dewar, Steuart. "Brown professor, wife, 2 children killed in crash" (Archive). The Associated Press, posted at Brown University.
• BBC Horizon Program interviewing Mercedes Ramirez Johnson, a survivor of AA flight 965
• CNN Evening News for Friday, 22 December 1995 Headline: Colombia / American Airlines Plane Crash Vanderbilt University Television Archive
• Mercedes Ramirez Johnson website
• Mercer, Pamela. "Pair Who Survived a Crash Relieved to Be on Home Soil." The New York Times. May 19, 1996.
• Piamba Cortes v. American Airlines Inc. (Archive)
• B757 Cali Accident in the Compendium of Computer-Related Incidents with Commercial Aircraft including a copy of the Colombian accident report.
• Cockpit voice recording transcript