Cali Accident Report

University of Bielefeld –  Faculty of technology

Networks and distributed Systems

Research group of Prof. Peter B. Ladkin, Ph.D.

AA965 Cali Accident Report

Near Buga, Colombia, Dec 20, 1995

Prepared for the WWW by
Peter Ladkin
Universität Bielefeld
Germany

Prepared November 6, 1996

[Preparer’s Note: Footnote markers are written in square brackets, e.g.,
[22], and footnotes appear denoted by the same figures in brackets at the
bottom of the same page, separated from the page contents by a dashed line.
Typographical errors have been retained in the
original as far as possible, except for occasional double full stops at
the ends of some paragraphs. PBL]

AERONAUTICA CIVIL
of THE REPUBLIC OF COLOMBIA

SANTAFE DE BOGOTA, D.C. – COLOMBIA

AIRCRAFT ACCIDENT REPORT

CONTROLLED FLIGHT INTO TERRAIN
AMERICAN AIRLINES FLIGHT 965
BOEING 757-223, N651AA
NEAR CALI, COLOMBIA
DECEMBER 20, 1995

CONTENTS

Final Report of Aircraft Accident
American Airlines flight 965, December 20, 1995

1.FACTUAL INFORMATION
1.1 History of Flight 1
1.2 Injuries to Persons 5
1.3 Damage to Aircraft 5
1.4 Other Damage
1.5 Personnel Information 5
1.6 Airplane Information 9
1.7 Meteorological Information 10
1.8 Aids to Navigation 11
1.9 Communications 11
1.10 Aerodrome Information<11>
1.11 Flight Recorders 12
1.12 Wreckage and Impact Information 13
1.13 Medical and Pathological Information14
1.14 Fire15
1.15 Survival Aspects15
1.16 Tests and Research15
1.17 Organizational and Management Information21
1.18 Additional Information22

2. ANALYSIS
2.1General 28
2.2The Decision to Accept Runway 19 29
2.3Situational Awareness 32
2.4Awareness of Terrain 35
2.5Automation40
2.6Crew Resource Management46
2.7Speedbrakes48
2.8The Cali Approach Controller49
2.9FAA Oversight51
2.10GPWS Escape Maneuver51
2.11Recording of FMS Data54

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3CONCLUSIONS
3.1Findings55
3.2 Probable Cause57
3.3Contributing Factors57

4RECOMMENDATIONS58

5APPENDIXES
Appendix A–Investigation62
Appendix B– Cockpit Voice Recorder Transcript63
Appendix C–Cali Approach Charts64
Appendix D–American Airlines Ops. Manual page65
Appendix E–Photos of Wreckage66
Appendix F–Route Pages Prior to Impact67

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AIRCRAFT ACCIDENT REPORT

AERONAUTICA CIVIL OF THE REPUBLIC OF COLOMBIA
SANTAFE DE BOGOTA, D.C. – COLOMBIA

CONTROLLED FLIGHT INTO TERRAIN
AMERICAN AIRLINES FLIGHT 965, BOEING 757-223, N651AA
NEAR CALI, COLOMBIA, DECEMBER 20, 1995

1. FACTUAL INFORMATION

1.1 History of Flight

At 2142 eastern standard time (est) [l], on December 20, 1995, American
Airlines Flight 965 (AA965), a Boeing 757-223, N651AA, on a regularly
scheduled passenger flight from Miami International Airport (MIA),
Florida, U.S.A., to Alfonso Bonilla Aragon International Airport
(SKCL), in Cali, Colombia, operating under instrument flight rules
(IFR), crashed into mountainous terrain during a descent from cruise
altitude in visual meteorological conditions (VMC). The accident site
was near the town of Buga, 33 miles northeast of the Cali VOR [2]
(CLO). The airplane impacted at about 8,900 feet mean sea level (msl),
near the summit of El Deluvio and approximately 10 miles east of
Airway W3. Of the 155 passengers, 2 flightcrew members, and 6
cabincrew members on board, 4 passengers survived the accident.

On the previous flight under a different crew, the airplane arrived at
MIA from Guayaquil, Equador, at 1438, on December 20, 1996. The
Guayaquil to MIA flightcrew reported that there were no significant
maintenance or operations-related discrepancies on the airplane. The
captain and first officer of AA965 (MIA to SKCL) arrived at the
airline’s MIA operations office about 1 hour before the proposed
departure time of 1640. The operations base manager later stated that

—————-
[1] All times herein are expressed in est, based on the 24-hour clock, unless
otherwise indicated. The Colombian and MIA local time was the same (est).

[2] Very high frequency (VHF) omni-directional radio range.

1

both the captain and first officer were in his office about 40 minutes
before the required check-in time, and appeared to be in good spirits.

According to the AA flight dispatcher at MIA, AA965 was delayed about
34 minutes, waiting for the arrival of connecting passengers and
baggage. The flight departed the gate at 1714, and then experienced
another ground delay of 1 hour 21 minutes that the flight dispatcher
stated was related to gate congestion due to airport traffic. AA965
departed MIA at 1835, with an estimated time enroute to Cali of 3 hour
12 minutes.

AA965 was cleared to climb to flight level (FL) 370 [3]. The route of
flight was from MIA through Cuban airspace, then through Jamaican
airspace, and into Colombian airspace, where the flight was recleared
by Barranquilla Air Traffic Control Center (Barranquilla Center) to
proceed from KILER Intersection direct to BUTAL Intersection. The
flight then passed abeam Cartegena (CTG). Bogota Center subsequently
cleared the flight to fly direct from BUTAL to the Tulua VOR (ULQ)

At 2103, AA965 estimated to Bogota Center that they would cross BUTAL
at 2107. As AA965 passed BUTAL, Bogota Center again cleared the flight
from its present position to ULQ, and told the flight to report when
they were ready to descend. At 2110, AA965 communicated via ACARS [4]
with AA’s System Operations Control (SOC) center, asking for weather
information at Cali. At 2111, Cali weather was reported as clear,
visibility greater than 10 kilometers, and scattered clouds. At
2126:16, AA965 requested descent clearance. The flight was initially
cleared to FL 240 and then to FL 200. At 2134:04, the flight was
instructed to contact Cali Approach Control (Approach).

AA965 contacted Approach at 2134:40. The captain, making the radio
transmissions [5] said, “Cali approach, American nine six five.” The
approach controller replied, “American niner six five, good
evening. go ahead.” The captain stated, “ah, buenos noches senor,
American nine six five leaving two three zero, descending to two zero
zero. go ahead sir.” The controller asked, “the uh, distance DME [6] from
Cali?” The captain replied, “the DME is six three.” The controller

—————-
[3] 37,000 feet. Flight levels are expressed in hundreds of feet above msl.

[4]Aircraft Communications Addressing and Reporting System.

[5] Based on the air traffic control (ATC) and cockpit voice
recordings (CVR), the captain made the radio communications and the
first officer was at the controls of the airplane.

[6]Distance measuring equipment, providing a display in nautical miles.

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then stated, “roger, is cleared to Cali VOR, uh, descend and maintain
one, fve thousand feet. altimeter three zero zero two…. no delay
expect for approach. report uh, Tulua VOR.” The captain replied, “OK,
understood. cleared direct to Cali VOR. uh, report Tulua and altitude
one five, that’s fifteen thousand three zero.. zero.. two. is that all
correct sir?” The controller stated, “affirmative.” The captain
replied at 2135:27, “Thank you. At 2135:28, the captain informed the
first officer that he had “…put direct Cali for you in there.” [7]

At 2136:31, Approach asked AA965, “sir the wind is calm. are you able
to [execute the] approach [to] runway one niner?” (see approach
charts, appendix C, “VOR DME Rwy 19” and “ILS RWY 01”) The captain
responded, “uh yes sir, we’ll need a lower altitude right away
though.” The approach controller then stated, “roger. American nine
six five is cleared to VOR DME approach runway one niner. Rozo number
one, arrival. report Tulua VOR.” The captain, replied, “cleared the
VOR DME to one nine, Rozo one arrival. will report the VOR, thank you
sir.” The controller stated, “report uh, Tulua VOR.” The captain
replied, “report Tulua.”

At 2137:29, AA965 asked Approach, “can American airlines uh, nine six
five go direct to Rozo and then do the Rozo arrival sir?” The Cali
approach controller replied, “affirmative. take the Rozo one and
runway one niner, the wind is calm.” The captain responded, “alright
Rozo, the Rozo one to one nine, thank you, American nine six five.”
The controller stated, “(thank you very much) [8]…. report Tulua and
e’eh, twenty one miles ah, five thousand feet.” The captain responded,
“OK, report Tulua twenty one miles and five thousand feet, American
nine uh, six five.”

At 2137, after passing ULQ [9], during the descent, the airplane began to
turn to the left of the cleared course and flew on an easterly heading
for approximately one minute. Then the airplane turned to the right,
while still in the descent. At 2139:25, Morse code for the letters
“VC” was recorded by navigation radio onto the airplane’s CVR. At
2139:29, Morse code similar to the letters “ULQ” was recorded. At
2140:01, the captain asked Approach, “and American uh,

—————-
[7] A reference to the airplane’s flight management system (FMS).

[8] “Questionable insertion” transcribed during hearing of the tape by CVR
invest1gators.

[9]Position based on ATC and CVR recordings, flight data recorder
(FDR) information, time and distance measurements, and reconstructed
data from the airplane’s flight management computer (FMC). (see
section 1.16).

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thirty eight miles north of Cali, and you want us to go Tulua and then
do the Rozo uh, to uh, the runway, right to runway one nine?” The
controller answered, “…you can [unintelligible word] landed,
runway one niner, you can use runway one niner. what is (you)
altitude and (the) DME from Cali?” The flight responded, “OK, we’re
thirty seven DME [10] at ten thousand feet.” The controller stated at
2140:25, “roger. report (uh) five thousand and uh, final to one one,
runway one niner.”

The CVR recorded the flightcrew’s conversations as well as radio
transmissions. At 2140:40, the captain stated, “it’s that [expletive]
Tulua I’m not getting for some reason. see I can’t get. OK now,
no. Tulua’s [expletive] up.” At 2140:49 the captain said, “but I can
put it in the box if you want it.” The first officer replied, “I don’t
want Tulua. let’s just go to the extended centerline of uh….” The
captain stated, “which is Rozo.” At 2140:56, the captain stated, “why
don’t you just go direct to Rozo then, alright?” The first officer
replied, “OK, let’s…The captain said, “I’m goin’ to put that over
you.” The first officer replied, “…get some altimeters, we’er out of
uh, ten now.”

At 2141:02, Cali Approach requested the flight’s altitude. The flight
replied, “nine six five, nine thousand feet.” The controller then
asked at 2141: 10, “roger, distance now?” The flightcrew did not
respond to the controller. At 2141:15, the CVR recorded from the
cockpit area microphone the mechanical voice and sounds of the
airplane’s ground proximity warning system (GPWS), “terrain, terrain,
whoop, whoop.” The captain stated, “Oh [expletive],” and a sound
similar to autopilot disconnect warning began. The captain said,
“…pull up baby.” The mechanical voice and sound continued, “…pull
up, whoop, whoop, pull up.” The FDR showed that the flightcrew added
full power and raised the nose of the airplane, the spoilers
(speedbrakes) that had been extended during the descent were not
retracted. The airplane entered into the regime of stick shaker stall
warning, nose up attitude was lowered slightly [11], the airplane came
out of stick shaker warning, nose up attitude then increased and stick
shaker was reentered. The CVR ended at 2141 :28.

The wreckage path and FDR data evidenced that the airplane was on a
magnetic heading of 223 degrees, nose up, and wings approximately
level, as it struck trees at about 8,900 feet msl on the east side of
El Deluvio. The airplane

—————-
[10] 37 DME north of the Cali VOR (CLO) places the airplane 6 miles
south of ULQ and 28 miles north of the approach end of runway 19 at
SKCL.

[11] From FDR data.

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continued over a ridge near the summit and impacted and burned on the
west side of the mountain, at 3 degrees 50 minutes 45.2 seconds north
latitude and 76 degrees 6 minutes 17.1 seconds west
longitude. Approach unsuccessfully attempted to contact AA965 several
times after the time of impact (see appendix D, two photographs of the
accident site).

1.2 Injuries to Persons

Injuries FlightcrewCabincrewPassengersTotal
Fatal 2 6 151 159
Serious 0 0 4 4
Minor 0 0 0 0
None 0 0 0 0
Total 2 6 155 163

1.3 Damage to Airplane

The airplane was destroyed.

1.4 Other Damage

None. Impact was in tree-covered mountainous terrain.

1.5 Personnel Information

The captain and first officer were certified by the U.S. Federal
Aviation Administration (FAA) to hold their respective positions in
the Boeing 757 (B-757) and each possessed a current first class
medical certificate. FAA records showed that neither had been involved
in an accident, incident, or enforcement action.

1.5.1. Cockpit Crew

Pilot In CommandFirst Officer
Age 57 39
Date of Birth 11/17/38 6/24/56
Date of Hire with American Airlines 9/22/6910/11/86
First Class Medical Certificate Issued 12/7/95

5

Approximate Total Flying Time13,000 hrs 5,800 hrs
Total on Type (B757/B767) 2,260 hrs 2,286 hrs
Total hrs last 90 Days 182: 13 163 :40
Total hrs last 60 Days 104: 14 101 :55
Total hrs last 30 Days 60:13 19:50
Total Last 7 Days 12:19 13:22
Accident Flight hrs (est.) 4:38 4:38
Hours On Duty Prior to Accident 5:58 5:58
Hours Off Duty Prior to Work Period120+ (5 days)120+(5 days)

1.5.2 Captain

The captain began flying as a civilian student pilot in September
1963. He then joined the U.S. Air Force, became an Air Force pilot
and flew a variety of military airplanes including fighters and
4-engine transport airplanes in domestic and foreign operations
through 1969. He became employed by AA on September 22,
1969. Employment records at AA indicated that he had acquired about
2,698 flight hours before being hired, and all except 36 hours were
with the U.S. Air Force. His service at AA began as a B-727 flight
engineer. As flew as captain on the B-727, -757 and -767 [12].

The captain underwent his last proficiency check in a flight simulator
on April 28, 1995. AA referred to this check as the “R2” check or the
“simulator check.” The check ended a S-day training and checking
sequence in which other annual requirements were also met, including
training regarding security and hazardous materials, crew resource
management (CRM), and international operations. The captain completed
annual line checks, administered by an AA FAA-approved check airman on
November 9, 1995 (domestic) and on December 9, 1995
(international). In the line check on December 9, 1995, he flew as
captain on AA965 from MIA to SKCL. Including flights to SKCL on
December 9, and December 14, 1995, the captain flew a total of 13
times into Cali before the accident flight.

—————-

[12] The FAA awards common type ratings to pilots qualifying on the B-757
and -767 because of the similarities between the two
airplanes. B-757/767 type rated pilots for AA and other airlines may
serve on both airplane types equally, without need of additional
certification.

6

The captain’s last medical examination was on December 7, 1995, when
his Class I medical certificate was renewed. His certificate bore the
following limitation: “Holder shall wear lenses that correct for
distant vision and possess glasses that correct for near vision while
exercising the privileges of this airman certificate.”

The captain was described by his colleagues as a non-smoker, avid
tennis player, in exemplary health, and respected for his professional
skills, including his skill in communicating with crewmembers and
passengers. Company records contained numerous letters from passengers
and company employees that reflected outstanding and courteous
performance. The captain was married and had two adult children who
lived outside of the home.

On the day of the accident, December 20, 1995, the captain arose
around 0500. His wife began to prepare for a trip in her capacity as
an AA flight attendant. She was later not sure whether the captain had
returned to sleep after she departed their home at 0600. She estimated
that he departed from home about 1200 for the drive to MIA.

The day prior to the accident, December 19, the captain awoke about
0700, and spent the day relaxing around the house and then playing
tennis about l 1/2 hours with his wife. They returned home about
2130. From December 15 through 18, the captain and his wife visited
his family in New Jersey, on what was described as an enjoyable
Christmas visit that they took early because of the scheduled trips.

1.5.3 First Officer

The first officer began his flying eareer as a college undergraduate
by enrolling in the U.S. Air Force Reserve Officer Training Corps. He
began pilot training with the Air Force in 1979, flying a variety of
aircraft, including trainers and F-4E fighters, through 1986. He
served as an instructor in ground school, in flight simulators, and in
airplanes, and in 1985 was awarded Air Force Instruetor of the Year.

The first officer beeame employed by AA on Oetober 11, 1986. Company
reeords indicated that he had accumulated a total of 1,362 flight
hours when hired. He began as a flight engineer on the B-727. Later
duties included first

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officer on the B-727, McDonnell Douglas (MD) 11, and B-757 and -767. He
possessed type ratings in the MD 11 and B757/B767.

The first officer attended the AA 5-day qualification and recurrence
course and satisfactorily completed the required annual simulator
check on November 27, 1995. As part of that sequence, annual recurrent
requirements also ineluded training regarding security, hazardous
materials, CRM, and international operations. The first officer’s
annual line cheek was aeeomplished on August 31, 1995.

The first offieer’s Class 1 medical certificate was renewed on June 21,
1995, with no limitations.

The first officer had never flown into Cali. However, he had flown to
other destinations in South America as an internationally qualified
B-757/767 first officer.

The first officer was described by his colleagues as professionally
competent, and appropriately assertive as a flightcrew member. He was
married and the father of three young children who lived at home.

On the day of the accident, the first officer arose about 0700, and
had breakfast with his family. Around 0830, he worked with his wife to
prepare for their children’s home schooling aetivities. He later
exercised. He visited with his father and family around midday and,
around 1230, left for the airport at Orlando, Florida, for the flight
to MIA.

On the day prior to the accident, December 19, the first officer arose
about 0700, and had an 0830, appointment with an aviation medical
examiner (AME) for a flight physical [13]. Afterwards, the first officer
visited with his brother at his brother’s place of business, and later
the two had lunch. The first officer returned home at 1530, and played
basketball with his children. The family had dinner about 1730, and at
1900, he, his wife, and children attended a basketball game where
their son was playing. The family returned home about 2015, and at
2115 the first officer helped put the children to bed. He and his wife
watched television briefly and retired about 2330.

—————-
[13] The AME later stated that the first officer was found in excellent health.

8

On December 18, the first officer arose about 0715, and after
breakfast exercised at the local YMCA. He assisted his wife in home
schooling their children and then had lunch with his wife. After
shopping for holiday gifts, they took the children to a restaurant for
dinner and returned home about 2100.

1.6 Airplane Information

The airplane, a Boeing 757-223, serial no. 24609, was operated by AA
since new on August 27, 1991. The airplane was owned by Meridian Trust
Company of Reading, Pennsylvania, U.S.A., and leased to the airline.

Before the accident flight, the airplane accumulated 13,782 flight
hours and 4,922 cycles. The airplane was equipped with two RB-211 535E
4B Rolls Royce turbofan engines. The left engine, serial no. 31146,
accumulated 10,657 hours and 3,768 cycles. The right engine, serial
no. 31042, had accumulated 13,274 total hours and 4,966 cycles.

There were no malfunctions or outstanding maintenance items on the
airplane prior to its departure from MIA on December 20, 1995. The
airplane received a B-level maintenance check (B-check) in November
1995, and all subsequent required maintenance checks were
performed. In addition, there was no record of repetitive navigation
or flight control system anomalies.

1.6.1 Weight and Balance Information

The airplane weight and balance was determined by AA’s dispatch center
at Dallas/Ft. Worth International Airport (DFW), Texas, U.S.A. The
airplane was loaded with 43,300 pounds of fuel for takeoff from MIA on
December 20, 1995. Its takeoff gross weight was calculated as 209,520
pounds. The airplane’s center of gravity (c.g.) at takeoff was
determined to be 25.2 percent mean aerodynamic chord (MAC). The gross
weight and c.g. were within limits for takeoff.

Estimated flight plan calculations indicated that the airplane
consumed 26,620 pounds of fuel prior to impact. Its impact gross
weight was 182,900 pounds and its c.g. was 23.8 percent MAC. The final
gross weight and c.g. were within landing limits.

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1.6.2 Flight Management System

The B-757 and -767 are flight management system (FMS)-equipped
airplanes. The accident airplane incorporated an FMS that included an
flight management computer (FMC), a worldwide navigation data base
that contained radio frequencies, and latitude and longitude
coordinates of relevant navigation aids as well as coordinates of
airports capable of B-757 operations. The FMC data base also included
B-757 performance data which, combined with pilot inputs, governed
autothrottle and autopilot functions. The FMS monitored the system and
engine status and displayed the information, as well as airplane
attitude, flightpath, navigation, and other information, through
electronically-generated cathode ray tube (CRT) displays [14].

Pilot input into the FMS could be performed either through a keyboard
and associated cathode ray tube (CRT), known as a control display unit
(CDU), or through more limited FMS input via controls on the
glareshield (see section 1.16, regarding post-accident testing of FMS
components).

1.7 Meteorological Information

The flight crew received the following AA terminal weather forecast
for Cali in the flight dispatch records:

Cali at 0606 universal coordinated time (utc) [15]: Winds calm, visibility
more than 10 kilometers, clouds scattered at 2,500 and 10,000 feet

Temporary change (Cali) from 0900 to 1300 utc: 8000 meters visibility,
rain showers in the vicinity, clouds scattered at 2,000, broken at
8,500 feet

Temporary change (Cali) from 2000 through 0200 utc: Winds 360 degrees
at 05 knots, rain showers in the vicinity, clouds scattered at 2,000
feet and broken at 8,000 feet

The flight departure paper recorded the weather at 1500 est as: Winds
calm, visibility more than 10 kilometers, clouds scattered at 2,000
and 12,000 feet,

—————-
[14] On the instrument panel before each pilot

[15] Universal coordinate time. Est is 5 hours behind utc.

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temperature 28 centigrade, dew point 18 degrees centigrade (C.),
altimeter (QNH) 29.94 inches of mercury

The flight crew received an updated weather message via the ACARS.
The weather was for 1700 est and was reported as:

(Cali): Winds 340 degrees at 06 knots, visibility more than 10
kilometers, rain showers in the vicinity, clouds scattered at 1,700
feet and broken at 10,000 feet, temperature 28 degrees C., dew point
18 degrees C., altimeter (QNH) 29.98 inches of mercury

Enroute, the flight crew requested the Cali weather via ACARS at 2050
est. The company replied at 2051, via ACARS, that there was “no
current data.”

At 2110 est, the flightcrew requested, again, the weather for Cali. At
2111, the flightcrew received via the uplink, the following weather
information for 2000 local at Cali: Winds 160 degrees at 04 knots,
visibility more than 10 kilometers, clouds scattered at 1,700 and
10,000 feet, temperature 23 degrees and dew point 18 degrees C.,
altimeter (QNH) 29.98 inches of mercury. This was the last request and
uplink of weather recorded.

1.8 Aids to Navigation

There were no difficulties with aids to navigation.

1.9 Communications

There were no difficulties with communications equipment.

1.10 Aerodrome Information

Alfonso Bonilla Aragon Airport (SKCL) in Cali, is located in a long,
narrow valley oriented north to south. Mountains extend up to 14,000
feet msl to the east and west of the valley. The airport is located
approximately 7.5 miles north of CLO, at an elevation of 3,162 feet
msl.

11

At the time of the accident, the airport control tower operated 24
hours a day, controlling departing and arriving traffic to runways 01
and 19. The runway was hard surfaced, 9,842 feet long, and 148 feet
wide, with a parallel taxiway running the full length. Runway 01 had
instrument landing system (ILS) CAT 1 and VOR/DME approaches
available. The ILS has a 2.5 degree glide slope, with precision
approach path indicator (PAPI) visual glide path lighting to match the
2.5 degree electronic glide slope. Runway 19 had a VOR/DME approach
available and the lighting included a PAPI system with a 3.0 degree
glide path. Two standard arrivals (STARs) were available, one from the
north of the airport (ROZO 1) and one from the east (MANGA 1). There
were 12 published departures available.

Radio navigation facilities included the ILS (IPAS), the Cali VOR
(CLO), Rozo NDB (R), the middle marker (AS), and the Cali NDB (CLO). The
Tulua VOR (ULQ) was approximately 33 nautical miles north of the airfield (43
DME from CLO), and was the initial point depicted on the ROZO 1 arrival.

The airport was served by Cali Approach. No approach control radar
was available.

The field report recorded in the AA dispatch records
indicated that runways 01 and 19 were open and dry. There were three
notices to airmen (NOTAMS) in the flight departure papers, they were:

1. Until further notice, runway 01 LM/AS frequency 240
Mhz ops on test period.

2. Fire and rescue services downgrades to VII cat.

3. Until further notice, MER/NDB 1.685 Khz inop.

1.11 Flight Recorders

1.11.1 Flight Data Recorder

The airplane was equipped a Sundstrand digital FDR, serial
no. 6707. FDR recorded parameters included: pressure altitude; radio
altitude; magnetic heading; computed airspeed; pitch attitude; roll
attitude; engine status; navigation mode; indicated airspeed;
autothrottle and autopilot parameters; ground proximity warning
alerts; and parameters indicating flight control position, including
speed

12

brake deployment. The data were recorded on a continuous 25 hour cycle
in which the oldest data were erased and new data recorded.

The FDR was extensively damaged by impact forces. There was
no evidence of fire damage to the recorder. The tape recording medium
was undamaged. The FDR was brought to the U.S. National Transportation
Safety Board’s (NTSB’s) laboratories in Washington, D.C., U.S.A., and
read out.

1.11.2 Cockpit Voice Recorder

The airplane was equipped with a Fairchild model A-lOOa CVR, serial
no. 59225. Examination in the NTSB CVR laboratory found exterior structural
damage. The exterior case was cut away to access the tape medium. The tape did
not sustain heat or impact damage. The recording was of good quality and a
transcript was prepared of the entire 30:40 minute recording.

1.12 Wreckage and Impact Information

The airplane struck near the top of a mountain ridge about
35 miles northeast of Cali. The elevation of the top of the ridge was
about 9,000 feet mean sea level. The airplane initially struck trees
on the east side of the ridge, and the preponderance of the wreckage,
which contained the occupants of the airplane and included both
engines, came to rest on the west face of the ridge. There was no
indication of in-flight fire or separation of parts before initial
impact.

The initial impact area was marked by an area of broken
trees, followed by a swath where the trees had been essentially
flattened or uprooted. The area of uprooted trees began about 250 feet
below the top of the ridge. The initial impact swath was oriented
along a heading of about 220°. Wreckage that was found at the
beginning of the wreckage path included thrust reverser parts, a fan
cowling, an APU tail cone, flap jackscrews, an engine fire bottle, the
FDR, and a small section of wing. The pattern of the broken trees
indicated that the airplane initially struck at a high nose up
attitude.

The main wreckage came to rest on the west side of the
ridge, about 400 to 500 feet from the top. In addition to the engines,
the largest portion of wreckage included the cockpit, a section of
center fuselage about 35 feet long, the CVR, aviation electronics
(avionics) boxes, a section of the aft fuselage, and a portion of the
wing center section.

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The wreckage evidence indicated that both flaps and landing
gear were in the retracted position at the time of impact.

Both engines were examined on site. The left engine showed
ingestion of soil and foliage as far aft as the inlet guide vanes to
the intermediate compressor section. There was a substantial bending
of fan blades in a counter-clockwise direction, with some bent
clockwise.

The right engine was found slightly buried into the
ground. The blade damage that was observable was similar to the damage
observed on the left engine. Soil and foliage were found as far aft
as the inlet to the intermediate compressor section. Neither engine
showed evidence of fire damage.

Numerous cireuit cards and other parts that were onsidered
likely to contain non-volatile memory were retrieved from the site,
packed in static free material, and shipped to the United States for
read out at the facilities of their manufacturers. With the exception
of one circuit card from the Honeywell- manufaetured FMC, the material
either did not contain non-volatile memory or was too severely damaged
to permit data retrieval. Discussion of the data retrieval of the
non-volatile memory from the FMC is located in section 1.16, Tests and
Research.

1.13 Medical and Pathological Information

The body of the first officer was recovered on the first day
after the accident. The body of the captain was retrieved from the
crash site on the third day after the accident. The cause of death of
each was determined to be blunt force trauma.

Specimens of liver, blood, and vitreous humor were obtained
and analyzed by the Colombian Instituto Nacional de Medicina
Legal. The samples from the body of the first officer were found to be
negative for alcohol and drugs of abuse. The blood and liver samples
from the captain were found to be positive for alcohol at 0.074
percent and 0.35 percent blood alcohol levels, respectively, and
negative for drugs of abuse. Vitreous specimens were found to be
negative for both pilots.

Portions of the liver and blood samples from the bodies of
the flightcrew members were then flown to the United States to be
further analyzed by

14

the Forensic Toxicology Laboratory of the U.S. Armed Forces Institute
of Pathology. The analysis and subsequent reexamination of the results
of the analysis in Colombia indicated that the positive alcohol level
derived from post-mortem microbial action, and not from pre-mortem
alcohol ingestion.

1.14 Fire

The was no evidence preimpact fire or explosion. There was
limited postimpact fire, where the main fuselage came to rest.

1.15 Survival Factors

Search and rescue facilities coordinators around the Cali
and Buga area were notified of the missing flight at 2150 local
time. At 2230, the Civil Defense, Red Cross, Police and Army
contingencies were mobilized to the Buga general area where the
airplane was last reported. The initial sighting of the crash site was
made by a helicopter at 06:30, December 21, 1995. Search teams arrived
by helicopter to the crash site within a few minutes of the sighting.

The characteristics and magnitude of the impact and
subsequent destruction of the airplane indicated that the accident was
non survivable. However, 5 passengers initially survived the crash,
having sustained serious injuries. One died later in the hospital.

Postmortem examination of the occupants indicated that the
characteristics of the fatal and non fatal injuries varied according
to the location of the persons in the crashed airplane. All of the
injuries were consistent with deceleration trauma of different
intensity consistent with the aircraft’s impact and breakdown
pattern. Because some passengers were found to have changed seats
within the airplane, evaluating individual injuries by seat assignment
was not successful.

1.16 Tests and Research

Follow-up examinations and testing were conducted regarding
aircraft systems, operations procedures, and human performance. These
were conducted in the United States at Flight Safety International
Academy in Miami, Florida; Honeywell Air Transport Systems, in
Phoenix, Arizona; Jeppesen Sanderson

15

Company, in Englewood, Colorado; American Airlines in Fort Worth, Texas; and
Boeing Commercial Airplane Group, in Seattle, Washington.

1.16.1 FMS Component Examinations

Portions of the FMS, including the FMC, that had been
recovered from the wreckage, were examined at Honeywell Air Transport
Systems.

After the components were cleaned for laboratory
examination, it was found that the FMC contained a printed circuit
card that had two non-volatile memory integrated circuits. Data
recovered from the integrated circuits included a navigation data
base, guidance buffer, built in test equipment (BITE) history file,
operational program, and other reference information.

A load test of the FMC memory showed that the operational
software and navigational data were current for the time of the
accident. The BITE showed that there had been no recorded loss of
function during the last 10 flights of the airplane.

The guidance buffer recorded that the FMC-planned route of
flight at the point of power loss [16] was from the last passed waypoint,
shown as KILER, direct to the next waypoint that had not yet been
passed, shown as ULQ. The route beyond ULQ was shown as waypoint R,
then CLO, then CLO03 [17], then the stored ILS runway 01 approach of
CI01, then FI01, then RW01, then ROZO, then a hold [18] at ROZO.

When the FMC memory was first restored, a modification to
the above route was displayed. The modified route was shown as ULQ, a
ROUTE DISCONTINUITY message, then R, another ROUTE DISCONTINUITY
message, then CLO, then CLO03, then CI01, then FI01, then RW01, then
ROZO, then a hold at ROZO.

The FMC was put through a short term (power transient)
initialization and the captain’s and first officer’s CDU displays were
identical, as follows:

—————-
[16] Coinciding with the time of impact.

[17] CLO03 was found to be a point-bearing distance location.

[18] BITE provided non volatile memory of FMC activity for previous 10
flights of the accident airplane. Hold indicates routing to a
preplanned holding pattern location.

16

MOD RTE 1 LEGS1/2
066°
R268/FL364
THEN
IIIIII
–ROUTE DISCONTINUITY –
CLO237/5510
161°3NM
CLO03207/5190
307°2NM
CI01189/5000

<ERASERTE DATA>

The CLO03 was not seen on a printed format of the route. When the (L4)
line select key (LSK) for CLO03 was pressed, the scratch pad area (LSK
L6) at the bottom of the screen was displayed:

CLO163.0/003.0

Pushing the NEXT PAGE button showed:

MOD RTE LEGS2/2
013°2NM
FI01170/5000
013°7NM
RW01130/3200
013°4NM
ROZO—/3560A
HOLD AT
ROZO—/5000

<ERASE RTE DATA>

—————-
[19] The font size on the airspeeds and altitudes associated with CLO
and CLO03 were smaller than the font sizes of comparable information
for CI01. These differences indicate that the information for CI01 was
inputted by the pilot whereas the information for CLO were generated
by the FMS.

17

REF NAV DATA was displayed for the following points:

IDENTLATLONGFREQ
MAG
VAR ELEV
ULQN04degO5.8W076degl3.6
177.70W1
CLON03deg24.2W076deg24.6
115.50W2
3300ft
CLO03 N03deg21.4 W076deg23.6
CI01 N03deg22.5 W076deg25.0
FI01 N03deg24.5 W076deg24.7
RW01 N03deg31.6 W076deg23.2
LENGTH=9842ft
3150ft
ROZO N03deg35.8 W076deg22.5
R N04deg40.7 W074deg06.3 [20]
SKCL N03deg32.8 W076deg23.1
3160ft
KILER N15deO0.0 W076deg52.0

All of the above points were within 0.1 mile of their
location in the ARINC-424 [21] navigational data for December 21, 1995,
with the exception of RW01 at SKCL. However, it was found that the FMC
display showed the threshold of the runway and the ARINC-424 data
showed the touch-down point for the instrument landing system.

During testing at Honeywell Systems, the memory card from
the accident airplane was installed into an FMC that was programmed in
the AA configuration and run on an engineering simulator. Different
route modifications were executed and timed for delays after the
EXECUTE button was pushed. Over ULQ, inputting “direct” changes to
ROZO from different orientations, as well as to KILER, resulted in
execution delays of not more than approximately 2 seconds (see
appendix E, Reconstructed Route Pages from accident FMC).

At the completion of the tests, the memory card was returned
to the original FMC computer case that had been recovered from the
accident site. Dirt

—————-
[20] R refers to an NDB in Bogota, located about 130 miles
east-northeast of Cali.

[21] Aeronautical Radio. Inc. of Annapolis, Maryland).

18

was vacuumed from the interior of the FMC and brushed from the faces
of dirty circuit cards. Although a number of connector pins were found
broken from the dented rear face, they were then box mounted into the
simulator without difficulty and operated successfully.

1.16.2 At Jeppesen Sanderson

The Jeppesen Sanderson Company described that software
inputs that are provided by contract to operators of FMS-equipped
aircraft are made in accordance with the guidelines of ARINC-424
Chapter 7, “Naming Conventions, ” establishes the coding rules of
identifiers and Name fields when government source data does not
provide these Identifiers or Names within the rules established by
International Civil Aviation Organization (ICAO) Annex 11. As stated
by the Jeppesen Sanderson Senior Vice President, Flight Information
and Technology, in a subsequent letter to the President of the
Investigation:

An important item to remember is that all of Jeppesen’s
navigation data is entered into our database using the ARINC 424
Aeronautical Database Specifications standard. This standard is the
result of an effort that began in August 1973 and has been
continuously updated and now is in its 14th revision. The ARINC spec
is a set of rules that has been established by industry, airlines,
avionics manufacturers, FAA, ICAO, international AIS offices, and
others to ensure agreement in concept of using aeronautical
information in automated systems worldwide.

As one of the first considerations, databases cannot accept
duplicate information. There cannot be two names for the same item.
Specifically, the Romeo NDB uses the letter R for its identifier. The
Rozo NDB also uses the same letter R for its identifier. The letter R
was assigned to both of these navaids by the Colombian government.

Both of these navaids are within the same country and therefore
have the same ICAO identifier. For enroute facilities, the combination
of both the NDB identifier and [emphasis in original] the ICAO code is
normally adequate to provide uniqueness for entering data in the
database.

19

When entering navaid information into the database, the navaid
identifier is used as the key identifier. This means that the letter R
is the default value for the Romeo NDB and the Rozo NDB. Since the
Bogota city and airport is larger than Cali, the larger airports are
entered sequentially at the beginning to satisfy the greatest amount
of users. The letter R was entered for the Romeo NDB as the “key” to
the navaid. Therefore, when using most FMSs, entering the letter R
when in Colombia will call up the Romeo NDB since it is the identifier
for the Romeo NDB.

When the Rozo NDB was entered into the database, the letter R was
attempted, but the computer rejected the letter R since it had already
been used for the Romeo NDB. According to the ARINC 424 standards,
when a duplicate exists, the name of the NDB can be used as the
identifier for entry into the database. In the case of Rozo, since the
name is four letters or less, the complete name of Rozo was used as
the identifier. At Jeppesen, we are not experts on the use of FMSs,
but we understand the access to NDBs in most FMSs is via their
identifier. In this case, an entry of the single letter R would
retrieve Rome since R is the identifier for Romeo. To retrieve the
Rozo NDB, the letters ROZO would need to be entered into the FMS since
that is the identifier for Rozo.

Under the NavData tab in the Jeppesen Airway Manual, there is an
explanation of most of the procedures specified in ARINC 424 as they
apply to the user of an FMS….

1.16.3 At Boeing

Following the examinations at Honeywell Systems and the
meehngs at Jeppesen Sanderson, tests were conducted at Boeing
Commercial Airplane Group, using a B-757 fixed base simulator as well
as a CDU/FMS bench-type simulator. Several different displays were
used to replicate the flightpath and routing information that was
recovered from the accident FMC non volatile memory at Honeywell
Systems, and the accident flight’s arrival, descent, approach phase,
and attempted escape maneuver were replicated as closely as possible
on the fixed-base simulator.

20

It was found that neither the Boeing fixed base simulator
nor the CDU/FMS simulator could be backdriven with the data obtained
directly from the accident airplane’s FDR. Instead, data obtained from
the FDR and non volatile memory data from the FMC were input into both
simulators, to replicate the flight as closely as possible from 63
miles north of CLO to and including the escape maneuver. It was found
that calling up R on the CDU displayed a series of waypoints and their
coordinates. They were located north and south of the equator and
ordered from top to bottom of the display by their distance from the
airplane. Romeo, a non directional radio beacon (NDB) in the City of
Bogota, was the first and closest waypoint displayed. Rozo, which was
also an NDB, was not displayed, and entering R would not call up
Rozo. Rozo could only called up by spelling out ROZO on the CDU.

The Simulations found that when R was entered into the CDU,
a white dashed line pointed off the map display towards the
east-northeast. When R was “executed,” the airplane turned towards R
(in the City of Bogota) and the white dashed line turned to a solid
magenta colored line on the display.

Investigators also attempted to replicate the GPWS escape
maneuver, particularly because wreckage examinations and FDR data
indicated that the speedbrakes were not retracted during the escape
maneuver. Because the B-757 flight simulators could not be back driven
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 escape attempt.

1.17 Organizational and Management Information

AA began operating its Latin American routes in July 1991,
and the MIA crew base opened at that time. At the time of the
accident, the MIA base was third in terms of the number of pilots,
behind DFW and Chicago-O’Hare International Airport (ORD). The
accident flightcrew members were based at MIA. On AA’s Latin American
and Caribbean routs, 98.4 percent of the flightcrews were based at MIA.

The MIA base was overseen by a base manager who was a
B-757/767 captain in their South American division. He had been a line
pilot until approximately one year before the accident. AA’s Latin
American operations and domestic operations from MIA were each
overseen by their own chief pilot.

21

Pilots based at MIA reported to the base manager. He was supervised by
the Assistant Vice President, Line Operations., who reported to the
Vice President, Flight Operations. He was supervised by the Executive
Vice President, Operations, who reported to the President of AA. The
President was responsible to the Chief Executive Officer of the
airline.

1.18 Additional lnformation

1.18.1 Air Traffic Control

Upon entering Colombian airspace on December 20, 1995, AA965
was under the control of the Barranquilla Center, and then Bogota
Center. Upon exiting the limits of the Bogota Center airspace, the
airplane entered the airspace controlled by Cali Approach.

At the time of the accident, the Cali approach
control facility was located in the control tower at SKCL. The
approach controller was located in a small cab 8 to 10 feet from the
tower controller. Flight progress strips were used to keep track of
aircraft that were inbound or outbound from the airport, or traversing
the Cali airspace. Radar coverage and radar services were not
available.

Colombian controllers operate under rules promulgated by the
Aeronautica Civil Communications. Pilots are governed by Annex 10 to
the Convention on International Civil Aviation, “Aeronautical
Telecommunications.” The annex establishes the rules under which
pilots and controllers, who are not conversant in each other’ s native
language, can communicate.

Section 1.2 of Annex 10 states:

The primary means for exchanging information in air-ground
communications is the language of the ground stations, which will in
most cases be the national language of the State responsible for the
station.

Paragraph 5.2.1.1 2 recommends, that where English is not the language
of the ground station the English language should be available on
request, thereby, the recommendations of the Annex indicate that the
English language will be available as a universal medium for
radiotelephone communications.

22

Section 1.4 of the Annex adds:

That means of assuring safety, however, can hardly be
satisfactory in practice. It is always possible that an emergency may
require communication with a ground station not foreseen in the
original planning, and that the handicapping or prevention of such
emergency communications by the lack of a language common to the
flightcrew and the ground station could lead to an accident.

In the Latin American Pilot Reference Guide that AA provided
to its Latin American division pilots, the following guidance was
given:

Because the controller may not understand any comments that
are unexpected, out of sequence, or not in the ICAO format, you
should use only ICAO accepted radio-telephony terminology.

Colombian rules included the following:

If a clearance given by the air traffic control center is not
satisfactory to the pilot of the aircraft, the pilot can request an
amended clearance, and if possible, he will receive an amended
clearance.

1.18.2 Cali Air Traffic Controller

The air traffic controller, who was on duty at the time of the
accident, in his first interview indicated to investigators that there
were no language difficulties in the communications between himself
and the accident flightcrew. However, in a second interview, when
asked a specific question regarding his opinion about the effects the
difference in native languages between the accident flightcrew and
approach control may have had, he stated that he would have asked the
pilots of AA965 more detailed questions regarding the routing and the
approach if the pilots had spoken Spanish. He stated that he believed
that his comprehension of the pilot’s transmission was satisfactory
and that the pilot also understood him. The controller said that, in
a non-radar environment, it was unusual for a pilot to request to fly
from his or her present position to the arrival transition. The air
traffic controller also stated that the request from the flight to fly
direct to the Tulua VOR, when the flight was 38 miles north of Cali,
made no sense to him. He said that his fluency in non-aviation English
was limited and he could not ask them to elaborate on the
request. Rather, he restated the clearance and requested their
position

23

relative to the Cali VOR. He believed that the pilot’s response, that
AA965 was 37 miles from Cali, suggested that perhaps the pilot had
forgotten to report passing the Tulua VOR.

The controller further stated that had the pilots been
Spanish-speaking, he would have told them that their request made
little sense, and that it was illogical and incongruent. He said that
because of limitations in his command of English he was unable to
convey these thoughts to the crew.

1.18.3 FAA Surveillance

At the time of the accident, FAA oversight of AA’s operations into
Latin America was the carried out by its Flight Standards District
Office (FSDO) No. 19, based at MIA. The FAA office responsible for
overall surveillance of AA was based near the airline’s headquarters
in at DFW. FSDO 19 was the largest FSDO in the United States,
responsible for the oversight of 11 carriers operating under 14 Code
of Federal Regulations (CFR) Part 121, 51 carriers under Part 135, 12
flight schools operating under Part 141, 233 repair stations operating
under Part 145, as well as several other certificates. FSDO 23, also
based at MIA was responsible for surveillance of Part 129 foreign
carriers operating into MIA. Under a memorandum of understanding (MOU)
with FSDO-19, FSDO-23 accomplished some of the surveillance of
U.S. carriers operating into Latin America. FSDO 19 was responsible
for performing geographic surveillance of AA surveillance as well as
surveillance of United Airlines and Continental Airlines operations
into Latin America and the Caribbean. AA management personnel
described the FAA presence at MIA as positive and cooperative.

During post accident interviews, FAA personnel indicated that AA
conducted about 1,870 of the 7,200 weekly operations at MIA, and that
enroute surveillance of operations into South America were often
conducted by airworthiness inspectors who were already traveling to
Latin America to perform facility inspections. Airworthiness
inspectors would plan and conduct enroute inspections on flights to
South America, inspect the facility at the destination, and conduct
enroute inspections on the return trip. Inspections were planned in
this manner to reduce the FAA expenses associated with overseas
travel. During interviews, FAA personnel verified that operations
inspectors, who perform cockpit enroute checks are given different FAA
training than airworthiness inspectors. Airworthiness inspectors
specialize in maintenance matters and are not qualified flightcrew
operational evaluators.

24

International Civil Aviation Organization (ICAO) document no. 8335,
Chapter 9, part 9.4.1 states:

Ideally a CAA inspector should be at least as qualified as the
personnel to be inspected or supervised. To carry out in-flight
inspections, a CAA inspector should not only be qualified in the type
of aircraft used but also possess appropriate route experience.

Part 9.6.33 states:

The following guidelines are suggested as minimum
requirements with respect to the frequency of conducting the various
inspections.

TypeFrequency
En-route inspectionquarterly

Three operations inspectors at FSDO-19 performed 1,807 flight
checks, including simulator, oral or actual airplane checks, out of
3,400 requests.

1.18.4 American Airlines Training in Latin American Operations

AA provided additional ground school instruction to all flightcrew
members who were to begin operations into Latin America. This followed
a 2-day ground school for all pilots who were to begin flying
international routes. In the Latin America training, the airline also
distributed to students a Jeppesen-sized reference guide devoted
exclusively to the hazards and demands of flying into Latin
America. Pilots also participated annually AA provided CRM training,
exclusive to Latin American flight operations. The training and
reference guide were not required by Federal Aviation Regulations
(FARs).

The following were among the title of topics addressed in both the
reference guide and initial ground school training:

• Warning! Arrivals May be Hazardous
• They’ll [ATC] Forget About You
• Know Where You Are!

25

• When “Knowing Where You Are” is Critical
• Howto Determine Terrain Altitude

In addition, the introduction to the reference guide included the
following guidance:

Flights into Latin America can be more challenging and far more
dangerous than domestic flying or the highly structured North
Atlantic/European operation. Some Latin American destinations have
multiple hazards to air operations, and ATC facilities may provide
little assistance in avoiding them.

Enroute and terminal radar coverage may be limited or non-existent.
Mountains, larger and more extensive than anything you’ve
probably ever seen, will loom up around you during descent and
approach, and during departure. Communications, navigation, weather
problems, and an Air Traffic Control philosophy peculiar to Latin
America may conspire with disastrous consequences.

There are many hazards in this environment, but the greatest danger is
pilot complacency. From 1979 through 1989, 44 major accidents
involving large commercial aircraft occurred in South America. Of
these 44 accidents, 34 were attributable to pilot error, or were
pilot-preventable with proper situational awareness (emphasis in
original).

1.18.5 Speedbrake System Description for the B-757

The speedbrake system in the B-757 consists of overwing control
surfaces that extend and retract at the command of the pilot through
the aft and forward movement of the speedbrake control lever located
in the top left side of the center control stand. In flight operation
of the speedbrake system is manual. Automatic extension and
retraction are restricted to the landing phase and is activated upon
main wheel touchdown and forward movement of the power levers
respectively. Due to the limited aerodynamic effect of the
speedbrakes, flightcrews may become unaware that they are in the
extended mode. Annunciation of speedbrake deployment only becomes
activated in landing configuration and / or below 800 feet. (see
appendix D, Aileron and Spoiler Controls)

26

1.18.6GPWS Escape Maneuvers

The Ground Proximity Warning Escape Maneuver procedure was contained
in American Airlines B-757 Flight Operations Manual under the section
entitled, “Instruments.” The procedure addressed the flightcrew
actions that must be carried out in order to attain maximum climb
performance of the airplane in order to overcome the obstacles ahead
of its flight path. These pilot actions include the dlsengagement of
autopilot and autothrottle system as well as selecting maximum power
and attaining best angle of climb.

27

2. ANALYSIS

2.1 General

There was no evidence of failures or malfunctions in the airplane, its
components, or its systems. Weather was not a factor in this
accident. Both crewmembers were properly qualified and certificated to
operate the airplane on this flight. The specific details of the
training history of the accident flightcrew was not available to the
accident investigation team, because of the AA policy of maintaining
training records which indicate only pass/fail on evaluations. No
evidence was found that either crewmember was experiencing a
behavioral or physiological impairment at the time that could have
caused or contributed to of the accident.

The evidence indicates that AA965 continued on the appropriate flight
path until it entered the Cali Approach airspace. After contacting the
Cali approach controller, the flightcrew accepted the controller’s
offer to land on runway 19 at SKCL, rather than runway 01 per the
flight planned route. After receiving clearances to descend, lastly to
5,000 feet msl, neither flighterew member made an attempt to terminate
the descent, despite the airplane’s deviation from the published
approach course, in a valley between two mountain ridges. After the
flightcrew recognized that the airplane had deviated from the
prescribed inbound course, as the first offieer stated less than 1
minute prior to impact, they attempted to turn back to the “extended
centerline” of the runway, which as the eaptain then stated, “…is
Rozo.” The accident occurred following the turn back to the right from
a track to the east of the prescribed course and an attempt to fly in
a southwesterly heading to directly intercept the extended runway
centerline.

The investigation examined flightcrew actions to determine how a
properly trained and qualified crew would allow the airplane to
proceed off course, and continue the descent into an area of
mountainous terrain. In addition, the investigation examined the
actions of the Cali approach controller to determine what role, if
any, his actions may have had upon the accident. The quality of the
FAA surveillance of the AA South American operation was examined. The
investigation also assessed survivability issues to determine the
extent to which the number of the injuries and fatalities could have
been reduced, and the design of the speedbrake, and AA’s procedures
and training in retracting speedbrakes during GPWS escape maneuvers..

28

2.2 The Decision to Accept Runway 19

The evidence indicates that the captain and first officer committed a
series of operational errors that led to the accident. The errors,
which individually were not causal, interacted in a way that caused
the accident. The CVR contained the final approximately 30 minutes of
cockpit voice recording, but did not contain details of an approach
briefing into Cali, and investigators were unable to determine whether
or how detailed a flightcrew approach briefing took place before the
beginning of recorded information. However, investigators were able to
identify a series of errors that initiated with the flightcrew’s
acceptance of the controller’s offer to land on runway 19 rather than
the filed approach to runway 01. This expectation was based on the
experience of AA pilots operating into Cali, where almost all landings
had been on runway 01, and AA’s operations office at SKCL had radioed
the accident flightcrew about 5 minutes prior to the controller’s
offer information regarding the active runway. Also, FMC
reconstruction found that the ILS approach to runway 01 had been
entered into the airplane’s FMS.

The CVR indicates that the decision to accept the offer to
land on runway 19 was made jointly by the captain and first officer in
a 4-second exchange that began at 2136:38. The captain asked: “would
you like to shoot the one nine straight in?” The first officer
responded, “Yeah, we’ll have to scramble to get down. We can do it.”
This interchange followed an earlier discussion in which the captain
indicated to the first officer his desire to hurry the arrival into
Cali, following the delay on departure from MIA, in an apparent
attempt to minimize the effect of the delay on the flight attendants’
rest requirements. For example, at 2126:01, he asked the first officer
to “keep the speed up in the descent.”

As a result of the decision to accept a straight in approach to runway
19, the flightcrew needed to accomplish the following actions
expeditiously:

• Locate, remove from its binder, and prominently position
  the chart for the approach to runway 19
• Review the approach chart for relevant information such
  as radio frequencies, headings, altitudes, distances, and missed
  approach procedures
• Select and enter data from the airplane’s flight
  management system (FMS) computers regarding the new approach

29

• Compare information on the VOR DME Runway 19 approach chart
  with approach information displayed from FMS data
• Verify that selected radio frequencies, airplane headings, and FMS-
  entered data were correct
• Recalculate airspeeds, altitudes, configurations and other airplane
  control factors for selected points on the approach
• Hasten the descent of the airplane because of the shorter distance
  available to the end of new runway.
• Monitor the course and descent of the airplane, while maintaining
  communications with air traffi1c control (ATC)

The evidence of the hurried nature of the tasks performed and the inadequate
review of critical information between the time of the flightcrew’s
acceptance of the offer to land on runway 19 and the flight’s crossing
the initial approach fix, ULQ, indicates that insufficient time was
available to fully or effectively carry out these
actions. Consequently, several necessary steps were performed
improperly or not at all and the flightcrew failed to recognize that
the airplane was heading towards terrain, until just before
impact. Therefore, Aeronautica Civil believes that flightcrew actions
caused the accident.

Researchers studying decision making in dynamic situations [22] have suggested
that experienced persons can quickly make decisions based on cues that
they match with those from previous experiences encountered in similar
situations. A referenced text refers to this characteristic as
Recognition Primed Decision Making, in which a decision maker’s rapid
assessment of the situation is almost immediately followed by the
selection of an outcome. It states:

Our research has shown that recognitional decision making is
more likely when the decision maker is experienced, when time
pressure is greater, and when conditions are less stable. [23]

It is likely therefore that when previously faced with similar
situations, such as the opportunity to execute an approach that was
closer to the airplane’s

—————-
[22] Klein, G., (1993), Naturalistic Decision Making: Implications for
Design. Wright-Patterson Air Force Base, Ohio: Crew System Ergonomics
Information Analysis Center.

[23] Klein, G., (1993), A recognition primed decision (RPD) model of
rapid decision making. In Klein, G. A., Orasanu, J., Calderwood, R.,
and Zsambok, C. E., (Eds.), Decision Making in Action: Models and
Methods. Norwood, New Jersey, Ablex, p. 146.

30

position than the approach anticipated, the pilots of AA965, each of
whom had acquired years of experience as air transport pilots,
accepted the offers and landed without incident.

However, recognition primed decision making can present risks to the
decision maker if the initial assessment of the situation is
incorrect, or if the situation changes sufficiently after the decision
has been made but the initial decision is not reconsidered. In this
accident, the latter scenario appears to have been the case; there is
no evidence that either flightcrew member reconsidered the initial
decision to accept the offer to land on runway 19 and all subsequent
actions were directed to completing the steps necessary to
successfully land.

The evidence suggests that either of two reasons could account for the
flightcrew’s persistence in attempting to land rather than
discontinuing the approach. These include the failure to adequately
consider the time required to perform the steps needed to execute the
approach and the reluctance of decision makers in general to alter a
decision once it has been made.

The CVR transcript indicates that the captain, at 2137:10, gave the
only consideration either flightcrew member expressed in reference to
the time available, after accepting the offer to land on runway 19,
when he asked the first officer, in response to an ATC clearance,
“Yeah he did [say the Rozo 1 arrival]. We have time to pull that
[approach chart] out?” There is no response to this question, but the
CVR records the sound of “rustling pages,” likely the approach
chart. Despite this comment, there is no evidence that either pilot
acknowledged that little time was available to perform the preliminary
tasks such as verifying their position relative to the navaids that
formed the basis for the approach or to execute the approach.

Once they began to prepare for the approach to runway 19, there is no
evidence that the flightcrew revisited the decision, despite
increasing evidence that should have discontinued the approach. This
evidence, supported by recovered FMC non volatile memory, includes the
following:

• Inability to adequately review and brief the approach
• Inability to adhere to requirement to obtain oral approval from the
  other pilot before executing a flight path change through the FMS
• Difficulty in locating the VLQ and Rozo fixes that were critical to
  conducting the approach.

31

• Turning left to fly for over one minute a heading that was
  approximately a right angle from the published inbound course, while
  continuing the descent to Cali

By not reconsidering that initial decision, the flightcrew acted
consistently with the findings of human factors research on decision
making that found that decision makers are reluctant to alter a
decision after it has been made. For example [24]:

Operators tend to seek (and therefore find) information that confirms
the chosen hypothesis and to avoid information or tests whose outcome
… could disconfirm it. This bias produces a sort of “cognitive tunnel
vision” in which operators fail to encode or process information that
is contradictory to or inconsistent with the initially formulated
hypothesis. Such tunneling seems to be enhanced particularly under
conditions of high stress and workload.

Thus, in addition to simply being too busy to recognize that they
could not properly execute the approach, once the decision to land on
runway 19 had been made, the course of action taken was to continue
the approach, rather to consider discontinuing it.

2.3 Situational Awareness

Once they made the decision to accept the offer to land on runway 19,
the flightcrew displayed poor situation awareness, with regard to such
critical factors as the following:

• Location of navaids and fixes
• Proximity of terrain
• Flight Path

The flightcrew’s situation awareness was further compromised by a lack
of information regarding the rules which governed the logic and
priorities of the navigation data base in the FMS.

—————-
[24] Wickens, C. D., (1984), Engineering Psychology and Human
Performance. Columbus, Ohio: Charles E. Merrill, p. 97.

32

Situational awareness has been defined [25] as the:

…perception of the elements in the environment within a volume
of time and space, the comprehension of their meaning, and the
projection of their status in the near future.

To airline pilots, situational awareness refers to a flightcrew’s
understanding of the status and flightpath of the aircraft, and the
accuracy of their prediction about its future status and
flightpath. Deficiencies in situation awareness can lead to
potentially catastrophic failures involving flightpath prediction or
comprehension and prediction of system parameters.

The accident CVR indicated that from the beginning of their attempt to land on
runway 19, the flightcrew exhibited a lack of awareness of fundamental
parameters of the approach. From 2137:11, when the sound of rustling
pages can be heard, the flightcrew attempted to both review the
approach and determine the airplane’s present and predicted position
in reference to critical points on the approach. Their inability to
effectively do both tasks is evidenced at 2138:49, when the first
officer asked, “where are we,” followed by a short discussion between
both the captain and first officer regarding their position relative
to the ULQ VOR. Again at 2139:30, two minutes before impact, neither
flightcrew member could determine which navaid they were to proceed
towards. The first officer stated, “left turn, so you want a left turn
back around to ULQ.” The captain replied, “Nawww… hell no, let’s
press on to…” The first officer stated, “well we’re, press on to
where though?” The captain replied, “Tulua.” The first officer staid,
“that’s a right u u. The captain stated, “where we goin’? one
two.. come to the right. let’ go to Cali first of all, lets, we got
[expletive] up her didn’t we.” The first officer replied, “yeah.”

The captain established the flightpath that initially led to the
deficiency in situational awareness by misinterpreting the Cali approach
controller’s clearance to proceed to Cali, given at 2134:59, as a
clearance “direct to” Cali. The captain’s readback of the clearance,
“… understood. Cleared direct to Cali VOR. Report Tulua … ”
received an affirmative response from the controller. The captain’s
readback was technically correct because he stated that he was to
report Tulua, thus requiring him to report “crossing” the fix
first. However, the CVR indicates that the

—————-
[25] Endsley, M R. (1995). Toward a theory of situation awareness in dynamic
systems. Human Factors, 37, 65-84, p. 36.

33

captain then executed a change in the FMS programmed flightpath to
proceed “direct to” the Cali VOR. In so doing he removed all fixes
between the airplane’s present position and Cali, including Tulua, the
fix they were to proceed towards.

There is no evidence in the CVR transcript that either pilot
recognized that ULQ had been deleted from the display until they were
considerably closer to Cali, and were in fact past ULQ at that
time. Consequently, largely as a result of this action, the flightcrew
crossed the initial approach fix ULQ, without realizing that they had
done so and without acknowledging the crossing to the controller.
Aeronautica Civil believes that the logic of the FMS that removed all
fixes between the airplane’s present position and the “direct to” fix
compromised the situational awareness of the flightcrew. In
particular, it affected their awareness of the position of the
airplane relative to critical fixes and navaids necessary for the
approach. Sinee the initial certification of the FMS on the
B-757/-767, the Boeing Company has developed and implemented a change
to the B-757 software that allowed such fixes to be retained in the
display. However, this retrofit, part of a product improvement package
for the airplane, had not been incorporated into the accident
airplane. Aeronautica Civil believes that the FAA should evaluate all
FMS-equipped aircraft and, where necessary, require manufacturers to
modify the FMS logic to retain those fixes between the airplane’s
position and those the airplane is proceeding towards, following the
execution of a command to the FMS to proceed direct to a fix.

Deficient situation awareness is also evident from the captain’s interaction
with the Cali air traffic controller. At 2137:29, the captain asked
the controller if AA965 could “go direct to [the non directional
beacon] Rozo and then do the Rozo arrival.” The controller later
stated that this question that made little sense since Rozo was a
beacon located just before the approach end of runway, and not an
initial or intermediate approach fix located considerably before the
runway. The interaction with the controller continued at 2140:01,
when the captain asked the controller a similar question. The captain
announced his position and properly interpreted the approach when he
asked “…You want us to go to Tulua and then do the Rozo … to the
runway?” While this question demonstrated that the captain understood
the appropriate flight path necessary to execute the approach, his
position report contradicted his statement, because the airplane had
already crossed ULQ and therefore would have to reverse course to
comply with his statement

34

2.4 Awareness of Terrain

In addition to deficiencies in situation awareness already noted,
there is no evidence that, before the onset of the ground proximity
warning system (GPWS) alert, the flightcrew recognized the proximity
of terrain to the airplane’s present and future flight path. The
evidence suggests several explanations for this deficiency in the
flightcrew’s situational awareness:

• Cali was not on the “hit list” [26] of South American airports
• The guidance given in the AA referenced guide and in training did
  not have sufficient impact to be recalled in a time of high stress and
  workload.
• They had become acclimated to the hazards of flying in
  mountainous terrain.
• The first officer relied primarily on the captain’s experience in
  operating into Cali and consequently relaxed his vigilance
• Terrain information was not shown on the electronic horizontal
  situation indicator (EHSI) or graphically portrayed on the approach
  chart
• The night visual conditions limited the ability to see the terrain

There was evidence that AA provided the captain and first officer of
AA965 with the information they needed to be sufficiently alert to the
need to maintain constant awareness of proximity to terrain when
operating in South America. The training and information that AA
provided to its crews on the hazards specific to Latin America
addressed many of the issues noted in the investigation of this
accident. Following its entry into the South American market, AA
developed the information in the reference guide and in training,
after making significant effort to identify and address the unique
demands of South American flight operations.

Aeronautica Civil believes that AA provided valuable information to
its flightcrews regarding flying in South America, including many
safety topics and advisories that were overlooked by the crew of
AA965. Despite the high quality of the training that AA provided to
their flightcrews, this accident demonstrates that the performance of
flightcrews in the cockpit may not manifest the attitudes, skills, and
procedures that such a training program addresses.

—————-
[26] AA defined airplanes deserving special pre approach briefing criteria.

35

Both the reference guide and the Latin American training program noted
that three South American airports: Bogota, Colombia; Quito, Ecuador;
and La Paz, Bolivia, were critical airports because of the effects
of their high altitudes on aircraft performance. Pilots were required
to meet additional training requirements before being permitted to fly
into these cities for the first time. Because Cali, Colombia, was not
at high altitude, it was not listed as a special airport
and no additional training or checking was required to operate into
it. Therefore, because it was not given “special consideration,” the
accident flightcrew may not have exercised the same level of vigilance
when operating into Cali as they would have when operating into the
three target airports.

In the years since the flightcrew members received their initial Latin
American training, both had operated in South America and the captain
had operated into Cali 13 times without incident. Over time, repeated
exposure to flight operations into potentially hazardous environments
can become routine as pilots acclimate to the environment and their
vigilance is diminished. Unless information is presented regularly in a
novel and interesting way, pilots may fail to display the lessons of
earlier training when those lessons are most needed. The Investigation
Team believes that the pilots of AA965 became task saturated and did
not recognize that the hazards the airline had warned them about as
they were encountered during the accident approach.

In addition, the first officer’s lack of experience in the Cali
environment served to increase his reliance on the captain for
situational awareness. For example, at 2133:25, the first officer
asked the captain for the transition level at which altimeter settings
were to be changed on approach to Cali. Two minutes later, at 2135:44,
he asked the captain whether speed restrictions were required, as
well. Throughout the approach, the captain’s experience into Cali
appears to have reduced the first officer’s otherwise assertive role
as the pilot flying.

The CVR indicates that the flightcrew had insufficient time to review
thoroughly or effectively the approach chart for Cali’s VOR DME
approach to runway 19. Had more time been available, the flightcrew
likely would also have selected the VOR DME runway 19 approach in the
FMS. By using the approach chart as the primary reference to execute
the approach into Cali, the pilots relied on it as their source for
terrain information. High point of the terrain were displayed by
several altitude dots on the chart and their associated elevations
above msl. Although this method presents the necessary information,
it takes pilots time to recognize and understand its significance
because of the lack of prominence of this

36

information. During a high workload period, or when insufficient time
may be available to adequately review the chart pilots may not be able
to assimilate that information to gain a comprehensive view of the
airplane, its flight path, and its adherence to the approach
parameters.

Before the accident, the Jeppesen Sanderson Company, the supplier of
approach charts and navigation information for electronic navigation
data bases, began to change the portrayal of terrain on the charts and
maps that it supplied to its customers. In the new method, terrain is
portrayed using graphics similar to those used in topographic charts,
with colors added to enhance the prominence of terrain and heighten
its contrast with other information on the chart. The criteria the
company uses to determine whether to display terrain information on
approach charts require that terrain is 2,000 feet above the airport
within 6 miles of the airport, and on local area charts, that terrain
is elevated more than 4,000 feet above the planned view of the
airport. Because neither of these criteria was met in the VOR DME
runway 19 approach chart, terrain was not graphically presented on it.

the terrain display criteria Jeppesen Sanderson developed were met
regarding the local area chart, at the time of the accident the
company had not yet converted the Cali local area chart to the new
format. The chart that was available displayed terrain high points,
but not in the same color graphic portrayal as is used in the newer
format. Consequently, the chart used by the flightcrew did not
graphically show the high terrain on either side of the descent into
Cali. The Investigation Team believes that graphically portraying
terrain information on approach charts is an effective means of
presenting critical information to flightcrews quickly and without
extensive interference with other tasks. Aeronautica Civil
appreciates the efforts of Jeppesen Sanderson in upgrading its
approach charts in order to present such information in an absence of
a requirement to do so. Had this portrayal of terrain been available
to the flightcrew, and had they referred to charts containing the
information, it may have heightened their awareness of the proximity
of terrain in their flightpath and the accident could have been
avoided. Therefore, Aeronautica Civil believes that the FAA should
require that all approach and navigation charts portray the presence
of terrain located near airports, or flight paths.

The evidence from the flightcrew’s statements on the CVR and their
inability to initially locate ULQ indicates that they did not refer to
the local area chart during the flight and only referred to the
approach chart. Therefore, during the descent they had no information
available that could have quickly informed them of

37

the proximity of terrain. AA did however, provide the flightcrew with
written terrain information on the flightplan. This noted that:
“Critical terrain exists during the descent–Strict adherence to STAR
necessary for terrain clearance.” The evidence suggests that the
flightcrew did not take this information into consideration during the
descent into Cali.

In FMS-equipped aircraft, the portrayal of flightpath, (in the
Boeing/Honeywell Systems-equipped airplanes by means of a magenta
colored line), is so accurate and informative that pilots are
permitted to rely on it as the primary means of navigation, believing
that they are secure in the knowledge that the airplane will be
maintained along a safe flightpath as long as the magenta line is
followed. However, unlike charts, the FMS-generated displays do not
present associated information, such as terrain, and do not display
navaids that are behind the airplane unless specifically directed to
by a flightcrew member. As a result, pilots who are accustomed to
relying exclusively on FMS-generated displays for navigation, can,
over time, fail to recognize the relative proximity of terrain and can
lose the ability to quickly determine that a fix or beacon is behind
them. The evidence suggests that this partially explains the
difficulty of the AA965 flightcrew in locating the ULQ. Aeronautica
Civil believes that the FAA should require pilots operating
FMS-equipped aircraft to have open and easily accessible the approach
and navigation charts applicable to each phase of flight before each
phase is reached.

In addition, technological advances in the more than one decade since the
introduction of “glass cockpit” aircraft allow for the presentation of
terrain information on FMS-generated displays, a feature that was not
possible at the time of their introduction. This information can
enhance pilot situation awareness and considerably expand the ability
of pilots operating glass cockpit aircraft to maintain awareness of
the proximity of terrain to the airplane’s flightpath. Therefore,
because of the importance of FMS-generated displays to flightcrew
situation awareness, Aeronautica Civil believes that that the FAA
should encourage manufacturers to develop and validate methods of
accurately displaying terrain information on airplane flightpath
displays.

Nevertheless, the history of flight indicates that the AA965
flightcrew did not effectively use all navigation information that was
available to them and that they relied almost exclusively on their
EHSI for navigation. Furthermore, they attempted to review the chart
of the Cali VOR DME runway 19 approach only during the period while
the airplane was descending towards Cali and while they

38

were engaged in numerous critieal tasks. There is no evidence that
they reviewed that chart earlier in the flight, or referred to the
Cali area chart at any time. Had they done so, it is possible that
they would have recognized that they had already crossed the initial
approaeh fix, (ULQ), were flying between two mountain ranges, that
necessitated adherence to approach charts, and as a result the
accident may have been avoided.

The captain’s communications also indicate a lack of appreciation for the
differences between South American airspace and that in the United
States. Terrain clearance in the United States is much more likely
because of the ATC surveillance available with radar coverage over
most of the airspace, the integration of computer programs with radar
to alert controllers to aircraft that are descending towards terrain,
and the common use of the English language. As a result, pilot
requests for clearances direct to a fix are often made, and often
granted. The captain’s misinterpretation of the controller’s clearance
to Cali indicates that, despite his experience in operating into South
America, his expectations of controller’s capabilities were still
largely influenced by his experience in the United
States. Irrespective of the controller’s “affirmative” response to the
readback of the clearance to Cali, the captain could not assume that
the controller understood the captain’s intent, could monitor the
airplane’s flight path to assure terrain clearance, or could even
assume that that the “direet to” clearance was legal. Aeronautica
Civil believes, based on the interactions with the controller, that
the captain and first officer both incorreetly assumed that a level of
redundancy existed in the ability of the Cali controller to provide
terrain clearance to the crew when no such ability existed.

The limited visibility resulting from nighttime conditions at the time of the
accident also hindered the flightcrew’s terrain awareness. As a
result, they were unable to visually reeognize the terrain until just
before impact while descending towards Cali, despite the visual
meteorologieal eonditions with visibility “greater than 10
kilometers” [27] that were present. The fact that the captain, the only
one of the two flightcrew members to have operated into Cali, had
likely previously landed only at night, also limited his appreciation
for the presence of the mountains along either side of the approach
into Cali.

—————-
[27] See section 1.7, Meteorological Information

39

2.5 Automation

The accident airplane, a B-757, is one of the first automated “glass
cockpit” types of transport aircraft introduced into the commercial
aviation fleet in reeent years. These automated airplanes employ
computers, known as FMSs on Boeing aircraft, extensively for
navigation, systems monitoring, and flight path control. The FMS
monitors and can display systems information and navigation data,
including the airplane’s predicted flight path, in an electronically
generated graphic format. The FMS, considered to be highly reliable,
can also exercise almost complete flightpath control through pilot
inputs into CDUs, which are located on the console, one for the
captain and one for the first officer. Either pilot can generate,
select, and execute all or part of a flightpath from origin to
destination through CDU inputs. In addition, as in other glass cockpit
aircraft, only a 2-pilot flightcrew is required to fly the airplane
and monitor its systems.

Among its features is the map display, which graphically displays on
the EHSI the airplane’s present position and future flightpath, as
well as the location and relative position of adjacent navigational
aids and airports, at the option of the pilot. The FMS also calculates
and can display the position of the airplane at the conclusion of a
constant rate climb or descent and can automatically tune and locate
navigational aids to assure positioning on the programmed flightpath.

The FMS navigation data base is developed and maintained for AA and
most other airlines by the Jeppesen Sanderson Company, the
organization that also supplies most airlines with navigation charts,
and is formatted by the manufacturer of the FMS itself. The data base,
updated at regular intervals as are the approach charts, includes
frequencies and positions of navigational aids worldwide. In addition,
instrument approach proeedures are maintained, using similar, but not
identical data, to those shown in the charts.

Pilots of glass cockpit aircraft can select an instrument approach
procedure from the approaches stored in the FMS data base. They can
then either direct the FMS to electronically fly the approach or
manually fly it. Retrieving the available approaches and selecting a
procedure requires several key strokes on the CDU. The FMS also
possess superior computational ability. It can perform highly complex
aircraft performance calculations more quickly and accurately than any
pilot can.

40

Human factors researchers have written extensively on the potential
risks that have been introduced by the automation capabilities of
glass cockpit aircraft [28]. Among those identified are: over reliance on
automation; shifting workload by increasing it during periods of
already high workload and decreasing it during periods of already low
workload; being “clumsy” or difficult to use; being opaque or
difficult to understand, and requiring excessive experience to gain
proficiency in its use. One researcher [29] has observed pilots on
numerous occasions, even ones experienced in the systems, asking
“What’s it doing now?” in reference to an action of the FMS that they
could neither explain nor understand.

In recent years aircraft automation technology has changed, and line
pilots, training departments, and flight standards and procedures
officials have attempted to adopt to its demands. Researchers have also
gained better understanding of the potential risks and benefits that
highly automated FMS systems have brought to air transport operations,
while identifying other risks as well. For example, with the
introduction of highly advanced “fly-by-wire” aircraft, researchers [30]
have noted that pilots can lose awareness of the flight mode the
aircraft is operating in. Investigators attempted to identify what
role, if any, use of the FMS played in the sequence of events that led
to this accident.

Both of AA965’s pilots were experienced in the airplane, and were
described as proficient in the use of the FMS by their peers. Yet,
most likely because of the self-induced time pressure and continued
attempts to execute the approach without adequate preparation, the
flightcrew committed a critical error by executing a change of course
through the FMS without verifying its effect on the flightpath. The
evidence indicates that either the captain or the first officer
selected and executed a direct course to the identifier “R,” in the
mistaken belief that R was Rozo as it was identified on the approach
chart. The pilots could not know without verification with the EHSI
display or considerable calculation that instead of selecting Rozo,
they had selected the Rome beacon, located near Bogota, some 132

—————-
[28] Wiener, E. L., & Curry, R. E., (1980). Flight deck automation:
Promises and problems. Ergonomics, 23, 995-1011. Billings, C. E.,
(1996). Human-centered aviation automation: Principles and
Guidelines. (TM No. 110381) Moffett Field, California: NASA-Ames
Research Center.

[29] Wiener, E. L. (1989). Human factors of advanced technology (Glass
cockpit) transport aircraft (NASA CP No. 177528). Moffett Field,
California: NASA-Ames Research Center.

[30] Sarter, N. B., & Woods, D. D. (1995). How in the world did we ever
get into that mode? Mode error and awareness in supervisory
control. Human Factors, 37, 5- 19

41

miles east-northeast of Cali. Both beacons had the same radio
frequency, 274 kilohertz, and had the same identifier “R” provided in
Morse code on that frequency. In executing a turn toward Romeo rather
than Rozo, the flightcrew had the airplane turn away from Cali and
towards mountainous terrain to the east of the approach course, while
the descent continued. At this time, both pilots also attempted to
determine the airplane’s position in relation to ULQ, the initial
approach fix. Neither flightcrew member was able to determine why the
navaid was not where they believed it should be, and neither noted nor
commented on the continued descent. The CVR indicates that the
flightcrew became confused and attempted to determine their position
through the FMS. For example, at 2138:49 the first officer asked, “Uh,
where are we?” and again, 9 seconds later asked, “Where [are] we
headed?” The captain responded, “I don’t know … what happened here?”
The discussion continued as each attempted to determine the position
and path of the airplane relative to the VOR DME 19 approach to
Cali. At 2140:40, the captain indicated that he was having difficulty
again, apparently in locating Tulua VOR through the FMS. Over 1-
minute later the deviation from course was recognized by both and a
return to the extended runway centerline was attempted by turning
right. However, since they had been flying on an easterly heading for
approximately 1 minute and were now well east of the prescribed
course, the direct track back towards “centerline,” or “Rozo,” about 2
miles north of the approach end of runway 19, took the flight towards
mountainous terrain which was then between them and the approach end
of the runway. Impact occurred shortly thereafter.

The first automation-related error by the flightcrew, the selection of
Romeo instead of Rozo, was a simple one, based on the method used to
generate a selection of navaids from the FMS data base, using the
single letter identifier. All navaids having that identifier are
displayed, in descending order of proximity to the airplane. The one
closest to the airplane is presented first, the second is further from
the position and so on. Selecting R resulted in a display of 12 NDBs,
each of which used the “R” as an identifier. Choosing the first beacon
presented in this list resulted from a logical assumption by the
pilot.

The investigation determined that because of rules governing the
structure of the FMS data base, Rozo, despite its prominent display as
“R” on the approach chart, was not available for selection as “R” from
the FMS, but only by its full name. The evidence indicates that this
information was not known by the flightcrew of AA965. Furthermore,
considerable additional differences existed in the presentation of
identical navigation information between that on the approach charts
and that in the FMS data base, despite the fact that the same company

42

supplied the data to both. For example, DME fixes for the Cali VOR DME
runway 19 approach that were labeled on the charts as D-21 and D-16
were depicted on the FMS using a different nomenclature entirely, that
is, CF19 and FF19. The company explained that it presented data in the
FMS according to a naming convention, ARINC 424, developed for
electronic data, while data presented on approach charts met
requirements of government civil aviation authorities.

Aeronautica Civil believes that the discrepancy between the approach
chart and FMS presentation of data for the same approach can hinder
the ability of pilots to execute an instrument approach, especially
since flightcrews are expected to rely on both the FMS-generated
display and the approach chart for information regarding the conduct
of the approach. When two methods of presenting approach information
depict important information differently or one readily show it at
all, that information can be counterproductive to flightcrew
performance in general, and their ability to prepare for an approach
in particular. The lack of coordinated standards for the development
and portrayal of aeronautical charts and FMS data bases and displays
has led to a situation in which, not only are the charts and displays
different in appearance, but the basic data are different. This lack
of commonality is confusing, time consuming, and increases pilot
workload during a critical phase of flight, the approach
phase. Therefore, Aeronautica Civil urges the FAA to develop and
implement standards for the portrayal of terminal environment
information on FMS/electronic flight instruments (EFIS) displays that
match, as closely as possible, the portrayal of that information on
approach charts. Furthermore, until such time as the differences
between FMS-based navigation data and data on approach and navigation
charts is eliminated to the extent possible, Aeronautica Civil
believes that the FAA should require the Jeppesen-Sanderson Company to
inform airlines operating glass cockpit aircraft of the presence of
each difference in the naming or portrayal of navigation information
on FMS-generated and approach chart information, and require airlines
to inform their flightcrews of these differences.

Although the differences between the presentation of the same
information could be confusing, and the selection of Romeo instead of
Rozo can be understood according to the logic of the FMS, the fact
remains that one of the pilots of AA965 executed a direct heading to
Romeo in violation of AA’s policy of requiring flightcrew members of
FMS-equipped aircraft to verify coordinates and to obtain approval of
the other pilot before executing a change of course through the
FMS. The failure to verify and to obtain verbal approval for the
execution of the course to “R” occurred primarily because of the
self-induced pressure of the pilots of AA965 to execute the approach
without adequate time being available. This exacerbated their
confusion regarding their

43

position, the positions of the critieal navaids, and the manner in
which the approach was to be flown.

Subsequently, the captain continued unsuccessful attempts to locate
Tulua VOR, the initial approaeh fix, through the FMS. Perhaps had more
time been available the flightcrew would have been under less pressure
and could have recognized earlier that the airplane had turned away
from Cali and was continuing to descend and could also have referred
to their Cali area navigation charts to help determine their position.
Furthermore, with more time the flightcrew may have selected the VOR
DME Runway 19 approaeh on the FMS. The continued use of the FMS to
mitigate their confusion was unsuccessful and contributed to their not
using other sources of information, such as charts, to reduce their
confusion, as well as to their failure to consider discontinuing the
approach.

The FMS is highly reliable and presents navigation information in an
easily interpretable manner. Researchers have shown [31] that operators
will increase their use of and reliance on an automated system as
their trust in the system increases. Also, as noted, pilot confusion
regarding FMS-presented information is not unusual, even among
experienced pilots. Confusion about the FMS presentation, as is true
for use of any computer, is often resolved after persistent
interaction with it. Thus, it is likely that the captain believed that
the confusion he was encountering was related to his use of the FMS,
and that continued interaction with it would ultimately clarify the
situation. He could not be expected to recognize, because it rarely
occurs in regular flight operations, that the fix he was attempting to
locate (Tulua VOR) was by this time behind him, and the FMS-generated
display did not provide sufficient information to the flightcrew that
the fix was behind the airplane.

In addition, the actions of the captain are consistent with literature
that indicates that under stress, people tend to narrow their focus of
attention [32].

Probably the most widespread finding is that under various forms of
stress, people tend to narrow their field of attention to include

—————-
[31] Moray, N., Lee, J. D., & Hiskes, D. (1994). Why do people intervene
in the control of automated systems? In Mouloua, M. & Parasuraman,
R. (Eds.) Proceedings of the first Automation Technology and Human
Performance Conference. Washington, DC

[32] ibid. Endsley.

44

only a limited number of central aspects…. In many dynamic systems,
high mental workload is a stressor of particular importance…

Therefore because of the lack of time, the need to perform multiple
tasks in the limited time, with the difficulty in locating a critical
navaid, the accident captain appears to have been under considerable
stress, which further compromised his ability to perform in the
objective manner needed to develop and maintain good situation
awareness. His attention thus narrowed to further repeated
unsuccessful attempts to locate ULQ through the FMS.

The evidence indicates that AA, as other airlines operating
FMS-equipped aircraft, communicated to its pilots the appropriate
impression of the high reliability of the FMS. Failure of the FMS is
so unlikely that if it occurs it is it is believed to be likely be an
electrical system anomaly and not one of the FMS itself. Pilot
training in FMS-system failures is generally directed to display or
total computer failures and the response suggested is to substitute
working displays or computers for non-working ones. As a result,
flightcrews have been taught that the FMS is an all-or-none system
that will either work or not work, and that failures, which are few
and far between, will be total. Therefore, since the FMS and the
electronic displays were functioning, the appropriate pilot assumption
was that difficulty in interacting with it was because of pilot input,
and not something related to the FMS.

At the same time, the FMS is a complex system that requires extended
experience for pilots to gain proficiency it. Researchers [33], have
noted that it often takes pilots as long as a year of regularly flying
a glass cockpit airplane before feeling proficient in use of the
FMS. Pilots are generally trained to be able to use almost all of the
capabilities of the FMS, from programming simple courses, to
“building” a course or holding pattern with navaids that are not part
of a “canned” or FMS-stored flight plan in order to obtain the skills
needed to pass a flight check. However, pilots are not given much
information about the logic underlying much of the performance of the
FMS, or shown many of the numerous options available to achieve
identical goals in the FMS. This accident demonstrates that
proficiency in the use of the FMS, without knowledge of the logic
underlying such critical features as the design and programmed
priorities of its navigation data base, can lead to its misuse. Such
priorities in the system logic may result in one waypoint or fix being
easily called up via the CDU by inputting simply the first letter of
the name, and

—————-
[33] ibid. Wiener.

45

then selecting the nearest waypoint, at the top of the display, while
another, equally important waypoint, can never be called up unless it
is spelled out properly on the CDU keyboard. Such partially understood
logic may partially account for the finding that use of the FMS often
increases workload during periods of already high workload.

Aeronautica Civil believes that the circumstances of this accident
demonstrate the need for airlines to revise the procedures used to
operate FMS-equipped aircraft, and the training they provide to
pilots in the application of those procedures. Giving pilots
information on the FMS sufficient to pass a flight test, and relying
on sustained use of the equipment thereafter to gain fluency in its
use is counter to safe operating practices. Therefore, Aeronautica
Civil urges the FAA to evaluate the curricula and flight check
requirements used to train and certificate pilots to operate
FMS-equipped aircraft, and revise the curricula and flight check
requirements to assure that pilots are fully knowledgeable in the
logic underlying the FMS or similar aircraft computer system before
being granted airman certification to operate the aircraft.

2.6 Crew Resource Management

In a previous accident involving an FMS-equipped airplane, the
flightcrew of a Thai Airways Airbus A-310 that crashed into the side
of a mountain while on approach to Katmandu, Nepal, lost awareness of
terrain and of the location of navaids that were in reality behind the
aircraft [34]. Investigators found that after encountering and correcting
a system anomaly during the approach, which was a period of high
workload, the pilots lost awareness of the airplane’s course and did
not realize that they were headed towards, and not away from, high
terrain. The displayed navigation information was confusing to them
and they repeatedly attempted to use the FMS to clarify their
understanding of the airplane’s position. The airplane impacted the
terrain while both the captain and first officer were interacting with
the FMS.

Numerous parallels exist between the findings of the Thai accident and
the subject accident. In both, pilots of sophisticated glass cockpit
aircraft on approach in mountainous environments relied on the FMS and
continued to interact

—————-
[34] Aviation Accident Report, Thai Airways International Airways, Ltd.,
Airbus Industrie A310-304, HS-TID, Near Katmandu, Nepal, 23 NNE, 31
July 1992. His Majesty’s Government of Nepal. June 1993

46

with the FMS in futile efforts to gain situational awareness, at the
expense of reference to charts that could have enhanced terrain
awareness. Yet, to its credit, AA has used the report of the Thai
accident to train flightcrews on the potential risks of piloting
highly automated aircraft, in a recent recurrent CRM training session
that was given to well over 95 percent of AA’s pilots. It is likely
that the Cali accident pilots were trained in reference to lessons
learned from the Thai accident, in recurrent CRM training. AA had
also, in the recurrent CRM program, begun to inform pilots that they
should use charts and either partially or completely disengage the FMS
when they believe that the FMS is exacerbating and not alleviating a
confusing or difficult situation. Delta Airlines developed a similar
course, given to all pilots before they first transition to a glass
cockpit airplane, providing comparable guidance.

Nevertheless, the subject accident at Cali demonstrates that when they
encountered very similar circumstances to those experienced by the
Thai Airways crew, the flightcrew of AA965 was too busy attempting to
use the FMS in order to execute the approach to recognize the many
parallels between the two accidents, even as they were experiencing
them. This accident demonstrates that merely informing crews of the
hazards of over reliance on automation and advising them to turn off
the automation is insufficient and may not affect pilot procedures
when it is needed most.

This accident also demonstrates that even superior CRM programs, as
evidenced at AA, cannot assure that under times of stress or high
workload, when it is most critically needed, effective CRM will be
manifest. In this accident, the CRM of the crew was deficient as
neither pilot was able to recognize the following:

• The use of the FMS was confusing and did not clarify the situation
• Neither understood the steps necessary to execute the approach,
  even while trying to execute it
• Numerous cues were available that illustrated that the initial
  decision to accept runway 19 was ill advised and should be changed
• They were encountering numerous parallels with an accident
  scenario they had reviewed in recent CRM training
• The flight path was not monitored for over a minute just before the
  accident.

47

Although the accident flightcrew articulated misgivings several times
during the approach, neither pilot displayed the objectivity necessary
to recognize that they had lost situation awareness and effective CRM.

The FAA has encouraged airlines to implement effective CRM programs
and has mandated it as a fundamental part of the advanced
qualification program (AQP), an innovative method of training airline
pilots. The FAA has issued an advisory circular (AC), No. 120-51A,
that provides guidance to airlines on elements needed for a effective
CRM program. The AC identifies topics that should be included in a CRM
program. These include: communications processes and decision
behavior; briefings; inquiry/advocacy/assertion, crew self-critique;
conflict resolution; communications and decision making; team building
and maintenance; and individual factors/stress reduction. Within the
topic of team building, the AC suggests that workload management and
situational awareness be addressed, so that “… the importance of
maintaining awareness of the operational environment and anticipating
contingencies …” is addressed.

Aeronautica Civil believes that this accident demonstrates the
difficulty in training for enhanced pilot situational awareness. The
crew of AA965 was trained in a CRM program that adhered to the
guidance of AC 120-51A, and that had added additional information on
hazards unique to the South American operating environment. The
evidence indicates that this crew was given background material and
information necessary to avoid this accident, but during a stressful
situation, when it was most needed, the information was not applied,
most likely because the critical situation was not recognized.

Offering further guidance on training in situation awareness does not
address the fact that pilots who have lost or not achieved situation
awareness cannot be expected to recognize that they have lost or not
achieved it. More importantly, these pilots cannot be expected to
develop a mechanism to efficiently achieve it.

2.7 Speedbrakes

After the GPWS alerted, the first officer initiated a go around and
correctly followed AA’s procedures regarding GPWS escape
maneuvers. However, neither pilot recognized that the speedbrakes
(spoilers), deployed earlier to increase the descent rate, remained
deployed, and no effort was made to retract them. The evidence
indicates that few cues were available to the pilots to recognize the
speedbrake extension and the airline had no procedure at the time to
require

48

speedbrake retraction as part of a GPWS escape maneuver. Nevertheless,
because of the critical effect of speedbrakes on maximum performance
maneuvers, the flightcrew should have recognized that the spoilers
were still extended during the attempt to avoid the terrain, and
should have retracted them early in the escape maneuver.

2.8 The Cali Approach Controller

The investigation examined the performance of the Cali approach
controller to determine what role, if any, he may have played in the
cause of the accident. The evidence indicates that he provided
clearances in accordance with applicable ICAO and Aeronautica Civil
rules and requirements, maintained separation of the aircraft he was
controlling, and sequenced flights expeditiously and efficiently. His
offer to AA965 to land on runway 19 was consistent with standards of
safety and airspace management. By the standards of the FAA, ICAO and
Aeronautica Civil, the flightcrew and not the controller was in the
best position to determine the safety of the acceptance of that offer.

However, the Cali airspace differed in several critical ways from
comparable airspace in the contiguous 48 states of the United States,
the airspace in which the accident flightcrew had accrued the
overwhelming majority of their flight experience. The Cali airspace
was not provided with:

• radar coverage
• computer software to alert aircraft deviation from a safe altitude
• computer software to enhance the radar image of a particular flight
• a controller who shared a native language and culture with the
  flightcrew.

Because of these not insubstantial differences, unlike in domestic
U.S. airspace, the Cali approach controller was entirely dependent on
crew-provided information to determine the location, altitude,
airspeed and climb/descent rate of a flight, and to assess whether
that flight required air traffic control services beyond that provided
for in the applicable rules and regulations. Consequently, in this
airspace a controller’s perception of the state of a flight that he or
she is controlling is entirely dependent on the quality of the
information that flightcrew provides. Deficiencies in that
information directly caused deficiencies in the controller’s awareness
of the situation experienced by that particular flight.

49

The accident flightcrew did not request additional services from the
Cali controller and at all times expressed confidence in their
position, their flight path, and their ability to properly execute the
approach and landing that the controller had offered them. The
controller could not know and could not be expected to have known that
the conversation within the cockpit, as recorded by the CVR, indicated
that just the opposite was true.

Nevertheless, the investigation determined that within the
communications between the controller and the flightcrew, two critical
sources of information may have provided some indication that AA965
was experiencing difficulty: 1) the captain asked the controller two
questions regarding the execution of the approach to runway 19 that
made little sense, and 2) two of the captain’s position reports did
not match the time in which they were made.

The investigation team examined closely the quality of this
information to determine whether it was sufficient to enable the
controller to recognize that the flightcrew was facing imminent
danger. Although the crew expressed to him no misgivings about the
offer to land on runway 19, these elements may have provided some
indication of potential difficulty.

However, the approach controller was not trained to solicit the
information necessary from the flightcrew in order to determine first
hand the extent of the difficulty they were experiencing. He also
lacked the ability that radar coverage would have provided him to
observe the flightpath directly. In addition, he lacked the English
language fluency needed to probe the flightcrew, from the subtle hints
in the inconsistencies of their responses to him, to learn of the
extent of their difficulties. Both AA’s guidance and ICAO’s standards
made it clear that English language ability by a controller who was
not a native English speaker was limited to routine aeronautical
communications. It would have been very difficult, in any event, for a
Colombian controller to question or critically respond to the
statements of an airline captain. Moreover, based on his experience of
aircraft flying into Cali and their responses to the clearances he
provided them, had he been able to suspect that the airplane was off
course, he could not then be expected to suspect that, given the
nature of the terrain in the valley north of Cali, the flight would
also continue its descent.

The approach controllers experience in Cali was such that the
flightcrews of all aircraft arriving from the north recognized the
proximity of high

50

terrain to the flight path to the airport. Thus, if a flightcrew was
off course and needed assistance from the controller, the controller’s
natural expectation would be that they would ask for specific
assistance from him. His training, experience, and guidance under the
applicable rules in the non-radar environment of Cali would have made
it unlikely for him to solicit the necessary information from the
flightcrew of AA965 that would enabled him or the flightcrew to
recognize the precarious nature of their flight path. Consequently,
Aeronautica Civil concludes that the Cali controller neither caused
nor contributed to the cause of this accident.

2.9 FAA Oversight

The investigation examined the quality of FAA surveillance of AA’s
operations into Cali to determine whether surveillance played a role
in the cause of the accident. Aeronautica Civil believes that
deficiencies in FAA surveillance of these operations were present, but
that these deficiencies did not adversely affect the performance of
the flight crew or the safety of AA965.

Nonetheless, Aeronautica Civil is concerned that the FAA relied upon
airworthiness inspectors to perform en route inspections of flights
into Latin America. These inspections, which were primarily performed
to conserve expense involved in sending operations inspectors abroad,
were performed by inspectors who lacked the training that operations
inspectors received to assess the quality of flight operations in the
B-757, and crew compliance with required rules and procedures. Because
AA operations and training were considered to meet standards and were
not believed to have played a role in this accident, Aeronautica Civil
concludes that the quality of FAA surveillance was deficient, but that
this deficiency did not contribute to the accident. Nevertheless,
because of the importance of assessing the quality of flight
operations into the unique airspace of Latin America, Aeronautica
Civil urges the FAA to perform en route inspections of U.S. carriers
operating into Latin America in compliance with standards contained in
ICAO manual 8335, paragraphs 9.4.1, and 9.6.3.3.

2.10 GPWS Escape Maneuver

FDR data from AA965 showed that within 2 seconds of the GPWS warning,
the engines began to accelerate from flight idle at a rate of change
consistent with a rapid advancement of the throttles. The speedbrakes
were not retracted. Results of an initial study of the performance of
AA965 following the GPWS warning indicates that if the flightcrew had
retracted the speedbrakes l

51

second after initiating the escape maneuver, the airplane could have
been climbing through a position that was 150 feet above the initial
impact point. Therefore, because the airplane would have continued to
climb and had the potential to increase its rate of climb, it may well
have cleared the trees at the top of the ridge. The study also showed
that if the speedbrakes had been retracted upon initiation of the
escape maneuver and if the pitch attitude had been varied to perfectly
maintain the stickshaker activation angle [35] the airplane could have
been climbing through a position that was 300 feet above the initial
impact point.

Boeing’s B-757 Flight Crew Training Manual provides one method of
monitoring the status of speedbrake deployment. The manual states that
“The Captain should keep his right hand on the speedbrake lever
whenever they are used in-flight. This will preclude leaving the
speedbrakes extended.” AA does not have a similar
procedure. Furthermore, neither the Boeing Operations Manual
addressing terrain avoidance nor the AA Operating Manual addressing
GPWS escape procedures discuss the need to stow the speedbrakes to
extract maximum performance from the airplane during an escape
maneuver. The investigation team noted that Boeing placed the terrain
avoidance procedures in the Non-Normal Procedures section of the
manual while AA placed the GPWS escape procedures in Section 13 –
Flight Instruments. Airlines often place such procedures in
non-operational sections of their manuals. Aeronautica Civil believes that
the FAA should evaluate the Boeing procedure for guarding the
speedbrake handle during periods of deployment, and require airlines
to implement the procedure if it increases the speed of stowage or
decreases the likelihood of forgetting to stow the speed brakes in an
emergency situation. In addition, Aeronautica Civil believes that the
FAA should evaluate the controlled flight into terrain (CFIT) escape
procedures of air carriers operating transport category aircraft to
ensure that the procedures provide for the extraction of maximum
escape performance and ensure that those procedures are placed in
operating sections of the approved operations manuals.

The speedbrake handle may be pulled back to any desired level of
spoiler panel deflection. The speedbrake handle also has an armed
detent position to allow automatic deployment on landing. When the
automatic speedbrake feature is in use and the airplane is on the
ground, advancement of either thrust lever from flight idle will cause
any extended spoiler panels to stow. However, advancing the

—————-
[35] The FDR data revealed that, at the sound of the stickshaker, the
pilots “relaxed” back pressure on the control yoke and then again
pulled the control yoke to the point of stickshaker activation.

52

thrust levers in flight has no effect on deployed speedbrakes. In
addition, flightcrews would receive an amber center panel speedbrake
light and an amber engine indicating and crew alerting system (EICAS)
SPEED BRAKES EXT message, master caution light, and chime when a
speedbrake fails to retract. The speedbrakes remained extended and the
CVR did not record the chime which indicates that the crew did not
attempt to retract the speedbrakes.

Investigators interviewed numerous B-757/767 pilots who reported that
circumstances exist in which engine power may be advanced above flight
idle, when speedbrakes are extended and it is desired that they remain
extended. The B-757/767 Operating Manual states that to maintain
pressurization of anti-ice bleed devices during descent above 10,000
feet, the engines should be kept at more than 70 percent N1. Some
airplanes, such as the B-727, require engine power during descent to
provide adequate bleed air to pressurize the cabin. Speedbrakes are
required to counteract the effects of increased thrust. There are
operational requirements to maintain engine power at levels greater
than idle when the speed brakes are deployed, however, a need for
speedbrakes at maximum power could not be identified.

Although for both a controlled flight into terrain (CFIT) and
windshear escape maneuver, immediate retraction of the speedbrakes is
needed to achieve the maximum climb performance of the airplane,
during periods of high workload, flightcrews may not recognize that
speedbrakes have remained extended. Thus, it is possible that the
automatic stowing of speedbrakes may provide a significant safety
enhancement.

Examination of other large jet transport category airplanes showed
that 37 types do not have an automatic speedbrake stowing feature when
full forward thrust is used, while, at least eight jet airplanes
including one corporate jet, the Airbus A-330, A-340, and Fokker F28
and F100 airplanes have such a feature. However, the fly-by-wire
airplanes have enhancements to the pitch control system to compensate
for the automatic retraction of the speedbrakes. In addition, Boeing
engineers state that, for the B-757, automatic retraction of the
speedbrakes in a go-around maneuver may result in unwanted pitch
excursions. If the speedbrakes are stowed as the throttles advance,
the airplane would pitch down due to the aerodynamic effects of
stowing the speedbrakes. The pilot would likely pull back on the
control column to regain the desired pitch attitude as the engines
began to spool up. The pilot effort and the increasing thrust could
result in an undesirable upward pitch excursion. In fact, Boeing added
compensating features to the B-777

53

to minimize such effects which can occur during manual retraction of
the speedbrakes while in flight (the B-777 does not have automatic
speedbrake retraction). Aeronautica Civil believes that the FAA should
evaluate the dynamic and operational effects of automatically stowing
the speedbrakes when high power is commanded and determine the
desirability of incorporating on existing airplanes automatic
speedbrake retraction that would operate during windshear and GPWS
escape maneuvers, or other situations demanding maximum thrust and
climb capability. In addition, Aeronautica Civil believes that the FAA
should require that newly certified transport category airplanes
include automatic speedbrake retraction during windshear and GPWS
escape maneuvers, or other situations demanding maximum thrust and
climb capability.

Although such educational efforts enhance the flightcrew’s awareness
of CFIT issues, those efforts cannot provide the safety benefits
provided by the wind shear training or rejected takeoff training
programs. Those programs include not only training aids but also
specific simulator exercises that provide crew with sufficient
hands-on training in a realistic environment. Simulator training is
the best method for pilots to extract maximum performance from large
airplanes during a CFIT escape maneuver. Therefore, Aeronautica Civil
urges the FAA to require a CFIT training program that includes
realistic simulator exercises comparable to the successful windshear
and rejected takeoff training programs.

2.11 Recording of FMS Data

Aeronautica Civil, assisted by specialists from the NTSB, has been
hampered during the investigation by the lack of recorded FMS
information on AA965. Although the FDR provided considerable data
including the engagement status and mode selection of the airplane’s
automatic flight control system, other pertinent information were not
recorded, including pilot selected navigation aids; selected mode
specific parameter values such as heading, airspeed, altitude, and
vertical velocity; and selected electronic horizontal situation
indicator formats such as maps, scales, and radio facilities selected
to be displayed. This information would have enhanced the
investigation of the crew’s actions leading to the accident. Without
knowledge of the nature and display of FMS information presented to
flightcrews, and their interactions with FMS systems; investigators
may not be able to explain many potentially critical flightcrew
actions related to the FMS. Therefore, Aeronautica Civil believes
that flightcrew-generated/selected inputs to the FMC should be
recorded as parameters in the FDR.

54

3.0 Conclusion.

3. 1 Findings

1. The pilots were trained and properly certified to conduct the
flight. Neither was experiencing behavioral or physiological
impairment at the time of the accident.

2. American Airlines provided training in flying in South America that
provided flightcrews with adequate information regarding the hazards
unique to operating there.

3. The AA965 flightcrew accepted the offer by the Cali approach
controller to land on runway 19 at SKCL.

4. The flightcrew expressed concern about possible delays and accepted
an offer to expedite their approach into Cali.

5. The flightcrew had insufficient time to prepare for the approach to
runway 19 before beginning the approach.

6. The flightcrew failed to discontinue the approach despite their
confusion regarding elements of the approach and numerous cues indicating
the inadvisability of continuing the approach.

7. Numerous important differences existed between the display of
identical navigation data on approach charts and on FMS-generated displays,
despite the fact that the same supplier provided AA with the navigational
data.

8. The AA965 flightcrew was not informed or aware of the fact that the
“R” identifier that appeared on the approach (Rozo) did not correspond to the
“R” identifier (Romeo) that they entered and executed as an FMS command.

9. One of the AA965 pilots selected a direct course to the Romeo NDB
believing that it was the Rozo NDB, and upon executing the selection in the
FMS permitted a turn of the airplane towards Romeo, without having verified
that it was the correct selection and without having first obtained approval of
the other pilot, contrary to AA’s procedures.

55

10. The incorrect FMS entry led to the airplane departing the inbound
course to Cali and turning it towards the City of Bogota. The subsequent turn
to intercept the extended centerline of runway 19 led to the turn towards high
terrain.

11. The descent was continuous from FL 230 until the crash.

12. Neither pilot recognized that the speedbrakes were extended during the
GPWS escape maneuver, due to the lack of clues available to alert them
about the extended condition.

13 Considering the remote, mountainous terrain, the search and rescue
response was timely and effective.

14. Although five passengers initially survived, this is considered a non
survivable accident due to the destruction of the cabin.

15. The Cali approach controller followed applieable ICAO and
Colombian air traffic control rules and did not contribute to the
cause of the accident.

16. The FAA did not conduct the oversight of AA flightcrews operating
into South America according to the provisions of ICAO document 8335,
parts 9.4 and 9.6.33.

17. AA training policies do not include provision for keeping pilots’ flight
training records, which indicate any details of pilot performance.

18. AA includes the GPWS escape maneuver under section 13 of the Flight
Instrument Chapter of the Boeing 757 Flight Operations Manual and Boeing
Commercial Airplane Group has placed the description of this maneuver in
the Non Normal Procedures section of their Flight Operations Manual.

56

3.2 Probable Cause

Aeronautica Civil determines that the probable causes of this accident
were:

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 critieal phase of the flight.

3.3 Contributing Factors

Contributing to the cause of the accident were:

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.

57

4.0 Recommendations

As a result of this accident, Aeronautica Civil issues the following
recommendations to the Federal Aviation Administration:

1. Develop and implement standards for the portrayal of terminal
environment information on FMS/EFIS displays that match, as closely as
possible, the portrayal of that information on approach charts.

2. Evaluate all FMS-equipped aircraft and, where necessary, require
manufacturers to modify the FMS logic to retain those fixes between he
airplane’s position and one the airplane is proceeding towards, following the
execution of a command to the FMS to proceed direct to a fix.

3. Require airlines to provide pilots through CRM and flight training
with the tools to recognize when the FMC becomes an obstacle to the
proper conduct of the flight and correctly evaluate when to
discontinue the use of the FMC and revert to basic radio navigation.

4. Require that all approach and navigation charts used in aviation
graphically portray the presence of terrain that are located near
airports, or flight paths.

5. Require pilots operating FMS equipped aircraft to have open and easily
accessible the navigation charts applicable to each phase of flight before each
phase is reached.

6. Encourage manufacturers to develop and validate methods to present
accurate terrain information on flight displays as part of a system of early
ground proximity warning. (Enhanced GPWS)

58

7. Require Jeppesen-Sanderson Company to inform airlines operating
FMS-equipped aircraft of the presence of each difference in the
naming or portrayal of navigation information on FMS-generated and
approach chart information, and require airlines to inform their
pilots of these differences, as well as the logic and priorities
employed in the display of electronic FMS navigation information.

8. Evaluate the curricula and flight check requirements used to train and
certificate pilots to operate pilots to operate FMS equipped aircraft, and
revise the curricula and flight check requirements to assure that pilots are
fully knowledgeable in the logic underlying the FMS or similar aircraft
computer system before being granted airman certification to operate the
aircraft.

9. Perform en route inspections of US carriers operating into Latin
America in compliance with standards according to the provisions of ICAO
document 8335 part 9.4 and 9.6.33.

10. Evaluate the Boeing procedure for guarding the speedbrake handle
during periods of deployment, and require airlines to implement the
procedure if it increases the speed of stowage or decreases the
likelihood of forgetting to stow the speed brakes in an emergency
situation.

11. Evaluate the dynamic and operational effects of automatically stowing
the speedbrakes when high power is commanded and determine the
desirability of incorporating on existing airplanes automatic speedbrake
retraction that would operate during windshear and GPWS escape maneuvers,
or other situations demanding maximum thrust and climb capability.

12. Require that newly certified transport category airplanes include
automatic speedbrake retraction during windshear and GPWS escape
maneuvers, or other situations demanding maximum thrust and climb
capability.

13. Develop a mandatory CFIT training program that includes realistic
simulator exercises that are comparable to the successful windshear and
rejected takeoff training programs.

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14. Evaluate the CFIT escape procedures of aircarriers operating transport
category aircraft to ensure that the proeedures provide for the extraction of
maximum escape performance and ensure that those procedures are placed in
operating sections of the approved operations manuals.

15. Alert pilots of FMS equipped airplanes to the hazard of cornmonly
identified navigation stations when operating outside of the United States.

16. Review the pilot training record keeping systems of airlines operated
under FAR Parts 121 and 135 to determine the quality of the information
contained therein, and require the airlines to maintain appropriate information
on the quality of pilot performance in training and checking programs.

17. Evaluate the possibility of requiring that flight crew generated inputs to
the FMC be recorded as parameters in the FDR in order to permit
investigators to reconstruct pilot – FMS interaction.

The following recommendations are issued to the International Civil
Aviation Organization:

1. Urge the members states to encourage its pilots and air traffic
controllers to strictly adhere to ICAO standards phraseology and terminology
in all radio telecommunications between pilots and controllers.

2. Evaluate and consider the adoption of the recommendations produced
by the CFIT Task Force that has been created under the initiative of the Flight
Safety Foundation.

Establish a single standard worldwide that provides an unified criteria for
the providers of electronic navigational databases used in Flight
Management Systems.

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The following recommendations are issued to American Airlines:

1. Review the guidelines for ensuring that the flight crew preparation
rendered by the training given at the Flight Training Academy is maintained
throughout the different operational pilot bases by the standardizing the
evaluation criteria of the check pilots.

2. Address the analysis of flight crew performance in flight crew
training records in order to reinforce CRM and the individual aspects
of flight training programs.

BY AERONAUTICA CIVIL

/s/ Rodrigo Cabrera C.
Chief of the Investigation Committee

/s/ Orlando Jimenez R.
Senior Investigator

/s/ Saul Pertuz G.
Senior Investigator

September, 1996
Santafe de Bogota D.C., Colombia

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5. APPENDICES

APPENDIX A

INVESTIGATION

Aeronautica Civil was notified of the accident at 2150 est, December
20, 1995. An investigative team was dispatched, departing Bogota at
0600, necember 21 and arriving at the crash site at 0830, December 21,
1995.

Aeronautica Civil was assisted by a U.S. Accredited Representat1ve
throughout the investigation and preparation of the draft Report. The
substance of the Accredited Representative’s comments have been
included in the Final Report. It should be noted that investigative
groups were formed using specialists from Aeronautica Civil and the
NTSB. The following groups participated in the investigation and in
the preparation of the Final Report as follows:

      
Aircraft Performance
Aircraft Systems
Air Traffic Control
Cockpit Voice Recorder
Flight Data Recorder
Human Performance
Operations
Powerplants
Structures
Survival Factors

Aeronautica Civil wishes to acknowledge with gratitude the
participation of the following parties to the investigation:

      
U.S. Federal Aviation Administration
Allied Pilots Association
American Airlines
Boeing Commercial Airplane Group
Rolls Royce Engines

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Peter B. Ladkin, 1999-02-08

Last modification on 1999-06-15