American Airlines Flight 965 Accident Report Cali, Colombia, Exercises of Communication

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American Airlines Flight 965 Accident Report

Cali, Colombia

December 20, 1995

Paul Mitchell Sylvain Bruni

Outline

i.

Accident Description

ii.

Human Factors Analysis

iii.

Investigation Recommendations

iv.

References

Navigational Confusion

Accident Description

Human Factors

Recommendations

• Speed and altitude too high for this stage of the newapproach – speedbrakes deployed.• ATC had cleared 965 to execute the Rozo One arrival, acharted standard instrument arrival route to Cali VOR viaTulua VOR/Rozo NDB.• Flight crew thought they had been cleared direct to Caliand were confused when the ATC asked 965 report atTulua.• Flight crew asked to fly direct to Rozo which ATCwrongly confirmed.• Captain programmed into the FMC an erroneouswaypoint, Romeo NDB waypoint 132 miles NE of Cali,resulting in a wide turn to the east.

2134:

ATC

Roger, is cleared to CaliVOR, uh, descend

and

maintain one, five thousandfeet, altimeter three zerozero two.

2135:

ATC

…no delay expect forapproach. Report uh,Tulua VOR.

2135:

^965

OK understood. Cleareddirect to Cali VOR. Uh, reportTulua and altitude onefive, that’s fifteen thousandthree zero…zero…two. Isthat all correct sir?

2135:

ATC

Affirmative.

2137:

^965

Can American Airlines uh,nine six five go direct toRozo and then do the Rozoarrival sir?

2137:

ATC

Affirmative. Take the RozoOne and runway one niner,the wind is calm.

Source: Aeronautica Civil of the Republic of Colombia Accident Report

16.422Human Supervisory Control

February 26, 2004

• Speed and altitude too high for this stage of the new approach, so the first officer deployed the speedbrakes. They remained in effect the remainder of the flight. • ATC cleared 965 to execute the Rozo One arrival, a charted standard instrument arrival route to Cali VOR via Tulua VOR then the Rozo NDB. • VOR = Very High Frequency Omnidirectional Range, NDB = Non Directional Beacon. • Flight crew thought they’d been cleared directly to Cali and were confused by “report Tulua”. • Asked for confirmation of approach adding in “direct” to Cali that ATC had NOT originally used, ATC confirmed. • Flight crew could not find the Tulua identifier in the FMS – the direct to command had removed intermediate waypoints, and the identifier was ULQ which the crew did notrecognize as being Tulua. • After ATC wrongly confirmed 965 could go direct to Rozo Captain put in a wrong waypoint.

Controlled Flight Into Terrain

Accident Description

Human Factors

Recommendations

• Flight crew knew something was wrongbecause Rozo 1 was a straightapproach. • Knowing Cali was south the flight crewturned the aircraft right while trying to geta fix on their relative position. • GPWS kicked in before impact and thepilots performed a terrain avoidancemaneuver, applying full throttle andincreasing pitch until the 757 “stickshaker” warned of aerodynamic stall. • Plane struck the mountainside only250ft below the summit of a ridge.

Source: Flight Safety Digest

16.422Human Supervisory Control

• Feeling the aircraft start to turn the flight crew got even more concerned, Rozo One arrival was a straight approach. • Could not find relative position of airplane. • GPWS kicked in before impact and the pilots performed a terrain avoidance maneuver, applying full throttle and increasing pitch until the 757 “stick shaker” warned ofaerodynamic stall. • Plane struck the mountainside only 250ft below the summit of a ridge, belly up, riding on the trees briefly before ploughing into the mountainside.

(Courtesy of the Flight Safety Foundation. Used with permission.)

Human Factors Issues

Accident Description

Human Factors

Recommendations

-^

Over-Reliance on Automation

-^

Lack/Loss of Situational Awareness

-^

Communication Problems

-^

Complacency/Time Pressure

Over Reliance on Automation

Accident Description

Human Factors

Recommendations

•^

Radio navigation was not used when FMS-assisted navigation

became confusing and cognitively demanding during a criticalsegment of flight.

Programming of direct-to Cali VOR dropped all intermediate waypoints. ¾

Captain’s incorrect selection of Romeo NDB when intention was to select Rozo NDB. ¾

Discrepancy between the approach chart and FMS waypoint representation.

Communications Issues

Accident Description

Human Factors

Recommendations

•^

Between ATC and the flight crew of 965

The ATC’s lack of basic English skills beyond “routine aeronautical communications”. ¾

ATC had no way of knowing 965’s position without verbal confirmation. ¾

Non-pertinent phone conversation, music and other distractions were present for the ATC. ¾

Ambiguous communications were not clarified by both parties. ¾

Confirmation bias.

•^

Between the first officer and captain

An appropriate approach briefing was not done. ¾

Captain did not verify provisional path on the FMS display or confirm with the first officer before executing it in at least two separate cases.

Complacency and Time Pressure

Accident Description

Human Factors

Recommendations

Complacency • An adequate approach review was not performed.

Difficulties included lack of airport experience, night landing, proximity to terrain, no ATC radar and language barrier.

Time Pressure •^

Amended approach clearance to runway 19 was accepted

without proper evaluation.

Neither the captain or first officer had prior experience with the runway 19 approach procedure.

-^

Failure to abort approach despite the flight crew being

rushed, confused and uncertain of their position.

Recommendations

Accident Description

Human Factors

Recommendations

-^

Specific CFIT training in the following areas^ ¾

When levels of automation should be “stepped down”. ¾

Ensuring comprehensive approach briefings take place. ¾

Detection of ambiguous ATC clearances and procedures forclarification. ¾

Careful evaluation of unexpected runway changes by ATC. ¾

One pilot must always monitor and control the flight path. ¾

Verify all waypoint changes with another crew member. ¾

Proper completion of all checklists. ¾

To delay landing if unsure of any aspect of the approach.

Recommendations

Accident Description

Human Factors

Recommendations

-^

FMS/Approach Charts

Modify FMS logic to retain intermediate waypoints when a direct command is entered. ¾

Make waypoint selection in the FMS more user-friendly. ¾

Match FMS displays to approach charts more closely and use the same naming conventions for navigational information in both. ¾

Implement graphical terrain information into flight displays. ¾

Require that all approach charts display nearby terrain.

-^

Obstacle Avoidance Aids

Have the speedbrakes automatically disengage when full throttle is commanded. ¾

Install an easy to interpret angle of attack indicator in all large airplanes. ¾

Development of an enhanced GPWS.