Embry-Riddle Aeronautical University
Author Note
Taught by Professor Bill Little.
Correspondence concerning this paper should be addressed to Martins M. Avaan
Email: avaanm@my.erau.edu
According to Aeronautica Civil of the Republic of Columbia (1995). American Airlines 965 (AA965) a Boeing 757-223, registered N651AA on December 20, 1995 at 2142 Eastern Standard Time, crashed into mountainous terrain during descent into Alfonso Bonilla Aragon International Airport, Cali, Columbia while on a scheduled flight from Miami International Airport, Florida. Out of 163 souls on board; 155 passengers, 2 flight crew and 6 cabin crew members, 4 passengers survived the accident. The probable cause of the accident was the action of the flight crew; Mission planning failure, in executing an approach to runway 19, poor decision making against discontinuing the approach despite cues alerting to same, loss of situational awareness regarding terrain proximity and vertical navigation, and poor use of Flight Management System automation in a critical phase of flight without reverting to basic radio navigation. (Aeronautica Civil of the Republic of Columbia, 1995). Contributing factors to the accident were flight crew
Crew Performance
This accident resulted from a failure of crew resource management (CRM) despite the training and experience of the flight crew. Some form of threat and error management was attempted by the Captain who informed the First officer as pilot flying (PF) to notify him earlier to request descent as language barrier may delay effective communication with Cali ATC (Air Crash Investigation, 2003). The crew under pressure to make up for delay at departure aerodrome in order to ensure on time departure the next day, succumbed to an ATC suggestion of straight in approach to runway 19 (Air Crash Investigation, 2003). This was poor decision making, as it was a hurried decision, devoid of operational risk management Kanki et al. (2019) and a deviation from the mission planning without consideration to the most imminent threat in this operating environment – the elevated terrain. The series of mistakes continued as more CRM skills were violated by the crew.
Communication
The ambiguity of a direct routing only arouse when the crew had lost their bearing and attempted to recover a track to the airport. The ATC instructions and clearances were determined to be in line with International Civil Aviation Organisation (ICAO) and Aeronautical Civil standards (Aeronautica Civil of the Republic of Columbia, 1995). Considering the Captain anticipated communication problems with the ATC, it is ironical that the CRM skill of communication between the flight crew broke down as the Captain, who was PM insisted “we push on” at another time, “come to the right” (Air Crash Investigation, 2003) both subjective and non-standard communication.
Automation Management
Probably the single most reckless error of the sequence of mistakes by the Captain, selecting R and executing the flight management system (FMS) without confirmation with the pilot flying (Air Crash Investigation, 2003). This changed the flight path of the aircraft towards Bogota.
Situational Awareness
Once the decision of accepting a straight in approach while unprepared was made, the can of worms was opened, in a bid to expedite, task management was overwhelming; setting up the approach, getting charts from the binders and position reporting all ensured situational awareness was out of the window, who is flying the airplane? The flight crew acknowledged they had messed up the approach setup and couldn’t find the reporting point. (Aeronautica Civil of the Republic of Columbia, 1995). According to Aeronautica Civil of the Republic of Columbia (1995) the accident highlighted difficulty in teaching situational awareness as a CRM skill, despite prior instruction and reference material on the hazards of the South American operating environment, failed to apply this training when required.
Conclusion
Fire and Rescue was slow due to the remoteness of the mountainside location of the crash site, and emergency helicopters had no night vision, even after rescue commenced, there was another delay due weather conditions, similar constraints of non-availability of radar for ATC monitoring accounted for these crew inadequacies hence little blame can be allocated to ATC and Rescue teams as they could only work within these limitations.
The flight crew on the other hand had poor threat and error management application, once poor decisions were made, they dug themselves deeper by “pushing on” (Air Crash Investigation, 2003). The flight crew once lost, should have notified ATC who would have offered some guidance. The CRM failure of automation management could have been prevented by confirming with PF who in the least may have noticed the turn towards Bogota once “R” was inputted and executed.
References
Aeronautica Civil of the Republic of Columbia. (1995). Controlled flight into terrain American
airlines flight 965,Boeing 757-223,N651AA near Cali, Columbia, December 20,1995.
https://reports.aviation-safety.net/1995/19951220-1_B752_N651AA.pdf
Air Crash Investigation. (2003) Mayday 05-Lost (American Airlines Flight 965)
[Video].www.dailymotion.com/video/x7tn8j2
Kanki, B. G., Anca, J. M., & Chidester, T. R. (2019). Crew resource management (Third ed.).
Amsterdam: Academic Press.