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.
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.
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).
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.
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 | Flightcrew | Cabincrew | Passengers | Total |
| 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 Command | First Officer | |
| Age | 57 | 39 |
| Date of Birth | 11/17/38 | 6/24/56 |
| Date of Hire with American Airlines | 9/22/69 | 10/11/86 |
| First Class Medical Certificate | Issued 12/7/95 |
| Approximate Total Flying Time | 13,000 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 Period | 120+ (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.
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
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.
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.
