| 20
December 1995 - American
965 |
American Airlines Flight 965, a Boeing 757 registered N651AA, was a
scheduled flight from Miami International Airport in Miami, Florida
to Alfonso Bonilla Aragón International Airport in Cali, Colombia,
which crashed into a mountain in Buga, Colombia on December 20, 1995,
killing 151 passengers and 8 crew members. The crash was the first U.S.-owned
757 accident and the highest death toll of any accident in Colombia.
It is also the highest death toll of any accident involving a Boeing
757 at that time. It was surpassed by Birgenair Flight 301 which crashed
on 6 February, 1996 with 189 fatalities. It was the deadliest air disaster
involving a U.S. carrier since the downing of Pan Am Flight 103 on December
21, 1988. Four passengers survived the crash, all of whom were seated
in the same row.
At that time, Flight 965 mainly carried people returning to Colombia
for the Christmas holiday, vacationers, and businesspeople. A winter
storm in the northeast United States caused the airline to delay the
departure of the airliner for thirty minutes to allow for connecting
passengers to board the flight, so Flight 965 pushed back from gate
D33 in Miami at 5:14 pm, and then taxied to runway 27R, but seasonal
congestion caused the Boeing 757 to take off two hours late. Some other
passengers booked on Flight 965 missed the flight due to missed connections.
Nicholas Tafuri served as the captain and Donnie R. Williams served
as the first officer. Pedro Pablo Calle served as the chief flight attendant.
Due to an attack by anti-government guerrillas in 1992, Cali's air
traffic controllers had no radar to monitor the 757 as the pilots flew
the approach using the area's radio navigation aids and the airport's
instrument approach system. Cali's approach uses several radio beacons
to guide pilots around the mountains and canyons that surround the city.
The airplane's flight management system already had these beacons programmed
in, and should have, in theory, told the pilots exactly where to turn,
climb, and descend, all the way from Miami to the terminal in Cali.
Since the wind was calm, Cali's controllers asked the pilots if they
wanted to fly a straight-in approach to runway 19 rather than coming
around to runway 01. The pilots agreed, hoping to make up some time.
The pilots then erroneously cleared the approach waypoints from their
navigation computer. When the controller asked the pilots to check back
in over Tuluá, north of Cali, it was no longer programmed into
the computer, and so they had to pull out their maps to find it. In
the meantime, they extended the aircraft's speed brakes to slow it down
and expedite its descent.
By the time they found Tuluá's coordinates, they had already
passed over it. In response to this, they attempted to program the navigation
computer for the next approach waypoint, Rozo. However, the Rozo NDB
was identified as R on their charts. Colombia had duplicated the identifier
for the Romeo NDB near Bogotá, and the computer's list of stored
waypoints did not include the Rozo NDB as "R", but only under
its full name "ROZO". In cases where a country allowed duplicate
identifiers, it often listed them with the largest city first. By picking
the first "R" from the list, the captain caused the autopilot
to start flying a course to Bogotá, resulting in the airplane
turning east in a wide semicircle. By the time the error was detected,
the aircraft was in a valley running roughly north-south parallel to
the one they should have been in. The pilots had put the aircraft on
a collision course with a 3,000-meter mountain. The air traffic controller
believed that some of the requests of the pilots did not make sense,
but did not know enough non-aviation English to convey this.
Twelve seconds before the plane hit the mountain, the Ground Proximity
Warning System activated, announcing an imminent terrain collision and
sounding an alarm. The captain and first officer attempted to climb
clear of the mountain, but the deployed speed brakes reduced the rate
of climb and the aircraft hit the mountain near its summit. Research
has shown that the aircraft would probably have cleared the terrain
if the crew had immediately retracted the speed brakes when the GPWS
alarm sounded.

Transcript of the Cockpit Voice Recorder (CVR)
2125:40 First Officer: Well let's see, we got a hundred and
thirty six miles to the VOR, and thirty two thousand feet to lose, and
slow down to boot so we might as well get started.
2125:49 Captain: Alright sir.
2126:01 Captain: And if if you'd keep the speed up in the descent,
I'd, it would help us too, OK?
2126:04 First Officer: OK.
2126:16 Captain (radio): Bogota, American nine six five request
descent.
2126:20 Bogota Center: American nine six five, descend and maintain
flight level two four zero, report reaching.
2126:26 Captain (radio): OK, we're leaving three seven zero.
Descend and maintain two four zero, twenty four. Thank you ma'am. American
nine six five.
Flight Level Change selected, V-NAV disengaged.
2126:33 Bogota Center: That's correct.
Engine thrust reduced, descent begins out of FL370.
2126:35 Captain: Yes sir.
2126:40 Captain: I'm goin' to call the company.
2126:42 First Officer: OK.
2126:42 Captain (radio): American Airlines operations at Cali,
this is American nine six five, do you read?
2126:49 AAL Cali Ops: Go ahead American nine six five, this
is Cali ops.
2126:51 Captain (radio): Alright Cali. we will be there in just
about twenty five minutes from now, and go ahead the weather.
2127:00 AAL Cali Ops: OK sir, the the change over, the temperature
is twenty three degrees. the altimeter, the (QNH) is two nine point
nine eight. conversion is two six point seven one.
2127:18 Captain (radio): OK, understand the weather is good.
Twenty three degrees, two nine eight. two six seven one. Is that correct?
2127:24 AAL Cali Ops: that's correct.
2127:25 Captain (radio): OK, are we parking at gate two tonight?
2127:28 AAL Cali Ops: Gate two and uh runway zero one.
2127:32 Captain (radio): Runway zero one roger and the weather
is good, huh?
2127:34 AAL Cali Ops: OK, Captain.
2127:36 Captain (radio): See you on the ground, nine six five.
2127:39 Captain: Two nine nine eight, two six seven one. that
sounds about right, let's see. three twenty six. nine nine eight, three
two six is two seven six, uh, right on the money, OK, that's good. uhhh,
the weather's good, runway one, gate two.
2127:58 First Officer: Alright. [unintelligible]
2127:59 Captain: Alright baby.
2127:59 First Officer: Sounds good.
2128:00 Captain: Alright.
2128:05 Captain: And I'm gonna put the headlights on early here
because there's a lot of VFR and who knows what good deal. so the headlights
might just help us a little bit.
2128:23 Captain: And also...what was that position [unintelligible]
five? We're just about at it, aren't we?
2128:27 First Officer: yeah. forty seven north of Rio Negro.
Uh, 'course we didn't go to Rio Negro.
2128:33 Captain: Sorry?
2128:35 First Officer: Talking about the uh....
2128:36 Captain: Yeah, it was Rio Negro plus forty seven I think...
2128:38 First Officer: Rio Negro plus forty seven.
2128:39 Captain: ...What's, what they show lat long?
2128:41 First Officer: Well, let me find it.
2128:42 Captain: Just out of curiosity, five something.
2128:45 First Officer: I had the flight plan..
2128:46 Captain: Alright, [unintelligible] I wouldn't worry
about it.
2128:56 First Officer: There we go.
2128:B7 First Officer: North uh, zero five one four six. four,
so zero five forty one...
2129:00 Captain: We're passed it. OK, we're passed it, we press
on, right?
2129:04 First Officer: Right.
2129:15 Captain: I'm going to talk to the people.
2129:17 First Officer: OK.
2129:18 Captain: I'm off.
2129:23 Captain (cabin PA): Uh ladies and gentlemen, this is
captain Tafuri. We have begun our descent for landing at Cali. It's
a lovely evening as we had expected. We'll pass a shower or two on the
way in but uh, at the field right now it's uh, good visibility, the
temperature is two three, that's twenty three degrees Celcius, and if
you prefer Fahrenheit, that's seventy two degrees on the Fahrenheit
scale. The winds are ten miles an hour from the northwest. It's a very
very pretty evening. I'd like to thank everyone for coming with us.
Again, I apologize for, being late tonight. These things do happen sometimes,
very frustrating but there wasn't very much we could do about it. Again
I appreciate your patience in the matter. Like to wish everyone a very
very happy holiday, and a healthy and prosperous nineteen ninety six.
Thank you for coming with us.
2130:14 Captain: I'm back.
2130:28 First Officer: Uh I may have to slow down if it gets
too rough.
2130:30 Captain: Sure.
Passing FL257, Vertical Speed Mode engaged. Flight leveled
off at FL240.
2131:08 Captain: You want any of these nuts, Don?
2131:09 First Officer: No thank you.
2131:H Captain: You want me to call for the water or do you
want to wait till we get on the ground, 'bout your water?
2131:14 First Officer: Oh, I'll get it on the ground.
2131:22 First Officer: One to go.
2131:25 Captain: Aye, aye.
2131:29 Captain: You got the engine heat off good.
2131:53 Captain (radio): American nine six five is level two
four zero.
2131:11 Captain (radio): American nine six five is level two
four zero.
2132:13 Bogota Center: Standby two minutes for lower.
2132:21 Captain: Pretty night, huh?
2132:23 First Officer: Yeah it is, lookin' nice out here.
2133:25 First Officer: Let's see, what is the transition level
here?
2133:28 Captain: Oh yeah, it's a good check.
2133:28 Captain: Eighteen thousand?
2133:32 First Officer: One ninety, eighteen thousand, yeah.
2133:40 First Officer: Well if she doesn't let us down in a
little while, she's goin' to put me in a jam here.
2133:50 Captain (radio): And American nine six five, request
lower.
2133:53 Bogota Center: American nine six five, descend to flight
level two zero zero. Report leaving two four zero.
2133:59 Captain (radio): We're leaving two four zero now and
descending to two zero zero.
Flight Level Change selected, descent starts out of FL240.
2134:04 Bogota Center: Call Cali frequency one one niner decimal
one. buenos noches.
2134:07 Captain (radio): Please say the frequency again.
2134:09 Bogota Center: One one niner decimal one.
2134:13 Captain (radio): One one niner decimal one. Feliz navidad
seniorita.
2134:15 Bogota Center: Muchas gracias, lo mismos.
2134:19 Captain (radio): Gracias.
2134:22 Captain (radio): Center, American nine six five, leaving
flight level two four zero descending to two zero zero. buenos tardes.
2134:37 First Officer: Nineteen one or..
2134:39 Captain: That's Cali.
2134:40 Captain (radio): Cali approach, American nine six five.
2134:44 Cali Approach: American niner six five, good evening.
go ahead.
2134:47 Captain (radio): Ah buenos senior, American nine six
five leaving two three zero, descending to two zero zero. Go ahead sir.
2134:55 Cali Approach: The uh, distance DME from Cali?
2134:57 Captain (radio): The DME is six three.
2134:59 Cali Approach: Roger, is cleared to Cali VOR, uh, descend
and maintain one five thousand feet, altimeter three zero zero two...
2135:09 First Officer: One five.
Aircraft turns right from heading 189 to heading 198. Throttle
Hold annunciator changed to "Hold".
2135:14 Cali Approach: ..No delay expect for approach. Report
uh, Tulua VOR.
2135:25 Cali Approach: Affirmative.
2135:27 Captain (radio): Thank you.
2135:28 Captain: I put direct Cali for you in there.
2135:29 First Officer: OK, thank you...
2135:44 First Officer: Two fifty below ten here?
2135:47 Captain: Yeah.
2136:18 Cockpit Area Microphone: [Sound of single chime similar
to seat belt switch being activated]
2136:20 Captain (cabin PA): Uh, flight attendants please prepare
for landing, thank you.
2136:24 Captain: I sat 'em down and....
2136:27 Cali Approach: Niner six five, Cali.
2136:29 Captain (radio): Niner six five, go ahead please.
2136:31 Cali Approach: Sir the wind is calm. Are you able to
approach runway one niner.
2136:36 Captain: Would you like to shoot the one nine straight
in?
2136:38 First Officer: Uh yeah, we'll have to scramble to get
down. We can do it.
2136:40 Captain (radio): Uh yes sir, we'll need a lower altitude
right away though.
2136:43 Cali Approach: Roger. American nine six five is cleared
to VOR DME approach runway one niner. Rozo number one, arrival. report
Tulua VOR.
2136:52 Captain (radio): Cleared the VOR DME to one nine, Rozo
one arrival. Will report the VOR, thank you sir.
2136:58 Cali Approach: Report uh, Tulua VOR.
2137:01 Captain (radio): Report Tulua.
2137:03 Captain: I gotta give you to Tulua first of all. You,
you wanna go right to Cali, er to Tulua?
2137:09 First Officer: uh, I thought he said the Rozo one arrival?
2137:10 Captain: Yeah he did. We have time to pull that out...
2137:11 Cockpit Area Microphone: [Sound of rusting pages]
2137:12 Captain: ....and, Tulua one... Rozo... There it is.
2137:25 Captain: Yeah, see that comes off Tulua.
Passing 17,358 feet, speed brakes deployed 50%, and increased
to 75% and then 98% over the next 42 seconds. Airspeed starts to decrease
from 302 knots. The speed brakes remain deployed for the remainder of
the flight..
2137:27 First Officer: OK.
2137:29 Captain (radio): Can American Airlines uh, nine six
five go direct to Rozo and then do the Rozo arrival sir?
2137:36 Cali Approach: Affirmative. take the Rozo one and runway
one niner, the wind is calm.
2137:42 Captain (radio): Alright Rozo, the Rozo one to one nine,
thank you, American nine six five.
Descending 1,300 feet per minute. Left turn started, bank
angle between 16 and 18 degrees. L-NAV disengaged and Heading Select
engaged.
2137:46 Cali Approach: Thank you very much.... Report Tulua
and [unintelligible] twenty one miles, ah, five thousand feet.
2137:53 Captain (radio): OK, report Tulua twenty one miles and
five thousand feet, American nine uh, six five.
2137:59 First Officer: OK, so we're cleared down to five now?
2138:01 Captain: That's right, and... off Rozo... which I'll
tune here.
2138:26 Captain: see what I get..
2138:27 First Officer: Yeah.
2138:28 Captain: ..At twenty one miles at five thousand's part
of the approach. OK?
2138:31 First Officer: OK.
2138:33 Captain: Off ULQ, so let me put ULQ in here, seventeen
seven cause I want to be on raw data with you.
2138:39 Cali Approach: American niner six five, distance now?
2138:42 Captain (radio): Uuuh, what did you want sir?
2138:45 Cali Approach: Distance DME.
2138:46 Captain (radio): OK the distance from uh, Cali is uh,
thirty eight.
2138:49 First Officer: Uh where are we...
2138:49 Cali Approach: Roger.
2138:52 First Officer: We goin' out to....
2138:54 Captain: Let's go right to uh, Tulua first of all, OK?
2138:58 First Officer: Yeah, where we headed?
2138:58 Captain: Seventeen seven, ULQ uuuh, I don't know what's
this ULQ? What the, what happened here?
2139:04 First Officer: Manual..
2139:05 Captain: Let's come to the right a little bit.
2139:0G First Officer: ...Yeah he's wantin' to know where we're
headed.
2139:07 Captain: UL... I'm goin' to give you direct Tulua..
2139:10 First Officer: OK.
2139:10 Captain: ...Right now.
2139:11 Captain: OK, you got it?
2139:13 First Officer: OK.
2139:14 Captain: And...
2139:18 Captain: It's on your map. should be.
2139:19 First Officer: Yeah, it's a left uh, left turn.
Aircraft rolls from left turn to right turn as altitude
passes 13,600 feet. Heading reached 100 degrees before direction of
turn was reversed.
2139:22 Captain: Yeah, I gotta identify that [expletive] though
I...
2139:25 Navigation Receiver: [sound "VC" in Morse code]
2139:25 Captain: OK, rm gettin it. Seventeen seven. just doesn't
look right on mine. I don't know why.
2139:29 Navigation Receiver: [Sound of "ULQ" in Morse code]
2139:30 First Officer: Left turn, so you want a left turn back
around to ULQ.
Aircraft rolled from right turn to left turn. At 6 degrees
of left bank, aircraft rolled into right turn again, bank angle 20 degrees.
2139:32 Captain: Nawww.. Hell no, let's press on to...
2139:35 First Officer: Well we're, press on to where though?
2139:37 Captain: Tulua.
2139:39 First Officer: That's a right.
2139:40 Captain: Where we goin'? One two.. come to the right.
Let's go to Cali. First of all, lets, we got [expletive] up here didn't
we?
2139:45 First Officer: Yeah.
2139:46 Captain: Go direct... C..L..O.. how did we get [expletive]
up here?
2139:54 Captain: Come to the right, right now, come to the right,
right now.
2139:56 First Officer: Yeah, we're, we're in a heading select
to the right.
2139:59 Captain (radio): [Sound of click]
2140:01 Captain (radio): And American uh, 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?
2140:11 Cali Approach: Niner six five, you can land, runway
one niner, you can use, runway one niner. What is your altitude and
the DME from Cali?
2140:21 Captain (radio): OK, we're thirty seven DME at ten thousand
feet.
2140:24 Captain: Uou're OK. You're in good shape now.
2140:25 Cali Approach: Roger.
2140:26 Captain: We're headin'...
2140:27 Cali Approach: Report uh, five thousand and uh, final
to one one, runway one niner.
2140:28 Captain: We're headin' the right direction, you wanna...
Aircraft still in a 20 degree right bank. Rate of descent
starts decreasing from 2,700 feet per minute as pitch attitude increases
and airspeed decreases. Altitude passes 10,000 feet.
2140:32 Captain: [expletive].. you wanna take the one nine yet?
2140:34 Captain: Come to the right, come come right to Ca...
Cali for now, OK?
2140:35 First Officer: OK.
2140:40 Captain: It's that [expletive] Tulua I'm not getting
for some reason.
2140:44 Captain: See I can't get, OK now, no, Tulua's [expletive]
up.
2140:48 First Officer: OK. yeah.
2140:49 First Officer: But I can put it in the box if you want
it.
2140:52 First Officer: I don't want Tulua. Let's just go to
the extended centerline of uh....
2140:55 Captain: Which is Rozo.
2140:56 First Officer: Rozo.
2140:56 Captain: Why don't you just go direct to Rozo then,
alright?
2140:58 First Officer: OK, let's...
2140:59 Captain: I'm goin' to put that over you.
2141:00 First Officer: ...Get some altimeters, we're out of
uh, ten now.
2141:01 Captain: Alright.
2141:02 Cali Approach: Niner six five, altitude?
2141:05 Captain (radio): Nine six five, nine thousand feet.
Right bank of 20 degrees begins to decrease. Flight Level
Change disengaged, Vertical Speed and IAS modes engaged, altitude passes
8,600 feet.
2141:10 Cali Approach: Roger, distance now?
2141:15 Cockpit Area Microphone: Terrain, terrain, whoop, whoop...
Pitch attitude 4.5 degrees nose-up, roll attitude is 12
degrees right, airspeed down to 234 knots, rate of descent 1,500 feet
per minute, altimeter at 8,480' MSL, radar altimeter at 1,476' AGL.
Autopilot disengages. Master Warning activated. Engine EPRs at 1.0.
2141:17 Captain: Oh [expletive]..
2141:17 Cockpit Area Microphone: [Sound of autopilot disconnect
warning starts]
2141:18 Captain: ...Pull up baby.
2141:19 Cockpit Area Microphone: [Sound of aircraft stick
shaker]
Pitch attitude increases to 31 degrees. Aircraft rolls
out of right turn and reaches 13 degrees left bank. Master Caution issued
as radar altitude decreased below 500' AGL. EPRs increase to 1.35 as
radar altimeter decreases to 109' AGL and airspeed decreases to 187
knots. Landing gear and flaps remain up.
2141:20 First Officer: It's OK.
2141:21 Cockpit Area Microphone: Pull up.
2141:21 Captain: OK, easy does it, easy does it.
2141:22 Cockpit Area Microphone: [Sound of autopilot disconnect
warning. Sound of aircraft stick shaker stops]
2141:23 First Officer: Nope.
2141:24 Captain: Up baby...
2141:25 Cockpit Area Microphone: [Sound of aircraft stick
shaker starts and continues to impact]
2141:25 Captain: ...More more.
2141:26 First Officer: OK.
2141:26 Captain: Up, up, up.
2141:27 Cockpit Area Microphone: Whoop, whoop, pull up.
End of CVR recording.
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