American Airlines Flight 965

Overview

Analyzing critically the crash of American Airlines Flight 965 is the purpose of this
paper. According to the Aircraft Accident Report (1996), American Airlines Flight 965 was planned to fly from Miami International Airport in Florida to Alfonso Bonilla Aragon International Airport in Cali, Colombia, on December 20, 1995. Four of the 163 people on board survived. The American Airlines Flight 965 was delayed about 30 minutes before they towed the aircraft and they took off two hours later than scheduled, after waiting an hour and 21 minutes to take off again. The Cali approach control, which was the destination, was in a situation where controllers could not know the location of the plane because no radar was available. The ATC asked the captain to report when the plane was over the Tulua VOR, but he didn't report it. Eleven minutes before the estimated time of arrival, the ATC asked if the pilot would land without turning on runway 19 instead of runway 01 as originally planned, and the captain said he would. Flight 965 then entered the R button to find their route to the next waypoint, ROZO. However, among the more than 10 lists starting with R, the nearest ROZO did not appear as the first item. Without recognizing this, the pilots chose the first item, and eventually, the plane began to fly automatically on other routes. They changed course a minute later when they realized their mistake. Flight 965 requested a descent for landing. However, when the plane was descending after they got permission from the ATC, a ground proximity warning system(GPWS) suddenly alerted. The place off course due to the setting mistake was too close to the mountain. Since there was no radar available, the ATC could not grasp it in advance, and the flight crew could not perceive that there was a mountain visually because it was during the night. Flight 965 failed to escape the mountain and crashed at 2142 at 8,900 feet MSL on the mountain. Probable causes are as follows:
1. Improper use of Automation
2. Lack of Situational Awareness
3. Lack of basic navigation Skills

CRM & TEM

Crew Resource Management (CRM) is the effective use of all available resources for
flight crew personnel to assure a safe and efficient operation, reducing error, avoiding stress, and increasing efficiency (Skybrary, n.d.). CRM was the most necessary factor in this flight. The flight crew made a mistake in the use of FMS. Moreover, the flight path was not monitored for more than one minute just before the accident. They didn't use other resources to get out of the situation. If they had dealt with the situation according to the procedure they had been doing through CRM training, the accident would not have happened. The setting of the FMS should have been monitored and re-checked as soon as possible. They were also able to escape the situation with basic navigation procedures through work sharing but were complacent.Threat and Error Management (TEM) is an overarching safety concept regarding aviation operations and human performance. Aircraft accidents caused by human error account for 80 percent. Therefore, we must recognize and mitigate errors to reduce accident rates. Pilots found several threats but did not mitigate them. They did not discontinue the approach, despite numerous clues that the continuation of the approach was undesirable. They allowed the aircraft to turn left when it had to go straight.

Situational awareness

“Situational awareness is the accurate perception and understanding of all the factors and conditions within the four fundamental risk elements that affect safety before, during, and after the flight” (FAA, n.d.). After deciding to accept the offer to land on runway 19, the flight crew showed poor situational awareness. They had difficulty locating the aircraft after entering the wrong route into the FMS. Because of this, they did not realize that the terrain was close. Lack of situational awareness left them behind the plane. They could not afford to predict their condition in the near future. Lack of situational awareness has led to catastrophic failure.

Spoilers

There are many causes of the accident, but they turned on the spoiler for the landing and forgot about it. When they heard the GPWS alert, they tried to climb instantly, but the spoiler was operating and the spoiler adversely affected the rate of the climb because it increased drag. The accident could not have happened if they had retracted the spoiler while they attempted the climbing maneuver. This is the decisive cause of the accident. The consequences of their failure to follow the standard procedure caused various confusion and affected the error in a critical moment.

Conclusion

This accident is an example of the importance of CRM. It is also a disastrous result of human error and reliance on automation. Airline CRM training improves pilots' situational awareness and reduces workloads through task-sharing role training. In the event of an emergency, pilots are embarrassed by human factors, but continuous CRM training helps mitigate threats even in emergencies. Flight 965 pilots did not follow some of the company's procedures. Anti-authoritarian attitudes, lack of CRM, and lack of training have had disastrous consequences.


References

Aeronautica Civil of The Republic of Columbia. (1996). Aeronautica Civil of The
Republic of Columbia Aircraft Accident Report American Airlines Flight 965.
https://reports.aviation-safety.net/1995/19951220-1_B752_N651AA.pdf
Federal Aviation Association. (n.d.). Situational Awareness.
https://www.faasafety.gov/gslac/ALC/course_content.aspx?cID=408&sID=649&preview
=true
Skybrary. (n.d.). Crew Resource Management (CRM). https://skybrary.aero/articles/crew-
resource-management-crm
Skybrary. (n.d.). Threat and Error Management (TEM).
https://skybrary.aero/articles/threat-and-error-management-tem