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Flight Safety Digest May-June 1998

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Flight Safety Digest May-June 1998 FLIGHT SAFETY FOUNDATION MAY–JUNE 1998 FLIGHT SAFETY DIGEST SPECIAL DOUBLE ISSUE Boeing 757 CFIT Accident at Cali, Colombia, Becomes Focus of Lessons Learned Approximate ROMEO Track of 274 R Accident Aircraft . – . 6000 TULUA 117.7 ULQ . – . – . – – . – 202˚ 8000 10000 ★ Accident12000 Site 12000 6000 D21.0 4000 12000 14000 193˚ 6000 D16.0 ROZO 274 R 8000 . 4000 – 10000 D10.7 12000 6000 4000 193˚ CALI 115.5 CLO – . – . – . – – – NOT TO SCALE 013˚ 6000 5000' 193˚ FLIGHT SAFETY FOUNDATION For Everyone Concerned Flight Safety Digest With the Safety of Flight Vol. 17 No. 5/6 May–June 1998 Officers and Staff Stuart Matthews Chairman, President and CEO In This Issue Board of Governors James S. Waugh Jr. Boeing 757 CFIT Accident at Cali, Colombia, Treasurer Becomes Focus of Lessons Learned 1 Carl Vogt General Counsel and Secretary The author has identified 27 errors that he believes were Board of Governors involved in the controlled-flight-into-terrain accident. His ADMINISTRATIVE analysis suggests specific operational methods and training Nancy Richards strategies that might prevent similar accidents. Executive Secretary Ellen Plaugher U.S. 1997 Rotorcraft Accident Rate Executive Support–Corporate Services Was Lowest in Seven Years 32 FINANCIAL Elizabeth Kirby U.S. air-taxi accident rate also declined slightly. Controller TECHNICAL The U.S. General Accounting Office Robert H. Vandel Reports Lag in Implementation of Airline 34 Director of Technical Projects Security Measures Robert H. Gould Managing Director of Aviation Safety Audits National Business Aviation Association marked its and Internal Evaluation Programs 50th anniversary by publishing comprehensive history of Robert Feeler business flying. Manager of Aviation Safety Audits Robert Dodd, Ph.D. Manager, Data Systems and Analysis Bird Ingestion Causes A320 Engine Joanne Anderson Failure and Fire during Takeoff 37 Technical Assistant MEMBERSHIP Joan Perrin Director of Marketing and Development Susan M. Hudachek Membership Services Manager Ahlam Wahdan Assistant to the Director of Membership and Development David A. Grzelecki Librarian, Jerry Lederer Aviation Safety Library PUBLICATIONS Roger Rozelle Director of Publications Rick Darby Senior Editor Mark Lacagnina Senior Editor Wayne Rosenkrans Senior Editor Flight Safety Foundation (FSF) is an international membership John D. Green organization dedicated to the continuous improvement of flight safety. Copyeditor Nonprofit and independent, FSF was launched in 1945 in response to the Karen K. Ehrlich aviation industry’s need for a neutral clearinghouse to disseminate Production Coordinator objective safety information, and for a credible and knowledgeable body Ann L. Mullikin that would identify threats to safety, analyze the problems and recommend Assistant Production Coordinator practical solutions to them. Since its beginning, the Foundation has acted in the public interest to produce positive influence on aviation safety. Jerome Lederer Today, the Foundation provides leadership to more than 680 member President Emeritus organizations in 77 countries. Boeing 757 CFIT Accident at Cali, Colombia, Becomes Focus of Lessons Learned The author has identified 27 errors that he believes were involved in the controlled-flight-into-terrain accident. His analysis suggests specific operational methods and training strategies that might prevent similar accidents. David A. Simmon At 2142 local time on Dec. 20, 1995, American Airlines (AA) • “The lack of situational awareness of the flight Flight 965, a Boeing 757-223 on a regular, scheduled passenger crew regarding vertical navigation, proximity to flight from Miami, Florida, U.S., to Cali, Colombia, struck terrain and the relative location of critical radio aids; mountainous terrain during a descent from cruise altitude in [and,] visual meteorological conditions under instrument flight rules. The accident site was near the town of Buga, 33 nautical miles • “Failure of the flight crew to revert to basic radio (61 kilometers) northeast of the Cali very high frequency navigation at the time when the FMS [flight omnidirectional radio range (VOR). The aircraft struck near management system]-assisted navigation became the summit of El Deluvio, at the 8,900-foot (2,670-meter) level, confusing and demanded an excessive workload in a approximately 10 nautical miles (19 kilometers) east of Airway critical phase of the flight.”1 W3. Of the 163 passengers and crew on board, four passengers survived the accident. The Aeronáutica Civil said that factors contributing to the accident were: In its final report on the accident, the Aeronáutica Civil of the Republic of Colombia (Aeronáutica Civil) said that the • “The flight crew’s ongoing efforts to expedite their probable causes of the accident were: approach and landing in order to avoid potential delays; • “The flight crew’s failure to adequately plan and execute the approach to Runway 19 at SKCL [Cali’s • “The flight crew’s execution of the GPWS [ground- Alfonso Bonilla Aragon International Airport], and proximity warning system] escape maneuver while the their inadequate use of automation; speed brakes remained deployed; • “Failure of the flight crew to discontinue the approach • “FMS logic that dropped all intermediate fixes from into Cali, despite numerous cues alerting them of the the display(s) in the event of execution of a direct inadvisability of continuing the approach; routing; [and,] FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • MAY–JUNE 1998 1 • “FMS-generated navigational information that used a 3. An adequate approach review was not performed. different naming convention from that published in (***), K, (2112–2126) navigational charts.” Data indicate that an adequate approach review was not Representatives from AA, the Allied Pilots Association (APA, accomplished by the flight crew. There was no information on the union that represents AA flight crews) and the Boeing the CVR either of an approach briefing or that the descent Commercial Airplane Group were parties to the accident checklist was performed. There was confusion about the investigation. The article on page 19 summarizes the party aircraft’s position and an absence of dialogue about planned submissions that were made to the Aeronáutica Civil and the speeds, crossing altitudes, radio tuning and management of U.S. National Transportation Safety Board (NTSB) regarding displays. During this period, the captain was confused about the investigation, insofar as they added to or differed from the the meaning of ULQ, the Tulua VOR identifier. The CVR Aeronáutica Civil report. transcript showed that there was concern about whether there was time to retrieve the approach chart and that there was a This analysis of human errors that might have contributed to sound similar to rustling pages. The captain took 37 seconds this accident is based upon the aircraft-accident report of the to decide how to implement the amended clearance to Runway Aeronáutica Civil and the NTSB factual reports from the 19, and he then requested clearance to Rozo (a nondirectional chairmen of the Operations, Air Traffic Control (ATC), Flight beacon radio navigation aid [NDB]). Data Recorder (FDR) and Cockpit Voice Recorder (CVR) groups. (The NTSB assisted Colombian authorities in the While one of the crewmembers did enter a preliminary arrival accident investigation.) Explanation of the asterisk and single- path to Runway 01 in the FMS during the flight, this action letter codes, and definitions of italicized human factors terms did not constitute an adequate approach review. that may not be familiar are in “Taxonomy of Human Error,” page 3. The analysis uses excerpts from the CVR transcript. Most crewmembers review the approach prior to the top of The complete CVR transcript is in “Cockpit Voice Recorder descent. This is a low-workload period that allows each Transcript, American Airlines Flight 965, Dec. 20, 1995,” page crewmember to assess the risks and problems associated with 20. the approach, determine the key physical features of the approach area, derive appropriate operational constraints and 1. The crew read back the wrong transponder code. (*), calculate the planned landing fuel and the minimum fuel that L, (approximately 2104) will be needed if a diversion to the alternate is necessary. This process — vigilance tuning — will result in an appropriate Shortly after contacting Bogota (Colombia) Control, AA 965 focus of attention for each approach. was issued the following instruction: “report ready for descent and please squawk code alpha two three one four.” The approach review should have considered that the approach (a) would be made at night, (b) at a terrain-critical The captain (the pilot not flying [PNF]) said, “OK squawk airport, (c) with a nonprecision approach (as well as a two two one four uh and report ready for descent, gracias.” precision approach), (d) without the benefit of radar and (e) in a country where the controller’s native language (Spanish) This minor error had no bearing on the accident because the was different from the crew’s (English). These five conditions controller amended the transponder code to coincide with the are the common elements of most controlled-flight-into- code acknowledged by the captain. This error is included terrain (CFIT) accidents.2 Moreover, during this review, the because human factors analysis must focus on the error crew should have determined the overall approach strategy, irrespective of the consequences of the error. management of the radios
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