American Airlines Flight 965 - Crash Investigation and Final Report

Crash Investigation and Final Report

The crash was investigated by the Special Administrative Unit of Civil Aeronautics (Aeronáutica Civil) of the Republic of Colombia, with assistance from the U.S. National Transportation Safety Board (U.S. NTSB) as well as other parties, including the U.S. Federal Aviation Administration, Allied Pilots Association, American Airlines, Boeing Commercial Airplane Group and Rolls Royce Engines.

The Aeronáutica Civil prepared a final report of its investigation in September 1996, which was released through the U.S. NTSB.

In its report, the Aeronáutica Civil determined the following probable causes of the accident:

1. The flightcrew's failure to adequately plan and execute the approach to runway 19 at SKCL and their inadequate use of automation.
2. Failure of the flightcrew to discontinue the approach into Cali, despite numerous cues alerting them of the inadvisability of continuing the approach.
3. The lack of situational awareness of the flightcrew regarding vertical navigation, proximity to terrain, and the relative location of critical radio aids.
4. Failure of the flightcrew to revert to basic radio navigation at the time when the FMS-assisted navigation became confusing and demanded an excessive workload in a critical phase of the flight.

In addition, the Aeronáutica Civil determined that there were the following contributing factors to the accident:

1. The flightcrew's ongoing efforts to expedite their approach and landing in order to avoid potential delays.
2. The flightcrew's execution of the GPWS escape maneuver while the speedbrakes remained deployed.
3. FMS logic that dropped all intermediate fixes from the display(s) in the event of execution of a direct routing.
4. FMS-generated navigational information that used a different naming convention from that published in navigational charts.

The Aeronáutica Civil's report also included a variety of safety-related recommendations to the following parties (number of individual recommendations in parentheses):

• U.S. FAA (17)
• International Civil Aviation Organization (3)
• American Airlines (2)

Investigators later labeled the accident a Nonsurvivable event.