1997Beat Reporting

Did mistakes by crew doom flight to Cali?

By: 
Byron Acohido
January 18, 1997
Index | Cali | TWA 800 | Pre737 Series | 737 Series

Last month's crash of an American Airlines Boeing 757 in Colombia has sparked an intense debate among pilots and aviation-safety experts over perceived shortcomings in airline equipment, training and air-traffic-control standards.

While initial reports suggest pilot error in the crash of Flight 965, airline critics are asking whether the apparent missteps of Capt. Nick Tafuri and First Officer Don Williams can be tied in part to an impetus to cut costs and a general deterioration of pilot-navigation skills among many U.S. carriers.

Many of those weighing in on computer-bulletin boards think U.S.-trained pilots have become too reliant on air-traffic controllers guiding them to the quickest possible landing with the help of powerful airport radar.

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Moreover, the Air Line Pilots Association has stepped up a long-running campaign to urge the Federal Aviation Administration (FAA) to expand terse descriptions of nonradar landing procedures and techniques in the basic pilot manual.

Officials from the FAA, the pilot's association and American Airlines decline to discuss the burgeoning debate within the aviation community, citing the ongoing Cali crash investigation.

But some insiders, who requested anonymity, hope the Cali disaster reverses what they perceive to be a trend toward airlines hastily expanding foreign routes without fully understanding potentially dangerous factors unique to flying abroad.

"What we have more and more is an operator going in and getting exposed to a different environment they know little about, and (airline) marketing won't allow them to follow anything except the minimum standards," said a source involved in discussions about upgrading the pilot manual.

Little is being done to establish special procedures reflecting the difference between flying to and from radar-equipped airports, found mostly in the United States and Western Europe, and the hundreds of other airports throughout the rest of the world that have no radar, aviation sources said.

Al Prest, vice president of operations for the Air Transport Association, a Washington D.C.-based airline-trade group, disputes that view. Prest contends better technology, improved understanding of human behavior and diligent training make for very skilled pilots and very safe flying.

"The skill level today is higher than it has ever been since this industry took off as a commercial entity in 1914 with its first paying passenger," Prest said. "And I think the data will support that."

The debate focuses on the actions of the pilots on the ill-fated American flight Dec. 20.
On a calm, moonless night, with no airport radar to guide them, Tafuri and Williams made a wide S-shaped turn while descending into a narrow canyon rimmed by treacherous mountain peaks on their approach to Cali, Colombia.

The pilots were trying to complete the turn and climb out over the canyon floor when their jetliner smashed, nose up, into the summit of a 9,000-foot mountain about 38 miles north of Cali. Of the 167 people on board American Airlines Flight 965, four passengers, along with a dog, survived.

In many countries, as well as at remote airports in some states, there is no airport radar. Pilots perform "instrument landings," navigating a descent by sequentially flying over a series of radio beacons on the ground.

Instrument landings typically take several minutes longer than radar-guided descents, and arguably require more pilot skill. Yet U.S. carriers increasingly emphasize radar-assisted landings in training, reflecting a priority given to squeezing as many flights as possible into busy hub airports, as well as saving fuel and staying on schedule.

With the evidence released thus far by Colombian officials pointing to a botched instrument-landing attempt in Cali, pilots and safety experts have exchanged hundreds of messages on aviation-related computer-bulletin boards questioning the underlying causes of the disaster.

Among the questions: Were communications between the Colombian air-traffic controllers and American pilots as clear as they could have been? Did the pilots rely too heavily on computers, compounding what should have been a series of inconsequential missteps?

A 'needless crash?'

"It was such a needless crash, and that's what has everybody so upset," said Mike Hynes, an independent crash investigator and aviation consultant from Oklahoma City. "Each error was so small, but the cumulative effect was so terrible."

Some observers believe shortcomings outside the cockpit predisposed the crew to make mistakes. These critics are calling for airlines to do more to catalog risks at airports ringed by mountains or man-made obstructions. They want to see regulators write stricter rules and mandate recurrent training for instrument-landing procedures.

In November, more than 400 aviation officials from around the world convened in Seattle for a weeklong seminar on managing safety at which many of the same issues raised by the Cali crash were discussed.

"Every single one of the hazards that existed in this case has been widely recognized," noted C.O. Miller, an aviation consultant from Sedona, Calif., who attended the conference. "These kinds of things have been getting a lot of attention in recent months and years. It makes me wonder if some of the stuff going on has been window-dressing."

Whether the crash of Flight 965 prompts safety improvements remains to be seen. An official cause isn't expected to be determined for months. Still, portions of transcripts from the airplane's cockpit voice recorder and flight data recorder provide an approximation of how the crash unfolded.

The flight departed Miami with its flight-management computer already programmed to execute an instrument-landing that would take the jet safely down the center of the canyon and beyond Cali, where it would circle back and land to the north.

As the plane crossed over Colombia, Tafuri and Williams held an extensive conversation about flight-attendant work hours. Some observers believe the pilots should have been reviewing charts of the canyon they soon would be traversing and watching for a ground beacon at a site called Tulua.

As Flight 965 descended through 20,000 feet, Tafuri began talking to the air-traffic controller in Cali. The controller noted the weather was calm and asked if Tafuri might want to fly directly to a southbound runway.

"Ah, yes, sir," Tafuri said. "We'll need a lower altitude right away, though."

The controller cleared Flight 965 to land to the south, as long as Tafuri reported his initial approach position at Tulua, 43 miles north of Cali. But the standard landing approach programmed into the flight computers in Miami did not include a check-in at Tulua.

As the pilots began looking for Tulua on their charts, Tafuri asked the tower to approve a rapid descent to a beacon near the south-facing runway.

Extension of 'spoilers'

The controller affirmed that approach but again reminded Tafuri to report the plane's position as it crossed over Tulua.

The pilots then extended wing panels, called spoilers, to make the jet descend faster.

But unbeknownst to the crew, the jet had by this time passed Tulua. When the pilots finally found the code for Tulua and dialed it into the flight computers, the autopilot began a gentle, wide turn to the left, circling back to Tulua.

The pilots let the turn continue for 90 seconds before realizing they were heading off course to the east; they then dialed in a heading to Cali. The autopilot broke off the left turn and banked slowly to the right, to the southwest. With its spoilers extended, the jet continued a rapid descent on a collision course with the summit.

With just nine seconds to impact, the ground-warning computer sounded a voice alarm: TERRAIN!, then PULLUP! PULLUP! PULLUP!

The pilots reacted within two seconds, revving the engines to maximum thrust and pulling the nose up, but the spoilers, still extended, restricted the jet's ability to climb fast.

Three seconds is considered a quick response to an unexpected cockpit event. Some observers speculate that Tafuri and Williams reacted so quickly because, by this time, they sensed they were in a dangerous area.

Flight 965 skidded, nose up, into treetops, then slammed into the mountain a few hundred feet from the summit.

Capt. Bud Leppard, who flies McDonnell Douglas MD-11s for World Airways, contends Flight 965 never would have gotten into trouble had the pilots been flying an old-style jetliner with less-sophisticated computers and a flight engineer on board to help keep track of the airplane's systems. Computers have replaced the flight engineer on late-model jets.

"The FAA and manufacturers want you to believe the glass cockpit is a great time-saver and reduces the workload, but nothing could be further from the truth," Leppard said.

"Computers are wonderful to have, but they increase your workload tremendously, especially if you deviate from the programmed flight plan."

Pilots used to calculate course changes by hand and "go fly it," he said. On high-tech jets, altering the pre-programmed course requires giving a host of commands on multiple computer screens in the proper sequence.

"The problem is when you're reprogramming the computer, you're not looking out the (cockpit) window," Leppard said.

Some pilots and safety experts believe the jet might have safely cleared the summit had Tafuri and Williams been given more than nine seconds warning, or had their jet been equipped with spoilers that retract automatically any time the engines are revved to high thrust. Auto-retract spoilers are used on several models of Airbus jets.

Some safety experts believe airlines should be required to upgrade the current generation of ground-warning computers, which monitor a jet's position relative to the ground directly below, with units that keep track of obstructions ahead of the plane.

All agree that Flight 965 never would have gotten into trouble if it had stayed on the standard approach path programmed in Miami, or if the pilots had kept better track of the Tulua ground beacon.

"The big issue is they should have never got to the point to where the spoilers needed to be retracted on a timely basis," said one veteran airline pilot.

The Federal Aviation Administration has begun a review of American Airlines' operating procedures and training "to see whether changes would build an even greater margin of safety," said FAA Administrator David Hinson.

But some in the aviation community contend the agency itself is part of the problem.

For more than three years, the pilots association has been lobbying the FAA to publish detailed instrument-landing procedures in the Aeronautical Information Manual. Some in the industry believe that is an important first step toward requiring special training for crews assigned to fly into mountainous airports lacking radar.

Beat Reporting 1997