avia 400
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Liberty University *
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400
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Industrial Engineering
Date
Jan 9, 2024
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docx
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Running Head: Accident Report
Liberty University
AVIA-400
Running Head: Accident Report
Abstract
In this paper I will briefly explain the cause and the event that occurred on December 20, 1995.
On this day American Airlines flight 965 departed Miami and did not make it too its designed
destination. In this paper I will also be using the swiss cheese model to determine the risk
analysis and risk management that was involved with the aircraft on this significant date.
Running Head: Accident Report
On December 20,1995 American Airlines flight 965 departed Miami international airport
scheduled to land at Alfonso Bonilla Aragon International Airport. Early on the flight was
delayed for about thirty minutes as they were waiting for the arrival of passengers and baggage.
As the plane left its designed gate it then experienced another delay due to airport traffic.
Eventually flight 965 was cleared for takeoff and cleared to climb to flight level. While
communicating with the control tower the captain and first officer received their flight route
which was declared by the Barranquilla air traffic control tower. The fight received clearance for
the Rozo 1 arrival but the flight crew had selected the wrong directional beacon and began to fly
off track crossing mountainous terrain. The crew realized they were in trouble as warnings began
to grab their attention in the cockpit. The captain and first officer tried to pull the airplane up, but
the plane continued over a ridge and impacted on the west side of the mountain and burned. This
crash is listed as one of aviation deadliest crashes as 151 passengers lives were taken including 8
crewmembers. The airplane was destroyed and located in Buga Colombia. Implementing the
swiss cheese model in this aviation accident will fall under the area of preconditions for unsafe
acts. The probable cause of this accident is due to
the lack of situational awareness of the flight
crew regarding vertical navigation, proximity to terrain, and the relative location of critical radio
aids. The flight crew may have experienced mental fatigue as they were almost delayed two
hours and had intentions to just get to where they were going. Disappointment of the flight group
to return to essential radio route when the FMS-helped route ended up befuddling and requested
an extreme remaining task at hand in a basic period of the flight. Adding to the reason for the
mishap were the flight group continuous endeavors to speed up their flight and arriving so as to
maintain a strategic distance from any additional postponements. The flight team's execution of
the departure while the speed brakes remained locked FMS rationale that dropped all moderate
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Running Head: Accident Report
fixes from the display in case of execution of a direct steering. FMS-produced navigational data
that utilized an alternate naming show from that distributed in navigational diagrams. This is
another area were mental fatigue may have effected the pilots as they were searching for the
Rozo non directional beacon on the flight management computer but selected the Romeo
navigation which is 150 nautical miles from Rozo. In this accident the cockpit crew consisted of
the captain and the first officer, both were trained and over 2,000 miles flown in the B757. There
seemed to be no contributing factors of stress for the pilots as they were relaxed and living their
everyday lives prior to the flight. Due to no potential hazards or situations that may have
occurred out of the cockpit or in the cockpit crew daily life, another area of the swiss cheese
model that can play a part of this accident is unsafe acts and a loss of situational awareness.
During flight there were no difficulties with aids to navigation neither were there any difficulties
with the communication equipment. The accident airplane incorporated an FMS that included an
flight management computer (FMC), a worldwide navigation data base that contained radio
frequencies, and latitude and longitude coordinates of relevant navigation aids as well as
coordinates of airports capable of B-757 operations. The FMC data base also included B-757
performance data which, combined with pilot inputs, governed auto throttle and autopilot
functions. The FMS monitored the system and engine status and displayed the information, as
well as airplane attitude, flightpath, navigation, and other information, through electronically
generated CRT displays. The airplane was fully equipped with navigational equipment to help
the pilots. Navigational systems or a lack of communication was not the probable cause for this
aircraft accident. More of a lack of focus, mental fatigue and situational awareness was the cause
of American Airlines flight 965 to crash. There was no evidence of failures or malfunctions in the
airplane, its components, or its systems. Weather was not a factor in this accident. Both
Running Head: Accident Report
crewmembers were properly qualified and certificated to operate the airplane on this flight.
There was no proof of disappointments or glitches in the plane, its parts, or its frameworks.
Climate was not a factor in this mishap. Both crewmembers were appropriately qualified and
certificated to work the plane on this flight. With this accident I would have to say human factors
was the ultimate cause for the crash. The areas for the swiss cheese model that this aircraft
incident falls under is preconditions for unsafe acts and unsafe acts. They lacked in the area of
situational awareness as they were unable to locate the flight path and the proximity of terrain
and also the location of navaids.
Conclusion this aviation accident was one of the deadliest in aviation history and can be a
teachable lesson for future aviators. We can learn from this incident that situational awareness is
key and focus is significant at all times when flying an airplane.
Running Head: Accident Report
Reference
Ladkin, peter (1995). AA965 Cali accident report.
Aeronautica civil of the republic of Colombia.
1-35. https://www.skybrary.aero/bookshelf/books/1056.pdf
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