Table Judged Reasons for Failure in Events Cited 22 XIV




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2.8American Airlines B-757 Crash Over Cali, Columbia (confusion over FMS waypoint codes)



Two significant events in the loss of a B-757 near Cali, Colombia, in 1995, were the pilot asking for clearance to take the Rozo approach followed by the pilot typing “R” into the FMS. The pilot should have typed the four letters “ROZO” instead of “R.” The latter was the symbol for a different radio beacon (called Romeo) near Bogota. As a result, the aircraft incorrectly turned toward mountainous terrain.


While these events are non-controversial, the link between the two events could be explained by any of the following (Leveson, 2001):


  • Crew Procedure Error: In the rush to start the descent, the captain entered the name of the waypoint without normal verification from the other pilot.

  • Pilot Error: In the rush to start the descent, the pilot executed a change of course without verifying its effect on the flight path.

  • Approach Chart and FMS Inconsistencies: The identifier used to identify ROZO on the approach chart (R) did not match the identifier used to call up ROZO in the FMS.

  • FMS Design Deficiency: The FMS did not provide the pilot with feedback that choosing the first identifier listed on the display was not the closest beacon with that identifier.

  • American Airlines Training Deficiency: The pilots flying into South America were not warned about duplicate beacon identifiers and were not adequately trained on the logic and priorities used in the FMS on the aircraft.

  • Manufacturers’ Deficiencies: Jeppesen-Sanderson did not inform airlines operating FMS-equipped aircraft of the differences between navigation information provided by Jeppesen-Sanderson FMS navigation databases, Jeppesen-Sanderson approach charts, or the logic and priorities used in the display of electronic FMS navigation information.

  • International Standards Deficiency: There was no single worldwide standard for the providers of electronic navigation databases used in flight management systems.


In addition to the pilot not starting with an accurate mental model, a mental model may later become incorrect due to lack of feedback, inaccurate feedback, or inadequate processing of the feedback. A contributing factor cited in the Cali B-757 accident report was the omission of the waypoints behind the aircraft from cockpit displays, which contributed to the crew not realizing that the waypoint they were searching for was behind them (missing feedback) (Leveson, 2004).

2.9A320 Crash in Bangalore, India (control mode error, misunderstanding the automation)



In this accident the pilot had disconnected his flight director during approach and assumed that the co-pilot would do the same. The result would have been a mode configuration in which airspeed was automatically controlled by the autothrottle (the speed mode), which is the recommended procedure for the approach phase. Since the co-pilot had not turned off his flight director, the open descent mode activated when a lower altitude was selected instead of speed mode, eventually contributing to the crash of the aircraft short of the runway (Sarter and Woods, 1995).

2.10 Aero Peru 613 Crash (pitot tubes taped for painting: sloppy maintenance, poor inspection by pilot)



After a routine walk-around pilot inspection of a freshly painted Aero Peru B757, the aircraft took off for a night IFR flight from Peru to Chile. Immediately, the pilot could not understand what was happening to the aircraft. Neither the altimeter nor the airspeed indicators made any sense, with readings as though the aircraft was still on the ground. A request was made to air traffic control (ATC), which gave them their speed and altitude, but these numbers disagreed with the instruments. Alarms started to go off. Forty miles over the Pacific, they requested vectors for circling and returning to the Lima airport. Soon the crew requested another aircraft rendezvous with them and guided them back. Lima dispatched a 707. The crew was confused when an overspeed alarm sounded at the same time as a stall warning, with no correlation to throttle settings. After receiving a ground proximity warning and trying to pull up, they felt the aircraft bounce off the water. The resulting damage was too great and the aircraft rolled over. The aircraft crashed into the Pacific, killing all aboard.


The investigation found that during the painting all the pitot tubes were covered with plastic tape and the tape was never removed. The pilots had not noticed this in the walk-around. ATC was giving them speed and altitude based on the transponder, which was incorrect (Casey, 2006).
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