reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

1995 B757 CFIT Cali Colombia

Brief account : 

On a night approach to an airport with high terrain, the crew accepted a shorter routing. Situational awareness was lost when confusion arose about FMS waypoint identification and the aircraft turned away from the desired track into a region of higher ground.

While recovering towards the cleared track the crew reacted to a GPWS alert but were unable to avoid striking a hill, and the aircraft was destroyed. 

Crew-related factors : 

Both pilots were experienced and well qualified. The Captain had operated into the airport on multiple occasions, but the F/O (pilot flying and nominally "in charge") had not.

This appeared to result in some crossover and confusion of the crew roles, in that the Captain continued to initiate steps normally assigned to the pilot flying (decision making) as well as activating some FMS settings, while also acting as pilot monitoring.

It is likely that the crew had briefed for a lengthier approach going past the airport. When they were offered a shorter straight in approach, the Captain wished to accept this as the aircraft had been delayed on departure, and the F/O acquiesced in this. However both pilots recognised as a result they were seriously pressed for time. 

Confusion then arose about the waypoint they were proceeding to. Discrepancies in waypoint identification led to an incorrect one with the same name being used, causing the aircraft to turn unexpectedly towards the high ground while still descending when the Captain inserted it in the route. Resolving this led to high workload in both pilots, leading to loss of situational awareness and a breakdown in CRM, with neither pilot having a mental picture of the overall situation.

The report noted "This accident ... demonstrates that even superior CRM programs .... cannot assure that under times of stress or high workload, when it is most critically needed, effective CRM will be manifest". It went on to conclude that "Offering further guidance on training in situation awareness does not address the fact that pilots who have lost or not achieved situation awareness cannot be expected to recognize that they have lost or not achieved it. More importantly, these pilots cannot be expected to develop a mechanism to efficiently achieve it."

​In this case there was a breakdown of monitoring. The Captain as PM was clearly not inhibited in the monitoring, but rather he was actively influential over the aircraft flight path to a very significant degree. Consequently when the FMS error was made, neither pilot was in a position to see that the overall situation had rapidly become very unsafe, 

This accident illustrates some of the complex issues involved in "First Officers sectors".  

 

Type: 
B757
Where: 
Cali, Colombia
Expected weather: 
Instrument
Pilot in charge: 
F/O
Early transition: 
Unknown
Go-around : 
No
Damage: 
Serious
PicMA potential: 
Major
Year: 
1995
Time: 
Night
Deterioration: 
No
Vert Guidance: 
None
Both Head Up: 
No
LoC: 
No
Operator: 
American Airlines
Fully prepared: 
No
Actual Weather: 
None relevant
Autopilot : 
Y
CCAG: 
Normal