RFT 499: Flameout! LaMia Flight 2933


Manage episode 292412870 series 2801590
By George Nolly and Captain George Nolly. Discovered by Player FM and our community — copyright is owned by the publisher, not Player FM, and audio is streamed directly from their servers. Hit the Subscribe button to track updates in Player FM, or paste the feed URL into other podcast apps.

28 November, 2016. The aircraft was an Avro RJ85, registration CP-2933, serial number E.2348, which first flew in 1999. After service with other airlines and a period in storage between 2010 and 2013, it was acquired by LaMia, a Venezuelan-owned airline operating out of Bolivia.

The captain was 36-year-old Miguel Quiroga, who had been a former Bolivian Air Force (FAB) pilot and had previously flown for EcoJet, which also operated the Avro RJ85. He joined LaMia in 2013 and at the time of the accident he was one of the airline's co-owners as well as a flight instructor. Quiroga had logged a total of 6,692 flight hours, including 3,417 hours on the Avro RJ85.

The first officer was 47-year-old Fernando Goytia, who had also been a former FAB pilot. He received his type rating on the Avro RJ85 five months before the accident and had had 6,923 flight hours, with 1,474 of them on the Avro RJ85.

Another pilot was 29-year-old Sisy Arias, who was undergoing training and was an observer in the cockpit. She had been interviewed by TV before the flight.

The party flew with a different airline from São Paulo to Santa Cruz, where it boarded the LaMia aircraft. The refuelling stop at Cobija was cancelled following a late departure from Santa Cruz.

The aircraft was carrying 73 passengers and 4 crew members on a flight from Viru Viru International Airport, in the Bolivian city of Santa Cruz de la Sierra, to José María Córdova International Airport, serving Medellín in Colombia, and located in nearby Rionegro. Among the passengers were 22 players of the Brazilian Associação Chapecoense de Futebol club, 23 staff, 21 journalists and 2 guests. The team was travelling to play their away leg of the Final for the 2016 Copa Sudamericana in Medellín against Atlético Nacional.

Chapecoense's initial request to charter LaMia for the whole journey from São Paulo to Medellín was refused by the National Civil Aviation Agency of Brazil because the limited scope of freedom of the air agreements between the two countries, under International Civil Aviation Organization (ICAO) rules, would have required the use of a Brazilian or Colombian airline for such a service. The club opted to retain LaMia and arranged a flight with Boliviana de Aviación from São Paulo to Santa Cruz de la Sierra, Bolivia, where it was to board the LaMia flight. LaMia had previously transported other teams for international competitions, including Chapecoense and the Argentina national team, which had flown on the same aircraft two weeks before. The flight from São Paulo landed at Santa Cruz at 16:50 local time.

The RJ85 operating LaMia flight 2933 departed Santa Cruz at 18:18 local time. A Chapecoense team member's request to have a video game retrieved from his luggage in the aircraft's cargo delayed departure. The original flight plan included an intermediate refueling stop at the Cobija–Captain Aníbal Arab Airport, near Bolivia's border with Brazil; however, the flight's late departure meant the aircraft would not arrive at Cobija prior to the airport's closing time. An officer of Bolivia's Administración de Aeropuertos y Servicios Auxiliares a la Navegación Aérea (AASANA – Airports and Air Navigation Services Administration) at Santa Cruz de la Sierra reportedly rejected the crew's flight plan for a direct flight to Medellín several times despite pressure to approve it, because of the aircraft's range being almost the same as the flight distance. The flight plan was approved by another AASANA officer. The distance between Santa Cruz and Medellín airports is 1,598 nautical miles (2,959 km; 1,839 mi). A fuel stop in Cobija would have broken the flight into two segments: an initial segment of 514 nautical miles (952 km; 592 mi) to Cobija followed by a flight of 1,101 nautical miles (2,039 km; 1,267 mi) to Medellín, a total of 1,615 nautical miles (2,991 km; 1,859 mi).Bogotá's airport is 1,486 nautical miles (2,752 km; 1,710 mi) from Santa Cruz's airport and 116 nautical miles (215 km; 133 mi) from Medellín's.

The flight crew anticipated a fuel consumption of 8,858kg for their planned route of 1,611nmi (including 200kg for taxiing). After refueling at Santa Cruz, CP2933 had 9,073kg on board. ICAO regulations would have required them to carry a total fuel load of 12,052kg, to allow for holding, diversion and other contingencies. The RJ85's fuel tanks have a capacity of 9,362kg. At around 21:16, approximately 180nmi from their destination, the aircraft displayed a low fuel warning. At this point they were 77nmi from Bogotá, but the crew took no steps to divert there, nor to inform ATC of the situation. The RJ85 continued on course and began its descent towards Medellín at 21:30.

Another aircraft had been diverted to Medellín from its planned route (from Bogotá to San Andres) by its crew because of a suspected fuel leak. Medellín air traffic controllers gave that aircraft priority to land and at 21:43 the LaMia RJ85's crew was instructed to enter a racetrack-shaped holding pattern at the Rionegro VHF omnidirectional range (VOR) radio navigation beacon and wait with three other aircraft for its turn to land. The crew requested and were given authorisation to hold at an area navigation (RNAV) waypoint named GEMLI, about 5.4 nautical miles (10 km; 6 mi) south of the Rionegro VOR. While waiting for the other aircraft to land, during the last 15 minutes of its flight, the RJ85 completed two laps of the holding pattern. This added approximately 54 nautical miles (100 km; 62 mi) to its flight path. At 21:49, the crew requested priority for landing because of unspecified "problems with fuel", and were told to expect an approach clearance in "approximately seven minutes". Minutes later, at 21:52, they declared a fuel emergency and requested immediate descent clearance and "vectors" for approach. At 21:53, with the aircraft nearing the end of its second lap of the holding pattern, engines 3 and 4 (the two engines on the right wing) flamed out due to fuel exhaustion; engines 1 and 2 flamed out two minutes later, at which point the flight data recorder (FDR) stopped operating.

Shortly before 22:00 local time on 28 November (03:00 UTC, 29 November), the pilot of the LaMia aircraft reported an electrical failure and fuel exhaustion while flying in Colombian airspace between the municipalities of La Ceja and La Unión. After the LaMia crew reported the RJ85's electrical and fuel problems, an air traffic controller radioed that the aircraft was 0.1 nautical miles (190 m; 200 yd) from the Rionegro VOR, but its altitude data were no longer being received. The crew replied that the aircraft was at an altitude of 9,000 feet (2,700 m); the procedure for an aircraft approaching to land at José María Córdova International Airport states it must be at an altitude of at least 10,000 feet (3,000 m) when passing over the Rionegro VOR. Air traffic control radar stopped detecting the aircraft at 21:55 local time as it descended among the mountains south of the airport.

At 21:59 the aircraft hit the crest of a ridge on a mountain known as Cerro Gordo at an altitude of 2,600 metres (8,500 ft) while flying in a northwesterly direction, with the wreckage of the rear of the aircraft on the southern side of the crest and other wreckage coming to rest on the northern side of the crest adjacent to the Rionegro VOR transmitter facility, which is in line with runway 01 at José María Córdova International Airport and about 18 kilometres (9.7 nmi; 11 mi) from the southern end. Profile of the flight's last 15 minutes

Helicopters from the Colombian Air Force were initially unable to get to the site because of heavy fog in the area, while first aid workers arrived two hours after the crash to find debris strewn across an area about 100 metres (330 ft) in diameter. It was not until 02:00 on 29 November that the first survivor arrived at a hospital: Alan Ruschel, one of the Chapecoense team members. Six people were found alive in the wreckage. The last survivor to be found was footballer Neto who was discovered at 05:40. Chapecoense backup goalkeeper Jakson Follmann underwent a potentially life-saving leg amputation. 71 of the 77 occupants died as a result of the crash. The number of dead was initially thought to be 75, but it was later revealed that four people had not boarded the aircraft. Colombian Air Force personnel extracted the bodies of 71 victims from the wreckage and took them to an air force base. They were then taken to the Instituto de Medicina Legal in Medellín for identification.

The Grupo de Investigación de Accidentes Aéreos (GRIAA) investigation group of Colombia's Unidad Administrativa Especial de Aeronáutica Civil (UAEAC or Aerocivil – Special Administrative Unit of Civil Aeronautics) began investigating the accident and requested assistance from BAE Systems (the successor company to British Aerospace, the aircraft’s manufacturer) and the British Air Accidents Investigation Branch (AAIB) as the investigative body of the state of the manufacturer. A team of three AAIB accident investigators was deployed. They were joined by investigators from Bolivia's national aviation authority, the Dirección General de Aeronáutica Civil (DGAC – General Directorate of Civil Aviation). In all, twenty-three specialists were deployed on the investigation; in addition to ten Colombian investigators and those from Bolivia and the United Kingdom, Brazil and the United States contributed personnel to the investigation. On the afternoon of 29 November the UAEAC reported that both flight recorders – the flight data recorder (FDR) and cockpit voice recorder (CVR) – had been recovered undamaged.

Evidence very quickly emerged to suggest that the aircraft had run out of fuel: the flight attendant who survived the accident reported that the captain's final words were "there is no fuel", and transmissions to that effect from the pilots to ATC were overheard by crews of other aircraft, and recorded in the control tower. Shortly after the crash, the person leading the investigation stated that there was "no evidence of fuel in the aircraft" and the aircraft did not catch fire when it crashed. Analysis of the FDR showed all four engines flamed out a few minutes before the crash.

The investigation found that LaMia had consistently operated its fleet without the legally required endurance fuel load, and had simply been lucky to avoid any of the delays that the mandated fuel load were meant to allow for. An investigative report by Spanish-language American media company Univision, using data from the Flightradar24 website, claimed that the airline had broken the fuel and loading regulations of the International Civil Aviation Organization on 8 of its 23 previous flights since 22 August. This included two direct flights from Medellín to Santa Cruz: one on 29 October transporting Atlético Nacional to the away leg of their Copa Sudamericana semifinal, and a flight without passengers on 4 November. The report claimed the eight flights would have used at least some of the aircraft's mandatory fuel reserves (a variable fuel quantity to allow for an additional 45 minutes of flying time), concluding the company was accustomed to operating flights at the limit of the RJ85's endurance.

On 27 April 2018, the investigators, led by Aerocivil, released the final investigative report for the crash of Flight 2933, listing the following causal factors:

  • The airline inappropriately planned the flight without considering the necessary amount of fuel that would be needed to fly to an alternate airport, fuel reserves, contingencies, or the required minimum fuel to land;
  • The four engines shut down in sequence as a result of fuel exhaustion;
  • Poor decision making by LaMia employees "as a result of processes that failed to ensure operational security";
  • Poor decision making by the flight crew, who continued the flight on extremely limited fuel despite being aware of the low fuel levels aboard the aircraft and who did not take corrective actions to land the aircraft and refuel.

Additional contributing factors cited by the investigators were:

  • Deploying the landing gear early;
  • "Latent deficiencies" in the planning and execution of non-regular flights related to the insufficient supply of fuel;
  • Specific deficiencies in the planning of the flight by LaMia;
  • "Lack of supervision and operational control" by LaMia, which did not supervise the planning of the flight or its execution, nor did it provide advice to the flight crew;
  • Failure to request priority or declare an emergency by the flight crew, particularly when fuel exhaustion became imminent; these actions would have allowed air traffic services to provide the necessary attention;
  • Failure by the airline to follow the fuel management rules that the Bolivian DGAC had approved in certifying the company;
  • Delays in CP-2933's approach to the runway resulting from its late declaration of priority and of fuel emergency, added to dense traffic in the Ríonegro VOR area.

The CVR had recorded the pilots discussing their fuel state and possible fuel stops en route, but they were so accustomed to operating with minimal fuel that they decided against a fuel stop when ATC happened to assign them an adjustment in their route which saved a few minutes of flight time. For unknown reasons, the CVR stopped recording an hour and forty minutes before the FDR, when the aircraft was still about 550 nautical miles (1,020 km; 630 mi) away from the crash site at the Rionegro VOR. Aviation analyst John Nance and GRIAA investigators Julian Echeverri and Miguel Camacho would later suggest that the most probable explanation is that the flight's captain, who was also a part owner of LaMia, pulled the circuit breaker on the CVR to prevent a record of the subsequent discussions, knowing that the flight did not have the appropriate fuel load.

The aircraft was estimated to be overloaded by nearly 400 kilograms (880 lb).

Due to restrictions imposed by the aircraft not being compliant with reduced vertical separation minima (RVSM) regulations, the submitted flight plan, with a nominated cruising flight level (FL) higher than 280 (approximately 28,000 feet (8,500 m) in altitude), was in violation of protocols. The flight plan, which was filed with AASANA, included a cruising altitude of FL300 (approximately 30,000 feet (9,100 m)). The flight plan was sent for review to Colombian and Brazilian authorities as well, in accordance with regional regulations.

A week after the crash, Bolivian police detained the general director of LaMia on various charges, including involuntary manslaughter. His son, who worked for the DGAC, was detained for allegedly using his influence to have the aircraft given an operational clearance. A prosecutor involved with the case told reporters that "the prosecution has collected statements and evidence showing the participation of the accused in the crimes of misusing influence, conduct incompatible with public office and a breach of duties."

An arrest warrant was issued for the employee of AASANA in Santa Cruz who had refused to approve Flight 2933's flight plan - it was later approved by another official. She fled the country seeking political asylum in Brazil, claiming that after the crash she had been pressured by her superiors to alter a report she had made before the aircraft took off and that she feared that Bolivia would not give her a fair trial. A warrant was also issued for the arrest of another of LaMia's co-owners, but he still had not been located four weeks after the crash.

544 episodes