LAMIA Bolivia RJ85 near Medellin on Nov 28th 2016, electrical problems, no fuel, impact with terrain
Last Update: August 21, 2018 / 17:53:58 GMT/Zulu time
Inappropriate planning and flight execution because the amount of fuel required to fly from the airport of destination to an alternate airport nor a quantity of reserve fuel nor the contingency fuel nor the minimum fuel of landing were taken into account, these fuel quantities are required by aeronautical regulations for carrying out this type of international flight like the one made by CP 2339 aircraft.
Sequential shutdown of the four (4) engines while the aircraft was in descent performing a holding pattern at GEMLI as a result of the exhaustion of fuel on board.
An inadequate decision-making process by the aircraft operating company management as a result of a lack of operational safety assurance.
Loss of situational awareness and mistaken decision- making process by the crew who insisted on continuing a flight with an extremely limited amount of fuel. The crew was aware of the low level of remaining fuel; however, the crew members did not take the corrective actions required to land at an aerodrome and refuel, fact that would allow them to continue the flight safely.
Premature configuretion of the aircraft for landing during descent in holding pattern at GEMLI since considering the absence of thrust, this configuretion affected the plane's glide distance to Rionegro airport runway.
Latent deficiencies in the planning and execution of non-regular transportation flights by the aircraft operator related to insufficient supply of the required amount of fuel.
Specific deficiencies in the planning of the flight involved in the accident by the aircraft operator.
Lack of oversight and operational control of the flight by the Operator, it did not supervise the planning of the flight nor its execution nor it made a follow-up of the flight that would have allowed to support the crew in making decisions.
On Apr 27th 2018 Colombia's GRIAA released their final report in Spanish concluding the probable causes of the crash were:
Inappropriate planning and execution of the flight with an amount of fuel that did not include any fuel for a diversion from destination to an alternate airport, any contingency, any reserve, the required minimum fuel after landing as would have been required by regulations for the type of international flight performed by CP-2933.
The four engines shut down in sequence while the aircraft descended towards the holding pattern at GEMLI as result of depletion of fuel.
Inadequate decision making within the operator's management resulting in lack of assurance of operational safety.
Loss of situational awareness and inadequate decision making by the crew which maintained their fixation to complete the flight with an extremely limited amount of fuel. The crew was aware of the low level of remaining fuel, however, did not take corrective actions required, e.g. to land at an aerodrome and replenish the fuel.
Contributing factors were:
Premature configuration of the aircraft for landing during the descent towards the holding pattern at GEMLI. Considering the absence of thrust this configuration affected the gliding distance to Rionegro Airport's runway.
Latent deficiencies in the planning and execution of non-regular transportation flights by the operator, in particular insufficient supply of fuel.
Specific deficiencies in the planning of the accident flight by the operator of the aircraft.
Lack of supervision and operational control of the flight by the operator who did not supervise the planning of the flight nor its execution and did not follow up on the flight to assist the crew in decision making.
Absence of timely calls requesting urgency or declaring emergency (or similiar) by the crew of the aircraft during the flight, especially when fuel depletion was already imminent during the descent, which could have alerted air traffic control to provide the support needed.
Organizational and operational deviation from fuel management procedures by the operator, who in practise did not comply with the approval by Bolivia's DGCA during certification of the company.
Delay during the approach of the aircraft to Rionegro runway due to its late priority request and late emergency call for fuel added to the traffic density in the VOR RNG holding pattern.
The GRIAA reported in 2015 an inspection revealed operational deficiencies within the operator, in particular due to inadequate fuel management. In 2016 the operator performed three flights from Rio Negro to Cobija (as declared destination of the flight), however continued to Viru Viru (which was declared alternate aerodrome but was the real destination), as such it was likely the operator did not comply with the minimum fuel requirements.
CP-2933 was originally chartered to perform two flights, one from Sao Paulo to Rio Negro and then from Rio Negro to Chapeco. Brazil's Authorities had denied authorization for the flight based on their regulations preventing flights from Brazil to a third country (Brazil as point of origin, Bolivia for the operator and Colombia as destination). Therefore another company performed the flight Sao Paulo-Santa Cruz and CP-2933 was to fly from Santa Cruz to Rio Negro with a crew different from the one that had originally been scheduled to perform the flights.
The operator managed to get the request for the flight not rejected by Colombian Aeronautical Authority who did not have an Air Safety Secretariat nor made a study of the current insurance which excluded operation of the aircraft in Colombia.
The ARO/AIS office noticed, that the flight plan presented by the operator showed an estimated enroute time (EET) similiar to the endurance of the aircraft. This observation was not considered by the operator and the flight plan was filed.
The aircraft departed Santa Cruz with a total of 9,073 kg of fuel. The minimum fuel required to perform the flight to Rio Negro in accordance with regulations was 12,052kg however, above the aircraft's fuel tank capacity. The aircraft departed Santa Cruz with a computed takeoff weight of 42,148 kh, 348kg above maximum takeoff weight. There was no evidence of a load sheet at the operator's office in Santa Cruz.
According to the CVR the crew repeatedly discussed the fuel situation and optimization of cruise and descent, including a possible diversion to Bogota for refueling.
Colombia's ATC had cleared the flight for the most direct route from point of entry into Colombian Airspace to Rio Negro. A clearance by Bogota Area Control Center to proceed direct to NIRSO, near the destination airport, motivated the crew to definitely rule out a diversion to Bogota. The CVR recording ended prematurely about 550nm from Rio Negro, 100 minutes prior to the accident. The investigation was unable to determine why the CVR stopped that early. The flight data recordings ceased about 180nm from VOR RNG. About 40 minutes prior to the last FDR recording a low fuel level warning had occurred. At that point the aircraft was 77nm from Bogota and 135nm from Cali. However, the crew did not inform ATC about the fuel situation.
In the meantime ATC dealt with an aircraft suspecting a fuel leak on approach to Rio Negro, which delayed CP-2933 (as the fuel situation was unknown to ATC) and three other aircraft. 68nm from VOR RNG ATC instructed the crew to enter the hold of RNG without providing an estimate for the anticipated time of approach. Again, the crew did not advise of the critical fuel situation.
24nm from RNG VOR the crew requested and was approved to hold at GEMLI, again without advising of the low fuel quantity remaining. The aircraft completed one round in the holding, before starting the second circuit the crew requested priority due to fuel problems. ATC advised they would be vectored onto the localizer in 7 minutes. The crew accepted again without declaring emergency.
71 seconds after CP-2933 had requested priority ATC cleared the other aircraft arriving with a suspected fuel leak for the approach to Rio Negro.
During the second circuit in the hold, 195 seconds after the crew requested priority, the crew declared Mayday, immediately veered left out of the holding pattern and left FL210. ATC cancelled the approach clearance for the other aircraft and instructed other aircraft in the hold of RNG to fly towards the west to get out of the way.
When leaving FL210 the crew deployed the speed brakes, extended the landing gear at FL205 and at FL180 began to extend the flaps reaching 24 degrees of flaps. ATC cleared CP-2933 for the approach, provided traffic information about the other aircraft in the area and advised the runway was wet. At FL196 engine #3 shut down, at 18,876 feet engine #4 shut down, at 17,946 feet the flaps were set to full, at 17,290 feet engine #2 shut down and at 15942 feet engine #1 shut down. Seven seconds after the last engine shut down the FDR ceased recording 15.5nm before the runway 01 threshold at an CAS of 115 KIAS, 142 knots over ground and an altitude of 15,943 feet. The crew reported a total electrical failure and requested vectors repeatedly. After the last engine shut down the aircraft glided a further 5.5nm until impact. 71 people perished in the crash, 6 people survived.
This article is published under license from Avherald.com. © of text by Avherald.com.
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