Not Enough Fuel: The Disgusting Truth About LaMia Flight 2933

2 Dec 16 26 Comments

On the 28th of November 2016, LaMia flight 2933 departed Santa Cruz de la Sierra (the largest city in Bolivia) for a chartered flight to Medellín in Colombia. The aircraft held 68 passengers and 9 crew. At 21:56 local time, the aircraft disappeared from radar screens. The wreckage was found on the slopes of Cerro Gordo. Search and rescue found seven survivors, one of whom died after being transferred to hospital. There were 71 fatalities, including the flight crew and all but one of the cabin crew.

The Colombian Civil Aviation Authority has confirmed that the aircraft did not have the mandatory fuel reserves, which are defined by the International Civil Aviation Organization (ICAO) Annex 6, part 1.

This is probably the most important point to understand. A flight plan lists

  • the departure airport
  • the destination airport
  • an alternate airport in case there is an issue at the destination

A commercial flight doesn’t just have to carry enough fuel for the trip. It must have enough fuel to fly to its destination, fly a missed approach (i.e. attempt to land and fail), divert to its alternate airport and then it needs further reserve fuel for another 30 minutes of possible holding patterns.

According to the Colombian Air Safety Secretary, the flight should have gone from Santa Cruz de la Sierra to Cobija Airport in Bolivia, for refuelling, a ninety minute hop, before continuing to Medellín. Apparently, the departure from Santa Cruz was delayed and Cobija Airport doesn’t operate at night, which might be why the refuelling stop didn’t happen. However, the flight could equally have stopped at Bogotá to refuel.

Instead, it seems that LaMia filed a flight plan from Santa Cruz de la Sierra directly to Medellín, a route spanning 1,588 nautical miles. The alternate airport filed was Bogotá, which is a 128 nautical miles from Medellín (going back on yourself). So this flight plan required enough fuel for a minimum flight of 1,716 nautical miles along with enough fuel for at least one missed approach plus enough fuel for the aircraft to hold for up to 30 minutes.

The actual range of the aircraft was 1,600 nautical miles. The aircraft could just barely make it from Santa Cruz to Medellin, if nothing went wrong. It never was going to make it back to Bogotá. It never had enough fuel to hold for 30 minutes at Medellín, even if it didn’t bother with Bogotá.

It should never have flown that route.

The LaMia Avro RJ85 accident aircraft, taken by Graham of GSAirpics
The LaMia Avro RJ85 accident aircraft, taken by Graham of GSAirpics

The aircraft was an Avro RJ-85. The Avro RJ is a high-wing cantilever monoplane easily recognisable because of its T-shaped tail. It runs quietly despite its four engines, giving it the nickname Whisperjet. It’s popular as a regional jet for short-haul flights, especially as it is able to use short runways and even rough airstrips with only minor modifications. The standard aircraft has a range of 1,600 nautical miles (1,840 miles, 2,960 km) and a service ceiling of 31,000 feet (9,500 metres).

This video shows an Air France Avro RJ-85 doing a crosswind landing at Dublin Airport:

The operator of the aircraft was LaMia, short for Línea Aérea Mérida Internacional de Aviación and a play on words (la mía is a possessive phrase for a feminine object, as in “that thing which is female is mine”).

LaMia started as a Venezuelan operation which failed twice (in 2009 and 2013). The Venezuelan owners rented their three RJ85s to Bolivian entrepreneurs, who stuck with the name LaMia as it was already painted on the aircraft. In November 2015, LaMia was launched as a legally distinct company offering domestic charter flights in Bolivia. The two owners were Gustavo Vargas Gamboa and Miguel Alejandro Quirogo Murakami, who was piloting flight 2933 when it crashed.

The operations coordinator said that resource extraction (mining) companies, travel agencies and soccer teams were their target audience. LaMia previously operated flights for the national teams of Argentina, Bolivia and Venezuela along with Colombian Atlético Nacional, the Paraguayan Club Olimpia and local sides Oriente Petrolero, The Strongest and Club Blooming. The airline had three RJ85 aircraft but two of them were under maintenance.

That night, LaMia flight 2933 was about 80 nautical miles south of Medellín and descending from its cruise altitude of FL300 (30,000 feet).

Another aircraft, VivaColombia flight FC-8170, was en route from Botogá to San Andrés Island when they experienced an alarm in the cockpit, which turned out to be a malfunctioning fuel gauge. At 21:11 local time the VivaColombia flight crew decided to divert to Medellin, which is about halfway from Bogotá to San Andrés. The aircraft was vectored in for a priority landing. It started its approach for runway 01 at 21:45 and touched down safely at 21:51.

VivaColombia have issued a statement that they did not declare an emergency and that the diversion was simply an “unscheduled stopover due to a technical related issue”. Certainly, it’s clear that the passengers of that aircraft were never in any danger and that the aircraft would not have been given priority if another aircraft had declared an emergency. The Colombian Aerocivil Secretary of Aviation Safety commented that it would not be uncommon for controllers to prioritise a national flight higher than a foreign charter flight.

During this time, LaMia flight 2933 had started its descent and was about 80 nautical miles south of Medellín at 21:34. At 21:48, they entered a holding pattern.

A third aircraft, Avianca flight AV-9771 from Cartagena (Colombia) to Medellín, was arriving at Medellín at the same time and was also in a holding pattern while the VivaColombia flight was on approach.

Normally this would not have been an issue. Every commercial jet should have had enough fuel for their destination (including enough for a missed approach and an approach) and fuel for the alternate airport and reserve fuel for a further thirty minutes of flight.

The LaMia flight was told that they were number three for the approach.

The fight crew apparently asked what the expected delay would be and then stated that they were coming in for the approach immediately as they had issues with fuel. By now, it was much too late. It’s just crazy that they did not admit their fuel situation the moment they were asked to hold. If they had declared a fuel emergency, they would have been given priority over VivaColombia and brought straight into Medellín. I can’t help but wonder if the captain, being one of the owners, did not want to admit that they did not have enough fuel on board for the flight, for fear of reprisals against the airline.

At 21:54 the flight left the holding pattern for the approach. It disappeared from radar at 21:56 while descending through FL155 (15,500 feet).

ICAO rules are that the declaration of minimum fuel is required if you can’t land with at least thirty minutes holding fuel in your tanks, even if you are absolutely sure you are going to land safely. It’s straight forward: you should not use the final reserve and, if you realise that you might have to, you must declare an emergency.

The Airport of Medellín have stated that the aircraft had declared an emergency at 22:00 local time, reporting electrical problems. It sounds like the flight crew did not realise that the engines flaming out could cause the electrical failure.

A recording from Medellín has been leaked. Warning: it’s difficult to listen to.

LaMia flight 2933 Señorita, Lamia 933 está en falla total, falla eléctrica total, sin combustible.
Lamia 933 is experiencing a total failure, total electrical failure, out of fuel.
Medellín You are now 0.1 miles from Rionegro.
Medellín I can’t see your altitude.
LaMia flight 2933** We’re at 9,000 feet. Vectors. We need vectors!
Medellín You are 8.2 miles from the runway.
LaMia flight 2933 [expletive]
Medellín What is your current altitude?
background voice They aren’t going to respond any more.

There’s no explanation for their sudden descent rather than an attempt to glide as far as they could. I’ve seen estimates that they probably could have glided for 10 minutes if they had set up the aircraft. But then, if they’d set up correctly, they wouldn’t have attempted this flight with only just enough fuel to make it if all went well.

LaMia entered the holding pattern at 21:48. The hold added about 54 nautical miles to the flight. At 22:00 the flight crew finally declared an emergency but, by then, they were completely out of fuel.

Photo of one of the engines by the CCAA
Photo of one of the engines by the CCAA

There was no fire which is one reason why there were any survivors at all. There was no fire because there was no fuel. In 12 minutes in the hold, they’d used everything they had.

Under ICAO rules, the investigation will be led by the Colombian Civil Aviation Authority as the accident took place in Colombia. They have requested the help of the British AAIB as the state of manufacture. Both the cockpit voice recorder and the flight data recorder have been recovered and the data is in good condition.

The leak of the ATC recording, in which the captain states he has had a total electrical failure and no fuel, has been confirmed as authentic, although there has been an implication that some segments may have been omitted, either for effect or to protect air traffic controllers involved.

The Colombian spokesman has already stressed that they will be investigating why LaMia authorised a flight which was beyond the range of the aircraft.

The Bolivian civil aviation authority immediately suspended LaMia’s Air Operator Certificate (AOC) as a result of the crash. Bolivian Law requires all employers to be registered with the Ministry of Labour but, although LaMia has eight employees, it turns out that it was never registered with the government.

The Bolivian Ministry of Public Services has announced that in addition to suspending LaMia’s AOC, they are investigating how the AOC was approved. There will be an internal investigation into the conduct of Bolivia’s Administración de Aeropuertos y Servicios Auxliares a la Navegación Aérea (Administration of Airports and Air Navigation Services) regarding administrative and operational permits. It turns out that the Director of Aircraft Registries at Bolivia’s Civil Aviation Authority is the son of Gustavo Vargas Gamboa, the surviving owner of LaMia.

The problems with this flight add up frighteningly fast.

The airline operator may not have been properly approved and monitored. Even if it was, the flight plan was clearly not a reasonable flight plan for that aircraft as a single hop. The flight, as planned, would use all of the fuel in the tanks, with no reserve and no fuel for contingencies, let alone a flight to Bogotá if Medellin had ended up with (for example) a blocked runway. The LaMia dispatcher accepted the flight plan, even though it must been obvious that it did not meet minimum requirements for fuel. The flight crew don’t appear to have monitored the fuel during the flight nor to have considered stopping to refuel on the way. They should have declared an emergency the moment it became clear that they couldn’t make it to Medellín and back to Bogotá but, on that basis, they wouldn’t have taken off at all. However, it’s unbelievable that they still didn’t react when they reached their 30 minute reserve. When asked to fly a holding pattern, they were already within the last minutes of useable fuel. Even then, they did not immediately make it clear to the controller that they needed to land as quickly as possible.

The flight crew did eventually declare an emergency; however it was much too late. They were already out of fuel and their only remaining chance was to glide the aircraft to land. Instead, they descended rapidly and seemingly without a plan.

On top of all that, there is evidence that the LaMia captain had flown that same route four times before. He was literally playing Russian Roulette with the aircraft.

The whole thing is just heart-breaking. The passengers and the rest of the crew deserved better.

Sources include:
http://www.eldeber.com.bo/mundo/historia-del-avion-estrello-colombia.html
http://nsnbc.me/2016/12/02/its-official-colombias-caa-confirms/
http://www.eluniversal.com.co/deportes/el-avion-de-vivacolombia-en-ningun-momento-se-declaro-en-emergencia-241482
http://avherald.com/h?article=4a16583c&opt=0
http://www.pprune.org/rumours-news/587574-jet-goes-down-its-way-medellin-colombia.html

26 Comments

  • Here’s the leaked flight plan, which has not yet been verified as authentic: https://i.redd.it/iqo9wilsp51y.jpg

    You’ll note that the Total EET (Estimated Elapsed Time) for the flight and the Total Endurance (range) of the aircraft are both listed as 4 hours 22 minutes.

    The Colombians, however, state that the flight plan they received said that the aircraft was departing Cobija (the refuelling stop) for the final leg of the flight: http://www.eltiempo.com/politica/justicia/investigacion-tras-accidente-de-vuelo-de-lamia-en-antioquia/16764039

  • Silvia thanks for this article. I felt starved of well informed news on this crash. Mainstream journalism about this tragedy has been emotional and lightweight on facts.

    I am disturbed to read your final comments that this owner/Captain had gotten away with this gamble four time previously.

    Was he exploiting a loophole by filing a flight plan to Cobija Airport in Bolivia and then changing/updating his flight plan whilst en-route?

    Did this escape scrutiny by officialdom because it fell between three different national jurisdictions?

    If so how can cowboy operators be detected using loopholes between jurisdictions and is there any way that scrutiny can be applied?
    Is there any way to alert authorities to audit such operators?

    I know that charter operators in many countries get away with less regulation & oversight. Shouldn’t that be the reverse?

    • I know that charter operators in many countries get away with less regulation & oversight. Shouldn’t that be the reverse?

      I think that is becoming very clear!

    • The ‘loophole’ of which you write is a perfectly legitimate flight planning tool to allow an aircraft to reach an airfield just beyond its normal range. Normal range in this case is the maximum distance an aircraft can fly without burning its diversion fuel, contingency fuel and final reserve fuel. It is important to understand that this tool can only be used if the fuel burn to the decision point has been less than planned, thus allowing the ‘saved’ fuel to extend ones range and one is still required to finally land with at least final reserve fuel (enough for 30 mins flight) remaining in the tanks.

  • The previous comments sum it all up, but there remains a question: the relationship between the (surviving) owner and the government reeks of nepotism.

  • Another factor worth considering is that several news outlets showed an interview with Sisy Arias, the co-pilot of the plane, from before the flight. In this it’s made clear that this was going to be her first flight in this role. So from a CRM point of view this looks very dangerous. The captain is the co-owner of the company and is dangerously cutting corners, while the other pilot is very inexperienced and therefore unlikely to challenge his reckless decisions. Even worse, if she did her training at LaMia she might actually have been taught that stretching the fuel capacity to the limit in this way was a perfectly normal practice.

  • Sylvia, does that mean, am I correct: a pilot who had not even completed her training and therefore not yet qualified to act as a first officer was nevertheless acting as such? I have heard of “cowboy operators” but if this is true then this would be one of the worst cases I ever came across!!

    • I’m not sure. I’ve yet to see a definitive statement as to the flight crew. I presumed that meant there was a first officer on board along with the trainee, there is a jumpseat in the Avro RJ-85. But you may be right. What a mess.

  • It is interesting to know if the company carries a valid insurance for the passengers and at an international required level. Also important is to see how the airline is being managed; this is Accountable manager, post holders, etc.Where was the aircraft registered?

  • Friends working at Madrid Airport was telling me that most planes get delayed when arriving. Ryanair is flying with as little fuel as possible (I guess that’s good for efficiency) and helps when arriving by playing the “empty fuel” card each time to land earlier.

    • Well, flying with the minimum required fuel (including enough to divert *and* reserve fuel) is not really in the same class. In the instance in Spain where Ryanair flights declared an emergency, they’d been holding, then diverted, then holding again. They correctly declared an emergency once it was clear they were going to have to use the minimum reserves. If only this airline had done the same, or at least declared an emergency the moment he was asked to hold for another aircraft.

  • Jeesus. This looks an awful lot like a repetition of the mistakes made when Air Avianca flight 52 crashed on approach to New York.
    Anybody who thinks that South American airlines should maybe put more emphasis on fuel consumption and aircraft range/flighttime in their training?

    • Um, Avianca flight 52 was 26 years ago. I’m not sure you can draw conclusions about South American airlines based on two incidents that far apart…or at least if you do, then North America ends up looking pretty bad as well!

  • Would very much like to see a copy of the weight and balance chart for this flight.
    Whether it was manually written or computer produced the fuel figures should have shown up a problem and it should have been brought to the attention of the captain.

  • I remember “Manx2 Flight 7100” which crashed on its third attempt to land at Cork Airport. The aircraft did not crash due to fuel emergency but I’m just bringing up this incident to highlight how chartered airlines operate around the world. There was so much negligence and mismanagement. Everything has to be taken into account when a air crash occurs. It’s not just one factor that is responsible for a crash. Why is it that chartered airlines in some countries are almost not monitored for safety issues and aircraft maintenance. Is that too much to ask. One person loses his/her life or a 100 lose their lives, it’s somebody’s loss at the cost of what, saving money in some way or the other.

    • Funnily enough, I thought of the crash at Cork too. But in that instance, they used multiple countries to escape oversight in terms of training and safety. The various aviation authorities lost track of the operation. In this case, they don’t appear to have been regulated at all.

  • This pilot and co workers is a joke. Risking the lives of not only himself just to save a few bucks. Seeing there are claims that he had flown this exact same route before with minimal fuel reserves and landed on fumes, already indicates that he knew how risky this was.

    He could easily have diverted to Bogota before aiming for Medellin to refuel, regardless of whether Bogota itself was heavily trafficked upon arrival.

    And him only declaring an emergency after coming to the realization that his only choices left, was to rather be investigated or die trying to land this plane with everything all systems down, by than it was way too late. All because he was to stingy to spend a few bucks to refuel. That is what it comes down to, him not stopping to refuel could have made the difference to whether they live or die. If this was anything other than a fuel mistake, than one could understand and chalk this up to an accident.. But this was way to stupid, dumn and malicious to ever excuse.

  • I flew as flight engineer for almost 20 years for Lan Chile Airlines, and I never imagined this level of irresponsibility among a commercial flight crew-pilot. An aspect that should be considered is that the pilot was recently retired from the bolivian air force (actually was being prosecuted because his “retirement” was not complying air force regulations). The pilot was in essence a military pilot, and not a commercial pilot. Military pilot’s priority is the mission and not safety, and I think this did not allow Lamia pilot to act correctly. Anyway, what he did is unforgivable, he committed a crime, in legal terms seems to be something like unvoluntary homicide. The airlines got used to skip elementary regulations (I’m afraid they took off exceeding MTOW as well), many other persons inside and outside the airlines are also responsible for this disaster.

  • Stretching the flight by what actually amounts to swapping destination with an enroute alternate and using this trick to fly to a destination actually beyond legal range is fortunately not widely practiced.
    Manx, which has been referred to in a few comments, actually used to be a small but very professional little airline before it ceased its own operations and instead became a seller of tickets on aircraft operated under the same name. This had to do with a complicated process of switching the operating licence. Yes, unfortunately not only the passengers but also the authorities lost track of “who was who”.
    The passengers did not realise that they did not fly with the well-respected Manx Airlines but with an operator of doubtful standards, under the same name and I suppose flight numbers.
    I have been part of an operation that under the name “Shannon Executive Aviation” operated a Metroliner on a scheduled service between Shannon and Dublin. This company might well have cut some corners but certainly did not commit grave sins when it came to safety.
    They had to give up the route because of extremely bad luck with maintenance, unscheduled engine removals, the same engine when returned from the overhaul shop having an internal oil leak. This forced them to hire in another aircraft with crew and extend the lease unexpectedly. The final blow came when a pilot, at night, on his way to the hangar from a cargo flight, hit a taxi edge light with a propeller. The taxi route had been a disused runway, the tarmac was a lot wider than the section actually marked by the blue lights. One intersection marker had been inoperative and the pilot, seeing plenty of pavement, took the turn too soon. The prop was damaged and had to be sent for repair. The lamp was shattered so there was no evidence that it actually had not been working.
    But these things had nothing to do with the operational standards. Safety-wise the company met all standards, passengers were never exposed to unprofessional risk taking.

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