Estado: | Accident investigation report completed and information captured |
Fecha: | lunes 28 noviembre 2016 |
Hora: | 21:58 |
Tipo: | Avro RJ85 |
Operador: | LaMia |
Registración: | CP-2933 |
Numéro de série: | E2348 |
Año de Construcción: | 1999-03-26 (17 years 8 months) |
Horas Totales de la Célula: | 21640 |
Ciclos: | 19737 |
Motores: | 4 Lycoming LF507-1F |
Tripulación: | Fatalidades: 3 / Ocupantes: 4 |
Pasajeros: | Fatalidades: 68 / Ocupantes: 73 |
Total: | Fatalidades: 71 / Ocupantes: 77 |
Daños en la Aeronave: | Destruido |
Consecuencias: | Written off (damaged beyond repair) |
Ubicación: | 18 km (11.3 milles) S of Rionegro/Medellín-José María Córdova Airport (MDE) ( Colombia)
|
Elevación del lugar del accidente: | 2600 m (8530 feet) amsl |
Fase: | En ruta (ENR) |
Naturaleza: | Vuelo Internacional No Programado |
Aeropuerto de Salida: | Santa Cruz-Viru Viru International Airport (VVI/SLVR), Bolivia |
Aeropuerto de Llegada: | Rionegro/Medellín-José María Córdova Airport (MDE/SKRG), Colombia |
Número de Vuelo: | LMI2933 |
Descripción:LaMia flight 2933, an Avro RJ85, was destroyed after impacting a wooded hillside south of Rionegro/Medellín Airport, Colombia. The aircraft carried the Brazilian Chapecoense football team for a match to Medellin.
Six of the 77 occupants have survived the accident. One flight attendant and four passengers survived with serious injuries and one passenger sustained minor injuries.
The initial plans were for LaMia to fly the Brazilian Chapecoense football team from São Paulo, Brazil to Medellin for the first leg of the 2016 Copa Sudamericana Finals against Atlético Nacional.
A refueling stop was planned at Cobija in northern Bolivia. LaMia requested a permit to fly from the Brazilian aviation authorities, ANAC, but this was denied as there were no provisions in the current aviation agreements between Brazil and Bolivia to allow such a commercial flight. The Chapecoense team was then flown to Santa Cruz in Bolivia on a regular commercial flight. This routing caused delays to the schedule and Cobija could no longer be used to refuel because of night time closure of the airport, according to the LaMia's general director.
The distance of the flight planned from Santa Cruz to Medellín was 2983 km. The flight plan of LMI2933 showed an estimated flying time of 4 hours and 22 minutes and a fuel endurance of the same time.
The flight crew calculated the takeoff weight to be 41,610 kgs, which was just below the maximum takeoff weight of 41,800 kgs. Investigators believe the luggage weight was underestimated and that the actual takeoff weight was 42,148 kgs.
At 22:08 UTC the engines of the RJ85 were started and permission was received to taxi to runway 34 for departure. Flight LMI2933 took off from runway 34 at Santa Cruz-Viru Viru Airport at 22:18 UTC.
The flight initially climbed to FL280 and later, at 23:54 UTC it climbed to FL300. En route the crew repeatedly spoke about the fuel calculations and the possibility of landing at Leticia or Bogotá to refuel, but it was decided to continue to Rionegro/Medellín. At 01:15 UTC the cockpit voice recorder (CVR) stopped recording.
At 02:36 hours, as the aircraft was descending through FL250, the Master Caution sounded in the fight deck, notifying the flight crew that they had 20 minutes worth of fuel left.
At 02:42 the Medellin Approach controller cleared the flight to continue their descent to FL210 and to head for the GEMLI RNAV point which is located about 30 km short of the runway 01 threshold at Rionegro/Medellín Airport.
At the same time, a VivaColombia Airbus A320, flight FC8170 from Bogotá to San Andrés, was diverting to Rionegro/Medellín due to indications of a fuel leak. Three other aircraft were in a holding pattern at FL190, FL180 and FL170.
At 02:45 UTC the flight reported entering the holding at GEMLI at FL210. Four minutes later the flight requested priority for landing because of "problems with the fuel". The controller then stated that she would get back with vectors to the localizer and that it would take seven minutes before they could commence their approach.
The controller then cleared a preceding flight, LAN3020, to start the approach.
At 02:52 UTC the controller reported to LMI2933 that there was another aircraft holding below them and asked if they could hold a little while longer. The flight then responded that they had a fuel emergency and requested a final approach course and immediate descent clearance. The controller cleared the flight to turn right before it could initiate descent. She subsequently cancelled the approach clearance of LAN3020.
At 02:53 selected full flaps and undercarriage down and used speed brakes in their descent. Then engine no.3 automatically shut down due to fuel exhaustion, followed by engine no.4. The flight crew did not notify the controller of this, but requested permission to immediately join the localizer. The controller assumed they were still at FL210, but the flight crew stated they were already in descent.
This forced the controller to issue instructions to the other aircraft in the holding pattern to manoeuvre them away from LMI2933. She warned the flight of another aircraft ahead at FL180. LMI2933 responded that the other traffic was on their TCAS above them and that they were on final approach course.
At 02:55 UTC engines no. 2 and no. 1 also shut down. At that time the aircraft was at 15,934 feet, 15.5 NM south of the runway 01 threshold.
At 02:57 the crew radioed in Spanish that they had suffered a "total electric total eh fault with no fuel". The controller reported that the flight was 0,1 mile from the Rionegro VOR and stated that she could not have altitude information of the flight. LMI2933 then reported being at 9000 feet.
According to the instrument approach procedure published in the SKRG AIP, the minimum altitude upon passing the Rionegro VOR is 10000 feet. During the last radio contact with the flight, the crew requested vectors for the runway. The controller stated that the flight was 8.2 miles from the runway. The aircraft impacted the top of a hillside at an elevation of about 2600 m. Part of the wreckage came to rest down the wooded hillside right next to the RNG VOR beacon, 18 km short of runway 01.
Probable Cause:
Causas probables
Inapropiado planeamiento y ejecución del vuelo, pues no se contempló la cantidad de combustible necesaria que se requeriría para volar desde el aeropuerto de destino a un aeropuerto alterno, ni una cantidad de combustible de reserva, ni el combustible de contingencia, ni el combustible mínimo de aterrizaje, cantidades de combustible que son requeridas por la normatividad aeronáutica para la ejecución del tipo de vuelo internacional que efectuaba el avión CP 2339.
Apagada secuencial de los cuatro (4) motores mientras la aeronave se encontraba en descenso en el circuito de espera de la posición GEMLI, como consecuencia del agotamiento de combustible a bordo.
Inadecuada toma de decisiones de la administración de la compañía explotadora de la aeronave, como consecuencia de la falta de aseguramiento de la seguridad operacional en sus procesos.
Pérdida de la conciencia situacional y equivocada toma de decisiones de la tripulación, que mantuvo la fijación de continuar un vuelo con una cantidad de combustible extremadamente limitada. La tripulación era consciente del bajo nivel de combustible remanente, sin embargo, no tomó las acciones correctivas requeridas para aterrizar en un aeródromo y obtener el reabastecimiento que le permitiera continuar el vuelo de manera segura.
Factores Contribuyentes
Configuración prematura de la aeronave para el aterrizaje, durante el descenso en el patrón de sostenimiento de la posición GEMLI, ya que, considerando la ausencia de empuje, esta configuración afectó la distancia de planeo del avión hacia la pista del aeropuerto de Rionegro.
Deficiencias latentes en el planeamiento y en la ejecución de vuelos de Transporte No Regular, por parte del explotador de la aeronave, relacionadas con el abastecimiento insuficiente de la cantidad de combustible requerido.
Deficiencias específicas en el planeamiento del vuelo accidentado, por parte el explotador de la aeronave.
Falta de supervisión y control operacional del vuelo por parte del Explotador, que no supervisó el planeamiento del mismo, ni su ejecución, ni efectuó un seguimiento del vuelo que hubiera permitido apoyar a la tripulación en la toma de decisiones.
Ausencia de llamados oportunos de prioridad, de emergencia u otros, por parte de la tripulación de la aeronave, durante el vuelo, y especialmente cuando era inminente el agotamiento de combustible en la fase de descenso y sostenimiento, que hubieran alertado a los servicios de tránsito aéreo para brindar el apoyo necesario.
Desviación organizacional y operacional por parte del Explotador en la aplicación de los procedimientos de gestión de combustible, pues no cumplía en la práctica, lo aprobado por la DGAC de Bolivia en el proceso de certificación de la empresa.
Demora en la aproximación del CP 2933 a la pista de Rionegro, originada por su tardía solicitud de prioridad, y tardía declaratoria de emergencia por combustible, sumada a la densidad de tránsito en el patrón de sostenimiento de VOR RNG.
Accident investigation:
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Investigating agency: | Aerocivil Colombia |
Status: | Investigation completed |
Duration: | 1 year and 5 months | Accident number: | COL-16-37-GIA | Download report: | Final report
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Fuentes:
»
rcnradio.com»
Exame.com»
ANAC Press release»
Medellin ATC audio, purportedly from the accident flight
METAR Weather report:
01:00 UTC / 20:00 local time:
SKRG 290100Z 01003KT 9999 SCT017 SCT200 17/16 A302002:00 UTC / 21:00 local time:
SKRG 290200Z 00000KT 9999 BKN015 SCT200 17/16 A302303:00 UTC / 22:00 local time:
SKRG 290300Z VRB02KT 9999 -DZ BKN015 SCT080 17/16 A302504:00 UTC / 23:00 local time:
SKRG 290400Z 00000KT 8000 DZ BKN015TCU SCT080 16/15 A3024 RMK RERA
Subsiguiente / acciones de seguridad
Aerocivil issued 11 Safety Recommendations
Issued: -- | To: DGAC Bolivia | REC. 01-201637-1 |
Review its policies and procedures for the surveillance of air operators, so as to ensure they are planned on the basis of a risk assessment exercise. |
Issued: -- | To: DGAC Bolivia | REC. 02-201637-1 |
Strengthen normal criteria on financial, operational and technical requirements, both during the certification process and in the surveillance of air operators providing transport services, whether domestic or international and whether for cargo or passengers, particularly for aircraft classified as large. |
Issued: -- | To: DGAC Bolivia | REC. 03-201637-1 |
Strengthen regulatory criteria for inspection, certification and surveillance of international non-scheduled air charter operations in order to verify compliance with the rules, subsequent to the granting of Air Operator Certificates (AOC). |
Issued: -- | To: DGAC Bolivia | REC. 04-201637-1 |
Strengthen regulations on certification, inspection and monitoring of Air Navigation Services (ANS) and the extent of the resource that performs these functions. |
Issued: -- | To: DGAC Bolivia | REC. 05-201637-1 |
Publish a document that emphasizes air operators strict compliance with the regulations related to the planning and administration of fuel for all types of flight, especially in relation to the minimum amount of fuel on board required to make a flight. |
Issued: -- | To: DGAC Bolivia | REC. 06-201637-1 |
Review the procedures for granting and control of language proficiency in the English language so that crews carrying out international flights comply with this requirement. |
Issued: -- | To: AASANA Bolivia | REC. 07-201637-1 |
Optimize ARO / AIS management through the implementation of a control mechanism that allows verifying flight autonomy and time in order to approve it or reject it in compliance with regulations.
Also, it should strengthen the Operations Manual and review the adequacy of the available human resources for provision and supervision of Air Navigation Services (ANS). |
Issued: -- | To: ICAO | REC. 08-201637-1 |
Review the Annexes to the Convention and relevant ICAO Documents and issue guidance to States in relation to financial, administrative and safety requirements which should be required of international charter operators, which are carried out on aircraft classified as large. |
Issued: -- | To: Aerocivil | REC. 09-201637-1 |
Conduct a review of RAC 3.6.5.6 regulations and GSAC 2.0-12-017 procedure which deal which deal with the authorization of charter flights, with the instruction to improve and ensure compliance with legal, regulatory and operational safety by operators performing such flights. |
Issued: -- | To: Aerocivil | REC. 10-201637-1 |
Improve coordination between the Directorate of Air Navigation Services (DSNA) and the Centre for Aeronautical Studies (CEA), in order to ensure that the academic programme at the latter that is given to ATC personnel corresponds to current operational needs and similarly, to review the Manuals to ensure that they incorporate the lessons learned from this accident and other events that have already occurred involving the provision of ATS. |
Issued: -- | To: Aerocivil | REC. 11-201637-1 |
Publish, through the Secretariat of Operational Safety and Civil Aviation a document that emphasizes to air operators the strict compliance with the regulations related to the planning and administration of fuel for all types of flights, especially those related to the minimum amount of fuel on board required to carry out a flight. |
Show all...
Fotos
location of surivors
accident date:
28-11-2016type: Avro RJ85
registration: P4-LOR
Video, social media
Aircraft history
26 March 1999 |
G-6-348 |
BAe |
first flight
|
30 March 1999 |
N523XJ |
Mesaba Airlines |
delivered
|
18 Sept. 2007 |
EI-RJK |
CityJet |
delivered, opf Air France
|
2 Oct. 2010 |
EI-RJK |
CityJet |
stored
|
16 Oct 2013 |
P4-LOR |
LAMIA |
|
Sept. 2014 |
YV3035 |
LAMIA |
new registration
|
Jan. 2015 |
CP-2933 |
LAMIA |
new registration |
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Santa Cruz-Viru Viru International Airport to Rionegro/Medellín-José María Córdova Airport as the crow flies is 2960 km (1850 miles).
Accident location: Exact; deduced from official accident report.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.