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Last updated: 16 November 2019
Estado:Final
Fecha:lunes 28 noviembre 2016
Hora:21:58
Tipo:Silhouette image of generic RJ85 model; specific model in this crash may look slightly different
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 LMI2933, 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:
cover
Investigating agency: Aerocivil
Status: Investigation completed
Duration: 1 year and 5 months
Accident number: COL-16-37-GIA
Download report: Final report

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 A3020

02:00 UTC / 21:00 local time:
SKRG 290200Z 00000KT 9999 BKN015 SCT200 17/16 A3023

03:00 UTC / 22:00 local time:
SKRG 290300Z VRB02KT 9999 -DZ BKN015 SCT080 17/16 A3025

04:00 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

Show all...

Fotos

photo of Avro-RJ85-CP-2933
photo of Avro-RJ85-CP-2933
location of surivors
photo of Avro-RJ85-P4-LOR
accident date: 28-11-2016
type: Avro RJ85
registration: P4-LOR
 

Video, social media

Aircraft history
date registration operator remarks
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.
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