2016-11-28 LAMIA Avro RJ-85 crashed near Medellin out of fuel
eaving the only aircraft of LaMia without insurance coverage.
The aircraft crashed into mountainside on descent to Medellin when it approached the airport from the south at night. On board was the brazilian football team Chapecoense. There were 71 fatalities and 6 survivors.
According to a CNN report, the insurance policy of the accident aircraft has been suspended in October 2016 because of non-payment of premiums leaving the only aircraft of LaMia without insurance coverage. Also mentioned was the fact that the insurance policy expressively excluded flights to Colombia, but LaMia carried out as much as eight flights to Colombia prior to the accident flight.
Aerocivil released the official Preliminary Report [DOWNLOAD LINK] (pdf)
On 2018-04-27 Aerocivil released the official Final Report [DOWNLOAD LINK] (pdf in Spanish)
Lamia flight LMI 2933 took off from runway 34 at Santa Cruz-Viru Viru Airport, Bolivia at 18:18L. It climbed to 28,000 ft (FL 280) and followed airway UA301 to Trinidad and Rio Branco VOR (Brazil) to Colombian airspace.
The en-route altitude changed to 30,000 ft. before the pilots began their descent to Medellin at around 21:30L. The landing runway in use at the time was runway 36, meaning the approach was carried out from the south.
It was dark at the time. The winds were calm. Light rain was falling at the airport. The approach was flown without further abnormalities. Minutes before there was a priority flight supposed to land ahead of them. VivaColombia flight VVC8170 from Bogota to San Andres reported their diversion to Medellin due to a suspected fuel leak. This traffic – an Airbus A320 – was turning to final approach when the RJ85 was instructed to enter a holding to give way to preceding traffic. At 21:43L LMI2933 accepted the instruction and began to fly a holding pattern at 21.000 ft (FL210) over the Rio Negro VOR, about 17 miles southeast of their destination airport
Whilst in the hold, LMI2933 continued the descent and the pilots indicated some kind of electrical problems. A minute later the pilots requested priority handling indicating fuel issues to Air Traffic Control (ATC).
After two circles, the aircraft canceled the holding and proceeded northbound its altitude gradually decreasing to 15,000 ft. and further down before radar contact was lost. Last indication on Flightradar24 showed an airspeed of just 142 Knots. In a distressed voice the pilots requested vectors (heading) towards the airport reporting they still fly on a heading of 360 (northbound). This was the last transmission of LMI2933.
© Aerocivil.gov.co | The flight route of LMI2933, at a point 2 h 57 min into flight the Cockpit Voice Recorder (CVR) ceased to operate.
The aircraft was found to have crashed against Cerro Gordo in wooded, downsloping terrain. (approx. coordinates N 05°58’49.8″, S75° 25′ 05.8″) It cut a swathe in the forest until it broke up and came to rest in many fragments. It appears the tail and parts of the empennage hit the northern crest of the mountain and broke off, the fuselage, wings and engines fell down right through the forest on the other side, coming to rest about 100 meters further down on a level clearing.
The crash site is only accessible by off-road vehicles. Ground fog hampered any helicopter rescue operations.
Aviation officials corrected earlier casualty reports. Only 68 passengers (not 72) boarded the flight bringing the overall number of occupants to 77. A total of 71 people are confirmed dead while six have survived the crash.
The accident location is about 18 Km (10 NM) away from the beginning of the runway.
Medellin is surrounded by mountains. In the area of the presumed accident site, the mountain summits reached an altitude of 11,000 ft (FL110) .
Bolivian Authority DGAC provided personal information about the flight crew in a press statement.(pdf)
METAR: Medellin-Intl Airport (SKRG):
METAR SKRG 290300Z VRB02KT 9999 -DZ BKN015 SCT080 17/16 A3025=
METAR SKRG 290200Z 00000KT 9999 BKN015 SCT200 17/16 A3023=
On 2016-12-26 Colombia’s Civil Aviation Authority Aerocivil reported the accident aircraft took off at Santa Cruz carrying a total weight of 42,148 Kg which was 348 Kg above the maximum allowable take-off weight. All flight crewmembers were aware of their precarious fuel situation but neglected to divert to Leticia or Bogota. During the hold over Rio Negro VOR, about 6 minutes prior ground impact, engine #3 (inner right) flamed out due to fuel exhaustion. 5 minutes before the crash, the flaps were lowered to pos 1 increasing drag followed by a further down to pos 2 whilst in the hold. Additionally, the landing gear was lowered . Engine #2 flamed out soon followed by the remaining two engines 4 minutes and 45 seconds before impact. Two minutes before impact the pilots declared emergency stating a total power loss.
© Aerocivil.gov.co | LMI2933was entering the holding at GEMLI waypoint and made two circuits before its final descent.
© Aerocivil.gov.co | Total fuel load was 9.300 Kg. All three fuel gauges on the panel indicated zero.
On 2018-04-27 Aerocivil released the official Final Report [DOWNLOAD LINK] (pdf in Spanish)
The Colombian Aerocivil accident investigation unit published its final report, highlighting the following accident factors:
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.
IMAGES and VIDEO
TIME (UTC) , Source of Transmission, Content
02:47:49 LMI2933 ‘Flight level two one zero inbound’
02:49:11 LMI2933 ‘Two one zero inbound request priority for the approach, a fuel problem has occurred’
02:49:37 ATC ‘Understand you request priority for your landing?’
02:49:44 LMI2933 ‘Affirmative’
02:49:49 ATC ‘Standby, I will give you vectors to proceed to the localizer and do the approach. Estimate seven minutes for approach’
02:50:00 LMI2933 ‘???? for vectors Lima Mike India two nine three three’
– ATC then cleared LAN3020, the aircraft holding at 17,000ft for the approach. –
02:50:57 ATC ‘Lima Mike India two nine three three say heading’
02:51:04 LMI 2933 ‘One seven nine on outbound’ 02:51:07 ATC to LMI 2933 ‘Keep present heading and wait to start [PAUSE] continue your descent’
02:51:12 LMI 2933 ‘We will keep present heading and are waiting’
02:52:04 LMI 2933 ‘Lima Mike India two nine three three request vectors for inbound Miss’
02:52:18 ATC ‘Standby I have an aircraft below you on the approach and in addition they are doing a runway check. How long can you remain on the approach?’
02:52:26 LMI 2933 ‘With fuel emergency Miss that why I request final course’
02:52:45 LMI 2933 ‘And request immediate descent, Lima Mike India two nine three three’
– ATC then canceled the approach clearance for LAN 3020 –
02:53:03 ATC to LMI 2933 ‘Lima Mike India two nine three three can you start your turn now to the right to start descent? You have traffic one mile below you.’
At 02:53:07 hrs the thrust levers were reduced and the aircraft commenced a descent. At 02:53:09 hrs the airbrake was extended
02:53:14 LMI 2933 ‘Traffic in sight, it’s not a factor and request proceed to localizer’
At 02:53:24 hrs the gear was selected down.
02:53:20 ATC to LMI 2933 ‘Captain you are at two one zero, I need to lower your level would have to maintain [PAUSE] turn to your right to start your descent’
02:53:29 LMI 2933 to ATC ‘Negative Miss. We’re now starting descent and we are going to the localizer’
At 02:53:36 hrs FLAPS24 were selected and the aircraft speed began to reduce and continued to do so until the end of the FDR recording. At 02:53:45hrs the Number 3 engine speed no longer matched the thrust lever demand and began to run down. 13 seconds later the same occurred on the Number 4 engine.
02:54:09 ATC ‘Lima Mike India 2933 you have traffic ahead of you 18,000 feet Alpha 320’
02:54:19 LMI 2933 ‘Identified in TCAS and we have it above us and we are in final course’
02:54:24 ATC ‘The aircraft is at 18,000 Captain traffic is now leaving to the left. Additionally, you have traffic that left 18,500’
02:54:35 LMI 2933 ‘In sight and we are at 18,000’
At 02:54:36hrs the FDR recorded FLAPS33 selected. At 02:54:47 hrs the Number 3 and Number 4 engine low oil pressure states were recorded on the FDR together with a MASTER WARNING. At the same time, over a 12 second period, the Number 1 engine N12 reduced from 39.5% to 29.0% and recovered.
At 02:55:04hrs the Number 2 engine speed no longer matched the thrust lever demand and began to run down.
02:55:06 ATC ‘Lima Mike India 2933 seventeen seven hundred, continue on the approach, runway damp, call the VOR one zero thousand if possible and if you require any ground service’
02:55:17 LMI 2933 ‘We will confirm you for ground service and we are through one six thousand for the localizer’
At 02:55:19hrs, over a period of 10 seconds, the Number 1 engine N1 reduced again, from 38.1% to 29.9%, and recovered. At 02:55:27hrs the Number 2 engine low oil pressure state and a MASTER WARNING were recorded on the FDR.
02:55:25 ATC ‘I remind you QNH 3027’ 02:55:28 LMI 2933 ‘3027’
Following the loss of all engines, at 02:55:48hrs the FDR ceased recording. At this time the FDR data showed that the aircraft was at a CAS of 115 kt, a ground speed of 142 kt and a pressure altitude of 15,934 ft msl.
The aircraft was 15.5 nm to the south of the threshold of Rionegro Runway 01 and 5.4 nm south of the accident site (which was at an elevation of about 8,500 ft amsl). Radar recording report indicates Mode C lost at 02:55:52hrs at which time there was only a primary radar contact for the aircraft.
02:57:10 LMI 2933 ‘Miss, Lima Mike India 2933 is in total failure, total electrical failure and without fuel’
02:57:29 ATC ‘Runway clear and operable, rain over station, Lima Mike India 2933, fire trucks on alert’
02:57:40 LMI 2933 ‘Roger, Lima Mike India. Vectors Miss, vectors to the runway.’
02:57:46 ATC ‘Radar signal lost, I don’t have you. Say heading now.’
02:57:55 LMI 2933 ‘We are with [PAUSE] with heading three six zero.’
02:58:01 ATC ‘With heading, turn left zero one zero, would proceed to localizer of Rionegro VOR 1 mile ahead of VOR, at this time you are at, correct, I confirm you [PAUSE] turn left heading three five zero’
02:58:18 LMI 2933 ‘Left heading 350 Miss’
02:58:20 ATC ‘Yes, correct, you are at 0.1 miles from the Rionegro VOR’
02:58:30 ATC ‘I don’t have you [PAUSE] with the altitude Lima Mike India’
02:58:38 LMI 2933 ‘9,000 feet Miss’
02:58:42 LMI 2933 ‘Vectors’
02:58:48 ATC ‘You are at 8.2 miles from runway’
02:58:53 LMI 2933 ‘Altitude’
02:58:54 ATC ‘What is your altitude now?’
NOTE: The direct distance from Santa Cruz-Viru Viru (SLVR) to Medellin-O Herrera Airport (SKMD) is 1605 nautical miles (equiv of 2975 Km). This distance is greater than the official maximum range of a standard Avro RJ-85, which is only 1600 nm (2965 km). To Medellin-Intl Airport (SKRG) the distance is exactly 1600 nm.
© BAE Systems Remote Runway Ops, Avro RJ-85 Range Performances
Green Line = RJ-85 Standard
Blue Line = RJ-85 Standard + Pannier (aux tank)
Olive Line = RJ-85 Standard + Pannier (aux tank) + Rear Bay tank
Red Line = RJ-85 Standard + Pannier (aux tank) + Rear Bay tank + Front Bay tank
Based to realistic calculations by the AviatonHerald there was no way the accident flight could have reached its destination legally without an en-route fuel stop.
Possible alternate aerodromes were Cobija, Tabatinga or Leticia but only Leticia would have been available for refuelling. (see map below)
© Skyvector.com | AviationHerald
FILED FLIGHTPLAN – LMI2933
Below is the original flight plan of LMI2933, believed to be genuine. The alternate aerodrome was Bogota (SKBO). The total flying time was set at 4 hours and 22 minutes (yellow box) a what experts said an ultra- long nonstop distance for a RJ-85 aircraft.
The document was signed-off by both the captain and the dispatcher.
The flight was chartered by the brazilian football team Chapecoense, Chapéco. The team was on its way to play the final of the Copy Sudamericana against Atletico Nacional de Medellin. Their itinerary consisted of a scheduled flight on board a Boliviana BOA 767 (OB739, CP-2881) from Sao Paulo-Guarulhos (GRU) to Santa Cruz-Viru Viru (VVI) where their ongoing aircraft (CP-2933 was already waiting for their boarding to the rest of the journey (LMI2933).
The team of Chapecoense before boarding their final flight LMI2933.
© RabonaApp | Twitter
FLIGHTPATH and TRAFFIC SITUATION
Flightpath (provided by Flightradar24)
According to Flightradar24 information, the traffic situation south of Medellin was complex at the time LMI2933 was approaching. Several aircraft had entered a holding pattern over RioNegro VOR. There were at least three landing ahead of the accident flight. One of them was VIVAColombia flight VVI8170 that previously canceled its flight to San Andres and diverted to Medellin-Intl Airport due to a suspected fuel leak. This flight requested priority handling as well.
(The ADSB-radar tracks provided by Flightradar24 may have a margin of error and inaccuracy.)
Type: Avro RJ-85
Age a/c: 17.7 years
Constr. No.: 2348
Previous owners: Mesaba Airlines (1999), CityJet Ireland (2008), LaMia (2013)
Occupants & Casualties
Date: 2016-08-28 Time: ~22:00L
Location: 20 NM SE of Medellin
Flight phase: ENR3 – Descent IFR Descent from cruise to Initial Approach Fix (IAF) or VFR pattern entry.
Damage to a/c: hull loss
Flight no.: LMI 2933
From: SLVR/VVI: Santa Cruz-Viru Viru Intl Airport To: SKRG/MDE: Medellín José María Córdova International
Operator: LAMIA Bolivia
JACDEC 25-year Statistics :
- 2nd safety occurence for the operator
- 28th safety occurence of type (Avro RJ-85)
– 2nd worst Avro RJ accident ever
- 11th safety occurence near Medellin Airport
- 2nd safety occurence for aircraft in question
– 2015-01-06 ran off taxiway at Tacna, Peru
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