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RJ85, vicinity Medellín International (Rionegro) Colombia, 2016

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Revision as of 14:12, 20 June 2018 by Content.Manager (talk | contribs) (Investigation)
Summary
On 29 November 2016, a BAe Avro RJ85 failed to complete its night charter flight to Medellín (Rionegro) when all engines stopped due to fuel exhaustion and it crashed in mountainous terrain 10 nm from its intended destination killing almost all occupants. The Investigation noted the complete disregard by the aircraft commander of procedures essential for safe flight by knowingly departing with significantly less fuel onboard than required for the intended flight and with no apparent intention to refuel en route. It found that this situation arose in a context of a generally unsafe operation subject to inadequate regulatory oversight.
Event Details
When November 2016
Actual or Potential
Event Type
Air-Ground Communication, Human Factors, Loss of Control
Day/Night Night
Flight Conditions IMC
Flight Details
Aircraft BAE SYSTEMS AVRO RJ-85
Operator LaMia Airlines
Domicile Bolivia
Type of Flight Public Transport (Passenger)
Origin Viru Viru International Airport
Intended Destination José María Córdova International Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Descent
ENR / APR
Location - Airport
Airport vicinity José María Córdova International Airport
General
Tag(s) Inadequate Aircraft Operator Procedures,
Ineffective Regulatory Oversight
AGC
Tag(s) Low Fuel Status
HF
Tag(s) Plan Continuation Bias,
Procedural non compliance
LOC
Tag(s) Loss of Engine Power,
Flight Management Error
EPR
Tag(s) Delay in Declaration of Emergency,
Fuel Status
Outcome
Damage or injury Yes
Aircraft damage Hull loss
Injuries Few occupants
Fatalities Most or all occupants (71)
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation,
Air Traffic Management
Investigation Type
Type Independent
EDITOR’S NOTE: This summary is based on a Final Report released only in Spanish. The text of this Official Report has been unofficially and selectively translated and may therefore not reflect the original source with complete accuracy

Description

On 29 November 2016, a BAe Avro RJ85 (CP 2933) being operated by LaMia Airlines on an international passenger charter flight from Santa Cruz (Viru Viru), Bolivia to Medellín International (Rionegro), Colombia as LME 2339 declared a fuel related emergency shortly after encountering a traffic-related delay to its approach at destination. As ATC prioritised its approach from the south to runway 01 in night IMC, contact was lost and the aircraft was subsequently discovered to have crashed into terrain which was almost 1500 feet higher than the altitude of the airport 10nm further south. There was no fire but the aircraft was destroyed and 71 of the 77 occupants were killed, 5 sustained serious injuries and one was documented as “unharmed/minor injury”. Three of the four operating crew members, including both pilots, were amongst those killed and the surviving member of the cabin crew was one of those seriously injured.

The route flown. [Reproduced from the Preliminary Report]

Investigation

An Investigation was carried out by the Colombian Grupo de Investigación de Accidentes Aéreos (GRIAA). The FDR and CVR were recovered from the crash site and data relevant to the Investigation was successfully downloaded from both, although the CVR stopped recording for unexplained reasons 2 hours 57 minutes into the flight and the FDR stopped recording due to lack of electrical power just over 3 minutes before impact. Relevant ATC radar and voice recordings were also available.

Both pilots were Bolivian nationals and both held ATPLs. Shortly before the accident, the 36 year-old Captain had recorded 6,692 total flying hours which included 3,417 hours on type. Since 2013, he had been a part owner of the airline and involved in its management as well as being a Captain on its flights. He had 285 hours as an Instructor on the RJ85. The 47 year-old First Officer had 6,923 total flying hours which included 1,474 hours on type. He had 20 years service as an Officer in the Bolivian Air Force and since then had acquired P1 ratings for the B462 and the F27 and a P2 rating for the RJ85.

It was established that a Brazilian football team had chartered the aircraft to take them from Sao Paulo to Medellín (Rionegro) and then, four days later, to return from Medellín to Chapecó (Brazil) but the Brazilian authorities would not accept an airline which was not domiciled in either Brazil or Colombia operating these flights so it was arranged for another operator to bring the passengers from Sao Paulo Garulhos to Santa Cruz where they boarded the accident flight. The accident aircraft had earlier in the day positioned to Santa Cruz from Cochabamba.

When the dispatcher filed a FPL for a non-stop flight to Rionegro at FL 280 with an Estimated En-route Time (EET) of 4 hours and 22 minutes, it was found that the AIS Office had identified “inconsistencies” in it including that the fuel endurance given was the same as the Estimated Enroute Time (EET) to Rionegro and had requested that it should be changed and re-submitted. However, it was stated that the dispatcher had declined to change the plan in respect of any of the highlighted details and said that on the matter of the of the EET being the same as the endurance, “the actual flight time would be less than that on the plan”. The AIS Offfice accepted the FPL but sent a report to the Bolivian DGAC about the incident stating that under the relevant regulations, they were not empowered to reject it.

The Captain requested that maximum fuel (9,300kg) should be loaded whereas the Investigation found that the minimum fuel required to conduct the flight non-stop would have been 12,052kg, approximately 3 tonnes more than the maximum possible fuel load. An initial statement by an unspecified survivor was noted as including that the aircraft would make a refuelling stop at Cobija, a Bolivian airport en route and close to the Brazilian border but this airport only stays open at night by arrangement and on this evening, it had closed 25 minutes after the accident aircraft took off.

After departing from runway 34 at Santa Cruz with a third ‘Observer’ pilot occupying the flight deck supernumerary crew seat, the aircraft initially climbed to reach FL260 after 23 minutes. Then, after 8 minutes at that level, the climb was continued to the filed level of FL 280 which was reached 40 minutes after takeoff. After an hour at FL 280, a final climb to FL 300 was made. During the cruise, the CVR recorded conversations about fuel management and how best to optimise fuel use but about 2½ hours into the flight and shortly before transferring to Bogota ACC, one of the pilots remarked that they would divert their route to Bogota to refuel. However, when Bogota ACC then confirmed a more or less direct track towards the intended destination in Medellín TMA, CVR data indicated that this clearance had been enough to remove the option of a ‘Tech Stop’ at Bogota from the crew’s active consideration and an approach briefing for Rionegro was given. Apart from a very brief deviation requested by the crew for weather avoidance soon after check in with Bogota, the essentially direct track towards the destination was maintained. However, after 25 minutes on the ACC frequency, the CVR ceased recording for no identifiable reason.

After almost 4 hours airborne, FDR data showed that a LOW FUEL alert had been annunciated. At this point the aircraft was approximately 190 nm from destination, 135 nm from the airport at Cali and 77nm from the airport at Bogota. No mention of any fuel endurance concern was made to ATC and 13 minutes later, there was a change of ACC radio frequency as the flight was transferred from the Southeast Sector to the Northwest Sector. No mention was made of low fuel status on the new frequency either but after 5 minutes on it, descent from FL 300 to FL 250 was accepted as was a re-clearance to FL240 six minutes later. After 4 hours 21 minutes airborne, the flight was then transferred to Medellín APP and re-cleared to the RNG VOR at FL 210 - this VOR is 10 nm from touchdown on the extended centreline of runway 01 at Rionegro, the runway in use.

Then as the flight approached the RNAV waypoint at GEMLI, also on the extended centreline for runway 01 but at a range of just over 16 nm, the accident aircraft crew requested to take up the hold there at FL 210 aware that there were aircraft ahead at lower levels in the RNG VOR hold as well as one on final approach which had been given priority after reporting a “fuel leak” (see the illustration below). After one hold had been completed in 4 minutes by the accident aircraft, the crew, after 4 hours and 31 minutes airborne, asked APP for “priority due to a fuel problem” - the first time ATC had been made aware of any fuel endurance concern. The controller responded by offering radar vectors and an approach beginning in 7 minutes behind the first of the three aircraft below in the hold. This was initially accepted but three minutes later, a “fuel emergency” was declared and an immediate start of descent requested. In response, ATC cancelled the approach clearance just given to the aircraft ahead and approved descent which began at once with the thrust reduced and the air brakes extended. Flap 24 was then selected and the FDR-recorded airspeed began to steadily reduce. After 4 hours 35 minutes airborne, fuel starvation began to take effect. Engine 3 began to run down first, followed by engines 4, then 1 then 2 over a two minute period. Power to the FDR was lost soon after the final engine ran down and Mode ‘C’ returns ceased. The aircraft was 15½ nm from the runway (threshold elevation 6967 feet amsl) and the final recorded parameters were altitude 15,934 feet amsl with 115 KCAS and 142 knots ground speed.

The crew announced “a total electrical failure without fuel” to APP who replied that the runway was clear, that it was raining and that the Airport Fire Service had been alerted. Three minutes after the loss of FDR data, with the controller attempting to give guidance for track adjustment onto the extended centreline, the crew announced in their final transmission that they were passing 9,000 feet QNH and the controller replied that they were 8.2 nm from the runway. Within seconds, the aircraft had impacted sloping mountainous terrain just below the highest point on an approximate track of 310°. It was destroyed by the effects of this impact and a subsequent slide downslope of approximately 460 feet but there was no fire. Most of the wreckage was found at an altitude of 8,240 feet.

The track flown approaching and in the GEMLI hold also showing the accident site. [Reproduced from the Preliminary Report]

In analysing the assembled evidence, the Investigation highlighted various aspects concerning the conduct of the flight. These included, but were not limited to the following:

  • It was not possible to carry out an inspection of the fuel system because of the damage caused to it at impact but all other evidence pointed to fuel exhaustion as the primary cause of a loss of control.
  • The economic situation of the aircraft operator was deficient as a result of a lack of regular flights and this was also evident in the lack of a proper organisation and remuneration arrears to their employees. It was also found that the liability insurance maintained by the aircraft operator excluded operation of the accident aircraft in Columbia.
  • Operational safety at the Airline was deficient and without a clearly implemented Safety Management System, a risk management and tools to allow decision-making to maintain an adequate balance between productivity and safety. It was noted that the departure of the accident fight from Santa Cruz had been made 348 kg above the certified MTOW and there was no evidence that a copy of the load and trim sheet for the accident flight had been left at Santa Cruz and no copy of it was found at the accident site.
  • Considerable evidence was found that the airline involved had a history of not complying with the fuel policies established in its Operations Manual in relation to the minimum amounts to be carried on international flights.
  • The aircraft flew in RVSM airspace but although it complied with the technical requirements for such airspace, the requisite approval for entry to such airspace was not held.
  • The request by the crew to take up the RNAV hold at GEMLI was invalid as the aircraft operator’s approvals did not include that for the PBN operations which this required.
  • Neither pilot held a valid language proficiency certificate which was a requirement when conducting international flights. The Captain had previously held one but it had expired and the First Officer had never held one.

Four Probable Causes of the Accident were identified as follows:

  • The inappropriate planning and execution of an international flight, since the amount of fuel available to make the intended flight did not include reserve fuel or contingency fuel which are required by the applicable aeronautical regulations.
  • The sequential shutdown of all four engines while the aircraft was in the GEMLI holding pattern as a result of the exhaustion of all (useable) fuel on board.
  • Inadequate decision-making by the management of the aircraft operator attributable to a lack of focus on operational safety.
  • A loss of situational awareness and inappropriate flight crew decision-making after they had become fixated on continuing the flight with an extremely limited amount of fuel - they were aware of the low level of remaining fuel but did not take action to land at an en-route aerodrome to refuel so as to allow the flight to continue safely.

Seven Contributory Factors were also identified as follows:

  • The premature configuration of the aircraft for landing during descent in GEMLI holding pattern which reduced the aircraft’s gliding range as the crew sought to reach the designated landing runway at Rionegro.
  • Latent deficiencies in the planning and execution by the aircraft operator of non-scheduled public transport flights in respect of the amount of fuel required.
  • Some specific deficiencies in the planning of the accident flight by the aircraft operator.
  • A lack of supervision and operational control of the flight by the aircraft operator, which failed to oversee either the planning of the flight or its in-flight progress thus depriving the flight crew of decision-making support.
  • The absence of timely declarations to ATC requesting "priority" or declaring an "emergency" during the flight, especially when it became obvious that the remaining fuel endurance may be insufficient, which meant ATC could not respond appropriately.
  • A significant organisational and operational deviation by the aircraft operator from the procedures approved by the Bolivian DGAC when awarding its AOC.
  • A delay in the approach of the flight to the runway at Rionegro caused by its late request for priority and its late declaration of a fuel emergency which added to the complexity of managing traffic in the RNG VOR Holding Pattern.

A total of 11 Safety Recommendations were made as a result of this Investigation as follows:

  • that the DGAC Bolivia should 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. [REC 01-201637-1]
  • that the DGAC Bolivia should 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’. [REC 02-201637-1]
  • that the DGAC Bolivia should strengthen its normal 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. [REC 03-201637-1]
  • that the DGAC Bolivia should strengthen regulations on certification, inspection and monitoring of Air Navigation Services (ANS) and the extent of the resource that performs these functions. [REC 04-201637-1]
  • that the DGAC Bolivia should issue a document emphasising to air operators the need for strict compliance with procedures related to the planning and administration of fuel for all types of flight, especially in relation to the minimum amount of fuel to be on board for an intended flight. [REC 05-201637-1]
  • that the DGAC Bolivia should review procedures for approving and controlling English language proficiency of crews operating international flights to comply with the prevailing requirements. [REC 06-201637-1]
  • that the Bolivian Airport and Air Navigation Services Agency (AASANA) should optimise the management of ATS Notification / AIS management by implementing a control mechanism to verify that the Flight Plan fuel endurance complies with the regulations relating to its adequacy for the estimated flight time as a basis for accepting or rejecting a Plan. 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). [REC 07-201637-1]
  • that the International Civil Aviation Organisation (ICAO) should 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’. [REC 08-201637-1]
  • that the Aeronautical Authority of Colombia should implement a review by the Head of the Air Transport Office of the regulations RAC 3.6.5.6 and the GSAC 2.0-12-017, which deal with the authorisation of charter flights, with the instruction to improve and ensure compliance with legal, regulatory and operational safety by operators performing such flights. [REC 09-201637-1]
  • that the Aeronautical Authority of Colombia should improve coordination between the Directorate of Air Navigation Services and the Centre for Aeronautical Studies, 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. [REC 10-201637-1]
  • that the Aeronautical Authority of Colombia should publish, through the Secretariat of Safety and Civil Aviation, a document emphasising to air operators the need for strict compliance with the procedures covering the planning and loading of fuel for all types of flight, especially in relation to the minimum amount of fuel on board to be no less than that required for a flight. [REC 11-201637-1]

The Final Report of the Investigation has only been published in Spanish and although it is dated 16 August 2017, it was only released on 27 April 2018. A Preliminary Report published on 22 December 2016 was issued in English and Portuguese as well as in Spanish and although it is no longer an authoritative source now that the Investigation is complete and the Final Report has been completed, with this caveat, it may be useful to refer to this.

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