Jet goes down on its way to Medellin, Colombia

[Winterapfel]

Live: Aerocivil press conference with investigation update of the LaMia crash near Medellin #Chapecoense :
https://t.co/m6tOIjOfMB

[MotoMendez]

Bolivia closed its official investigation last week, issuing a final report last Tuesday and naming the pilot and company as directly responsible for the crash. Functionaries of AASANA and DGAC plus the flight dispatcher now in Brazil also received criticism and blame. There have been no public findings into the role of the highest authorities in Bolivian aviation (e.g. at ministerial level), in terms of how LaMia was allowed to continue to operate in light of information which has emerged since the date of the accident. In effect, the Bolivian government has sought to distance itself from any potential malpractice on its own part and close down the story. The ruling party (MAS) are currently under pressure over mismanagement of water resources and infrastructure which has led to water rationing here in La Paz. MAS is at the same time seeking to overturn the result of a February referendum which prevents incumbent President Evo Morales from standing for an (unconstitutional) fourth term. (This is the same President who claimed not to be aware of LaMia the airline, until footage emerged showing him recently posing for pictures onboard the incident aircraft in Rurrenabaque.) Opposition figures have conversely sought to establish and publicise links between LaMia and the Morales administration. Against this political backdrop, it should be of no surprise that the Bolivian government would rather that this story disappear.

The swift release of Bolivia's official final report led to criticism from Colombia's Director of Civil Aviation, who has stated that Bolivia has neither the faculty ("facultad", which can be translated as either authority or ability) nor competence to come up with such investigation findings. This in turn led to a statement from Bolivia's Vice President at a press breakfast on Christmas Eve that the Bolivian investigation report would serve as a contribution to the overall Colombian investigation, and that the final word regarding any immediate and underlying causes of the accident remains with Colombia.

Chapecoense de Brasil - Bolivia: Investigación a Lamia es "contribución" a Colombia | Latinoamérica | Mundo | El Comercio Peru (http://elcomercio.pe/mundo/latinoamerica/bolivia-investigacion-lamia-contribucion-colombia-noticia-1955851)

Chapecoense de Brasil: "Lamia y piloto son responsables de la tragedia" | Latinoamérica | Mundo | El Comercio Peru (http://elcomercio.pe/mundo/latinoamerica/chapecoense-lamia-y-piloto-son-responsables-tragedia-noticia-1954898?ref=nota_mundo&ft=contenido)

Colombia tiene la última palabra sobre el accidente - Diario Pagina Siete (http://www.paginasiete.bo/seguridad/2016/12/25/colombia-tiene-ultima-palabra-sobre-accidente-121643.html)

[alemaobaiano]

G1 have a brief rundown on the press conference given today by the Colombian authorities.

Avião da Chapecoense viajou com pouco combustível e excesso de peso, dizem investigadores | Mundo | G1 (http://g1.globo.com/mundo/noticia/aviao-da-chapecoense-viajou-com-excesso-de-peso-e-no-limite-de-combustivel-diz-investigacao.ghtml)

Overweight, crew were aware of the fuel situation, discussed two refuelling stops, and didn't advise ATC even with two engines out.

[MotoMendez]

This article was published in the Brazilian press an hour ago:

Colômbia responsabiliza órgão do governo boliviano por autorização irregular a voo da LaMia (http://extra.globo.com/esporte/colombia-responsabiliza-orgao-do-governo-boliviano-por-autorizacao-irregular-voo-da-lamia-20695334.html)

Key points include:

- Colombia's Secretary of Air Safety, Colonel Fredy Bonilla, holds AASANA (noted to be a Bolivian government body) responsible for the crash due to irregular authorisation of the flight plan.

- LaMia did not hold proper authorisation to carry passengers nor market national or international flights.

- Colombian civil aviation authorities have stated that according to the Chicago Convention they have sole responsibility for investigating the accident. This may be in response to the Bolivian "final report" already released.

- The flight was over permitted weight, in addition to Medellin being at the limit of its fuel.

- CVR evidence reveals that the pilots discussed making a refuelling stop in Leticia or Bogota. Colonel Bonilla states that the pilots were aware that fuel on board was neither adequate nor sufficient.

A comment on the article notes that alternative refuelling stops were also available in Brazil in Rio Branco and Tabatinga (the latter being right next to Leticia - the two are effectively one town with an international border down the middle).

[DaveReidUK]

Overweight, crew were aware of the fuel situation, discussed two refuelling stops, and didn't advise ATC even with two engines out.

The report confirms that the aircraft departed 500 kg overweight.

That is not considered a primary factor ("fator prioritário") affecting the outcome, though the previously posted RJ85 payload-range curve suggests that would have knocked about 20 nm off the range, so who knows ...

[MotoMendez]

Hey whats all this talk of whitewash? Thats the stuff of Politics, Governments, Enquiries etc, dedicated to finding someone, anyone, on whom to pin the blame. I dont ever recall hearing that said of an ICAO-mandated accident report only dedicated to digging out the facts and causes and coming to meaningful conclusions from which something can be learned. I am expecting Colombia's reports to be the usual high standard.
I agree. I would be less confident had the plane come down, say, next door in Venezuela, where the administration there would certainly be more sympathetic towards protecting Bolivian government interests, but I have full confidence that the Colombians will come up with a good report. Brazil as key stakeholder and the regional major power also has a big interest in ensuring that contributory factors to the incident are properly identified and good recommendations made.

[foxcharliep2]

The report and a reconstruction of flight and accident including ATC exchanges ( all in Spanish ) :

https://www.youtube.com/watch?v=9GXr8zQN6fY

[atakacs]

Not declaring an emergency with engines shutting down on them is just unbelievable. Absolute, utter madness.

[donotdespisethesnake]

The madness started well before that when they decided not to stop, when they knew fuel was a problem. The rest of the journey was conducted in a state of pure denial, their primary thought probably being "how will we cover this up?"

[unworry]

The report and a reconstruction of flight and accident including ATC exchanges ( all in Spanish ) :

https://www.youtube.com/watch?v=9GXr8zQN6fY

thanks @foxcharliep2 - very informative

9GXr8zQN6fY

[unworry]

a couple of screenshots from near the end of the preso

http://i.imgur.com/nnp4GLu.png

http://i.imgur.com/Fz7VSle.png


stills and aerial views of crash site starts here: https://youtu.be/9GXr8zQN6fY?t=23m32s

[averow]

Very true atatacs. Madness indeed. Just a lowly PPL myself but I do some legal consulting in my profession of Anesthesiology as an expert witness in malpractice. Hubris can be a real problem in Medicine as well as Aviation. IMHO these "cowboys" illustrated classic normalization of deviance: they got away with skeletal flight planning by being careless/reckless with fuel margins many times in the past on similar routing. The added "prestige" of taking this team and perhaps extra weight made for an even greater recklessness on their part. Utter madness and completely preventable.

[SteinarN]

Quote from the Aviation Herald with link:
Crash: LAMIA Bolivia RJ85 near Medellin on Nov 28th 2016, electrical problems, no fuel, impact with terrain (http://avherald.com/h?article=4a16583c&opt=7681)

On Dec 26th 2016 Colombia's Aerocivil introduced their preliminary report in a press conference (the preliminary report itsself was not released) stating, that the aircraft did not show any technical fault, there was no sabotage or suicide attempt. The evidence revealed the aircraft suffered fuel exhaustion. The crew was aware of their fuel status and considered fuel stops in Leticia (Bolivia) and Bogota (Colombia), however did not decide to perform such stops. The aircraft was operated at a takeoff weight of 42,148 kg, maximum takeoff weight permitted 41,800 kg, this takeoff weight was not a factor into the accident however. According to cockpit voice recordings the first officer and observer repeatedly calculated the fuel and considered a fuel stop in Leticia but did not follow up as they did not know whether the airport was open. The aircraft features a system that activates an alarm if the fuel remaining was no longer sufficient for more than 20 minutes of flight, however, this system did not activate. 10 minutes prior to impact the crew requested priority for landing and selected the first stage of flaps. The aircraft began to turn and descend without ATC clearance causing separation problem with the other aircraft in the hold. 6 minutes prior to impact engine #3 is the first to flame out, 5 minutes prior to impact the crew selected the next stage of flaps and selected the landing gear down, the crew advised ATC ground services were not needed. Engine #2 fails. 3:45 minutes prior to impact all engines had flamed out, the aircraft was without power, the APU also failed due to lack of fuel. 2 minutes prior to impact the crew declared emergency reporting total power failure. The aircraft impacted Cerro Gordo at a speed of 230km/h below 9000 feet when they needed to be above 10,000 feet to safely cross the mountain.

Seems like Lemme have been pretty spot on with his "investigation". Crew selected both flaps and gear down before the last engine flamed out. The last engine flamed out 3:45 min before impact.

[thcrozier]

Admittedly I haven't read this entire thread and all links herefrom, but the idea that Celia in Bolivia could have prevented this tragedy is ridiculous. Had she not accepted the laughable flight plan, they would have dismissed her and found someone else. That's just the way it is.

[DownWest]

Had she not accepted the laughable flight plan, they would have dismissed her and found someone else. That's just the way it is. Quote.

Yes, but she is an easy one to blame.

[portmanteau]

Celia would not now be hiding in Brazil if it wasnt for that endurance figure on the flight plan. We will never know why it appeared like that or even who actually wrote it in. It must be certain that it was not the captain so was it another crew member trying to send a signal? Having heard of Celia's efforts to get the fpl changed but to no avail,I cant believe that she would not have brought that to the attention of the duty Atco, probably only a room or so above her. If she did the Atco is just as much if not more to blame than Celia, even if he/she also failed to stop the flight ( for reasons already discussed), according to the Bolivians' logic.

[ATC Watcher]

Portmanteau :If she did the Atco is just as much if not more to blame than Celia,
Already discussed at length before , None of the 2 had authority to prevent a/c from departing. Easy scapegoats,for people that do not know how really the system works and want to pass the buck to lower echelons.That's all.

On a side note on the PLN : what is interesting in the report is the fact that they filed W in the PLN while the aircraft was not RVSM certified , and really flew at FL300.. also disregard of safety and implications for other aircraft .. Did not spot that one .
But one more thing in a long list ..

Lemme :Your speculations turned out to be quite correct , I have to say. . of course the engines did quit at different times as expected, , and a few bits we did not know before the report , but overall , not bad at all .Credits when it is due.
But do not take this as proof that it will always work like this in the future. I still maintain that to make such detailed speculations bring nothing , and if you are wrong , or if your calculations differ from the official report , it will cause more far more harm than good.

I already see in the EVA/LAX thread comments like " ADS-B ( e.g FR24) is better than radar " or " US controllers do not have to monitor and correct readbacks " etc.. statements posted as " facts" , and those arguments being used by others to call the EVA pilots and the controller various names and of course blaming / accusing . Dangerous games. Especially if there are victims and some of those victims family members look for immediate justice/ vengeance.

[catch21]

But Celia didn't accept the flight plan. It was stamped in the "Additional Information" box and she pointed out the short comings.

[AtomKraft]

Anyone who blames the recipient of the IFR flight plan, for this accident, is an idiot.

[safetypee]

A clearer understanding of what happened does not mean that all of the safety lessons have been identified.
Consider:- "the first officer and observer repeatedly calculated the fuel and considered a fuel stop in Leticia but did not follow up"
What was discussed, decided, and why. What were the calculations based on, gauge, fuel used, GNS/FMS.
Distance remaining, ground speed, wind, fuel flow; consider the fuel display switching between contents and fuel used, hold-on button or cyclic selection, seven segment digital display format ...

and:- "an alarm if the fuel remaining was no longer sufficient for more than 20 minutes of flight, however, this system did not activate."
Why didn't the warning system activate (two or four feed tanks, two or more separate alerts?), system failure, or was there something in the tank, what ...

http://www.pprune.org/rumours-news/587574-jet-goes-down-its-way-medellin-colombia-48.html#post9613312

[portmanteau]

ATC Watcher, perhaps you would advise how you know Celia and the atco did not have authority to prevent aircraft from departing. From Motomendes posts 1019 and1022 it is clear that both Colombia and Bolivia government officials believed that they did and I think they would know more about such matters than yourself.

[ATC Watcher]

portmanteau : I think they would know more about such matters than yourself.
To be honest with you I doubt they do. These statements look to me as just face saving exercises to hide their own regulatory shortcomings.
Unless Bolivia filed a difference with ICAO on Flight plan handling (mind you they might, I have no real wish to spend the time looking for it) under normal worldwide accepted standards, an ARO cannot refuse to transmit a PLN based on EET/Endurance figures.
Responsibility for filing those values and signing for it are the Pilot in Command and him alone.
As to the TWR Controller he would not know since those details are not part of ATC flight plan processing. End of story.

Explained already before .
Do not take for granted everything that "officials" are saying.

[Mora34]

I'm pretty disappointed that in the "preliminary report" video of the Colombian Aerocivíl they were pointing at her direction as well.

[snowfalcon2]

Another irregularity found is that the plane was allegedly not certified to fly above 29,000 feet, and in the flight plan submitted to Bolivia it was noted that it would fly at 30,000 feet. Approval of this flight plan, therefore, was not correct, Bonilla said.

I'm confused. In the FPL copy we've seen in the media such as here (http://www.pprune.org/rumours-news/587574-jet-goes-down-its-way-medellin-colombia-30.html#post9598286) the cruising level is entered as F280. No mention of 30,000 feet.

[DaveReidUK]

I'm confused. In the FPL copy we've seen in the media such as here (http://www.pprune.org/rumours-news/587574-jet-goes-down-its-way-medellin-colombia-30.html#post9598286) the cruising level is entered as F280. No mention of 30,000 feet.

Correct. FL300 was the actual cruising level for at least part of the flight, whereas the flightplan showed FL280.

[Hotel Tango]

Not that the RFL (Requested Flight Level) has any bearing on this. Aircraft will fly at levels other than their original requested level for numerous reasons, such as weather avoidance, ATC initiated level changes due to conflicting traffic, avoiding areas of turbulence etc.

[DaveReidUK]

Another irregularity found is that the plane was allegedly not certified to fly above 29,000 feetWhat's the source for that assertion?

The Type Certificate makes no mention of a 29,000 ft limitation.

[vmandr]

FL300 is RVSM level for which they had no cert (in AOC OPS SPECS) according to Colombians.

[condorox]

A clearer understanding of what happened does not mean that all of the safety lessons have been identified.
Consider:- "the first officer and observer repeatedly calculated the fuel and considered a fuel stop in Leticia but did not follow up"
What was discussed, decided, and why. What were the calculations based on, gauge, fuel used, GNS/FMS.
Distance remaining, ground speed, wind, fuel flow; consider the fuel display switching between contents and fuel used, hold-on button or cyclic selection, seven segment digital display format ...

and:- "an alarm if the fuel remaining was no longer sufficient for more than 20 minutes of flight, however, this system did not activate."
Why didn't the warning system activate (two or four feed tanks, two or more separate alerts?), system failure, or was there something in the tank, what ...

http://www.pprune.org/rumours-news/587574-jet-goes-down-its-way-medellin-colombia-48.html#post9613312

Don't know what were the calculations based on, but according to th preliminary report press
conference statement, the PIC concludes that they would need to make as fuel efficient approach as possible.

On the fuel alarm, that is a misreporting. It did go off according to the FDR.
The mis-report may come from the wording. What is said in the press conference is that the alarm had NOT gone off by the time Bogota control handed over the flight to Medellín control (21 minutes before the crash), but that it did go off 2 minutes after that, so 19 mins before the crash.

[Hotel Tango]

Well, they would have been cleared to FL300 by ATC. Still has no real direct bearing on the accident itself though.

[DaveReidUK]

FL300 is RVSM level for which they had no cert (in AOC OPS SPECS) according to Colombians.

True, but that's a clearance issue, nothing to do with aircraft certification.

According to the TC, the aircraft would have been certificated for a maximum altitude of between 31,000 and 35,000 ft, depending on mod state. I can't find a 29,000 ft certification limit anywhere.

[vmandr]

Dave

what I meant is in the Ops Specs of an AOC it is defined whether they are MNPS, RNP, RVSM, ILS CAT II etc certificated, and apparently there was no RVSM authorization by the state issuing the AOC. so after FL280 next level is FL310 and after FL290 next is FL330 (semi-circ rule).

so by entering 'W' in item 10, of ICAO FPL they -falsely- declared to ATC they were RVSM certificated, so ATC granted the request for FL300.

[noflynomore]

Overweight, crew were aware of the fuel situation, discussed two refuelling stops, and didn't advise ATC even with two engines out.

As stated by many of us this "accident' was clearly a result of a macho, rule-averse crew working in an inadequately regulated and nepotistic environment who lacked the "professionalism" (lower case intended) or judgement to even declare their error when it must have been clear that it was of fatal proportions.

As the engines began to fail they clearly had the altitude to glide directly to the field yet declined to do so, preferring to pursue a fatal 3-dimensional flight pattern that saw them squander their glide range immediately in a max-drag descent that ate up no distance to home in order to capture an utterly inappropriate glideslope that was clearly only attainable to a powered aircraft, but not a glider.

With all the pre-flight showboating, big I AM pics, and load of high-level high-living pax could they have been partaking too much of the cabin fever that surrounds such prima-donnae - Peruvian Marching Powder perhaps? I can't think of anything else that would make sense in this most senseless of crashes.

How else can you rationalise deliberately flying beyond your available range, deliberately passing en route fuel stops, deliberately arriving at destination with a fraction of required fuel, deliberately going into a hold and saying nothing, losing engines due to fuel starvation and STILL saying nothing...

They clearly weren't in their right minds. Given the nature of the pax perhaps recreational pharmaceuticals played a part?

[portmanteau]

noflynomore, but was it "the crew" or all down to just the captain? The description by Colombia Civav of the discussions around fuel do not indicate whether there was collusion or argument at any point. Yes we know that aviation accident reports are not concerned with apportioning blame so it is to be hoped that someone in the blame department will make clear one day who, if any, of the crew, can be exonerated from it. This is surely required out of respect for the dead and the comfort of their families.

[MotoMendez]

Confirmation that Bolivia's airport administrator, AASANA, refused Colombian investigators access to the recordings of communications between tower and pilot during takeoff.

Caso LaMia: Colombia revela graves anomalías en Bolivia | Erbol Digital (http://www.erbol.com.bo/noticia/internacional/26122016/caso_lamia_colombia_revela_graves_anomalias_en_bolivia)

[deadheader]

"They clearly weren't in their right minds."

You are of course correct. However, that is not necessarily the result of the mind-altering substances. The pattern of miscalculation and escalation throughout this tragedy also fits known sociopathic behavioural traits. The constant raising of the stakes when facing diminishing returns, ever greater risk taking in order to hide a dishonest act, is a common occurrence in certain personality profiles.

The total lack of regard for professional, moral and legal standards displayed by this skipper is a telltale sign, as is his de facto criminal attitude towards the safety of all those aboard.

I'm willing to bet that learning about his dealings with close associates will make for some very interesting reading indeed. But, for that reason, I think it unlikely we ever will.

IMHO

[portmanteau]

21 page preliminary report in english at aerocivil.gov.co/aeronautica civil/accidentes 2016 .Report has been added to the list someone mentioned earlier. some surprises in there, including cvr stopped 01hrs:45 mins before crash. No loadsheet located yet. etc

[Snyggapa]

Direct working link to the report, in English

http://www.aerocivil.gov.co/autoridad-de-la-aviacion-civil/investigacion/2016/English%20-%20Preliminary%20Report%20CP2933%20V01%20-%20STATES%20REVISION.pdf?Web=1

[dsc810]

So the CVR mysteriously stopped 1 hour 40:45 minutes prior to the accident.
Now I'm sure we are all going to be very interested in why this might have been and in particular whether it was (indeed if it can be) deliberately switched off by the crew.

[Hotel Tango]

I believe it can be switched off simply by pulling the appropriate CB.

[noflynomore]

Twelve minutes from the start of the landing brief to the CVR becoming inop and not a word about what was said. Methinks there must be some telling information in those passed-over 12 minutes but I suppose we can only wait for the Colombian authorities to reveal what it was.

[MotoMendez]

Legal action will be taken against the Regional Director of AASANA Santa Cruz by the Bolivian government for not cooperating with the Colombian investigators.

Caso LaMia: Director de Aasana Santa Cruz será procesado por no cooperar con Colombia - Diario Pagina Siete (http://www.paginasiete.bo/seguridad/2016/12/28/caso-lamia-director-aasana-santa-cruz-sera-procesado-cooperar-colombia-121925.html)

[MrSnuggles]

This really is a hornet's nest full of, let's say, surprises.

A dodgy operator with suspicious connections and cowboy attitude to everything that is survival has obliterated a whole football team. Why is the Bolivian gouvernment that thick? Damn it, I heard (and this is no joke) that they cancelled the postal services there because the prez thinks it is too expensive.

[Passenger 389]

Re: why the CVR ceased recording

1. Most likely (but NOT only) scenario seems to be CB pulled to conceal what was being discussed or might be discussed -- from fuel situation to 'we did it before' or the financial and other implications if they did stop for fuel, or any discussion of how airline got the contract or would get others, or ???

2. Yet it seems premature to rule out another possibility: that someone with access to the cockpit other than the Cptn -- whether FO, "observer," or ??? -- who heard or learned of the fuel discussions -- pulled the CB to preserve a CVR record of what had been discussed thus far, including that Cptn (and others) knew short on fuel yet decided against stopping.

Perhaps this person had disagreed with the decision and wanted that dissent recorded. Or simply had no say in the matter.


3. The "to preserve a record" scenario admittedly is less likely than "to coverup what was going to be said thereafter" scenario.

But we don't yet know what is on the portion of the CVR that was preserved. Some related info might also be informative (eg, was someone momentarily out of the cabin when the CVR stopped recording? Was the CB accessible from the observer position, or ?)


4. In theory the stoppage also could have been unintentional. But that seems relatively low on the probability list.

[M68]

Considering the force of the impact (several people survived the crash) wouldn't it be quite likely that the circuit breaker for the CVR was preserved well enough so that the state it was in could be determined?

[DuncanF]

...

3. The "to preserve a record" scenario admittedly is less likely than "to coverup what was going to be said thereafter" scenario.

...
What makes no sense was that the CB was pulled to cover up some discussion, as that would imply that they were planning to crash and therefore have the CVR reviewed. There was some dumb thinking at the pointy end of this flight, but not to the extent of planning to crash and thinking ahead to deceive the accident investigation. :ugh:

[catch21]

I'm struggling to pull any clear lessons out of this apart from the blindingly obvious ones.

It seems that some regions should be taking a good look at themselves and their practices. Apart from that, what the heck??

Being prepared? One thing that has struck me about this from page 1 is that the crew seemed inexplicably and entirely unprepared for the imminent and inevitable fuel exhaustion situation.

Is there anything to be learnt from this?

[DaveReidUK]

What makes no sense was that the CB was pulled to cover up some discussion, as that would imply that they were planning to crash and therefore have the CVR reviewed.

Well that's one explanation, I suppose.

The CVR stopped recording roughly 1 hour 45 minutes before the end of the flight. In the final 30 minutes of recording there was discussion on whether or not to divert to Bogota to refuel.

While the CVR recorded a decision not to do so, it seems highly likely that as the fuel state became more apparent there would have been further debate about how fine they were cutting things. If so, it's no surprise that the crew would not want that discussion recorded.

[EstorilM]

What makes no sense was that the CB was pulled to cover up some discussion, as that would imply that they were planning to crash and therefore have the CVR reviewed. There was some dumb thinking at the pointy end of this flight, but not to the extent of planning to crash and thinking ahead to deceive the accident investigation. :ugh:
Nah, the guy was part-owner of the company, and understood the liability involved with the horrible decision-making which got them into the mess they were clearly in at that point of the flight. This is further implied by his obvious reluctance to declare an emergency, regardless of fuel warnings, which provides an important clue into his (perhaps "their") frame of mind re: deception and liability.

He also realized (I'm guessing, based on their prior experience) that punishment for operating commercial aircraft with a couple gallons of fuel remaining by the time they get to the gate is BAD. I believe there were some stories, documents, etc which hinted at this in past ops with them, like when they flew the same route successfully, they'd obviously be bingo fuel.

They could easily (try) to claim some mistake on the part of the ground crew, fuel calculations, etc - but it wouldn't necessarily imply criminal intent. I'm guessing whatever was said in that cockpit in the last 30 min of that flight CLEARLY showed criminal intent, like "well boss, we knew it'd catch up to us some time!" "damn, I knew we were close but I can't believe it's actually happening" or "ok, once we get on the ground, if we need a tug what's our story going to be? Shred that fuel calculation sheet for me" - etc etc etc.

That's very different than just playing dumb.

A crash implies death, though I guess that's not usually how a pilot would think gliding in dead stick - but still, I think if they actually pulled CVR CB, it was because they were more worried they'd land intact after having to declare emergency, priority, etc.. and be met by govt. officials after landing. Especially considering there was already an active arrest warrant out for one of the guys.

[neila83]

As stated by many of us this "accident' was clearly a result of a macho, rule-averse crew working in an inadequately regulated and nepotistic environment who lacked the "professionalism" (lower case intended) or judgement to even declare their error when it must have been clear that it was of fatal proportions.

As the engines began to fail they clearly had the altitude to glide directly to the field yet declined to do so, preferring to pursue a fatal 3-dimensional flight pattern that saw them squander their glide range immediately in a max-drag descent that ate up no distance to home in order to capture an utterly inappropriate glideslope that was clearly only attainable to a powered aircraft, but not a glider.

With all the pre-flight showboating, big I AM pics, and load of high-level high-living pax could they have been partaking too much of the cabin fever that surrounds such prima-donnae - Peruvian Marching Powder perhaps? I can't think of anything else that would make sense in this most senseless of crashes.

How else can you rationalise deliberately flying beyond your available range, deliberately passing en route fuel stops, deliberately arriving at destination with a fraction of required fuel, deliberately going into a hold and saying nothing, losing engines due to fuel starvation and STILL saying nothing...

They clearly weren't in their right minds. Given the nature of the pax perhaps recreational pharmaceuticals played a part?
I can think of few passanger loads less likely to be indulging in recreational drugs than a Brazillian professional football team on their way to the most important game of their lives.

I think deadheader has it right.

[noflynomore]

how a pilot would think gliding in dead stick

But it seems they didn't think of gliding it in - they appear to have set up a dirty dive for the localiser at or near the RioNegro VOR as though they were intending a standard 3' approach and continued in this full drag config even as engines failed and they squandered life saving height - so much height that they could still have reached the field even as the first engine failed if only they'd been at min clean sped and gear up.

[sandiego89]

There have been several comments speculating that the co-owner/crew may have been worried about the repercussions about a safe arrival without adequate reserves. Could someone explain how that would have worked at this arrival airport if they had made a safe arrival but on fumes? Process? What do they submit and who checks and how do they verify? Sorry if I missed it.


Thank you in advance.

[vmandr]

the easy answer would be, they could have had the AOC, crew licences, suspended and possibly a fine too, if poor planning on the part of the company / crew was proven to be the cause.

[Chronus]

Bolivian operator and licensed crew, hence Colombia not being the issuing authority cannot pull licences. Most severe, but most unlikely consequence, a ban from Colombian airspace for the operator.
To answer sandiego89`s question in full, Medellin ATC would have written it up and filed it with aerocivil, that is if they had not made it to the gate but needed a tow off the rwy. As some distruption would have ensued to operations. Should they however managed it to the apron, chances are nothing further would have happened.

[DirtyProp]

I'm struggling to pull any clear lessons out of this apart from the blindingly obvious ones.

It seems that some regions should be taking a good look at themselves and their practices. Apart from that, what the heck??

Being prepared? One thing that has struck me about this from page 1 is that the crew seemed inexplicably and entirely unprepared for the imminent and inevitable fuel exhaustion situation.

Is there anything to be learnt from this?

Yes, there is.
The right attitude and the right mindset can and will make all the difference in the world, esp in our industry.
It doesn't matter how many rules, regulations, safety checks you can come up with. If someone is willing to deliberately ignore and violate them, they are totally useless.

[ams6110]

But it seems they didn't think of gliding it in - they appear to have set up a dirty dive for the localiser

As others have observed here more than once, what competency did this crew and operator demonstrate that in any way makes you think they would be prepared and able to handle a nighttime complete loss of power when the inevitable happened?

I don't think they thought of gliding it in. I don't think at that point they were thinking at all. Just shouting "vectors! vectors!" and staring desperately out the window hoping to see runway lights.

[EstorilM]

noflynomore - True - and I agree, which was very poor airmanship (or, a continuation of poor airmanship, which shouldn't surprise me given what we know now!)

I simply mentioned it as an observation into what their frame of mind may have been regarding pulling CVR CB's, which has about an entire book of (albeit) circumstantial evidence at this point.

Also as far as what the ramifications would be for landing dry on a commercial flight; as many have said, there would be significant actions against the pilots and carrier, plus subsequent investigations most likely - BUT (again, re: thought process of potentially pulling CVR CB's) if they had to declare an emergency or even mention some type of fuel problem, etc, they'd almost certainly be under Govt investigation - as I assume that's SOP out there as well?

Again, without the CRV they gain some level of deniability - but that's almost guaranteed to be totally out-the-window based on what was probably said in the last 30 min of that flight.

I'm curious if this had been done previously? I wouldn't think it's exactly second nature to reach up (behind?) and yank a CB in the middle of a crisis. Given the continued evidence of sustained 'normalization of deviance' ops by the carrier and specifically, that PIC (who again, had an arrest warrant out on him!) I wouldn't put it past him to pull the CVR CB's on some of the other tight fuel flights.

In fact, at that point in the flight, there probably wouldn't have been any significant difference from their other extreme-range flights on that aircraft in the past. No obvious reason (at that point) to pull the CB, unless (again) it became "a thing" as they approached bingo fuel on these flights.

How long do these CVR's record? Did we figure out the model? I know some of the more modern units record for a LONG time. I'd assume the investigators went back to check if there were cut-outs towards the end of other flights.

[ungoliat]

English preliminary report:
http://www.aerocivil.gov.co/autoridad-de-la-aviacion-civil/investigacion/2016/English%20-%20Preliminary%20Report%20CP2933%20V01%20-%20STATES%20REVISION.pdf?Web=1

[jack11111]

No fooling around...says "fuel exhaustion" on cover page.

[MotoMendez]

This really is a hornet's nest full of, let's say, surprises.

A dodgy operator with suspicious connections and cowboy attitude to everything that is survival has obliterated a whole football team. Why is the Bolivian gouvernment that thick? Damn it, I heard (and this is no joke) that they cancelled the postal services there because the prez thinks it is too expensive.
That ECOBOL (post office) issue is an ongoing saga. Unfortunately the maladministration and lack of effective governance that seems to have contributed to this LaMia accident is typically Bolivian (and nothing new; in 1878 they started a sea war with Chile despite having no navy, losing their entire coastal region and access to the sea ever after).

It will be interesting to see what fallout if any is suffered by BoA and Amaszonas, Bolivia's two operators of scheduled international passenger services.

With regard to Bolivian airlines operating at the limit of their fuel, in the mid 2000s a friend of mine was travelling on a Lloyd Aéreo Boliviano 767 non-stop service from Madrid to Santa Cruz. At the time the airline was in financial crisis and it eventually ceased operations for good in 2008. The plane made a landing at a Brazilian air force base on Brazil's northern Atlantic coast, and couldn't leave until the passengers had a whip-round to pay for more fuel to get them to VVI.

[noflynomore]

Anyone care to comment on what it takes to get and keep a Bolivian type rating?

Are we at risk of making a W European assumption that the "must" have done all the sim exercises in the BAe syllabus? Or do they concentrate on just operating the thing normally and leave out some of the more esoteric emergencies such as loss of all engines and glide approach? Are these less common emergencies things routinely practices in the sim as we all do in Europe - or maybe you were shown them once on the conversion course and they never appear again?

I'm wondering if these clowns even knew how to glide it in - they seem to have displayed no knowledge of any such technique and even while still in glide range of the field when doing so stood a chance of a landing but failure to do so was guaranteed fatal they left full flap and gear down diving at a glideslope that they could not achieve without power?

Perhaps they simply didn't know how?
What depth of skills and knowledge does one expect in that part of the world?

[Hippy]

Anyone care to comment on what it takes to get and keep a Bolivian type rating?
Knowing the right people and/or greasing the right palms, it would appear. :rolleyes:

[broadreach]

In an earlier post I suggested we not hold our breath waiting for the preliminary report. I based that comment on having seen how long it usually takes Aerocivil/GRIAA to get the reports out. LaMia was obviously a different case. I should have realised this and I apologise to anyone I may have offended with my remark.

Having just read the report - and seen the earlier PowerPoint presentation - I’m beginning to think the captain may actually have decided, when the engines began to quit, that they'd never make Rio Negro, that a crash was inevitable and that his only option was to drop all the anchors and do so at the slowest possible speed.

[donotdespisethesnake]

That might have been his only option, but surely he would have warned at least his colleagues in the cabin of his intent? Quite possibly more would have survived if they had been prepared.

This pilot was no Sully, but despite his workload Sully managed to address the cabin with three short words : "brace for impact."

[broadreach]

FCS! It was obviously not his only option, as we see it in 20/20 hindsight. I was just suggesting that, in the life/death mindset of the moment, it might have seemed, to the captain, the best solution.

[Passenger 389]

On 31st Dec 2016, 21:17, broadreach wrote:

Having just read the report - and seen the earlier PowerPoint presentation - I’m beginning to think the captain may actually have decided, when the engines began to quit, that they'd never make Rio Negro, that a crash was inevitable and that his only option was to drop all the anchors and do so at the slowest possible speed. Respectfully, I'm unable to discern the basis for your conclusion, having carefully reviewed the detailed chronology in the Preliminary Report that combines FDR data (until it stopped recording) with the radio communications between LaMia 2933 and ATC.

Everything in that chronology seems to point to the opposite conclusion - that they "drop[ped] all the anchors" in an effort to descend rapidly to reach the glideslope (the one for 'powered' planes, not gliders).

The chronology indicates they set flaps 18, reduced thrust, extended speedbrakes, lowered the landing gear, then set flaps 24 and eventually 33.

All that was done before the FDR stopped recording, approximately 3 minutes prior to the crash, when it showed "a CAS of 115 kt, a ground speed of 142 kt and a pressure altitude of 15,934 ft msl."

And it was done at a time when they needed to maintain sufficient altitude to clear the mountains between them and the airport (or even to reach the flatter terrain beyond the mountains).

And most of it was done as they were requesting from ATC (or undertaking) an immediate descent toward the localiser and final approach.

Even while they were losing engine power -- and continuing after they lost engine power entirely -- they appeared to have been fixated on trying to reach the glideslope, and kept urgently requesting "vectors" to the runway.

11 seconds before the final recorded communication, they were still requesting "vectors."

Experienced pilots and/or accident investigators may see something I have overlooked. And the Report lacks (and will lack) the benefit of a CVR for the relevant time window.

However, I see nothing that suggests they were looking for a place to set the plane down short of the runway, and that is why they 'drop[ped] all the anchors' (as you put it.)

On the contrary, the timing seems all wrong for such a scenario. The "anchors" already had been dropped by then.

[neila83]

In an earlier post I suggested we not hold our breath waiting for the preliminary report. I based that comment on having seen how long it usually takes Aerocivil/GRIAA to get the reports out. LaMia was obviously a different case. I should have realised this and I apologise to anyone I may have offended with my remark.

Having just read the report - and seen the earlier PowerPoint presentation - I’m beginning to think the captain may actually have decided, when the engines began to quit, that they'd never make Rio Negro, that a crash was inevitable and that his only option was to drop all the anchors and do so at the slowest possible speed.

Perhaps you could learn from your earlier post and think a little harder before posting?

[ciderman]

Knowing the right people and/or greasing the right palms, it would appear. :rolleyes:
Can anyone explain how a 36 year old Bolivian managed 3417 hours in a 146/RJ? He must have operated in Europe at some time. Anyone heard of him?

[Trebar]

Perhaps he previously flew for TAM the Bolivian Air Force's airline, which operates the same aircraft type?

[Mora34]

Can anyone explain how a 36 year old Bolivian managed 3417 hours in a 146/RJ? He must have operated in Europe at some time. Anyone heard of him?
He was previously employed by TAM before starting "his own" airline. TAM has 6 146's on it's fleet according to Wikipedia. So it's somewhat plausible.

[svhar]

There is nothing logical about this flight and this crew. It was doomed before takeoff.

[H Peacock]

Despite clearly being well above ILS glide-path when in the hold, these guys could surely have tuned in to get a valid localiser signal. Despite the shocking decision on the plan v range issue, it looks as if there was no absolutely no attempt by them to think ahead about the likely loss of all 4 engines and the associated loss of electrical power.

It was clearly a shock to them all when the lights and PFD/MFDs went out, but I'm still amazed they didn't ensure they maintained a position with enough height/range to enable them to reach the field.

[safetypee]

Assuming that the FDR stopped recording with the loss of essential electrical power, an indication that all engines had failed, then the previous selection of wheels and flap down could indicate some aspects of standard operation. The crew appeared to have set up for a 'normal' approach, perhaps also indicating a weak understanding of the fuel state.
(I hope that someone will be able correlate the loss of FDR with the ATC timelines and crew communication).

Lack of fuel awareness might be interpreted by the 'bad apple' theory of human performance (illogical, irrational thought / rouge behaviour), but a more tempered view of the crew's lack of concern probably represents their joint view of the situation at that time - normal behaviour (rational thought.)
Alternatively this could suggest that the crew did not look, appreciate, or have accurate indications of fuel quantity, or even any indication at all (MEL?); we don't know.
And of course there are many options between these views, again we don't, and may never know.
Faced with a total loss of power, the very surprising realisation that fuel had run out, and the inability to retract flaps and gear, then there would be very few options. If the crew knew where the airfield was (not indicated by ATC comms) then the next judgement would be if the aircraft was capable of reaching it, probably not.

The alternative, and extremely fraught and surprising reality required an off airport landing, which demands significant rethinking of normal flight operations in severely stressful circumstances.
Without knowing position relative to the airfield, and thus terrain, then there would be little choice of landing site; + night time.
Thus if there were a logical decision (under stress), the choice of a slow speed and lowest rate of descent flight appears to the best, if only option.

[ATC Watcher]

I’m beginning to think the captain may actually have decided, when the engines began to quit, that they'd never make Rio Negro, that a crash was inevitable and that his only option was to drop all the anchors and do so at the slowest possible speed

Emergency landing in the field , at night ?.. no way , except going for an illuminated motorway, but in a 146? I do not think that was in their mind setting. illogical, but OK nothing was very logical in this accident.

Flying at slowest possible speed = no way to avoid sudden obstacles or to stretch the glide if too short. No-one would do that in an emergency .

My guess is that they realized they would soon loose hydraulics and dropped everything they could and thought they would make the runway. They did not see/ count to overfly a hill at 9000 ft on the way ...looking at the pictures of the accident , they just missed 20-30 feet. :(

[Gusz]

Drives me crazy when people call "this " an accident.... This was no accident.
That's all.

[Kulverstukas]

Doesn't the FDR on this type operate independent of electrical generation?

Assuming it was 115V/400Hz AC powered 980-4700-003 (Plessey or Honeywell) it states 200 ms of power interruption max.

[HighAndFlighty]

Why would the FDR stop recording? Doesn't the FDR on this type operate independent of electrical generation?

Lemme has previously noted the following:

The cockpit voice recorder and the flight data recorder operate on ESS AC power. The flight data acquisition unit operates on ESS DC power.

With all engines off and no APU, the only source of power is battery to EMERG DC/AC.

The recorders would not be operating on battery power, and would not record the information from the point power was lost (flameout).

Satcom Guru: LMI2933 LAMIA AVRO RJ85 Medellín Deadstick (http://www.satcom.guru/2016/12/lmi2933-lamia-avro-rj85-medellin.html)

For those wondering about the Cockpit Voice Recorder stopping when the airplane reverted to EMERG AC/DC power. There is a mandate for a 10 minute Remote Independent Power Supply (RIPS) for the CVR that applies here in the US to newly manufactured airplanes starting in 2010. I doubt that CP2933 was modified voluntarily to add this feature.

The flight data recorder relies on a cascade of sensors that are not reliable under EMERG AC/DC power, along with the drain to power the acquisition unit and the data recorder. Keeping in mind that the battery is needed for the continued safe operation, data recording takes too much current.

FYI, there is an ICAO GADSS initiative that in 2021 mandates an autonomous tracking system that will operate on its own power, but the jury is out whether ELT or ADS-B will be used for compliance. I am hopeful ADS-B, but it will take work to make it self-sufficient.

[mosteo]

According to Spanish media, the final report is out: https://www.eldiario.es/internacional/informe-tragedia-Chapecoense-produjo-gasolina_0_765374394.html

[DaveReidUK]

COL-16-37-GIA (http://www.aerocivil.gov.co/autoridad-de-la-aviacion-civil/investigacion/_layouts/15/download.aspx?sourceUrl=http%3A%2F%2Fwww%2Eaerocivil%2Egov%2 Eco%2Fautoridad%2Dde%2Dla%2Daviacion%2Dcivil%2Finvestigacion %2Flistado%20de%20accidentes%202016%2FCOL%2D16%2D37%2DGIA%20 CP2933%2Epdf)

[aterpster]

Will there be one in English?

[pattern_is_full]

Aviation Herald has an English translation of key parts: Crash: LAMIA Bolivia RJ85 near Medellin on Nov 28th 2016, electrical problems, no fuel, impact with terrain (http://avherald.com/h?article=4a16583c/0017&opt=0)

[aterpster]

Aviation Herald has an English translation of key parts: Crash: LAMIA Bolivia RJ85 near Medellin on Nov 28th 2016, electrical problems, no fuel, impact with terrain (http://avherald.com/h?article=4a16583c/0017&opt=0)

Thank you!

[Carbon Bootprint]

Thanks for posting the translation. I don't really see much here we didn't already know or suspect before. Nevertheless, it's a damning report that shows what messed up deal this was. An entire city in Brazil and much of the rest of the country will weep for years over an incident caused by pure malfeasance. I know this carrier was shut down, but does anyone know what the regulatory response has been to step up the game of similar operators?

[TowerDog]

Agree, nothing new.
These guys did not load enough fuel for the trip.
Either they had no common sense or they were lacking IQ.
This here flying business is really easy: Follow the rules, use your head and be conservative.
i worked for 19 outfits all over the world, including South America. One of my F/Os told me he was forced to fly with 20,000 lbs over weight for a Peruvian carrier on the DC-8. Otherwise you are fired..
Also macho mentality loading less than minimum fuel: Oops, missing airplane, lost in space from SXM to STX. At least the pilot was a brave macho Latino but no common sense, no nothing.
I trained pilots down there but you can’t teach responsibility or common sense.:(

[aterpster]

Thanks for posting the translation. I don't really see much here we didn't already know or suspect before. Nevertheless, it's a damning report that shows what messed up deal this was. An entire city in Brazil and much of the rest of the country will weep for years over an incident caused by pure malfeasance. I know this carrier was shut down, but does anyone know what the regulatory response has been to step up the game of similar operators?
Because of the lack of the CVR for a long time before the crash, there was not much more to learn beyond what we knew the first few weeks.

I think of the CVR breaker being pulled, but that is not mentioned in the report. Surely, the breakers were documented since there was no fire.

[jack11111]

Quote:
" These guys did not load enough fuel for the trip....Also macho mentality loading less than minimum fuel."

If I recall correctly the tanks were full. The mission was at or beyond range of aircraft. And they had an ATC hold. That sealed the fate.

[TowerDog]

Quote:
" These guys did not load enough fuel for the trip....Also macho mentality loading less than minimum fuel."

If I recall correctly the tanks were full. The mission was at or beyond range of aircraft. And they had an ATC hold. That sealed the fate.

Duh....
Yes of course the tanks were full, but not enough fuel for the mission.
The whole operation was criminal and amateurish at the same time.
ATC hold being a factor.. ?
No, just the last nail in the coffin.

[rmac2]

I suspect being full flaps and gear down very early didnt do much for their gliding range and options.

[Passenger 389]

ATC hold being a factor.. ?
No, just the last nail in the coffin.

Respectfully, the "last nail in the coffin" was refusing to disclose true fuel situation to ATC when might still have mattered.

Surely would have received priority over the other aircraft. Except that would have required admitting they had grossly insufficient fuel, have triggered an investigation, resulting in loss of contracts and probably other serious consequences. Especially given the pax on that flight, and the publicity it would have garnered.

Perhaps an even later "nail in the coffin" was when they "drop[ped] all the anchors" (so to speak) in an effort to descend rapidly to reach the glideslope (the one for 'powered' planes, not gliders). Flaps 18, reduced thrust, extended speedbrakes, lowered landing gear, then set flaps 24 and eventually 33.

When they actually needed to maintain as much altitude and energy as possible to cross the high ridges they were approaching on the path to the runway. They did the opposite, and thus impacted near the top of the ridge. Game over.

[Nicophil]

English final report (http://www.aerocivil.gov.co/autoridad-de-la-aviacion-civil/investigacion/_layouts/15/WopiFrame.aspx?sourcedoc=/autoridad-de-la-aviacion-civil/investigacion/listado%20de%20accidentes%202016/Final%20Report%20-%20ACCIDENT%20CP2933%20-%20English%20Version.pdf&action=default) :

[T28B]

Nico, thank you, I've inserted the link so that it properly opens.
To all and sundry: let us please discuss this with professionalism foremost in our deliberations.

[misd-agin]

Lowest fuel flow and best glide performance is achieved by remaining 'clean' as long as possible. Flying 101.

[AerocatS2A]

Lowest fuel flow and best glide performance is achieved by remaining 'clean' as long as possible. Flying 101.
Yeah, based on book figures, they were within gliding distance of the runway when they ran out of fuel.

[atakacs]

Yeah, based on book figures, they were within gliding distance of the runway when they ran out of fuel.
I muss say this is one of the craziest one for quite some time. And thinking that they could make it despite all is just mind-boggling.

[JumpJumpJump]

I really find it hard to believe that suicide has yet to be mentioned in this, I do not mean to say that he took off with the intention of dying, in the sense of Lubnitz. However, it is very possible that his planning had the intention of death should his fuel planning strategy not work it (as we know... it did not work out). The final act of flaps down, gear down and nose down, as not the actions of anybody that wants to live after losing all power. The Captain would have known that the likely outcome of reaching the airport would have been an arrest, closure of his business, prison and bankruptcy for his family. Compare that to the out come of his death, being, no prison, possible obfiscation of the facts, the company survivng (he wasn`t to know that we would all know the truth in numbers) and a hefty insurance payout...

... Has this crossed anybody else's mind?

[tdracer]

... Has this crossed anybody else's mind?
I consider it more like playing Russian Roulette with the 70+ lives.
As for the aircraft being 'dirty' after the engines quit, I suspect the pilots were still hoping there was some fuel in the tanks and they'd make it right up to the point the engines cut out. Once you've lost all four engines, it's really too late to clean up the aircraft.

[rog747]

not a good read sadly -

beggars belief that a 146 could even be imagined for planning (or the lack of, as shown here) for almost a 4 hour sector with 77 folk on board - that's like sending an almost full 146 from LGW non-stop to the Greek Islands !

incredible that it almost made it - had they not held in the hold but had opted to declare a fuel emergency and go straight in then this would likely not have happened although landing on fumes could be expected

I am sure this was not their (any of the crews) intention to commit suicide but the plan to commit to destination (despite cockpit discussions early on in the flight about fuel burn and status) was suicidal

what on earth possessed the crew to continue this flight to its ghastly end