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Jet goes down on its way to Medellin, Colombia

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Jet goes down on its way to Medellin, Colombia

Old 3rd Dec 2016, 22:08
  #581 (permalink)  
 
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Possible measurement error contribution?

Originally Posted by Livesinafield
Is anyone else finding it really hard to believe why a professional pilot with some degree of experience would be happy flying to an aerodrome and arriving with approx 7 minutes of fuel until engines stop working at night?
I'm not a pilot, but spent years in responsible positions in very high-value, high-technology factories. A lesson there is that maintenance of even the most critically important equipment was less likely to be successful for aspects of operation not having any impact in normal circumstances.

Obviously normal fleet operation does not involve frequent exploration of the zero-fuel end of fuel-state operations. I wonder whether there are plausible failure modes which might have introduced a modest zero-offset in the fuel readout of this aircraft, and whether (possibly slopply) maintenance and normal operational experience might have left that error in place for weeks.

If such an error was already in place on previous excessive range flights, all concerned might not have detected just how close those flights came to exhaustion. If the error was in place on this flight, alerts and indications may have come later than people posting on this thread are assuming.

Since normal operations seem unlikely to verify the zero-fuel readout point directly, what special procedure or maintenance is done which would catch such an error? How frequently?

None of which is in any way to suggest such an error as a primary cause here, but specifically a possible explanation to some of the late-stage lack of urgency.
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Old 3rd Dec 2016, 22:08
  #582 (permalink)  
 
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Am I wrong to say that this could have all been avoided if Celia had not permitted the flight to take off without raising the issues further instead of backing down...where does the buck stop? Aren't these systems in place to avoid this kind of thing?
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Old 3rd Dec 2016, 22:10
  #583 (permalink)  
 
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I dont think Celia had the power to do that
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Old 3rd Dec 2016, 22:12
  #584 (permalink)  
 
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It just seems to me that if one side is going to back down it shouldn't the one who has discovered the irregularity.
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Old 3rd Dec 2016, 22:13
  #585 (permalink)  
 
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References to the "Swiss Cheese" model for this accident are misplaced. This wasn't a case of the 'holes lining up' - the holes were aligned before this aircraft ever left the ground when they dispatched with insufficient fuel. This was a case of playing Russian Roulette with the lives of over 70 people, further magnified by the flight crews apparent reluctance to admit what they'd done and declare a fuel emergency as soon as they were directed to hold. If they did indeed do this previously and got away with it, it was simply dumb luck - the bullet wasn't in the chamber that time.+
Those responsible (that didn't perish in the crash) should go to prison for a very long time.
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Old 3rd Dec 2016, 22:55
  #586 (permalink)  
 
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archae86:

I'm not a pilot, but spent years in responsible positions in very high-value, high-technology factories. A lesson there is that maintenance of even the most critically important equipment was less likely to be successful for aspects of operation not having any impact in normal circumstances.

Obviously normal fleet operation does not involve frequent exploration of the zero-fuel end of fuel-state operations. I wonder whether there are plausible failure modes which might have introduced a modest zero-offset in the fuel readout of this aircraft, and whether (possibly slopply) maintenance and normal operational experience might have left that error in place for weeks.

If such an error was already in place on previous excessive range flights, all concerned might not have detected just how close those flights came to exhaustion. If the error was in place on this flight, alerts and indications may have come later than people posting on this thread are assuming.

Since normal operations seem unlikely to verify the zero-fuel readout point directly, what special procedure or maintenance is done which would catch such an error? How frequently?
I think i understand you, as electronic engineer and now an airline pilot, having flown both small props, turboprops, medium jets and now heavy jets.

Problem is (and always will be) the human being.

There are numerous procedures in place to operate/maintain and dispatch a(ny) commercial airplane.

(just try to imagine how can boeing/airbus/embraer/bombardier/fokker/atr etc etc sell aircraft all over the world)

All those manufacturers need to sell airplanes and make sure, south-americans, african, asian, european even american companies and pilots know how to operate those airplanes.

So, to prevent major court cases and lawyers at work, 99,9% is all written down.

Problem is how any company and/or pilot or crew is implementing it all.
Family-life, finances, kids, company-future, fatigue, rank, knowledge, pressure (or delays), etc etc

Inop fuel-gauges, instruments, sensors etc etc may be in the MEL.
(manufacturers make this very clear) problem may be how the company or engineer(s) or the pilot(s) comply with it.


tdracer:
References to the "Swiss Cheese" model for this accident are misplaced. This wasn't a case of the 'holes lining up' - the holes were aligned before this aircraft ever left the ground when they dispatched with insufficient fuel.
First of all you are contradicting yourself.
How can you explain "this wasn't a case of the holes lining up vs the holes were aligned ?

FYI the famous cheese model can start everywhere, from waking-up, entering head-quartars, meeting with the CEO/owner/engineer/cleaner/cabin-crew/refueler/first-officer/captain/ATC etc etc.....
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Old 3rd Dec 2016, 22:57
  #587 (permalink)  
 
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Fuel uplift tickets.

Previous uplift tickets for fill-ups will reveal how many times they pulled this malfeasance.
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Old 3rd Dec 2016, 23:13
  #588 (permalink)  
 
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"This was a case of playing Russian Roulette with the lives of over 70 people"

Not really Russian Roulette. Even the crazy Russians only play that game with one live round out of 6, this game was played with all 6 chambers loaded ...
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Old 3rd Dec 2016, 23:55
  #589 (permalink)  
 
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In addition to what appears to be crazy or non-existent flight planning, there comes the issue of what to do when it all goes quiet......and dark, as it surely will when the motion lotion has been consumed.

When I was trained on the RJ- (thanks Dai), we explored this in the sim. First time, even though I could see the field, I just had no idea how much height I needed or how far the thing would glide with the height we had. As a result one made a spectacular cock of the exercise arriving over the threshold way too high and fast to land.

But, having seen how the thing glided (MUCH better than I expected), and how fast to fly it, the re-run was quite straightforward.

I wonder if these guys had the benefit of such thorough training? It would be a jolly talented pilot who could pull off a deadsticker in the RJ without a little practice...
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Old 3rd Dec 2016, 23:56
  #590 (permalink)  

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. These unfortunate passengers and hapless crew have been killed by the actions of the PIC and the dispatcher, and those others that facilitated this dispatch, and the operation of such a reckless program operating outside of the law.
Did they even have a dispatcher.?
That position was put in place as a quality control to make sure us pilots would not do stupid sh!t like taking off without required fuel.
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Old 4th Dec 2016, 00:20
  #591 (permalink)  
 
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Originally Posted by peekay4 View Post
If these RJ85s are really transmitting at NUCp 0 data quality level as Dave says then forget about trying to match positions. NUCp 0 means the position error could be greater than 10 nm.
I think Dave is saying that the NUCp is set to zero because the RJ85 ADS-B installation is not compliant with the local regulations even though its accuracy may be much better than 10 nm.

For example, in Australia:

It is critical that aircraft only transmit ADS-B from approved equipment configurations. Transmissions from unapproved equipment configurations could mislead aircraft with ADS-B IN capabilities and could also mislead ATC.

It is the responsibility of aircraft owners and operators to ensure that their aircraft comply with the related CASA regulations.

The relevant CASA regulations have been in place for some years, and say :

“If an aircraft carries ADS-B transmitting equipment which does not comply with an approved equipment configuration, the aircraft must not fly in Australian territory unless the equipment is

(a) deactivated; or

(b) set to transmit only a value of zero for the NUCp or NIC.”
Mandate to deactivate some ADS-B transmissions | Airservices
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Old 4th Dec 2016, 00:45
  #592 (permalink)  
 
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Testpanel
To be a little more clear, the 'Swiss cheese' model assumes several random events occur in such a way that the 'holes' in the system align. That's not applicable when the holes are lined up by deliberate acts prior to dispatch. When it's done by a deliberate act (or combination of acts) it's no longer the Swiss cheese model since it's not random - it's simply gambling.
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Old 4th Dec 2016, 02:12
  #593 (permalink)  
 
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I'm not defending the pilot's actions, or what I view as egregious poor fuel planning, but as for the 4:22 in two places in the flight plan, that could just be a brain fart. I've been know to transpose numbers, this could be just that. I agree, I would never state my endurance to precision greater than half an hour.

But, as a pilot, I'm still offended by this pilot, and co pilot, that they would fuel plan so poorly, perhaps to the point of violating the regulations requiring fuel reserves.
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Old 4th Dec 2016, 02:29
  #594 (permalink)  
 
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Originally Posted by AtomKraft View Post
In addition to what appears to be crazy or non-existent flight planning, there comes the issue of what to do when it all goes quiet......and dark, as it surely will when the motion lotion has been consumed.

When I was trained on the RJ- (thanks Dai), we explored this in the sim. First time, even though I could see the field, I just had no idea how much height I needed or how far the thing would glide with the height we had. As a result one made a spectacular cock of the exercise arriving over the threshold way too high and fast to land.

But, having seen how the thing glided (MUCH better than I expected), and how fast to fly it, the re-run was quite straightforward.

I wonder if these guys had the benefit of such thorough training? It would be a jolly talented pilot who could pull off a deadsticker in the RJ without a little practice...
There have been some successful dead stick lands (as far as I know the talented pilots have also been glider pilots), but they have also been when they can see where they are going. Could even the most talented pilot have succeeded at night?
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Old 4th Dec 2016, 03:13
  #595 (permalink)  

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. I'm not defending the pilot's actions, or what I view as egregious poor fuel planning, but as for the 4:22 in two places in the flight plan, that could just be a brain fart. I've been know to transpose numbers, this could be just that. I agree, I would never state my endurance to precision greater than half an hour.

But, as a pilot, I'm still offended by this pilot, and co pilot, that they would fuel plan so poorly, perhaps to the point of violating the regulations requiring fuel reserves.
Just a brain fart on the flight plan?
Obviously not as they did not land safely with :45 minutes in the tanks.
The numbers Captain Einstein put down was the real deal, and he proved it.

Perhaps to the point of violating the regulations?
I would scratch perhaps and insert obviously.
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Old 4th Dec 2016, 04:11
  #596 (permalink)  
 
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Not a "Brain fart"

A lot of people have clearly not bothered to read the thread. I'll just repost earlier contributions from HDP (post #320) and Pseudo Pro (post #329) here.

From HDP - the original flight plan lodged at Santa Cruz, and the accompanying note from Celia Castedo Monasterio, who reluctantly accepted (but did not approve) it.







From Pseudo Pro - the translation of Celia's note.

Subject: Notification about received FPL LMI2399

I inform that in date 2111162010 [note: ddmmyyhhmm] Mr. Alex Quispe (+), Lamia's Dispatcher, presented himself to the OF. ARO-AIS/SLVR presenting the Flight Plan FM/SLVR TO/SKRG (Rio Negro, Colombia).

I stated 5 observations about the FPL (NO ERRORS IN THE FLIGHT PLAN):

1. SID - Not provided.
ANSWER: DISPATCHER: Please, Mrs., add NOMAJ DCT VIR. (Didn't do that, asking to request at TWR).

2. ALTN AD: I pointed several times and asked to add another one (there's just one ALTN, SKBO)
ANSWER: DISPATCHER: This is what the Captain told me. Please leave it as is, Mrs. Celia

3. AUTONOMY: (EET same as Autonomy)
ANSWER: DISPATCHER: This is it, this is what they and Captain told me.
ANSWER: ESP. ARO-AIS: This is not right, please check it throughly and update the flight plan.
ANSWER: DISPATCHER: These are the data, Mrs. Celia, these are the data that I was given for the FPL.
ANSWER: ESP. ARO-AIS: But the EET and Autonomy are just the same, you have mistaken it and you don't want to change it
ANSWER: DISPATCHER: No, Mrs. Celia. This is the autonomy that I was given, it is good enough.
ANSWER: ESP. ARO-AIS: No, because this the same as EET.
ANSWER: DISPATCHER: Yes, this is it as we filed, we will fly in less time, don't worry. This is it. Keep calm, this is fine. Leave it the way it is.
ANSWER: ESP. ARO-AIS: No longer insists, given the dispatcher's obstinacy.

4 - Dispatcher's name (just the signature)
ANSWER: DISPATCHER: Ah, yea, but here is my licence number.

- After these and other observations, the dispatcher was gone, pointing that, yes; there were due changes in the FPL, specially these 2 OBS (ALTN and AUT) and bring me another FPL when coming back to check the AIS MET and NOTAM information
- He was back after aprox. 30 minutes collecting the flight information (MET-ARO AIS) and sustained that everything was just the same and there was no other changes in the FPL.
Given that answer, I expressed my discomfort stating that several times the dispatchers does not takes our observations seriously.

NOTE:
FYI, there were at work:
MET Circuitry: Mr. Javier Gunter
COM Circuitry: Mr. Roger Roca.

Celia Castedo Monasterio
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Old 4th Dec 2016, 05:04
  #597 (permalink)  
 
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With the "facts" that have been leaked and "facts" that we understand to be true, and specially the ATC recording.

There is a couple of points, I normally don't like to jump to conclusions, however this accident it's looking pretty slam dunk.

A Captain, with clearly conflict of interest, money vs safety!

But for me it's an accident that makes me angry, because this is not an "accident" in terms of the definition of the word in traditional sense.

Accident = "an unfortunate incident that happens unexpectedly and unintentionally, typically resulting in damage or injury."

If the Flight Plan is correct, 4:22 / 4:22, in addition to the fact that the crew never seemed to have declared a Mayday - it's seems that this word Mayday has been omitted from many accidents I have read about, there seems to be a fear amongst some to use this word, most likely due to the potential paper-work and repercussions that follows after.

It seems rather they take the chance to end up dead, then utter this Universal ICAO emergency word, MayDay.

However I am in no doubt, this is the first time in a long time I have come to the conclusion that heads must role, and a few people have to be sent to 20 - 30 years in Brazilian / Bolivian prison, because this is a criminal act, and most likely it has been a culture of circumventing normal laws and regulations regarding fuel policy.

This is not accident, but a criminal act, that was made to save money, and sooner or later this would be the result, it's Murphy's Law!

I feel deeply sadden by these innocent young people who was murdered! They played Russian roulette, however in reverse style, there was only one chamber without a bullet, and this time the company ran out of luck.
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Old 4th Dec 2016, 05:12
  #598 (permalink)  
 
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@truckflyer

I don't know whose heads you would have roll. It seems all the active participants went down with the aircraft.
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Old 4th Dec 2016, 05:14
  #599 (permalink)  
 
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Originally Posted by DouglasFlyer View Post
Thank you for posting that Douglas, it may help to clarify procedures for many in this thread.

However, in the real world of LaMia2933 it would not have been helpful.

1. I doubt they belong to any IFALPA outfit and therefore, even though the bulletin is 4 years old, they would never have seen it. And, if by some chance they did see it, they would have ignored it -- just as they chose to ignore all of the pertinent regulations governing required fuel. Not by accident or human error - intentionally.

2. With respect to the specific accident [LaMia2933] - calling MAYDAY when you know you will go into your "reserve" fuel is a moot point.

3. Shortly before departure the LaMia Dispatcher took the Flight Plan to the airport office that accepts flight plans. The worker charged with recieving the FPL told the dispatcher that the flight plan was unacceptable because the aircrafts endurance and the estimated time enroute were identical. The dispatcher told her not to worry they would make it in less time. She told him he would have to recalculate and change the flight plan. Thirty minutes later the dispatcher came back for the weather. The worker again asked for the revised FPL. The dispatcher said that was the information he was given and approved by the Captain. There would be no changes to the FPL. She refused to approve it [but does not have the authority to ground the aircraft]. She told him he would have to get approval from the TWR [which he obviously did. The dispatcher also refused to list his name on the FPL but did sign it and wrote his license # in the space provided. BOG was listed on the FPL as the Alternate but based on the FPL there was no fuel to get there and no reserve fuel. That information is in writing and I have seen pictures of the actual FPL.

The operator in the flight plan office wrote an electronic memo to her supervisor outlining the incident and conversation with the dispatcher and stating her reasons for rejecting the FPL. I have also seen a photo of her memo.

Now that takes cojones on the part of the dispatcher and the Captain. That's the first time I have ever seen a Flight Plan on which the aircraft's endurance and the time enroute were the same - in writing and signed. I'm retired now but I drove commercial airliners for 40 years before retiring. That's incredible, but it is also true. I can't believe it But, I've seen the actual documents. They knew exactly what they were doing and just didn't give a damn. IMO, that is MORE than negligence, it is indicative of criminal intent. This flight plan was NOT transmitted, it was delivered, in person by the dispatcher and he was advised, in person, of the errors. Blatant disregard of the law and of safety.

There is not human error here, it was intentional. Totally irresponsible and 71 people, including this so-called captain, are now dead because of it.

It is pretty obvious that this flight would have had to call MAYDAY... during taxi and PRIOR to departure at the airport of origin in Bolivia. There was NEVER any Alternate or Reserve fuel in the tanks to begin with and only enough fuel, full tanks, to just reach Medellin with about 10 minutes left until flameout IF EVERYTHINGwent perfectlyenroute, i.e., no contingency fuel, no alternate fuel and no reserve fuel.. Something as small as being unable to get the requested FL could have caused fuel exhaustion before reaching the Medellin area. And, he didn't have the chance of a snowball in hell of reaching the filed Alternate.

They did NOT have an electrical emergency. The generators always stop running when the engines fail due to fuel exhaustion.

I've never written anything like this before and pray that I never will again but, IMHO, this was no "accident". The pilot in command made 3 very deliberate decisions that resulted in this crash.

A. He elected to depart with insufficient fuel to legally complete the intended flight legally and he knew it before the fact.
B. He elected to overfly Bogota where he could easily have refueled and thereby avoided this planned disaster.
C. He intentionally departed on a flight with the full knowledge that his planned time enroute was equal exactly to the aircraft's maximum endurance.

They also chose to ignore the warning lights on the annunciator panel that come on when fuel in the individual feeder tanks come on - all 4 of them. They mean that there is 23 minutes of operation remaining before the respective engines flame out. IF they had declared an emergency when those low-fuel lights came on they'd probably all be alive today. When impact ocurred, they were only about 8 miles from the airport.

That is not an accident. It is much more like a mass-murder/suicide. Very harsh words I know, but the evidence will substantiate it. I'm so angry I could scream!

Last edited by surplus1; 4th Dec 2016 at 05:37.
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Old 4th Dec 2016, 06:09
  #600 (permalink)  
 
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Indeed.
Had this Captain survived the flight, I've no idea what possible justification he could have provided to the accident investigators.

I think that macho culture, found so often in Latin America, played a part in this tragedy. Certainly all the factors seem to be in place....
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