Thursday, December 1, 2016

#LaMia #LMI #CP2933 - Pilot Error or Gross Negligience?

LaMia Airlines Flight 2933 (LMI 2933) was an Avro RJ85 that crashed in Colombia on 28 November 2016 while transporting the Brazilian Chapecoense football squad from Viru Viru International Airport in Santa Cruz de la Sierra, Bolivia, to José María Córdova International Airport in Colombia. The aircraft, registration CP-2933, serial number E.2348 operated by LaMia Airlines, a Venezuelan-Bolivian company, was on a direct, non-stop flight from the Bolivian city of Santa Cruz de la Sierra to Medellín in Colombia, carrying 68 passengers and 9 crew members. Among the passengers were members of the Brazilian Associação Chapecoense de Futebol who were travelling to play their away leg of the Final for the 2016 Copa Sudamericana in Medellín against Atlético Nacional.
The distance between the two airports is 1,605 nautical miles (2,972 km), slightly exceeding the specified standard range of the Avro RJ85, which is 1,600 nautical miles (2,963 km). During the last 15 minutes the flight had completed two laps of a racetrack holding pattern, adding about 54 nautical miles (100 km) to its flight. The crash site was 10 nautical miles (19 km) from José María Córdova International Airport's runway 36.

Data with the website FlightRadar24 indicates that this same aircraft had flown the same route at least twice before in the month of November 2016. So, the first question that arises is how could they do it if the distance between the airports exceeds maximum range of the aircraft? The answer lies in winds and safety margins. Theoretical calculations for maximum range are made for nil wind conditions and include a degree of safety margin. The crew was taking advantage of en-route tail winds that gave them an extra push and speed to cover a distance more than theoretical calculations for max range permitted them to fly. They were also using-up all the safety margin and counting on their ability to make a direct and straight-in approach & landing to the airport. They had succeeded in achieving this at least twice before. For sure, they would have landed with tanks almost empty, but having succeeded in doing it twice would have certainly boosted their confidence level in their own ability to pull it off again!

The standards for minimum fuel set by ICAO require the minimum fuel available to be much more than what is required to cover the straight line distance. Aircraft rarely fly on a straight line, because they need to follow air routes. Further, they often need to deviate from this route due to weather, turbulence or traffic. Additionally, fuel consumption varies considerably with the speed, altitude and atmospheric temperature. ICAO requires all these ‘foreseeable’ conditions to be accounted for in initial fuel calculations. Then they need to add go-around fuel, diversion fuel, and additional margins for not being able to land off the first approach at the diversion airfield also. All this is the level of safety in commercial aviation, and several airline companies require a further safety margin like 10 or 15% to be added to this ICAO standard, just to cater for any unforeseen eventuality.

LaMia flight had deviated from all these regulations. It is clear that the airline was habitually flying only with minimum fuel for a direct straight line flight between the two airports, without any kind of safety margin. Very simply, this aircraft was not designed to fly the distance it was scheduled to fly! A refueling halt was a mandatory requirement and could have been made at several en-route airports, including Bogota.

Medellin airport was handling a very unusual traffic situation on the night of Monday the 28th of November 2016. The video below has English subtitles and will help develop better understanding of the events:

The airport had a complicated situation at hand. VivaColombia Flight FC8170, an A320, had departed Bogota for San Andreas island. However, shortly after departure, the crew realized that they had a fuel leak. The aircraft declared an emergency and requested diversion to Medellin. While the aircraft was approaching Medellin, the accident flight LMI2933 also contacted Medellin and requested Priority Landing due to a fuel problem.

In aviation communications, a very clear distinction is made between declaring an emergency and requesting for a priority landing. Flight FC8170 had declared an emergency. It was also closer to the airport and at a lower altitude in comparison to LMI2933, which had only requested for a priority landing without declaring an emergency. Obviously, the controller was correct in allocating priority to FC8170, the aircraft she knew had an emergency as against LMI2933 which had only made a ‘priority landing’ request.

Now this was a fatal flaw in plans of LMI2933. They had no fuel to fly around in circles waiting to land. They needed to declare an emergency, but doing so would have exposed the flawed flight planning and the fact that they had departed without the minimum regulation fuel on-board! The crew gambled for too long and when they finally did declare the emergency, in response to which the controller cancelled the already issued clearance to Avianca flight AVA9771, and cleared flight LMI2933 to land, also alerting the rescue services, it was unfortunately too late for them to reach the runway! Their hesitancy in declaring an emergency cost 71 human lives!

So, is this pilot error? With due respect to the deceased Pilot, who was also one of the owners of LaMia airline, I would say, NO! This was not an error, but Gross Negligence, and not just on part of the pilot. The airline is expected to have an organization structure. Flight Despatchers, Operations assistants, Director of Operations, the MD or General manager…all have a responsibility to ensure airlines operations are always in compliance with the applicable regulations. There is no excuse for this kind of ‘error’, not once but at least thrice in a span of one month!

Bolivian Director General of Civil Aviation has today, 01 Dec 2016, cancelled the AOC of LaMia airline. The airlines website has gone off-line. Effectively, the airline has ceased to exist and several senior managers are reported to be missing, in hiding.

These 71 lives were not lost to an accident, they were murdered due to gross negligence of LaMia airline owners and operations staff!

Stay safe,

The Erring Human.

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