#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 28^th 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.

#Flydubai Flight #FZ981: Pilot Error or Weather?

We woke-up today morning to a shockingly sad news of the loss of #Flydubai Flight #FZ981. Even before the fire caused by the accident had died down, I was shocked even more to read the first press reports attributing the accident of 'Pilot Error'! It appears that the so call Aviation Experts had already closed the case by arriving at the conclusion of Pilot Error caused by the weather! Such indiscriminate and nonsensical reporting aimed purely at TRPs and creating a fear phobia always causes discomfort and hence it is important at this time to do a proper analysis of what is known, what can be assumed and what are (some) of the essential facts the investigators will need to ascertain to be able to arrive at a balanced and scientific conclusion.

Two significant links have been posted on You Tube already that give us a very good indication of what might have transpired. Have a look at these two you tube links below.

 

 

The first link above tells a very significant tale. It shows the aircraft descending to the ground at a very steep angle of about 60 to 80 degrees! This is certainly not a flight that 'struck a wing' during a mishandled go around as has been reported in a section of the press. This is an aircraft totally out of control. The audio in the second link above is the radio communication between the ATC and the Pilot. At minute 7:17 it tells another very significant tale. The Pilot states, 'Going around...' and the tone of his voice at this point in time is totally composed, with no indication of any nature of panic or concern. It is a matter-of-fact statement that has been made almost like a song, which is indicative of a very relaxed state of mind. It is safe to conclude here that at the point when a decision was made to go-around, there was no immediate danger to the aircraft's safety.

One of my friends questioned me, is a go-around not an emergency? Just because the pilot elected to go-around does it not indicate that there was a danger? The answer to these questions is clearly NO. A pilot could elect to go-around for several reasons, but most commonly because the approach was not stabilized. In simple English this means that three or more parameters required to execute a safe landing had not been satisfied and if a go-around is not executed then the aircraft safety would be jeopardized. Therefore, to go-around is not an action as a result of the aircraft being in danger, but to prevent it from getting into a dangerous situation that has been foreseen by the Pilot. In this case, given the strong winds and unstable weather, it is not surprising that the pilots elected to go-around because the aircraft was clearly being buffeted and battered by the winds.

Another significant bit of news has emerged about the go-around maneuver in a tweet from #Flightradar 24 (@flightradar24).

So, would a microburst alone succeed in developing a Rate of Descent of 21000 ft/min when the aircraft was at just about 5000 ft altitude and climbing? Maybe; but putting all the information above together, i.e. the relaxed state of mind of the pilot as evidenced from his calm voice, steep descent angle as seen in the security video and a ROD of 21,000 feet/min reported by Flight Radar, this does not seem to be a purely weather related case. While the bad weather might have played a role in this accident, but just the bad weather and even a microburst is not sufficient to explain such a sudden and steep descent into ground when the aircraft was already at climb power and in the process of going-around, already having achieved a steady climb momentum.

This then brings us to the next part of this puzzle. Is this an error made by the Pilot? Before we jump to that conclusion, we need to remember that pilot error, or human error as it ought to be called, is actually another name for an organizations failure to develop its human resource. As I have also brought out in my books 'Waiting... To Happen!' and 'I, Human', there are several sub-classifications of a human error, and all of them ultimately lead to a root cause of poor policies, procedures or training at the organization. So, those who are voicing the opinion of Pilot Error at this time, watch out... attributing this to pilot error actually amounts to an accusation that Fly Dubai, and its mother company Emirates Airlines, failed to develop their human resources... a claim one needs to think through a lot before stating, given the industry reputation and safety record of these carriers. Is it not possible that these airlines failed to develop their human resources? Well, it certainly is possible, but at this point in time there is insufficient evidence or historical record to arrive at this conclusion.

The next important question that comes to mind is, what do we know and where do we go from here?

We know that the flight was holding for the weather to improve for over 2 hours. We know that it made a second attempt to land in almost identical weather conditions in which the first attempt had to be aborted 2 hours ago. We know that the flight had on-board the fuel to remain flying for at least another 1:45 hours, so there was no urgency or panic to make a landing. 

From this, (at least) the initial work of investigators seems to be pretty well cut out. First they need to ascertain if there was any technical failure on board that resulted in this sudden and steep fall to the ground from a stabilized climb momentum. Could there have been a microburst of such astonishing power? Certainly yes, but it will need proof beyond any reasonable element of doubt to be believed. This could just as well have occurred due to severe aircraft icing, pilots disorientation, a serious technical failure or structural disintegration, like the loss of tail plane or a wing. Such nature of structural failures are not unheard of and there have been accidents in the past due to to these occuring in flight.

Further, one would like to look at other contributory causes. First and foremost question that begs an answer is, why in the first place the flight was holding for over 2 hours? What prevented the flight from diverting to another airport? What are the stated policies at Fly Dubai/Emirates with respect to such diversions? Is there any evidence of deviation from this stated policy? Is there any evidence of pilots being 'disciplined' officially, or unofficially, for diversions? Was there any nature of communication between the aircraft and Fly Dubai operations control during this 2 hours hold period and was a diversion discussed at all? In short, it seems very odd that the flight chose not to divert and the the reasons for this need a lot of investigation.

Then is the question of why the flight was at all permitted to depart from Dubai in the first place when the departure weather made it clear that the conditions on arrival will be below minima? Was there a communication lapse at the ATC level? at Flight Dispatch level? at operations control level? 

The flights data recorders have been recovered, but if the investigation is to be done properly, not with the intention of finding someone to blame but with the intention of preventing another accident, then the investigators would need to look far beyond the flight data recorders. I hope that they will have the mandate, support and the will to do so.

Stay Safe,

The Erring Human.