Introduction
In the 28th of November 2016, an airplane transporting the Brazilian football team, Chapecoense, crashed in Colombia.
The team was heading to Medellin, for the biggest match in their history: the first game of the Copa Sudamericana, against Colombian team Atlético Nacional.
The fatal flight was the LaMia Flight 2993. The aircraft was transporting the Brazilian Chapecoense football squad and their entourage. In total 77 people were inside the aircraft. One of the four crew members, three of the players, and two other passengers survived with injuries.
Brazil’s national aviation authority ANAC – National Civil Aviation Agency-, denied Chapecoense’s request to use LaMia’s aircraft for a direct flight from São Paulo to Medellín. In line with the freedoms of the air and bilateral traffic rights governing international air traffic under the Chicago Convention on International Civil Aviation, ANAC had required that the aircraft be operated by a Brazilian or Colombian company in order for a direct flight to take place.
Instead, the club opted to retain LaMia, and arranged to take a scheduled flight from São Paulo and transferred to the LaMia aircraft in Santa Cruz de la Sierra (Bolivia).
LaMia had already transported other football clubs, including teams playing in CONMEBOL. competitions, as it was Chapecoense’s case, and the Argentina national team (that had flown on the same aircraft 18 days prior).
An official from the Bolivian airline that transported the team and other members of the travelling party from Brazil to Santa Cruz de la Sierra stated that theaircraft departed São Paulo’s airport at 14:22 Bolivian time and landed at Santa Cruz at 16:50 local time.
After arriving at Santa Cruz, the team took an airplane to go to Medellín. The LaMia Flight 2933.
LaMia Flight 2933 was a charter flight of an Avro RJ85 (as the one shown in figure 2), operated by LaMia.
Chain of event
The chartered RJ85, operating as LaMia Flight 2933, departed Santa Cruz at 18:18 local time. A team member’s request to have his video game retrieved from his luggage in the aircraft’s cargo hold delayed the departure.
The original flight plan included a compulsory intermediate refuelling stop at Cobija–Captain Aníbal Arab Airport, near Bolivia’s border with Brazil; however, the flight’s late departure meant the aircraft would not arrive at Cobija prior to the airport’s closing time.
An officer of Bolivia’s AASANA — Airports and Air Navigation Services Administration- at Santa Cruz de la Sierra reportedly rejected the crew’s flight plan for a direct flight to Medellín several times despite pressure from the aircraft’s captain to approve it, because of the aircraft’s range being almost the same as the flight distance.
The flight plan was reportedly altered to include a refuelling stop in Bogotá instead and was approved by another AASANA officer.
Shortly before 22:00 local time on 28 November, the pilot of the LaMia aircraft reported electrical failure and fuel exhaustion while flying in Colombian airspace between the municipalities of La Ceja and La Unión. The RJ85 had begun its descent from its cruising altitude at about 21:30. Another aircraft had been diverted to Medellín from its planned route by its crew because of a suspected fuel leak. Medellín’s air traffic controllers gave the other aircraft priority to land there and at 21:43, the LaMia RJ85’s crew was instructed to wait with three other aircraft for its turn to land.
At 21:49, the crew requested priority for landing because of unspecified “problems with the fuel”, and were told to expect an approach clearance in about seven minutes.
At 21:52 they declared a fuel emergency and requested immediate descent clearance.
At 21:53, with the aircraft nearing the end of its second lap of the holding pattern, engines 3 and 4 (the two engines on the right wing) flamed out due to fuel exhaustion; engines 1 and 2 flamed out two minutes later, at which point the flight data recorder (FDR) stopped operating.
Air traffic control radar stopped detecting the aircraft at 21:55 local time as it descended among the mountains south of the airport. At 21:59 the aircraft hit the crest of a ridge on a mountain known as Cerro Gordo at an altitude of about 2,600 metres. In the image below the distance between the airport, where the plane was supposed to stop for refuelling, and the crash site can be seen (roughly 40 km).
Conclusion
Evidence very quickly emerged to suggest that the aircraft had run out of fuel: the flight attendant who survived the accident reported that the captain’s final words were “there is no fuel”, and transmissions to that effect from the pilots to ATC were overheard by crews of other aircraft, and recorded in the control tower. Shortly after the crash, the person leading the investigation stated that there was “no evidence of fuel in the aircraft” and the aircraft did not catch fire when it crashed.
The official report from Colombia’s civil aviation agency, Aerocivil, found the causes of the crash to be fuel exhaustion, due to an inappropriate flight plan by the airline, pilot error regarding poor decision making as the situation worsened, including a failure to declare an emergency after fuel levels became critically low, thus failing to inform air traffic control at Medellin that a priority landing was required.
As mentioned , this accident was due to human error, therefore being “avoidable”.
This hazard could have been prevented by the use of a system that does not allow for planes to take off if the flight plan is not reliable enough, in order to avoid such decisions to me made by humans.
For the error related to not declaring an emergency after the fuel levels becoming critically low, this could be avoided by doing this automatically, as soon as the fuel reaches such levels, so that the tower can communicate to the pilot the situation and immediately develop an emergency landing plan.