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LAMIA Bolivia 2933: Always a Lesson to be Learned

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LAMIA Bolivia 2933: Always a Lesson to be Learned

LAMIA Bolivia 2933: Always a Lesson to be Learned
December 08
09:00 2016

MIAMI — On the evening of November 28, 2016, LAMIA Bolivia Flight 2933, a British Aerospace Avro RJ85 carrying 68 passengers and 9 crew members, crashed southeast of Medellin, Colombia (MDE) during an attempt to make an emergency landing after running out of fuel. Only six souls on board would survive.

LAMIA Bolivia 2933: Fuel Emergency Reported Before Crash

On the morning of November 29, I awoke early to the news of the accident. I am a regional airline pilot based in Los Angeles (LAX) but living in Miami. I began my commute to LAX as normal, reading about the accident on the way to Miami Airport (MIA) before I boarded my flight to LAX. Fuel exhaustion was already being discussed as a possible cause on many aviation safety blogs and websites that I read. I usually refrain from commenting on possible accident causes before an interim or final report but I have become disconcerted by the reactions of many of my pilot friends and colleagues in the wake of this accident.

Pilots love to talk, and many of my friends have said or posted online in recent days “what a bunch of idiots” and similar statements regarding the crew of LAMIA 2933. This statement is a horrible approach to analyzing an accident, and at best a sophomoric approach to airline safety.

Fuel exhaustion and thus pilot error is certainly the cause in fact of this accident, but there are undoubtedly several social and cultural causes that contributed to this outcome and those must be discussed in order to learn from this accident.

Running out of fuel in a commercial airliner has happened several times, always with an element of human error to the occurrence. It just is not the type of situation that occurs in the absence of human involvement or mismanagement. Many pilots in the United States seem to have the attitude that this situation is one that “could never happen to me.”

For a thorough understanding of the history of fuel exhaustion, one must look at past accidents.

On May 2, 1970, an Overseas National Airways (ONA) McDonnell Douglas DC-9-30 operating on behalf of ALM Antillean Airlines as Flight 980, was on a scheduled flight from New York’s John F. Kennedy International Airport (JFK) to Saint Maarten (SXM). ONA was a US charter airline that was operating on behalf of ALM.

JFK-SXM is a city pair that pushes the range of a DC-9-30, and the route is really not meant for that type of airplane. Nonetheless, the flight could be done safely, and had on several previous occasions. During the descent, the crew was made aware that SXM Airport had gone below weather minimums necessary for landing and made a very safe decision to divert to San Juan (SJU). It had adequate fuel to make this diversion to this particular destination alternate. During the diversion, it was reported that the weather was now adequate for the approach to Saint Maarten, and the captain elected to discontinue the diversion and proceed back to the original destination.

After three failed approaches into Saint Maarten for various reasons (resultant of the weather), the crew elected to divert to nearby St. Croix (STX), a short 99 nautical miles from SXM. It would have taken roughly 18 minutes or so to fly this diversion but the DC-9 would run out of fuel over the Caribbean Sea, and a forced ditching would occur, and 23 of the 63 people on board would lose their lives in an avoidable disaster.

The point here is that this flight was by all means being flown by a qualified crew that fell into a series of operational pitfalls. They certainly did not takeoff from JFK that morning with the intent of running out of fuel and ditching into the Caribbean Sea but became so focused on completing the flight at the intended destination that once they received the weather report that indicated adequate weather, they failed to leave themselves an out in the event the weather became poorer at SXM.

Fast forward to December 28, 1978, when a United Air Lines Douglas DC-8, Flight 173, crashed about six miles from its destination of Portland Airport (PDX). The cause – fuel exhaustion.

The DC-8 departed Denver (DEN) with adequate fuel for the flight, approximately 46,700 pounds of it. Only 31,900 pounds of fuel was planned to be burned enroute to Portland. On approach to Portland (the weather was clear skies and light winds), the crew lowered the landing gear, but the right main landing gear free fell into its locked position due to a mechanical failure in the retraction cylinder on that side.

The gear, normally lowered through a hydraulic cycle, fell into its place due to gravity as designed in the event of a failure of that cycle. The landing gear was safely down and locked but the electrical circuit that would indicate a green light indicated “down and locked” was damaged in the free fall of the gear, leading to an “unsafe gear” indication.

Captain Malburn McBroom abandoned the approach and went around, as per proper procedure. Running a series of checklists, the crew was unable to get the gear unsafe light to go out (even though the right landing gear was safely down but they did not know this). The Captain became so preoccupied with the relatively minor landing gear issue that he did not adequately monitor the airplane’s fuel status. The First Officer and Flight Engineer both tried to give subtle hints to the Captain about the fuel but were not forward enough.

The airplane ran out of fuel in one of its holding circuits and crash landed in a neighborhood, killing 10 people. Miraculously, 179 passengers and crew survived the landing. This accident lead to the rapid development of Crew Resource Management (CRM), a concept that includes active involvement of all crew members, which puts first officers and captains essentially in the equal position of speaking up and taking action where something is not right.

United Air Lines began the aviation industry’s first CRM program in 1981 as a result of this. This accident is a pivotal one in aviation history, because we as a community went beyond “pilot error – fuel exhaustion” and went into what actually caused the breakdown of communications and small pitfalls that lead to the accident.

In January 1990, Avianca Flight 052, operated by a Boeing 707, crashed short of JFK Airport on a flight from MDE after holding several times and conducting a missed approach due to windshear. Again, the first officer did not speak up when fuel became an issue and they could have still proceeded to their alternate airport. 73 people died out of the 149 aboard when the 707 crashed in Cove Neck, NY. The First Officer also never relayed their emergency fuel status to air traffic control when it became an issue while they were still in a holding pattern.

These three accidents are just some of the fuel exhaustion accidents. In all three, distinct events unique to each event happened that ultimately led to a chain of decisions that resulted in fuel exhaustion. None of these pilots were “idiots”, but each of them fell into a decision chain that was faulty.

The term pilot error can be used to generally describe the cause of an accident, but in order to have a discussion on LAMIA 2933, we have to start at pilot error and not end there as a cause.

Now, lets talk about LaMia 2933.

Similar to ALM Flight 980, the airplane that operated as LMI2933 was not designed for such a long non-stop flight. The Avro RJ85 was scheduled to fly from Santa Cruz, Bolivia (VVI) to Medellin, Colombia (MDE), a straight line distance of 1,598 nautical miles. The actual flight plan distance was longer.

The Captain, Miguel Quiroga, filed an ICAO International Flight Plan stating that the estimated time enroute (ETE) was 4 hours and 22 minutes, but filed the endurance (for non-aviation readers the amount of time the airplane can stay in the air with its fuel load) as the same time. These two numbers should never be equal.

Endurance shall be ALWAYS greater than ETE. To file a flight plan and then execute a flight under those conditions is certainly grossly negligent. The Captain had most probably conducted similar flights before under the same type of scenario and it had “worked out.” He went a further step to file Bogota as the destination alternate airport. In other words, legally the aircraft had to carry enough fuel to fly from VVI to MDE, then to Bogota (BOG), and thereafter for 30 minutes at 1,500 feet above the airport under ICAO fuel reserve rules.

This was physically impossible with the fuel load the airplane had on board. It would take approximately 30 minutes to fly a missed approach from Medellin and then fly to Bogota. This would have made the required endurance of the airplane to be at a minimum of 5 hours and 22 minutes at brake release at the start of the takeoff roll in Bolivia (burnoff VVI-MDE + alternate fuel MSAP / MDE-BOG + 30 minute international reserve). The Captain filed 4:22, and filed a bogus alternate he could never reach in total disregard of all the facts telling him he essentially needed a fuel stop to fly safely.

Overhead Medellin, the flight entered a holding pattern for which they did not have fuel for. Instead of saying “unable” and declaring an emergency in a timely manner, the crew did as instructed until it was too late and they ran out of fuel.

Why did the Captain do this? He himself was a part owner of the airline, no doubt under pressure to deliver the team on time. He likely had flown flights where he stretched the range of his aircraft before and it worked out. The difference on that night was the fact that they were in a holding pattern he didn’t plan for, but he absolutely should have and any reasonably prudent pilot would.

The reason for the holding was that a VivaColombia Airbus A320 had a fuel leak and needed priority to the airport. The Captain’s luck ran out that evening.

As for the First Officer, it was her first flight at the airline. Just like the first officer and flight engineer on both United 173 and Avianca 052, and the first officer and navigator on ALM 980, she most likely did not speak up. Psychologically, if the safety culture around you does not support crew resource management, how could she? It was her first flight at the airline, flying with a co-owner in the airline.

She very well could have been fearful of losing her job after, and she probably had trust that the Captain had been in similar situations before and it would “work out”. During the long over four hour flight, the Captain had probably quelled her fears of being low on fuel and told her it would be “okay”. This crew was in absolutely no position to recover from any operationally unplanned event from the moment they left Bolivia. They had no contingency fuel.

It is easy to quarterback the crew and call them “idiots,” but as pilots, we need to do better than that. To be clear —I am absolutely not defending the Captain and his actions. There is never an acceptable excuse for running an airplane dry. I am talking about the crew as a whole and about having a discussion about the accident.

The Captain was reckless in attempting this flight, his actions certainly rising to the level of gross negligence, perhaps even criminal. But we need to have a fair discussion on this flight as we learn more details so we can learn from it.

To my pilot friends and colleagues – those of us that fly here in the United States cannot even begin to imagine the operational pressures experienced at other airlines around the world. When we ask our flight dispatcher for extra fuel, it is practically always given (most of the time).

Our airplanes realistically are never pushed closed to their maximum range and when they are, we have a plan and a way out in the event we cannot make it to our destination. That safety culture has been ingrained in us because of past accidents and we must learn from this tragedy as we have from others. It was not ingrained at all here, and probably frowned upon.

This accident says a lot about planning for alternate airports. Flying practically anywhere in the continental U.S., we can have an emergency and be on the ground somewhere within 20 minutes. Between Santa Cruz and Medellin, suitable en route alternates are not as frequent. The LAMIA Bolivia crew did not plan on this. As pilots we know that we should never, ever, plan on a “perfect flight.”

We plan to fly to the alternate airport, and not to our destination airport. When the weather is good enough that we do not legally require an alternate airport, we need to be thinking about what alternates we could reach with our fuel over the destination due to an unforeseen runway closure, or another airplane having an emergency that results in us holding. The time to be thinking about an alternate airport is not when you have made the decision to fly to one, it is before you even depart, and it is en route as we progress.

What lesson lies here? The crew was behind their airplane from the moment they left Bolivia and the Captain breached the highest standard of care incumbent on an airline pilot in his flight planning.

This flight had to go perfectly in order for it to work – it didn’t.

As with all accidents, we need to learn from this, not just say that this crew was “dumb” and leave it at that. No pilot takes off with the intent to fill their fuel tanks with air, but the accident history is there. This has happened before with different catalysts as the start of the accident sequence. Let’s have a discussion about this one just as we have in the past with other accidents and not be arrogant and say “they were dumb.”

Those that died in this accident deserve better and so does our piloting community.

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Cody Diamond

Cody Diamond

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1 Comment

  1. AirAusquin
    AirAusquin December 09, 08:56

    Mr. Diamond, hello from Venezuela. Many thanks for your article.

    A correction: As far as I know, the lady was not acting as FO, she was in the jump seat as an observer, this being her first flight in the type. The FO was Ovar Goytia, whom I have been told handle the communications.

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