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Colombia cites poor flight planning in LaMia Avro RJ85 fuel exhaustion accident near Rionegro
30 April 2018

Colombian investigators published their final report into the November 2016 accident of an Avro RJ.85 that ran out of fuel and crashed near Rionegro, Colombia.

On November 28, 2016, LaMia flight LMI2933 departed Santa Cruz, Bolivia on a flight to Rionegro/Medellín Airport, Colombia. The aircraft carried the Brazilian Chapecoense football team for a match to Medellin. On approach to Rionegro all four engines flamed out. The aircraft impacted a wooded hillside. Six of the 77 occupants survived the accident.

The Grupo de Investigación de Accidentes Aéreos Colombia (GRIAA) concluded the following:

Probable causes
– Inappropriate planning and execution of the flight, since the amount of fuel required to fly from the airport of destination to an alternate airport was not considered, nor was the amount of reserve fuel, nor the contingency fuel, nor the minimum landing fuel, quantities of fuel required by aeronautical regulations for the execution of the type of international flight that the aircraft CP-2339 was performing.
– Sequential shutdown of all four (4) engines while the aircraft was descending on the GEMLI standby circuit as a result of the exhaustion of fuel on board.
– Inadequate decision making by the management of the operating company of the aircraft, as a consequence of the lack of operational safety assurance in their processes.
– Loss of situational awareness and misguided crew decision making, which kept the fixation on continuing a flight with an extremely limited amount of fuel. The crew was aware of the low level of fuel remaining, however, they did not take the corrective actions required to land at an airfield and obtain refueling to allow them to continue the flight safely.

Contributing Factors
– Premature configuration of the aircraft for landing, during the descent in the GEMLI position support pattern, since, considering the absence of thrust, this configuration affected the plane’s glide distance to the runway of Rionegro airport.
– Latent deficiencies in the planning and execution of non-scheduled transport flights, by the aircraft operator, related to the insufficient supply of the amount of fuel required.
– Specific shortcomings in the planning of the accident flight, on the part of the operator of the aircraft.
– Lack of operational supervision and control of the flight by the Operator, which did not supervised the planning of the flight, its execution, and the follow-up of the flight that was would have allowed the crew to be supported in making decisions.
– Absence of timely “priority”, “emergency” or other calls from the crew of the aircraft, during the flight, and especially when the fuel depletion in the descent and holding phase, which would have alerted to air traffic services to provide the necessary support.
– Organizational and operational deviation on the part of the Operator in the application of the fuel management procedures, as it did not comply in practice with what had been approved by the the DGAC of Bolivia in the process of certification of the company.
– Delay in the approach of CP-2933 to the Rionegro track, due to its late application for priority, and late declaration of fuel emergency, in addition to the traffic density in the VOR RNG support pattern.

Investigating agency: Aerocivil 
Status: Investigation completed
Duration: 1 year and 5 months
Accident number: COL-16-37-GIA
Download report:  Final report

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