Professionalism/LaMia Flight 2933

Background


On November 29th, 2016, LaMia Flight 2933 (LMI2933), was en route to Medellin, Colombia; carrying on board journalists, crew members and Brazilian Chapecoense Football Club's players and staff, who were travelling to the city to play the first leg of the Copa Sudamericana final against Atletico National. Miles before reaching Medellin, the aircraft suffered what the pilot described as a "total failure" and crashed onto a hillside in Cerro Gordo, Colombia at 2:58 AM UTC time. Out of the 77 people on board, six survived. This chapter examines how different participant's decisions led to the crash.

The Chapacoense team had planned to fly straight from São Paulo, Brazil to Rionegro, Colombia (near Medellin). LaMia, being a Bolivian charter company, was denied the permit to transport the team directly from Brazil to Colombia. To satisfy international flight agreements, the new flight plan devised by LaMia included a layover stop in Santa Cruz, Bolivia. LaMia flight 2933 covered the second part of the team's journey and departed from Viru Viru International Airport in Santa Cruz de la Sierra, Bolivia, with final destination to José María Córdova International Airport.

The Crew
According to Colombia's Civil Aviation Administration: Autoridad de la Aviacion Civil, Flight 2933 was under the control of pilot Miguel Quiroga and co-pilots Ovar Goytia and Sisy Arias. Quiroga and Goytia had jointly accumulated over 13,000 hours of flight time; Goytia's flying experience with the Bolivian Air Force had lasted 20 years. Arias however, had recently been hired by LaMia and served her first charter flight with Flight 2933. Two flight attendants, Romel Vacaflores and Ximena Suarez were also present on the flight. All pilots perished in the crash. Ximena Suarez was the only crew member to survive.

Airplane Specifications
The aircraft used for the flight was an Avro 146 RF-85 manufactured by British Aerospace plc (BAE SYSTEMS). The Avro 146 RJ-85 is a 90-seat aircraft with maximum flight weight equal to 41,800 kg, can fly approximately 1600 nautical miles, , and has four Textron Lycoming LF507-1F jet engines with a total fuel capacity of 3,099 US gallons (9,300kg). LaMia 2933 was the ninth fatal accident and the second worst accident involving an Avro 146 RF-85.

Flight Path
The entire flight duration was 4 hours and 22 minutes with a fuel endurance of the exact amount of time, and the flight path was approximately 1,611 nautical miles. Along the path, there were three possible refueling stations: Cobija, Leticia, and Bogota. Cobija’s fuel services closed at 22:43, and was 500 nm from departure; Leticia’s fuel services closed at 00:30, and was 900 nm from departure; Bogota’s refueling station was 1,500 nm from departure. During the flight, fuel calculations took place between the pilots at 00:42:18 hours on November 29, and a fueling stop was decided to take place in Bogotá at 00:52:24 hours. Just after transferring to Colombian Air Traffic Control at 00:52:24 hours, the pilots withdrew their decision to refuel and instead decided to proceed to Rionegro and began to approach the airport at 01:03:01 hours.

At 02:36 hours, the Master Caution notified that only 20 minutes of fuel were left. The pilot began to communicate with ATC at 02:49:11 to request priority landing.

Final Minutes of Flight 2933
The morning of November 29, 2016, at approximately 01:30:01 hours Flight 2933 was transferred to Colombian air traffic control (ATC) and began its approach to Jose Maria Cordoba Airport in Rionegro, Colombia. At 2:43:39, pilot Quiroga was instructed to enter a holding pattern along with three other aircraft around Rionegro. At the time, another aircraft had reported a fuel leak and had been given priority to Runway 01 at Rionegro. At 2:49:37, Flight 2933 reports a "fuel emergency" and is given priority landing at Rionegro. Quiroga was then informed that an aircraft had reported a fuel leak and was given an estimate of seven minutes before the aircraft could begin its decent. This estimate was verbally acknowledge by the crew. At 2:52:26, Quiroga informed ATC that the aircraft was "with fuel emergency" and requested final course. Upon receiving this information ATC, cancelled all other aircraft's approach clearance and cleared Flight 2933 for final approach. Between 2:53:03 and 2:55:41 the aircraft suffered multiple engine failures, which were then recuperated. However, both engines ultimately failed. ATC reported that at 2:55:42 the aircraft's altitude was no longer visible to air traffic controllers. At 2:57:10 Quiroga informed ATC that the aircraft was in total failure, electric failure, and without fuel. Transcript of the dialogue that followed shows Quiroga repeatedly asking ATC for vectors to the runway and ATC informing that they no longer have radar contact. At approximately 03:00 hours the aircraft crashed into a mountain hilltop approximately 18 kilometers from Rionegro Airport.

Pilots
Colombian authorities attributed the crash to several factors: unexpected delays at the airport in Rionegro, a delayed request for priority on the Runway, a delayed declaration of emergency due to low fuel, and a high level of aircraft traffic around Rionegro. While Colombian authorities did not explicitly place blame on the pilots of the aircraft they did cite that Quiroga had an expired Linguistic Competency Certification and copilot Goytia had never completed such certification. Additionally, neither pilot clearly communicated with ATC in the minutes before the crash. According to the "Grupo de Investigacion de Accidentes e Incidentes de Aviacion" or GRIAA, for the emergency situation Flight 2933 found itself in, the pilots should have clearly communicated "PAN PAN or MAYDAY" to ATC. This would have immediately given them priority to Runway 01 and appropriate vectors to the runway. In 2017, GRIAA issued a 112-page report on LaMia flight 2933 which highlights Quiroga's co-ownership of LaMia and the financial hardship which had befallen the airline. It also documents previous flight logs in which too little fuel was allotted for the flight duration.

LaMia's Airline dispatcher & Management
LaMia's airline dispatcher on flight 2933, Alex Quispe Garcia, played a crucial role in the outcomes of the events. According to the International Civil Aviation Organization, a flight dispatcher's duties include devising a comprehensive flight plan, signing, and filing the flight plan with airport air traffic services. Garcia scheduled a 4 hours and 22 minutes flight knowing the airplane's endurance limit and the risks of fuel exhaustion. The fuel allotted did not take any considerations to the possibilities of delays or holding patterns. His "mistake" was recognized by a Bolivian air traffic officer who requested that Garcia devise a safer plan. He argued that the actual flight time would be less than than on the plan and refused to change any of the details. Garcia ultimately signed off on the plane for take off and had a huge part responsibility in the crash.

Celia Castego & Bolivian Airport Management Authority (AASANA)
On the night of November 28th, Celia Cruz was the Air Traffic officer in charged of reviewing LaMia 2933's flight plan prior to departure. Celia was employed by the Bolivian Airport Management Authority (AASANA) to make recommendations and to provide pilots and flight dispatchers with weather report. Fours hours before departure, Celia noticed that the flight time listed on the flight plan was the exact same as the plane's endurance limit and she requested that the flight dispatcher, Alex Garcia, provides an alternative flight plan. Thirty minutes later, Garcia came back to Castedo and informed her that no changes would be made to the flight plan. Celia expressed her disapproval and deplored the fact the " many times airline dispatchers didn't take their observations seriously". Conscious that she had no authority to ground the plane over a dubious flight plan, Castedo submitted a memo at 8:30PM local time, to the Bolivian Civil Aviation Agency (DGAC) regional office giving details of the incident, stating that under the regulations the AASANA office was not empowered to reject the submission. After the crash, Castego was pressured and harassed by bosses to modify her report. She sought asylum in Brazil, stating that she was being persecuted by Bolivian authorities.

Conclusion
The tragedy of Flight 2933 was the result of a combination of systematic defects which hindered several participants. The institutional barriers prevented participants, such as Celia Castedo, from raising awareness to the situation. In addition, the flight crew neglected to prepare an adequate flight plan that allowed enough fuel in the case of horrific events. This incident highlights a professional and internal conflict in Mr. Quiroga; he was in competition between his obligations to his passengers and his personal obligations to his enterprise. Participants such as co-pilot Goytia and first officer Arias were placed in an emergency situation in which their training as professionals may have saved the passengers of Flight 2933. This chapter examines the actions of the flight crew, LaMia airlines, and Bolivia's Airport Management Authority and how their actions led to the incident on the morning of November 29th. Multiple theories attempt to explain what transpired in the cockpit on LaMia flight 2933 in the moments prior to the incident. After the incident, Bolivia's Direccion General de Aeronautica Civil (DGAC) revoked LaMia's business license and surviving family members are pursuing legal action against the airline. Future chapters may include investigations into airline regulations, and how institutions can encourage, rather than obstruct, employees such as Ms. Castedo from preventing disasters like that of flgith 2933. Investigations into systematic limitations which silence employees such as Castedo are critical to improving the safety of international flights.