LaMia Flight 2933 was a regularly scheduled charter flight from Santa Cruz de la Sierra, Bolivia, to Medellín, Colombia. On 28 November 2016, the aircraft operating the flight crashed into Mt. Cerro Gordo near the town of La Unión, Antioquia, Colombia, killing 71 of the 77 people on board. The aircraft was transporting the first-team squad of the Brazilian football club Chapecoense and their entourage to Medellín where the team was scheduled to play at the 2016 Copa Sudamericana Finals. One of the four crew members, three of the players, and two other passengers survived with injuries.
The official report from Colombia's civil aviation agency, Aerocivil, concluded that the cause of the crash was a result of fuel exhaustion due to an inappropriate flight plan by the airline, and pilot error regarding poor decision-making as the situation worsened, including a failure to declare an emergency for 36 minutes after fuel levels became critically low, thus failing to inform air traffic control at Medellín – until just seconds before its fuel-starved engines flamed out, and 18 kilometres (9.7 nmi; 11 mi) from the airport – that an immediate landing was required.
Aircraft and occupants
The aircraft involved was an Avro RJ85, registration CP-2933, serial number E.2348. It was acquired by LaMia in 2013. The captain was 36-year-old Miguel Alejandro Quiroga Murakami, who had joined LaMia in 2013 and was a former Bolivian Air Force (FAB) pilot. The captain also had previously flown for EcoJet and had lots of experience flying the Avro RJ85. At the time of the accident, captain Quiroga was one of the airline's co-owners as well as a flight instructor. Quiroga had logged a total of 6,692 flight hours, including 3,417 hours on the Avro RJ85.
The first officer was 47-year-old Fernando Goytia, who was also a former FAB pilot. He received his type rating on the Avro RJ85 five months before the accident and had 6,923 flight hours, with 1,474 of them on the Avro RJ85.
29-year-old Sisy Arias, a trainee pilot, was an observer in the cockpit. She had been interviewed by TV before the flight.
There were additional crew members travelling in the cabin, flight attendants Ximena Suarez and Romel Vacaflores, flight technician Erwin Tumiri, flight dispatcher Alex Quispe García (who prepared and filed the aircraft's flight path), and LaMia representative Gustavo Encina.
Among the passengers were 22 players of the Brazilian Associação Chapecoense de Futebol club, 23 staff, 21 journalists, and two guests. The team was travelling to play the away leg of the Final playoff in the 2016 Copa Sudamericana against Atlético Nacional.
Accident
Background and transit to Bolivia
Chapecoense's initial request to charter LaMia for the whole journey from São Paulo to Medellín was refused by the National Civil Aviation Agency of Brazil because the limited scope of freedom of the air agreements between the two countries, under International Civil Aviation Organization rules, would have required the use of a Brazilian or Colombian airline for such a service. The club opted to retain LaMia and arranged a flight with Boliviana de Aviación from São Paulo to Santa Cruz de la Sierra, Bolivia, where it boarded the LaMia flight. LaMia had previously transported other teams for international competitions, including Chapecoense and the Argentina national team, which had flown on the same aircraft two weeks before. The flight from São Paulo landed at Santa Cruz at 16:50 local time.
Flight from Santa Cruz
The RJ85 operating LaMia flight 2933 departed Santa Cruz at 18:18 local time (22:18 UTC) on 28 November 2016. A Chapecoense team member's request to have a video game retrieved from his luggage in the aircraft's cargo delayed departure. The original flight plan included an intermediate refueling stop at the 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 Airports and Air Navigation Services Administration (AASANA – Spanish: Administración de Aeropuertos y Servicios Auxiliares a la Navegación Aérea) at Santa Cruz de la Sierra reportedly rejected the crew's flight plan for a direct flight to Medellín several times despite pressure to approve it, because of the aircraft's range being almost the same as the flight distance. The flight plan was approved by another AASANA officer. The distance between Santa Cruz and Medellín airports is 1,598 nautical miles (2,959 km; 1,839 mi). A fuel stop in Cobija would have broken the flight into two segments, an initial segment of 514 nautical miles (952 km; 592 mi) to Cobija followed by a flight of 1,101 nautical miles (2,039 km; 1,267 mi) to Medellín, a total of 1,615 nautical miles (2,991 km; 1,859 mi).
The flight crew anticipated a fuel consumption of 8,858 kilograms (19,529 lb) for their planned route of 1,611 nautical miles (2,984 km; 1,854 mi) (including 200 kg for taxiing). After refueling at Santa Cruz, CP2933 had 9,073 kilograms (20,003 lb) on board. ICAO regulations would have required them to carry a total fuel load of 12,052 kilograms (26,570 lb), to allow for holding, diversion, and other contingencies. The RJ85's fuel tanks have a capacity of 9,362 kilograms (20,640 lb). Around 21:16 local time (02:16 UTC, 29 November), about 180 nautical miles (330 km; 210 mi) from their destination, the aircraft displayed a low-fuel warning. At this point, they were 77 nmi from Bogotá, but the crew took no steps to divert there, nor to inform ATC of the situation. The RJ85 continued on course and began its descent towards Medellín at 21:30.
Another aircraft had diverted to Medellín from its planned route (from Bogotá to San Andres) because of a suspected fuel leak. Medellín air traffic controllers gave that aircraft priority to land and at 21:43 the LaMia RJ85's crew was instructed to enter a holding pattern at the Rionegro VOR beacon and wait with three other aircraft for its turn to land. The crew requested and were given authorisation to hold at an RNAV waypoint named GEMLI, about 5.4 nautical miles (10 km; 6 mi) south of the Rionegro VOR. While waiting for the other aircraft to land, during the last 15 minutes of its flight, the RJ85 completed two laps of the holding pattern. This added approximately 54 nautical miles (100 km; 62 mi) to its flight path.
At 21:49, the crew requested priority for landing because of unspecified "problems with fuel", and were told to expect an approach clearance in "approximately seven minutes". At 21:52, a full 36 minutes after the onboard low-fuel warning had notified the crew of its situation, the crew finally declared a fuel emergency and requested immediate descent clearance and "vectors" for approach. 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. Shortly before 22:00, while flying in Colombian airspace between the municipalities of La Ceja and La Unión, the pilot reported an electrical failure and fuel exhaustion. An air traffic controller radioed that the aircraft was 0.1 nautical miles (190 m; 200 yd; 610 ft) from the Rionegro VOR, but its altitude data were no longer being received. The crew replied that the aircraft was at an altitude of 9,000 feet (2,700 m); the procedure for an aircraft approaching to land at José María Córdova International Airport states it must be at an altitude of at least 10,000 feet (3,000 m) when passing over the Rionegro VOR. 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 2,600 metres (8,500 ft) while flying in a northwesterly direction, with the wreckage of the rear of the aircraft on the southern side of the crest and other wreckage coming to rest on the northern side of the crest adjacent to the Rionegro VOR transmitter facility, which is in line with runway 01 at José María Córdova International Airport and about 18 kilometres (9.7 nmi; 11 mi) from the southern end.
Rescue
Helicopters from the Colombian Air Force were initially unable to get to the site because of heavy fog in the area, while first aid workers arrived two hours after the crash to find debris strewn across an area about 100 metres (330 ft) in diameter. It was not until 02:00 on 29 November that the first survivor arrived at a hospital: Alan Ruschel, one of the Chapecoense team members. Six people were found alive in the wreckage. The last survivor to be found was footballer Neto who was discovered at 05:40. Chapecoense backup goalkeeper Jakson Follmann underwent a potentially life-saving leg amputation. 71 of the 77 occupants died as a result of the crash. These included captain Quiroga, first officer Goitya, training pilot Sisy Arias, flight attendants Garcia and Vacaflores, and LaMia representative Encina. The only crew members to survive were flight technician Tumiri and flight attendant Suárez. The number of dead was initially thought to be 75, but it was later revealed that four people had not boarded the aircraft. Colombian Air Force personnel extracted the bodies of 71 victims from the wreckage and took them to an air force base. They were then taken to the Instituto de Medicina Legal in Medellín for identification.
Investigation
Colombian crash investigation
The Air Accident Investigation Group (GRIAA – Spanish: Grupo de Investigación de Accidentes Aéreos), the investigation group of Colombia's Civil Aviation Authority (UAEAC or Aerocivil – Spanish: Unidad Administrativa Especial de Aeronáutica Civil), investigated the accident, with assistance from BAE Systems (the successor company to British Aerospace, the aircraft's manufacturer) and the British Air Accidents Investigation Branch (AAIB) as the investigative body of the state of the manufacturer. A team of three AAIB accident investigators was deployed. They were joined by investigators from Bolivia's national aviation authority, the General Directorate of Civil Aviation (DGAC – Spanish: Dirección General de Aeronáutica Civil). In all, twenty-three specialists were deployed on the investigation; in addition to ten Colombian investigators and those from Bolivia and the United Kingdom, Brazil and the United States contributed personnel to the investigation. On the afternoon of 29 November the UAEAC reported that both flight recorders – the flight data recorder (FDR) and cockpit voice recorder (CVR) – had been recovered undamaged.
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 lead investigator stated that there was "no evidence of fuel in the aircraft" and the aircraft did not catch fire when it crashed. Analysis of the FDR showed all four engines flamed out a few minutes before the crash.
The investigation found that LaMia had consistently operated its fleet without the legally required endurance fuel load, and had simply been lucky to avoid any of the delays that the mandated fuel load were meant to allow for. An investigative report by Spanish-language American media company Univision, using data from the Flightradar24 website, claimed that the airline had broken the fuel and loading regulations of the International Civil Aviation Organization on 8 of its 23 previous flights since 22 August, three of which came within a month, including two direct flights from Medellín to Santa Cruz: one on 29 October transporting Chapecoense's final opponent, Atlético Nacional to the away leg of their Copa Sudamericana semifinal, and a flight without passengers on 4 November, and flights involving the Argentina national team to a match for the 2018 World Cup Qualifiers a week later. The report claimed the eight flights would have used at least some of the aircraft's mandatory fuel reserves (a variable fuel quantity to allow for an additional 45 minutes of flying time), concluding the company was accustomed to operating flights at the limit of the RJ85's endurance.
Findings in the final report
On 27 April 2018, the investigators, led by Aerocivil, released the final investigative report for the crash of Flight 2933, listing the following causal factors: