Accident Overview
On 29 November 2016 at 02:59 UTC, an AVRO 146-RJ85 aircraft, registration CP 2933, operated by LAMIA CORPORATION S.R.L., crashed on Cerro Gordo in the municipality of La Unión, Antioquia, Colombia. The aircraft was executing a flight from Viru Viru International Airport (SLVR) in Santa Cruz, Bolivia, to José María Córdova International Airport (SKRG) in Rionegro, Colombia. The flight carried 77 occupants: 4 crew and 73 passengers. As a result of the accident, 71 occupants died and 6 survived with serious and minor injuries. The aircraft was destroyed, and no post-impact fire occurred.
Flight History
The aircraft had been chartered by a Brazilian football team and associated personnel for two non-regular passenger transport flights. After initial flight permit requests were denied by Brazilian authorities, the passengers flew from Guarulhos, Brazil, to Santa Cruz, Bolivia, where they boarded CP 2933. The flight departed SLVR for SKRG, with the accident occurring during the descent in the GEMLI holding pattern while attempting to intercept the localizer for runway 01 at SKRG. The aircraft struck mountainous terrain approximately 10 nautical miles south of the runway threshold.
Causal Factors
The investigation identified several causal factors:
- Inappropriate flight planning and execution by the operator, which did not include the required amount of fuel for an alternate airport, reserve fuel, contingency fuel, or minimum landing fuel as mandated by regulations.
- Sequential shutdown of all four engines during descent in the GEMLI holding pattern due to fuel exhaustion.
- Inadequate decision-making by the operator's management due to lack of operational safety assurance in their processes.
- Loss of situational awareness and erroneous decision-making by the crew, who maintained fixation on continuing the flight with extremely limited fuel and did not take corrective actions to land and refuel.
Contributing Factors
Contributing factors identified include:
- Premature configuration of the aircraft for landing during the holding pattern descent, which, given the lack of thrust, affected the glide distance to the runway.
- Latent deficiencies in the operator's planning and execution of non-regular flights, related to insufficient fuel supply.
- Specific deficiencies in the accident flight's planning by the operator.
- Lack of operational supervision and control by the operator, which did not monitor flight planning or execution.
- Absence of timely priority or emergency calls by the crew during the flight, especially when fuel exhaustion was imminent.
- Organizational and operational deviation by the operator in applying fuel management procedures, not following practices approved by the Bolivian DGAC.
- Delay in the aircraft's approach due to late request for priority and late fuel emergency declaration, compounded by traffic density in the VOR RNG holding pattern.
Investigation and Recommendations
The investigation, led by the GRIAA of Colombia with participation from Bolivia, the UK (AAIB), the US (NTSB), Brazil (CENIPA), and technical advisors from FAA and EASA, resulted in 11 safety recommendations.