This week we all woke up Tuesday morning to the tragic and sad news that the Bolivian Charter Airline LaMia had crashed into a mountain just outside Medellin, Colombia the day before on Monday Nov 28, 2016 in the late evening. The LaMia flight 2933 Avro RJ85 jet had departed from Santa Cruz de la Sierra (Bolivia) enroute towards Medellin (Colombia) with the members of the Chapeconese Brazilian futbol soccer team. This was yet again another flight which was fuel critical and never declared a fuel emergency on the black box recording to the ATC control tower. The universal code is “Mayday, Mayday, Mayday, Fuel” for a fuel emergency. This was never conveyed on the recordings from the cockpit. The only message referencing this issue was “it’s in failure, uh, total… electrical and fuel.” However, this message was only given at minutes before stall and impact. Part of this problem is that any captain who declares a fuel emergency faces an investigation from the aviation authorities, with possible consequences for the airline. The pilot in command, Captain Miguel Quiroga was part owner of this Bolivian charter air operation. Therefore, there are concerns that this could have been a pride or ego issue which prevented him from choosing to declare the fuel emergency to ATC.
This poor decision and lack of good sound CRM (Crew Resource Management) judgment in the cockpit ended up costing the lives of 71 onboard. There were only six survivors that made it out alive. This was a tragic event which could have been completely prevented. Now the lives of these young Brazilian athletes at the prime of their lives were needlessly extinguished that day. There is a saying: “Those who fail to learn from history are doomed to repeat it.” Well, that is the case here, unfortunately. As we had already been given this history lesson but it simply did not register. It was Jan 25, 1989 when Avianca flight 52 Boeing 707 was enroute from Medellin, Colombia to JFK, New York when it encountered a similar scenario. This is one of the most notable textbook examples of CRM failure in aviation history. Yet, it somehow still manages to keep happening. The Avianca cockpit was dealing with poor weather, a missed approach and multiple delays. These are all discussed in an old CRM course called the “Chain of Errors” which sadly most airlines have cut this program due to saving time and money in initial as well as recurrent airline training. We can not control the Chain of Errors which are the weather, mechanical failure, and unforeseen events. Yet, the last link in that chain is the CRM of the flight crew. Often, that last link in the chain, if broken, equals total loss of all life onboard. Once again Avianca refused to use the words: “Mayday” or “Emergency.” There was a language barrier where a crucial message which was not being understood stating: “We run out of fuel now” was not conveyed in time. The language barrier in the cockpit, as well as ego and shame, once again created a disaster. The fuel emergency was never properly declared or given to ATC. The aircraft had a final missed approach and instead of being given a direct re-routing, it was sent back around which ultimately caused it to crash into a wooded hillside in Cove Neck – Long Island, New York.
This was due to the aircraft running out of fuel with the inability to make another long approach into JFK. Another instance where lack of CRM, cockpit miscommunications, language barriers, ego, and shame ended up costing the lives of 30 passengers out of the 158 onboard. Sadly, this is not just a Latin America or 3rd world airline problem as many might think. The US Low-Cost Carrier Allegiant has been charged with multiple Fuel Emergency landings and more close calls than any other US Airline. Their pilot on a high profile media covered emergency was quoted as saying: “We’re on Bingo fuel here in about probably there to four minutes.” This is far too short of a close call for my personal comfort level. The lack of CRM in modern day aviation and the constant pervasive cultural corporate mindset of “More for Less” and “Profits over Safety” will continue to be our downfall until we demand policy change on this insane airline management policy and cockpit culture.
Link: CNN LaMia Charter Flight Cockpit Audio
Link: Flight Safety Avianca Cockpit Audio
Link: Cockpit Language and Communication Barriers
Link: CBS News Allegiant Fuel Emergency Audio
Link: CRM (Crew Resource Management)
Link: Brazilian Soccer Team Video on Aircraft
Link: FUME EVENT “Aviation’s Biggest Lie”
Link: Aviation Travel Writer – The Flight Times
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