For the Chapecoense soccer team, the LaMia airlines flight to Medellín, Columbia, on November 28 was supposed to be part of a fairy-tale ending: The scrappy underdogs from a small farm town in southern Brazil had pulled off an amazing season and were headed to the final of the Copa Sudamericana tournament. But four hours into their flight, and just 12 miles from their destination airport, that fairy tale turned to horror as the BAE 146 short-haul jet ran out of fuel and crashed into a mountainside, killing 71 of the 77 aboard.
If it sounds incredible that a competent pilot would let his plane be destroyed by running out of gas — well, yes, it is. Fuel-exhaustion accidents are extremely rare, making up just 0.5 percent of all crashes.
But they fit into a broader category that already makes up the largest portion of fatal air accidents: pilot error. As aeronautical engineering becomes more sophisticated, but human beings remain the same, an ever-increasing proportion of mishaps is ascribable to dumb mistakes, or “human factors” as they’re known in air-crash-investigation circles.
These mistakes come in definable categories. Here are some of the ones that may have played a role in the LaMia crash:
In a potentially dangerous environment like aviation, it’s important to set safety limits beforehand and then stick to them religiously. If you allow yourself to go past the limit a little bit, it’s easy to go a little more, and then a little bit more, until there is no safety margin at all. In the case of the LaMia flight, the BAE 146 had just enough fuel capacity to fly from Santa Cruz, Bolivia, to Medellín, but not enough for the required 30-minute fuel reserve. When pilot Miguel Quiroga was ordered to go into a hold pattern due to a delay on the runway at Medellín, his margin slipped away bit by bit until he had nothing left.
Plan Continuation Bias
Also known as “get-there-itis,” this is the tendency for one’s judgment to be clouded by the desire to achieve a certain outcome. As a group, pilots tend to be highly motivated, success-oriented people. This can be good in many circumstances, but extremely dangerous when it prevents them from reassessing the wisdom of their plans. Quiroga could have stopped to refuel at an airport en route, but the flight was already running late, reportedly because before takeoff one of the players asked that his video-game player be retrieved from the checked baggage.
According to the behavioral economist Daniel Kahneman, human beings instinctively put more value on avoiding a loss than they do in acquiring a gain of the same magnitude. This leads them to take gambles that don’t make sense from a strictly utilitarian point of view. Once he realized his fuel situation was critical, Quiroga could have declared a fuel emergency and landed at Medellín. But he might have faced an investigation and possible sanctions if he’d done so. In order to avoid that mildly negative outcome, he stayed in the holding pattern too long and incurred a far worse one.
Cockpit Resource Management
The plane’s first officer, a well-known Colombian model named Sisy Arias, was reportedly making her first flight as a commercial co-pilot. In several crashes, lack of seniority has led flight-crew members to refrain from pointing out critical safety issues, for fear of being seen as challenging the authority of the pilot in command.
There’s another human factor which may have played a role: social dysfunction in the airplane’s operational environment. Though details are still emerging, several aspects of the case raise eyebrows. The airline had been founded in 2009 in Venezuela by a political ally of Hugo Chávez, and in the years that followed, allegations swirled about the misappropriation of funds. Though the airline was supposed to be based in Venezuela and operate a dozen planes, it in fact operated only one — and what’s more, the captain of the flight was one of the owners, an almost unheard of circumstance in the airline business.
Other aspects of the case are puzzling, too, such as why Brazilian authorities refused to allow LaMia to take off from São Paolo. Rather than flying all the way to Medellín on a regularly scheduled commercial flight, the team elected to fly commercially to Bolivia to meet the charter airliner. Again, the reasons why the team did this are still hazy, but apparently LaMia had become a popular charter operator among South American soccer clubs.
Given the historically less-than-forthcoming nature of South American air-crash investigations, and the past heavy involvement of drug money in South American soccer clubs, it may be some time before everything about the LaMia crash becomes crystal clear.