Crash of a De Havilland DHC-6 Twin Otter 300 near Sanosware: 22 killed

Date & Time: May 29, 2022 at 1010 LT
Operator:
Registration:
9N-AET
Flight Phase:
Survivors:
No
Site:
Schedule:
Pokhara – Jomsom
MSN:
619
YOM:
1979
Flight number:
TRA197
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
22
Captain / Total flying hours:
17500
Captain / Total hours on type:
13500.00
Copilot / Total flying hours:
520
Copilot / Total hours on type:
315
Aircraft flight hours:
41336
Aircraft flight cycles:
71338
Circumstances:
On 29 May 2022, Tara Air’s 9N-AET, Twin Otter (DHC-6/300) aircraft was scheduled for three flights on Pokhara-Jomsom-Pokhara sector. Tara Air had also filed flight plans for two additional Charter flights on the same sector. Among those five flights, four flights were to be conducted by a set of crews already positioned at Pokhara while the last flight was scheduled to be commanded by the PIC who had reached Pokhara from Kathmandu that very morning. Since Jomsom Airport was closed for operations due to bad weather, the PIC went to Tara Air crew camp and waited for the updates of weather improvement of Jomsom. After Jomsom Airport was open for operations at 0321 UTC, Tara Air operation decided to operate the first scheduled flight. However suspecting the next flight operation to Jomsom could not be operated, the original PIC assigned to the flight seated on board as a passenger to Jomsom for his scheduled business trip and the PIC assigned for the last flight took command. The Flight Plan was amended accordingly. At 0342 UTC, Summit Air’s 9N-AKZ, LET-410 took-off from Pokhara to Jomsom. At 0405 UTC, it reported an altitude of 12,500 ft and patches of cloud over Tatopani. At 0409 UTC, Summit Air’s second aircraft 9N-AMG, LET-410, took-off for Jomsom and subsequently, at 0410 UTC, 9N-AET of Tara Air (TRA197) took-off with 19 passengers and three crews on board. The Copilot had initially reported 3 crew and 18 passengers onboard to Pokhara Tower but later, revised the passenger figure was 19 prior to takeoff. 9N-AET was supposed to take-off before SMT 601 but the PIC seemed hesitant to commence the flight due to weather PIREP from 9N-AKZ that, the en-route weather was not favorable for VFR flights and critical around LETE and TATOPANI. All the crew members of TRA 197 and SMT 601 were in their respective cockpits and communicating with the preceding flight 9N-AKZ as well as with Pokhara tower for the updated information of en-route and destination weather. No flights had been conducted since morning and most of the passengers of Tara air and Summit Air were already at airport. In this situation it can be assumed that there was pressure to conduct flight from each angle. While listening to the CVR of TRA 197, it was observed that someone, either ground staff or some intimate passenger to the crew, advising strongly to the PIC to conduct the flight. Following the PIREP from 9NAKZ, both TRA197 and SMT 601 subsequently started their engines to commence the flights. The PIC of TRA 197 was still hesitant to conduct the flight for Jomsom even after the engine start and delayed the taxi as he was not yet convinced about the weather report received from preceding 9N-AKZ aircraft. In the meantime, SMT 601 lined up for departure to Jomsom. That was one of the most important pressure points to the PIC of TRA 197 to initiate departure. TRA 197 finally lined up and took off from Pokhara at 0410 UTC following the SMT 601 based on the en-route weather information (VMC) from 9N-AKZ, through Pokhara Tower. The en-route weather provided by Summit Air’s 9N-AKZ to Pokhara Tower and the crewmembers of TRA 197 and SMT 601 was not the same. Aircraft took off from Pokhara from runway 04 heading North. Tower instructed “report 5 DME northwest RW 04”. Then after departure at 90 climb power aircraft turned left to maintain a heading of 345 and planned to join heading 305 degree towards Ghodepani. After four minutes, TRA 197 reported, “Now on course…. 6000 climbing and ETA Jomsom 32” (0432 UTC). At 04:21 TRA 197 reported to Pokhara Tower as position approaching Ghodepani 12000 climbing for 12500. After 6 Seconds ATC Pokhara asked TRA 197, “confirm would like to change level and TRA 197 replied, “No Ma'am we have crossed Ghodepani and like to be on”. Pokhara Tower instructed, “Tara 197 contact Jomsom Tower 122.5” CVR recordings show that after TRA 197 crossed Ghodepani, the PIC was not comfortable with the en-route weather. However, the flight was continued following the advice of SMT 601. At 0426 UTC, TRA 197made the first contact with Jomsom AFS and reported its position to which Jomsom Tower conveyed the prevailing weather as “Wind South Westerly up to 30 kts, QNH 1019, Temp 18º”. The PIC of TRA 197 reconfirmed twice if the wind was maximum, up to 30 Kts and currently South Westerly-25kts. The crew was discussing about the bad weather being encountered and the PIC himself voiced his dissatisfaction about the behavior of other pilots who conduct VFR flights in such unfavorable weather. The CVR recordings reveal that the aircraft was encountering clouds and the PIC was trying his best to remain clear of the clouds. During the course of flight, TRA 197 hadn’t reported any abnormalities encountered and neither any technical defect on aircraft either to Jomsom tower or Pokhara Tower. As per CVR, PIC was searching for light and brighter areas and adamantly heading towards it. As per CVR and V2 tracker data, the aircraft was maintaining 12000 ft and was in a climbing attitude. During the continuous attempts of crew to avoid the clouds with Terrain Avoidance and Warning System [TAWS] inhibited, the aircraft met with an unfortunate CFIT accident into the rocky terrain at an altitude of 4050 meter AMSL at Sanusare Mountain, Thasang Rural Municipality, Mustang. As per V2 tracker, last position of 9N-AET was 7.7 nm SW of Jomsom Airport. The aircraft was completely destroyed by the impact and there were no survivors.
Probable cause:
The probable cause of this accident was the flight crew's failure to monitor and maintain the proper course while inadvertently flying in IMC conditions with the aircraft Terrain Avoidance and Warning System (TAWS) inhibited which resulted into a Controlled Flight Into Terrain (CFIT) accident.
The following contributing factors were identified:
1. The flight crew's failure to follow the SOP of company.
2. The aircraft flight operation with TAWS inhibited during deteriorating en-route weather condition.
3. Loss of situational awareness of crew.
4. Deteriorating en route weather.
5. Less experienced copilot for that sector and high crew gradient.
6. Poor CRM during the flight.
7. The whole cockpit duties [both PF and PM] were undertaken by the PlC, which likely impaired his performance.
8. Underutilization of the available Navigation instruments.
Final Report:

Crash of a Viking Air DHC-6 Twin Otter 400 near Dana: 23 killed

Date & Time: Feb 24, 2016 at 0819 LT
Operator:
Registration:
9N-AHH
Flight Phase:
Survivors:
No
Site:
Schedule:
Pokhara – Jomsom
MSN:
926
YOM:
2015
Flight number:
TA193
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
20
Pax fatalities:
Other fatalities:
Total fatalities:
23
Captain / Total flying hours:
20108
Captain / Total hours on type:
18500.00
Copilot / Total flying hours:
760
Copilot / Total hours on type:
560
Aircraft flight hours:
270
Aircraft flight cycles:
482
Circumstances:
As per the flight plan submitted on 23rd February 2016, the aircraft was scheduled for VFR flight to Jomsom (VNJS) on 24th February with estimated off-block time of 01:00, intended cruising speed of 150 knots, intended level of 10,500 ft and via direct track. The first and second alternate aerodromes were Bhairahawa (VNBW) and Pokhara (VNPK) respectively and estimated elapsed time was 20 minutes with the fuel endurance of 2 hours and 30 minute. Based on the information from the CVR, FDR and ATC records, the following description of the history of the flight was reconstructed: At 01:55, the first-officer contacted Pokhara tower requesting Jomsom and Bhairahawa weather. Upon receiving Jomsom weather which was 8 km visibility towards Lete (arrival track) and foothill partially visible; at 01:56 F/O requested start-up for Jomsom. First-officer then briefed the weather to the captain, in response to this the captain responded by saying 'Let‘s have a look, if not possible we will return' (Translated from Nepali conversation). While performing the 'before start checklist', they received weather of Bhairahawa as closed. After completing the checklist and start-up the first-officer at 02:00 requested taxi clearance. The ATC informed runway change to 22 instead of runway 04 and gave taxi clearance. At 02:03 while taxiing the captain considering bad weather condition expressed his concern over the runway change with F/O but failed to express it to the ATC. As briefed by captain earlier, the control was transferred to F/O and at 02:04 F/O made a normal take-off. At 02:08 the captain reported 5 miles at 6,200 ft to ATC. At 02:09, while passing through 7,000 ft the captain informed the actual weather, which was light haze, mountain not visible but had ground contact, to an ultra-light aircraft upon his request. As per the cockpit conversation, the crew were comparing the base of the cloud which was higher than the day before and proposed to continue climb to 12,500 ft if not on-top of the cloud at 10,500 ft. Around 5 miles before Ghorepani passing 10,100 ft, the captain told that cells were still present so advised F/O to continue climb to 12,000 ft and told that they will proceed till TATOPANI and decide to continue or divert. At 02:14 approaching GHOREPANI and passing 11,400 ft, Captain told F/O to maintain level to be in between the cloud layers and briefed F/O that if they had to divert it would be a left turn. At the same time captain asked repeatedly to F/O if his side was raining for which F/O told and confirmed not visual, after which captain told they would see and decide (regarding continuation of flight). At 02:14:50 while over Ghorepani area at 11,500 ft the EGPWS TERRAIN alert and at 02:14:52 PULL UP warning came while they were not visual and at 02:15:01 it was stated that they were visual and by 02:14:53 the warning stopped. At 02:15 while maintaining 11,500 ft the captain reported ATC that they are at Ghorepani at level 10,500 ft after which frequency changeover to Jomsom tower was given. At 02:15:27 the captain instructed F/O to maintain heading of 3300 and flight level just below the cloud, after which a shallow descent was initiated. At this time captain asked F/O if his side was visual, in response F/O replied somewhat visual. The Captain then instructed F/O to descent to 10,000 ft. Once the descent was started at 02:15:55 passing 11,000 ft an OVERSPEED warning sounded in the cockpit for 2 seconds as the speed reached 152 knots. At 02:16 while passing 10,700 ft captain advised F/O to make a left turn so that it would be easy to turn if required as he was able to see his side. Then F/O asked if left side was visual for which the captain informed that not that side (towards the track) but somewhat visual to the left of him and told that the TRACK TO GO was TO THE LEFT whereas they were actually left of the track and had descended to 10,300 ft. At 02:17:58 EGPWS TERRAIN alert sounded when the aircraft was at 10,200 ft and descending on heading of 3210 with right bank angle of around 30 . At 02:18:06 when the aircraft had descended to 10,100 ft the PULL UP WARNING sounded for which the captain said not to worry and at 02:18:12; when the aircraft was at 10,000 ft the captain took-over the control, continued descent and asked F/O if his side was visual. The F/O informed that right side was not visual at all by which the aircraft had continued shallow descent on heading 3250 with right bank angle reaching up to 130 at 2:18:19 and by 02:18:23 the aircraft once again returned back to 0° bank angle. At 02:18:23 the captain started left bank followed by right bank again while still on a shallow descent until 02:18:27.Upon reaching 9,850 ft (lowest altitude) the aircraft started very shallow climb. At 02:18:35 when aircraft was 9,920 ft the captain told F/O that they reached Landslide (a checkpoint which is on track to Jomsom on the right side of the Kali-Gandaki River). At 02:18:44 when aircraft reached 10,150 ft captain told ―what I will do is now I will turn to heading of LETTE‖ (another way point on route to Jomsom); while the PULL-UP warning was continuously sounding. At 02:18:49 when the aircraft was at 10,300 ft right bank angle increased up to 16° with pitch up attitude of 7°. At 02:18:52 the captain told that he would start climb when the aircraft had reached 10,350 ft; pitch attitude of 10° and still on right bank. The aircraft reached zero degree bank at 02:18:53 and started shallow left bank with pitch attitude of 12° nose up. By 02:18:57 the bank angle reached 200 left with pitch attitude of 11.8 and altitude of 10,550 ft and captain was still questioning F/O about the visibility towards his side but F/O informed his side not visible completely. The last data recorded in FDR was at 02:19:03 when the altitude had reached around 10,700 ft; pitch attitude of 7° nose up and left bank angle of 25° heading of 335° with EGPWS PULL-UP warning ON.
Probable cause:
The Commission concludes that the probable cause of this accident was the fact that despite of unfavourable weather conditions, the crew‘s repeated decision to enter into cloud during VFR flight and their deviation from the normal track due to loss of situational awareness aggravated by spatial disorientation leading to CFIT accident.
The contributing factors for the accident are:
1. Loss of situational awareness,
2. Deteriorating condition of weather,
3. Skill base error of the crew during critical phases of flight,
4. Failure to utilize all available resources (CRM), especially insensitivity to EGPWS cautions/warnings.
Final Report:

Crash of a De Havilland DHC-6 Twin 300 Otter in Jomsom

Date & Time: May 16, 2013 at 0833 LT
Operator:
Registration:
9N-ABO
Survivors:
Yes
Schedule:
Pokhara - Jomsom
MSN:
638
YOM:
1979
Flight number:
RNA555
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8451
Captain / Total hours on type:
8131.00
Copilot / Total flying hours:
1396
Copilot / Total hours on type:
1202
Aircraft flight hours:
32291
Aircraft flight cycles:
54267
Circumstances:
The Twin Otter (DHC6/300) aircraft with registration number 9N-ABO, owned and operated by Nepal Airlines Corporation (NAC), departed Kathmandu to Pokhara for night stop on 15 May 2013 in order to accomplish up to 5 (five) Pokhara-Jomsom-Pokhara charter flights planned for the subsequent day on 16 May 2013. As per the programme, the aircraft completed first charter flight from Pokhara to Jomsom sector on 16 May 2013 morning after one and half hour waiting on ground due weather. For this second flight, the aircraft departed at 0225 UTC (08:10LT) from Pokhara to Jomsom in the command of Capt. Dipendra Pradhan and Mr. Suresh K.C. as co-pilot. There were 19 passengers including one infant and 3 crew members on board. The aircraft was operating under Visual Flight Rules (VFR). As per the CVR readout there was no reported difficulties and all the pre and post departure procedure and en-route portion of the flight were completed in normal manner. There was no indication of lacking of information and advice from Jomsom Tower. At first contact the co-pilot called Jomsom Tower and reported its position at PLATO (a compulsory reporting point) at 9 miles from Jomsom airport at 12500ft. AMSL. The Jomsom Tower advised runway 24 wind south westerly 08-12 KTS, QNH 1020, Temp 13 degree and advised to report downwind for runway 24.The co-pilot accepted by replying to join downwind for runway 24. There was no briefing and discussion between the two pilots regarding the tail wind at the airport. The PIC, then, took over the communication function from co-pilot and called Jomsom Tower, requesting to use runway 06 instead of runway 24, despite the advice of tower to use runway 24 to avoid tail wind effect in runway 06. Jomsom Tower repeated the wind speed to be 08-12 KTS for the runway 06, to which the PIC read back the wind and answered to have ”no problem”. As per the PIC request the Jomsom Tower designated runway 06 for landing and advised to report on final runway 06. The PIC did read back the same. The pre landing checklist was used, flaps with full fine in propeller rpm were taken and full flaps was also taken before touchdown. In the briefing of “missed approach” the PIC had answered to be “standard”. The aircraft touched down runway of Jomsom airport at 0245 UTC (08:30LT) at a distance of approximately 776 ft, far from the threshold of runway 06. After rolling 194 ft. in the runway, the aircraft left runway and entered grass area in the right side. The aircraft rolled around 705 ft in the grass area and entered the runway again. The maximum deviation from the runway edge was 19 ft. The Commission has observed that when aircraft touched down the runway, it was not heading in parallel to the runway centreline. After touchdown the aircraft rolled around 194ft on the runway, left the paved area and started rolling in the grass area in the right side. During the landing roll, when the aircraft was decelerating, the co-pilot had raised the flaps as per the existing practice of carrying out “after the landing “checks". As per the observation of passenger seated just behind the cockpit, after touchdown of the aircraft there was no communication between pilot and co-pilot. It seemed that pilot was busy in cockpit and facing problem. It was obvious that PIC was in dilemma in controlling aircraft. He added power to bring aircraft into the runway with an intention to lift up the aircraft. He did not brief anything to copilot about his intention and action. He started adding power with the intention of lifting up, but the aircraft was already losing its speed, due to extension of flaps by co-pilot without briefing to PIC and use of brakes (light or heavy, knowingly and unknowingly) simultaneously by the PIC. The accelerating aircraft with insufficient speed and lift to take off ran out of the runway 24 end, continued towards the river, hit the barbed fence and gabion wall with an initial impact and finally fell down into the edge of river. The left wing was rested in the mid of the river preventing the aircraft submerged into the river.
Probable cause:
The Accident Investigation Commission has determined the most probable cause of the accident as the inappropriate conduct of STOL procedure and landing technique carried out by the PIC, during landing phase and an endeavor to carry out take off again with no sufficient airspeed, no required lifting force and non availability of required runway length to roll. Contributory factors to the occurrence is the absence of proper CRM in terms of communication, coordination and briefing in between crew members on intention and action being taken by PIC, during pre and post landing phase.
Final Report:

Crash of a Dornier DO228-212 in Jomsom: 15 killed

Date & Time: May 14, 2012 at 0945 LT
Type of aircraft:
Operator:
Registration:
9N-AIG
Survivors:
Yes
Schedule:
Pokhara - Jomsom
MSN:
8216
YOM:
1997
Flight number:
AG-CHT
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
15
Captain / Total flying hours:
5776
Captain / Total hours on type:
596.00
Circumstances:
On final approach to Jomsom Airport runway 06, the crew lowered the landing gear when they noticed a technical issue. On short final, the captain decided to initiate a go-around procedure and to divert to Pokhara. He made a sharp U-turn to the left at a speed of 73 knots when the left wing impacted a rocky hill located 270 meters above the runway 24 threshold. The aircraft stalled and crashed on the slope of the hill and was destroyed by impact forces. The stewardess and five passengers were seriously injured while all 15 other occupants, among them both pilots, were killed.
Probable cause:
The captain took the decision to make a sharp turn to the left at 73 knots without considering the turn radial and the rising terrain, which resulted in a continuous stall warning during the remaining 12 seconds of flight. The left hand wing of the aircraft struck a rock and the aircraft crashed. The decision of the captain to initiate a turn to the left at this stage of the flight was against all published procedures. It was reported that the commander was a senior flight instructor employed by the Civil Aviation Authority of Nepal.

Crash of a De Havilland DHC-6 Twin Otter 300 in Pokhara: 18 killed

Date & Time: Aug 22, 2002 at 1005 LT
Operator:
Registration:
9N-AFR
Survivors:
No
Site:
Schedule:
Jomsom - Pokhara
MSN:
762
YOM:
1981
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
18
Circumstances:
The twin engine aircraft departed Jomsom Airport at 0941LT for a 25-minutes flight to Pokhara, carrying three crew members and 15 passengers, 13 Germans, one American and one British. While descending to Pokhara Airport, the crew encountered poor weather conditions with low clouds. At an altitude of 4,600 feet, the aircraft struck the slope of a mountain located 6 km southwest of the airport, near the village of Kristi Nachnechaur. The aircraft was totally destroyed by impact forces and all 18 occupants were killed. There was no fire.
Probable cause:
Controlled flight into terrain after the crew descended too low in poor visibility without maintaining visual clearance with the ground.

Crash of a De Havilland DHC-6 Twin Otter near Ghorepani: 18 killed

Date & Time: Aug 21, 1998 at 1124 LT
Registration:
9N-ACC
Flight Phase:
Survivors:
No
Site:
Schedule:
Jomsom - Pokhara
MSN:
710
YOM:
1980
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
18
Circumstances:
The twin engine aircraft departed Jomsom Airport at 1110LT on a 20-minutes flight to Pokhara, carrying 15 passengers and three crew members. While cruising at an altitude of 10,500 feet in good weather conditions, the aircraft struck the slope of a mountain. The wreckage was found two days later and all 18 occupants were killed.

Crash of a Harbin Yunsunji Y-12-II in Jomsom

Date & Time: Nov 8, 1993
Type of aircraft:
Operator:
Registration:
9N-ACS
Survivors:
Yes
Schedule:
Pokhara - Jomsom
MSN:
0044
YOM:
1991
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 24, the aircraft was unable to stop within the remaining distance. It overran, went down an embankment and came to rest in the Gandaki River with its right wing torn off. All 19 occupants were rescued, among them both pilots and three passengers were injured.
Probable cause:
For unknown reasons, the crew landed 240 metres past the runway 24 threshold (runway 24 is 600 metres long).

Crash of a De Havilland DHC-6 Twin Otter 100 in Jomsom: 1 killed

Date & Time: Feb 27, 1970
Operator:
Registration:
9N-RF9
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Jomsom - Kathmandu
MSN:
102
YOM:
1968
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Crashed in unknown circumstances while taking off from Jomsom Airport. A passenger was killed.