Region

Crash of a Let 410UVP-E20 in Lukla: 3 killed

Date & Time: Apr 14, 2019 at 0910 LT
Type of aircraft:
Operator:
Registration:
9N-AMH
Flight Phase:
Survivors:
Yes
Schedule:
Lukla - Kathmandu
MSN:
13 29 14
YOM:
2013
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The airplane was apparently carrying four passengers and a crew of three for Kathmandu. While taking off from runway 24, after a course of about 100 meters, the airplane veered off runway to the right and crashed on two parked Eurocopter AS350 registered 9N-ALC and 9N-ALK. The copilot of the Let 410 was killed as well as two people on the ground, among them a police officer. The pilot of the helicopter 9N-ALK was seriously injured and evacuated to hospital. All other occupants were treated for minor injuries.

Crash of a Cessna 208B Grand Caravan near Simikot: 2 killed

Date & Time: May 16, 2018 at 0645 LT
Type of aircraft:
Operator:
Registration:
9N-AJU
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Surkhet – Simikot
MSN:
208B-0770
YOM:
1999
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The single engine aircraft departed Surkhet Airport at 0612LT on a cargo flight to Simikot. At 0627LT, the crew made his last radio transmission with Nepalgunj Tower. About 18 minutes later, while cruising by night at an altitude of 12,800 feet, the airplane struck the slope of a mountain located near the Simikot Pass, some 12 km from Simikot Airport. The airplane disintegrated on impact and both crew members were killed.

Crash of a De Havilland DHC-8-Q402 Dash-8 in Kathmandu: 51 killed

Date & Time: Mar 12, 2018 at 1419 LT
Type of aircraft:
Operator:
Registration:
S2-AGU
Survivors:
Yes
Schedule:
Dhaka - Kathmandu
MSN:
4041
YOM:
2001
Flight number:
BS211
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
67
Pax fatalities:
Other fatalities:
Total fatalities:
51
Captain / Total flying hours:
5518
Captain / Total hours on type:
2824.00
Copilot / Total flying hours:
390
Copilot / Total hours on type:
240
Aircraft flight hours:
21419
Aircraft flight cycles:
28649
Circumstances:
On March 12, 2018, a US Bangla Airlines, Bombardier DHC-8-402, S2-AGU, flight number BS211 departed Hazrat Shahjalal International Airport, Dhaka, Bangladesh at 06:51 UTC on a schedule flight to Tribhuvan International Airport (TIA), Kathmandu, Nepal. The aircraft overflew part of Bangladesh and Indian airspace en-route to Nepal. At 0641, Dhaka Ground Control contacted the aircraft requesting for its Bangladesh ADC number which was recently made mandatory a few weeks ago by Bangladesh authority for all international outbound flights. The crew provided the ADC number as 2177 as provided in the Flight Plan. The Ground Controller again asked the crew if they had the ADC for Bangladesh. At 0642, PIC then contacted the Operations to confirm the Bangladesh ADC number. As per the CVR records, changes in the PIC’s vocal pitch and language used indicated that he was agitated and experiencing high levels of stress at the time while communicating with Dhaka Ground Control and airlines operations. The aircraft finally took off at 0651. As the aircraft was in a climb phase, the PIC overheard a communication between Operations and another US Bangla aircraft regarding the fuel onboard but the PIC without verifying whether the message was meant for him or not, engaged in some unnecessary conversation with the Operations staff. The Captain's vocal pitch and language used indicated that he was very much emotionally disturbed and experiencing high level of stress. The aircraft established its first contact with Kathmandu Control at 0752:04. At 0807:49 the First Officer contacted Kathmandu Control and requested for descent. Kathmandu Control gave descend clearance to FL160 with an estimated approach time of 0826 which was acknowledged by the First Officer. At 0810 the flight was handed over to Kathmandu Approach. At 0811, Kathmandu Approach instructed the aircraft to descend to 13,500 ft and hold over GURAS. The crew inserted the HOLD in the Flight Management System. At 0813:41 Kathmandu Approach further instructed the aircraft to reduce its speed and descend to 12500 ft. At 0816 Kathmandu Approach instructed the aircraft to further descend to 11500 ft., and cleared for VOR approach RWY 02 maintaining minimum approach speed. Both the crew forgot to cancel the hold on the FMS as they were engaged in some unnecessary conversation. Upon reaching GURAS, the aircraft turned left to enter the holding pattern over GURAS, it was noticed by PIC and FO and immediately PIC made correction and simultaneously this was alerted to the crew by Approach Control also. Once realizing the aircraft flying pattern and ATC clearance, the PIC immediately selected a heading of 027° which was just 5° of interception angle to intercept the desired radial of 202° inbound to KTM. The spot wind recorded was westerly at 28kt. The aircraft continued approach on heading mode and crossed radial 202° at 7 DME of KTM VOR. The aircraft then continued on the same heading of 027° and deviated to the right of the final approach course. Having deviated to the right of the final approach path, the aircraft reached about 2-3 NM North east of the KTM VOR and continued to fly further northeast. At 0827, Kathmandu Tower (TWR) alerted the crew that the landing clearance was given for RWY 02 but the aircraft was proceeding towards RWY 20. At 0829, Tower Controller asked the crew of their intention to which the PIC replied that they would be landing on RWY 02. The aircraft then made an orbit to the right. The Controller instructed the aircraft to join downwind for RWY 02 and report when sighting another Buddha Air aircraft which was already on final for RWY 02. The aircraft instead of joining downwind leg for RWY 02, continued on the orbit to the right on a westerly heading towards Northwest of RW 20. The controller instructed the aircraft to remain clear of RWY 20 and continue to hold at present position as Buddha air aircraft was landing at RW 02 (from opposite side) at that time. After the landing of Buddha Air aircraft, Tower Controller, at 08:32 UTC gave choice to BS211 to land either at RW 20 or 02 but the aircraft again made an orbit to the right, this time northwest of RWY 20. While continuing with the turn through Southeastern direction, the PIC reported that he had the runway in sight and requested tower for clearance to land. The Tower Controller cleared the aircraft to land but when the aircraft was still turning for the RWY it approached very close to the threshold for RWY 20 on a westerly heading and not aligned with the runway. At 08:33:27 UTC, spotting the aircraft maneuvering at very close proximity of the ground and not aligned with the RWY. Alarmed by the situation, the Tower Controller hurriedly cancelled the landing clearance of the aircraft by saying, "Takeoff clearance cancelled". Within the next 15-20 seconds, the aircraft pulled up in westerly direction and with very high bank angle turned left and flew over the western area of the domestic apron, continued on a southeasterly heading past the ATC Tower and further continued at a very low height, flew over the domestic southern apron area and finally attempted to align with the runway 20 to land. During this process, while the aircraft was turning inwards and momentarily headed towards the control tower, the tower controllers ducked down out of fear that the aircraft might hit the tower building. Missing the control tower, when the aircraft further turned towards the taxi track aiming for the runway through a right reversal turn, the tower controller made a transmission by saying, "BS 211, I say again...". At 08:34 UTC the aircraft touched down 1700 meters down the threshold with a bank angle of about 15 degrees and an angle of about 25 degrees with the runway axis (approximately heading Southeast) and to the left of the center line of runway 20, then veered southeast out of the runway through the inner perimeter fence along the rough down slope and finally stopped about 442 meters southeast from the first touchdown point on the runway. All four crew members (2 cockpit crew and 2 cabin crew) and 45 out of the 67 passengers onboard the aircraft were killed in the accident. Two more passengers succumbed to injury later in hospital during course of treatment. The aircraft caught fire after 6 seconds of touchdown which engulfed major portions of the aircraft.
Probable cause:
The Accident Investigation Commission determines that the probable cause of the accident is due to disorientation and a complete loss of situational awareness in the part of crewmember. Contributing to this the aircraft was offset to the proper approach path that led to maneuvers in a very dangerous and unsafe attitude to align with the runway. Landing was completed in a sheer desperation after sighting the runway, at very close proximity and very low altitude. There was no attempt made to carry out a go around, when a go around seemed possible until the last instant before touchdown on the runway.
The following contributing factors were reported:
- Improper timing of the pre-flight briefing and the commencement of the flight departure in which the operational pre-flight briefing was given in early morning but the flight departure time was around noon and there were four domestic short flights scheduled in between.
- The PIC, who was the pilot flying, seemed to be under stress due to behavior of a particular female colleague in the company and lack of sleep the preceding night.
- A very steep gradient between the crew.
- Flight crew not having practiced visual approach for runway 20 in the simulator.
- A poor CRM between the crew.

An investigation into the captain's behaviour showed that he had history of depression while serving in the Bangladesh Air Force in 1993 and was removed from active duty after evaluation by a psychiatrist. He was re-evaluated by a psychiatrist in January 2002 and was declared to be fit for flying. Examinations in successive annual medical checks were not focused on his previous medical condition of depression, possibly because this was not declared in the self-declaration form for annual medicals. During the flight the captain was irritable, tensed, moody, and aggressive at various times. He was smoking during the flight, contrary to company regulations. He also used foul language and abusive words in conversation with the junior female first officer. He was engaged in unnecessary conversation during the approach, at a time when sterile cockpit rules were in force. The captain seemed very unsecure about his future as he had submitted resignation from this company, though only verbally. He said he did not have any job and did not know what he was going to do for living.
Final Report:

Crash of a De Havilland DHC-6 Twin otter at Simikot

Date & Time: Nov 28, 2017
Operator:
Registration:
9N-ABM
Flight Phase:
Survivors:
Yes
Schedule:
Simikot - Surkhet
MSN:
455
YOM:
1975
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
13
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft was completing a flight from Simikot to Surkhet, carrying 13 police personnel who were returning after the elections, and three crew members. During takeoff roll, the airplane went out of control, veered off runway and eventually came to rest with its nose seriously bent. Both pilots and the steward were injured while all other occupants were evacuated safely. The aircraft was badly damaged. It is believed that a tire burst during takeoff.

Crash of a PZL-Mielec M28-05 Skytruck in Bajura: 1 killed

Date & Time: May 30, 2017 at 1210 LT
Type of aircraft:
Operator:
Registration:
NA-048
Flight Type:
Survivors:
Yes
Schedule:
Surkhet - Simikot
MSN:
AJE003-02
YOM:
2004
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The crew was performing a flight from Surkhet to Simikot but was unable to land at Simikot due to high winds and diverted to Bajura Airstrip. Upon arrival, the twin engine aircraft missed the runway, crashed and came to rest upside down. The captain was killed while both other crew members were seriously injured.

Crash of a Let 410UVP-E20 in Lukla: 2 killed

Date & Time: May 27, 2017 at 1404 LT
Type of aircraft:
Operator:
Registration:
9N-AKY
Flight Type:
Survivors:
Yes
Schedule:
Katmandou – Lukla
MSN:
14 29 17
YOM:
2014
Flight number:
GO409
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
On final approach to Lukla-Tenzing Hillary Airport while completing a cargo flight from Kathmandu, the twin engine aircraft hit the ground and crashed into a ravine adjacent to runway 06 threshold. The captain was killed while the copilot and the stewardess were injured. The aircraft was destroyed. At the time of the accident, the visibility was reduced due to foggy conditions. Summit Air is the new name given to ex-Goma Air. A day after the crash, the copilot died from his injuries.
Crew:
Paras Kumar Rai, pilot, †
Srijan Manandhar, copilot, †
Pragya Maharjan, stewardess.

Crash of a BAe Jetstream 41 in Siddharthanagar

Date & Time: Sep 24, 2016 at 1656 LT
Type of aircraft:
Operator:
Registration:
9N-AIB
Survivors:
Yes
Schedule:
Kathmandu – Siddharthanagar
MSN:
41017
YOM:
1
Flight number:
YT893
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
29
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The crew performed the approach in good weather conditions (wind from southeast at 4 knots and 8 km visibility). After touchdown on runway 28 at Gautam Buddha Airport, the aircraft did not stop within the remaining distance, overran, lost its left main gear (right main gear state to be confirmed) and came to rest in the bush, about 110 meters past the runway end. All 32 occupants were able to evacuate the cabin safely. The aircraft seems to be damaged beyond repair.

Crash of a Pacific Aerospace 750XL in Chilkhaya: 2 killed

Date & Time: Feb 26, 2016 at 1305 LT
Operator:
Registration:
9N-AJB
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Nepalgunj - Jumla
MSN:
160
YOM:
2010
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The single aircraft left Nepalgunj at 1230LT bound for Jumla. Thirty-five minutes later, it crashed in unknown circumstances in a field and eventually collided with an earth bank located near the village of Chilkhaya. Both pilots were killed and nine passengers were injured. The aircraft was written off.

Crash of a De Havilland DHC-6 Twin Otter 400 near Dana: 23 killed

Date & Time: Feb 24, 2016 at 0800 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:
20800
Circumstances:
The twin engine aircraft (a Viking Air DHC-6 Twin Otter 400 version) left Pokhara at 0750LT bound for Jomsom, a 18 minutes flight. About ten minutes later, while cruising in marginal weather conditions, the aircraft hit the slope of a mountain and crashed. As it failed to arrive at destination, SAR operations were conducted and the wreckage was found at 1325LT. The aircraft was destroyed by impact forces and a post crash fire and all 23 occupants were killed.
Probable cause:
It was determined that the crew deviated from the prescribed route to the left while descending to Jomsom due to the presence of clouds in the area. In doing so, the aircraft descended to 10,000 feet in clouds while flying under visual flight rules (VFR). When the GPWS warning sounded, the crew failed to react immediately and the aircraft hit a cliff at the altitude of 10,700 feet before coming to rest at the altitude of 10,982 feet. The commission reported that ignoring the GPWS warning had become habit with certain flight crews.

Crash of an Airbus A330-303 in Kathmandu

Date & Time: Mar 4, 2015 at 0744 LT
Type of aircraft:
Operator:
Registration:
TC-JOC
Survivors:
Yes
Schedule:
Istanbul – Kathmandu
MSN:
1522
YOM:
29
Flight number:
TK726
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
224
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
14942
Captain / Total hours on type:
1456.00
Copilot / Total flying hours:
7659
Copilot / Total hours on type:
1269
Aircraft flight hours:
4139
Aircraft flight cycles:
732
Circumstances:
The aircraft departed Istanbul at 1818LT on March 3 on a scheduled flight to Tribhuvan International Airport (TIA), Kathmandu with 11 crew members and 224 passengers .The aircraft started contacting Kathmandu Control from 00:02 hrs to 00:11hrs while the aircraft was under control of Varanasi and descending to FL 250 but there was no response because Kathmandu Control was not yet in operation. The airport opened at its scheduled time of 00:15hrs. The aircraft established its first contact with Kathmandu Approach at 00:17 hrs and reported holding over Parsa at FL 270. Kathmandu Approach reported visibility 100 meters and airport status as closed. At 00:22 hrs the aircraft requested to proceed to Simara due to moderate turbulence. The Kathmandu Approach instructed the aircraft to descend to FL 210 and proceed to Simara and hold. At 01:05 hrs when Kathmandu Approach provided an updated visibility of 1000 meters and asked the flight crew of their intentions, the flight crew reported ready for RNAV (RNP) APCH for runway 02. The aircraft was given clearance to make an RNP AR APCH. At 01:23 hrs when the aircraft reported Dovan, Kathmandu Approach instructed the flight crew to contact Kathmandu Tower. Kathmandu Tower issued a landing clearance at 01:24 hrs and provided wind information of 100° at 03 knots. At 01:27 hrs the aircraft carried out a missed approach due to lack of visual reference. The aircraft was given clearance to proceed to RATAN hold via MANRI climbing to 10500 feet as per the missed approach procedure. During the missed approach the aircraft was instructed to contact Kathmandu Approach. At 01:43 hrs the aircraft requested the latest visibility to which Kathmandu Approach provided visibility 3000 m and Kathmandu Tower observation of 1000 meters towards the south east and few clouds at 1000 ft, SCT 2000 ft and BKN 10,000 feet. When the flight crew reported their intention to continue approach at 01:44 hrs, Kathmandu Approach cleared the aircraft for RNAV RNP APCH runway 02 and instructed to report RATAN. The aircraft reported crossing 6700 ft at 01:55 hrs to Kathmandu Tower. Kathmandu Tower cleared the aircraft to land and provided wind information of 160° at 04 kts. At 01:57 hrs Kathmandu Tower asked the aircraft if the runway was insight. The aircraft responded that they were not able to see the runway but were continuing the approach. The aircraft was at 880 ft AGL at that time. At 783 ft AGL the aircraft asked Kathmandu Tower if the approach lights were on. Kathmandu Tower informed the aircraft that the approach lights were on at full intensity. The auto-pilots remained coupled to the aircraft until 14 ft AGL, when it was disconnected, a flare was attempted. The maximum vertical acceleration recorded on the flight data recorder was approximately 2.7 G. The aircraft pitch at touchdown was 1.8 degree nose up up which is lower than a normal flare attitude for other landings. From physical evidence recorded on the runway and the GPS latitude and longitude coordinate data the aircraft touched down to the left of the runway centerline with the left hand main gear off the paved runway surface. The aircraft crossed taxiways E and D and came to a stop on the grass area between taxiway D and C with the heading of the aircraft on rest position being 345 degrees (North North West) and the position of the aircraft on rest position was at N 27° 41' 46", E 85° 21'29" At 02:00 hrs Kathmandu Tower asked if the aircraft had landed. The aircraft requested medical and fire assistance reporting its position at the end of the runway. At 02:03 hrs the aircraft requested for bridge and stairs to open the door and vacate passengers instead of evacuation. The fire and rescue team opened the left cabin door and requested the cabin attendant as well as to pilot through Kathmandu Tower to deploy the evacuation slides. At 02:10 hrs evacuation signal was given to disembark the passengers. All passengers were evacuated safely and later, the aircraft was declared as damaged beyond repair.
Probable cause:
The probable cause of this accident is the decision of the flight crew to continue approach and landing below the minima with inadequate visual reference and not to perform a missed approach in accordance to the published approach procedure. Other contributing factors of the accident are probable fixation of the flight crew to land at Kathmandu, and the deterioration of weather conditions that resulted in fog over the airport reducing the visibility below the required minima. The following findings were reported:
- On March 2, 2015 i.e. two days before the accident, the crews of the flight to Kathmandu reported through RNP AR MONITORING FORM that all the NAV. accuracy and deviation parameter were perfectly correct at MINIMUM but the real aircraft position was high (PAPI 4 whites) and left offset,
- The airlines as well as crews were unaware of the fact that wrong threshold coordinates were uploaded on FMGS NAV data base of the aircraft,
- The flight crew was unable to get ATIS information on the published frequency because ATIS was not operating. ATIS status was also not included in the Daily Facilities Status check list reporting form of TIA Kathmandu,
- Turkish Airlines Safety Department advised to change the scheduled arrival time at Kathmandu Airport,
- It was the first flight of the Captain to Kathmandu airport and third flight but first RNAV (RNP) approach of the Copilot,
- Both approaches were flown with the auto-pilots coupled,
- Crew comments on the CVR during approach could be an indication that they (crews) were tempted to continue to descend below the decision height despite lack of adequate visual reference condition contrary to State published Standard Instrument Arrival and company Standard Operating procedures with the expectation of getting visual contact with the ground,
- The flight crew were not visual with the runway or approach light at MDA,
- The MET Office did not disseminate SPECI representing deterioration in visibility according to Annex 3,
- The Approach Control and the Kathmandu Tower did not update the aircraft with its observation representing a sudden deterioration in visibility condition due to moving fog,
- The Air Traffic Control Officers are not provided with refresher training at regular interval,
- CAAN did not take into account for the AIRAC cycle 04-2015 from 05 Feb 2015 to 04 March 2015 while cancelling AIP supplement,
- The auto-pilots remained coupled to the aircraft until 14ft AGL when it was disconnected and a flare was attempted,
- The crews were not fully following the standard procedure of KTM RNAV (RNP) Approach and company Standard Operating procedures.
Final Report: