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

Date & Time: Apr 14, 2019 at 0907 LT
Type of aircraft:
Operator:
Registration:
9N-AMH
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lukla - Manthali
MSN:
13 29 14
YOM:
2013
Flight number:
GO802D
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
15652
Captain / Total hours on type:
3558.00
Copilot / Total flying hours:
865
Copilot / Total hours on type:
636
Aircraft flight hours:
4426
Aircraft flight cycles:
5464
Circumstances:
On 14 April 2019, around 0322Hrs, Aircraft Industries' L410UPV-E20, registration 9NAMH, owned and operated by Summit Air Pvt. Ltd. met with an accident at Tenzing-Hillary Airport, Lukla when it veered right and excurred the runway during take-off roll from runway 24. The aircraft first collided with Manang Air's helicopter, AS350B3e, registration 9N-ALC, with its rotor blade running on idle power and then with Shree Airlines' helicopter, AS350B3e, registration 9N-ALK just outside the inner perimeter fence of the aerodrome into the helipad before coming to a stop. The PIC and Cabin Crew of 9N-AMH survived the accident, whereas the Co-pilot and one security personnel on ground were killed on the spot. One more security personnel succumbed to injury later in hospital during the course of treatment. 9N-AMH and 9N-ALC both were substantially damaged by impact forces. There was no post-crash fire. Prior to the accident the aircraft had completed 3 flights on Ramechhap-Lukla-Ramechhap sector. According to PIC, he was in the left seat as the pilot monitoring (PM) and the co-pilot, in the right seat was the pilot flying (PF). According to CCTV footages, the aircraft arrived at the apron from VNRC to VNLK at 0315Hrs and shut its LH engine. The PIC started the LH engine at about 0318 Hrs after unloading cargo and passengers. At 0322:30 Hrs, the PIC aligned the aircraft with the runway at the runway threshold 24 and then handed over the controls to the co-pilot for the take-off roll. The take-off roll commenced at 0322:50 Hrs. CCTV footage captured that within 3 seconds the aircraft veered right and made an excursion. The aircraft exited the runway and travelled about 42.8 ft across the grassy part on right side of runway 24, before striking the airport inner perimeter fence. It then continued to skid for about 43 ft, into the upper helipad, crashing into 9N-ALC. Eye witnesses statements, CCTV footages and initial examination of the wreckage showed that rotor blades of helicopter 9N-ALC were on idle when RH wing of the aircraft swept two security personnel (on ground) before slashing its rotor shaft. The moving rotors cut through the cockpit on the right side slaying the Co-pilot immediately. The helicopter toppled onto the lower helipad 6 ft below. The LH wing of the aircraft broke the skid of helicopter 9NALK and came to a halt with toppled 9N-ALC beneath its RH main wheel assembly. Due to 2impact, 9N-ALK shifted about 8 ft laterally and suffered minor damages. There was no post-crash fire. The PIC switched off the battery and came out of the aircraft through emergency exit along with the cabin crew. The captain of the helicopter 9N-ALC was rescued immediately. 9N-ALC's crew sustained a broken tail-bone whereas 9N-ALK's crew escaped without sustaining major injuries. All three deceased were Nepalese citizens. Aircraft 9N-AMH and helicopter 9N-ALC were substantially damaged while the helicopter 9N-ALK endured partial damages.
Probable cause:
The commission concluded that the probable cause of the accident was aircraft's veering towards right during initial take-off roll as a result of asymmetric power due to abrupt shifting of right power lever rearwards and failure to abort the takeoff by crew. There were not enough evidences to determine the exact reason for abrupt shifting of the power lever.
Contributing Factors:
1. Failure of the PF(being a less experienced co-pilot) to immediately assess and act upon the abrupt shifting of the right power lever resulted in aircraft veering to the right causing certain time lapse for PIC to take controls in order to initiate correction.
2. PIC's attempted corrections of adding power could not correct the veering. Subsequently, application of brakes resulted in asymmetric braking due to the position of the pedals, and further contributed veering towards right.
Final Report:

Crash of a Let L-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:
Kathmandu – 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
Captain / Total flying hours:
9687
Captain / Total hours on type:
1897.00
Copilot / Total flying hours:
1311
Copilot / Total hours on type:
1028
Aircraft flight hours:
2550
Aircraft flight cycles:
5467
Circumstances:
On May 27, 2017 9N-AKY, LET 410 UVP-E20 of Goma Air (now Summit Air), a domestic carrier of Nepal had a published program to operate 5 flights to Lukla from Kathmandu. The first flight departed Kathmandu at 0026 UTC. By the time 0647 UTC they had completed 4 flights. The fifth and the last flight departed Kathmandu at 0744 UTC for Lukla as call sign Goma Air 409. Goma Air 409 was the cargo flight carrying 1680 kg cargo for Lukla. There were two cockpit crews, one cabin crew and no passengers on board the flight. It was pre-monsoon period. Lukla weather on that particular day was cloudy since morning. But ceiling and visibility were reported OK. However, CCTV footage shows rapidly deteriorating weather condition before and after the crash. Automatic VHF recorder of Lukla Tower and CVR recording showed Tower was regularly updating pilots of deteriorating weather. All the pre-and post-departure procedure of the flight was completed in normal manner. Before departure from Kathmandu Pilots were found to have obtained latest weather of Lukla, Phaplu and Rumjatar. PIC decided to remain south of track to avoid the terrain and cloud. When Goma 409 was about 11 miles East from Kathmandu they were informed that Lukla was having heavy rain and airport closed. By that time air traffic congestion in TIA was slowly developing. Traffics were holding in the air and in the ground as well. So Goma 409 continued for Lukla. However, after crossing 26 miles from Kathmandu, they were again informed that the rain had ceased and airport was open. An AS350 helicopter, 9N AGU which departed Lukla at 0803 UTC for Kathmandu had reported unstable wind on final Runway 06. Enroute weather reported by 9N AGU upon request of Lukla Tower was good beyond the Lukla valley. However, it was apprehended that for fixed wing, weather might be difficult to enter valley. Lukla Tower relayed all available information when Goma Air 409 had first established contact at time 0810 UTC. Later, Goma Air and 9N AGY, two reciprocal traffics were also in contact each other. 9N AGY relayed the actual weather status to GOMA AIR. Lukla valley's ceiling and visibility was OK for VFR until 0812UTC ( 6 minutes before crash). Weather started to deteriorate very fast. Mountain Ridges were visible through thin layer of foggy cloud until 0814 UTC. After one minute (approx.) Right Base for Runway 06, was covered up and cloud from left base was moving towards final. Duty ATS Officer of Lukla Tower was regularly up dating pilots about deteriorating weather condition. However, Tower was found to be failed to close the runway as per SOP in spite of rapidly deterioratingweather. Pilots ventured to continue though the weather was marginal. Aircraft reported entering valley at 0816. CVR record showed that First Officer sighted the runway at 0817 (64 seconds before the impact). Instantly PIC acknowledged he had also the runway in sight. Aircraft was at 9100 ft (approx.) when the cockpit crews sighted the runway. It maintained 9000 feet (approx.) for further 21 seconds. At time 0817:12i.e. 48 seconds before the impact Tower gave the latest wind as Westerly 04 knots and runway was clear. PIC was still in doubt and asked whether there was rain. Upon confirmation of having no rain from the Tower the aircraft started to descend further. The PIC, who was also the PF, found to have lost situational awareness deviated to the right with continued descend. At 0817:35 (25 seconds before impact) when the flight was descending through 8650 ft First Officer warned PIC that they were too low. PIC did not respond the F/O's call-out and continued descend. On reaching 8500 ft. F/O again warned PIC in panic. Then PIC asked in panic where the runway was. F/O directed towards the runway. But it was already too low and too late. There was initially two short stall warning sound. Then a continuous stall warning sounded till the impact, which lasted for 13 seconds. The last words in CVR records was "w]/ gtfg " (Do not pull too much). Abrupt change in aircraft attitude in an attempt to climb and reach threshold height at 8900 ft. (on Kathmandu QNH) in a landing configuration, with landing gears down and on full flaps, created excessive drag resulting the aircraft to stall. Subsequently, its left wing first hit a small tree branch 180 ft. short of the threshold. Then impacted the sloppy terrain 100ft. short of the runway. After the crash aircraft engine was reported to be running for about a minute. But there was no postcrash fire. Aircraft was totally damaged by the impact.
Crew:
Paras Kumar Rai, pilot, †
Srijan Manandhar, copilot, †
Pragya Maharjan, cabin crew.
Probable cause:
The Commission concludes that the probable cause of this accident was aircraft stall as a result of excessive drag created by sudden increase in angle of attack of the aircraft supplemented by low speed (below Vref) in an attempt to initiate immediate climb on a landing configuration (full flap and landing gear down) warranted by the critical situation of the final phase of flight.
Contributing factors:
- Critical terrain and rapidly deteriorating weather condition.
- Pilot's loss of situational awareness.
- Improper pilot response to stall warning including failure to advance power lever to maximum at appropriate time.
- Violation of SOP by the ATS and Pilot as well.
Final Report: