Zone

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 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:

Crash of a Dornier DO228-202 in Kathmandu: 19 killed

Date & Time: Sep 28, 2012 at 0618 LT
Type of aircraft:
Operator:
Registration:
9N-AHA
Flight Phase:
Survivors:
No
Schedule:
Kathmandu - Lukla
MSN:
8123
YOM:
1987
Flight number:
SIT601
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
19
Captain / Total flying hours:
8308
Captain / Total hours on type:
7112.00
Copilot / Total flying hours:
772
Copilot / Total hours on type:
519
Circumstances:
Less than two minutes after take off from runway 20, during initial climb, crew informed ATC he encountered a bird strike and that an engine failed. Captain tried to return to Kathmandu Airport but aircraft turn left, stalled and crashed in flames near Manohara River, 420 meters from the end of runway 20. All 19 occupants, among them 7 British and 5 Chinese citizens, were killed.
Probable cause:
During level flight phase of the aircraft, the drag on the aircraft was greater than the power available and the aircraft decelerated. That resulted in excessive drag in such critical phase of ascent lowering the required thrust. The investigation was unable to determine the reason for the reduced thrust.
- The flight crew did not maintain the airspeed above the stall speed and there was insufficient height available to recover when the aircraft departed controlled flight.
Contributory factors:
- The flight crew did not maintain V2 during the climb and so the power required to maintain the level flight was greater than it would otherwise have been,
- The flight crew did not maintain the runway centerline which removed the option of landing the aircraft on the runway remaining.
No bird remains were found inside the engines, there was evidence however that the Black Kite had been struck by the right hand propeller.
The NAAIC concluded the analysis: "The investigation was unable to determine the cause of the thrust reduction."

Source: AvHerald

Crash of a Britten-Norman BN-2T Islander in Dhorpatan: 6 killed

Date & Time: Oct 18, 2011 at 1906 LT
Type of aircraft:
Operator:
Registration:
RAN-49
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Nepalganj - Katmandou
MSN:
2191
YOM:
1988
Location:
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
Aircraft was performing an ambulance flight from Nepalganj to the capital city Kathmandu with a patient, one accompanist, two doctors, a nurse and a pilot. It crashed in unknown circumstances near Dhorpatan, killing all six occupants.

Crash of a Beechcraft 1900D in Kathmandu: 19 killed

Date & Time: Sep 25, 2011 at 0731 LT
Type of aircraft:
Operator:
Registration:
9N-AEK
Survivors:
No
Schedule:
Katmandu - Katmandu
MSN:
UE-295
YOM:
1997
Flight number:
BHA103
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
19
Copilot / Total hours on type:
18
Circumstances:
Aircraft was performing a special flight with tourists above Himalayan mountains and especially a tour of the Everest in early morning. While returning to Kathmandu-Tribhuvan Airport, while descending to join the runway 02 glide, the twin engine aircraft hit tree tops, stalled and crashed in a wooded area located near the village of Bishanku Narayan, some 6,7 km from runway threshold. On scene, SAR evacuated a passenger seriously injured while all 18 other occupants were killed, but few hours later, the only survivor died from his injuries. The 16 tourists were respectively 10 Indians, 2 US, 1 Japanese and 3 Nepalese.
Probable cause:
The Accident Investigation Commission assigned by Nepal's Ministry of Tourism and Civil Aviation have submitted their report to the Ministry. The investigators said in a media briefing, that human factors, mainly fatigue by the captain of the flight, led to the crash. The aircraft was flown by the first officer and was on approach to Kathmandu at 5000 feet MSL instead of 6000 feet MSL as required, when it entered a cloud. While inside the cloud in low visibility the aircraft descended, hit tree tops and broke up.
The captain had flown another aircraft the previous day and had been assigned to the accident flight on short notice in the morning of the accident day, but did not have sufficient rest. The commission analysed that due to the resulting fatigue the captain assigned pilot flying duties to the first officer although she wasn't yet ready to cope with the task in demanding conditions. The newly assigned first officer had only 18 hours experience on the aircraft type.
The mountain view round trip had to turn back about midway due to weather conditions. While on a visual approach to Kathmandu at 5000 instead of 6000 feet MSL the aircraft entered a cloud and started to descend until impact with tree tops.
The crew did not follow standard operating procedures, that amongst other details required the aircraft to fly at or above 6000 feet MSL in the accident area, the interaction between the crew members did not follow standard operating procedures, for example the captain distracted the first officer with frequent advice instead of explaining the/adhering to procedures.
The commission said as result of the investigation they released a safety recommendation requiring all operators to install Terrain Awareness and Warning Systems (TAWS) in addition to eight other safety recommendations regarding pilot training, installation of visual aids, safety audit and fleet policies.

Source: AvHerald

Crash of a De Havilland DHC-6 Twin Otter in Okhaldhunga: 22 killed

Date & Time: Dec 15, 2010 at 1530 LT
Operator:
Registration:
9N-AFX
Flight Phase:
Survivors:
No
Site:
Schedule:
Lamidanda - Kathmandou
MSN:
806
YOM:
1984
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
22
Captain / Total flying hours:
6700
Captain / Total hours on type:
5000.00
Copilot / Total flying hours:
1100
Copilot / Total hours on type:
341
Circumstances:
Aircraft left Lamidanda at 1508LT bound to Kathmandu. Shortly after departure, crew was authorized to climb to 10,500 feet but ATC ask them to maintain 8,500 feet due to heavy traffic. Captain disagreed with this ATC instruction and continued to climb. Copilot asked the captain to accept the ATC proposal so finally, the captain authorized the copilot (who was the pilot in command) to descend to 8,500 feet despite the fact it was risky due to the mountainous terrain. Few minutes later, aircraft went trough the clouds when the right wing hit the ground. Aircraft crashed and was totally destroyed by impact forces. SAR were suspended due to the night and the first rescuers arrived on the scene the day after in early morning. On site, on the Palunge hill located near Okhaldhunga, rescuers did not find any survivor among the 22 occupants. IMC conditions prevailed at the time of the accident due to low visibility (cloudy conditions).
Probable cause:
The cause of the accident was the unwise decision taken by the crew to descend without taking the harsh mountain terrain into consideration.

Crash of a Dornier DO228 near Kathmandu: 14 killed

Date & Time: Aug 24, 2010 at 0725 LT
Type of aircraft:
Operator:
Registration:
9N-AHE
Survivors:
No
Schedule:
Kathmandu - Lukla
MSN:
7032
YOM:
1985
Flight number:
AG101
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
14
Circumstances:
On approach to Lukla, crew divert to Simara due to bad weather conditions. At Simara, crew decided to return to Kathmandu due to weather deterioration. On descent to Kathmandu, while approaching runway 02, a generator failed and aircraft crashed in an open field some 30 km southeast of Tribhuvan Airport. All 14 occupants were killed, among them four Americans, one British and one Japanese.
Probable cause:
Generator failure on approach for undetermined reason.

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

Date & Time: Oct 8, 2008 at 0731 LT
Operator:
Registration:
9N-AFE
Survivors:
Yes
Schedule:
Kathmandu - Lukla
MSN:
720
YOM:
1980
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
18
Captain / Total flying hours:
8185
Captain / Total hours on type:
7180.00
Copilot / Total flying hours:
556
Copilot / Total hours on type:
341
Circumstances:
The aircraft departed Kathmandu-Tribhuvan airport at 0651LT on a regular schedule flight to Lukla-Tenzing-Hillary airport. On final approach to runway 06 in bad weather conditions, the aircraft hit a rock and crashed near the runway threshold. The captain was the only survivor, all 18 other occupants were killed. Among the 19 occupants were 12 German citizens, 2 Australians and 5 Nepalese. On landing, the visibility was reduced due to fog and the aircraft was approaching too low.

Crash of an Airbus A300B4-203 in Kathmandu: 167 killed

Date & Time: Sep 28, 1992 at 1430 LT
Type of aircraft:
Operator:
Registration:
AP-BCP
Survivors:
No
Site:
Schedule:
Karachi - Kathmandu
MSN:
025
YOM:
1976
Flight number:
PK268
Country:
Region:
Crew on board:
19
Crew fatalities:
Pax on board:
148
Pax fatalities:
Other fatalities:
Total fatalities:
167
Captain / Total flying hours:
13186
Captain / Total hours on type:
6260.00
Copilot / Total flying hours:
5849
Copilot / Total hours on type:
1469
Aircraft flight hours:
39045
Aircraft flight cycles:
19172
Circumstances:
The ill-fated aircraft departed Karachi Airport Pakistan, at 0613 hours UTC on 28 September 1992 as Pakistan International Airlines Flight Number PK 268, a non-stop service to Kathmandu, Nepal. The accident occurred at 0845 UTC (1430 hours local time) when the aircraft struck a mountain during an instrument approach to Kathmandu’s Tribhuvan International Airport. The impact site was at an altitude of 7280 feet above sea level (2890 feet above airport level), 9.16 nautical miles from the VOR/DME beacon and directly beneath the instrument approach track from the VOR/DME beacon (9.76 nm from and 2970 ft above the threshold of Runway 02 which is 77 feet below the airport datum). The flight through Pakistani and Indian airspace appears to have proceeded normally. At 0825 hrs UTC (1410 hrs local time) two-way contact between Pakistan 268 and Kathmandu Area Control West was established on VHF radio and the aircraft was procedurally cleared towards Kathmandu in accordance with its flight plan. After obtaining the Kathmandu weather and airfield details, the aircraft was given traffic information and instructed to report overhead the SIM (Simara) non-directional beacon (214°R VOR/39 nm from Kathmandu’s KTM VOR/DME) at or above FL150 (flight level on standard altimeter) as cleared by the Calcutta Area Control Centre. At 08:37 hrs the copilot reported that the aircraft was approaching the SIM beacon at FL 150, whereupon procedural clearance was given to continue to position SIERRA (202°R/10 nm from the KTM beacon) and to descend to 11,500 feet altitude. No approach delay was forecast by the area controller and the co-pilot correctly read back both the clearance and the instruction to report at 25 DME. At 08:40:14 hrs, he reported that the aircraft was approaching 25 DME whereupon the crew were instructed to maintain 11,500 feet and change frequency to Kathmandu Tower. Two-way radio contact with the Tower was established a few seconds later and the crew reported that they were in the process of intercepting the final approach track of 022M (Magnetic) of Radial 202 KTM VOR ) They were instructed to expect a Sierra approach and to report at 16 DME. At 08:42:51 hrs the first officer reported “One six due at eleven thousand five hundred”. The tower controller responded by clearing the aircraft for the Sierra approach and instructing the crew to report at 10 DME. At 08:44:27 the first officer reported 10 DME and three seconds later he was asked, “Report your level”. He replied, “We crossed out of eight thousand five hun,’ two hundred now”. The controller replied with the instruction “Roger clear for final. Report four DME Runway zero two”. The copilot responded to this instruction in a normal, calm and unhurried tone of voice; his reply was the last transmission heard from the aircraft, thirty-two seconds after the copilot reported 10 DME the aircraft crashed into steep, cloud-covered mountainside at 7,280 feet amsl and 9.16 nm on radial 202 of KTM VOR. All 167 occupants were killed.
Probable cause:
The balance of evidence suggests that the primary cause of the accident was that one or both pilots consistently failed to follow the approach procedure and inadvertently adopted a profile which, at each DME fix, was one altitude step ahead and below the correct procedure. Why and how that happened could not be determined with certainty because there was no record of the crew's conversation on the flight deck. Contributory causal factors were thought to be the inevitable complexity of the approach and the associated approach chart.
The following findings were reported:
- The flight deck crew were properly licensed and medically fit,
- The aircraft had been properly maintained and was fit for the flight and the essential aircraft systems were operating normally during the approach,
- The SIERRA approach to Kathmandu is a demanding approach in any wide-bodied aircraft,
- Unlawful interference and extreme weather were not causal factors,
- The crash site was enveloped in cloud at the time of the accident,
- There was no ATC clearance error,
- The VOR DME beacons used for the approach were operating satisfactorily and there was no evidence of failure or malfunction within the aircraft’s DME equipment,
- The aircraft acquired and maintained the correct final approach track but began descent too early and then continued to descend in accordance with an altitude profile which was consistent with being 'one step ahead' and below the correct profile,
- At 16 DME the co-pilot mis-reported the aircraft’s altitude by 1,000 feet,
- The commander did not adhere to the airline’s recommended technique for the final part of the approach which commenced at 10 DME,
- The 10 DME position report requested by the Tower controller was made at an altitude below the minimum safe altitude for that portion of the approach,
- The altitude profile on the Jeppesen approach chart which should have been used by the pilots was technically correct. However, the profile illustrated could not be flown in the A300 at V app, in common with any other wide-bodied jet of similar size and the minimum altitude at some DME fixes was not directly associated with the fix,
- The aircraft did not have control column mounted chartboards,
- As described in the report, there is scope for improving the SIERRA approach procedure and its associated charts,
- Kathmandu was not a frequent destination for PIA’S A300 crews and neither pilot had operated that within the previous two months,
- PIA’s training of air crews, briefing material and self-briefing facilities for the SIERRA approach to Kathmandu leave room for improvement,
- PIA’s route checking and flight operations inspection procedures were ineffective,
- The accident was inevitable 15 seconds before impact,
- The Tower controller requested an altitude report immediately after the co-pilot reported at 10 DME. His failure to challenge the low altitude reported at 10 DME was a missed opportunity to prevent the accident but, even if he had done so, it is doubtful whether the accident could have been averted,
- Some air controllers at Kathmandu had a low-self-esteem and was reluctant to intervene in piloting matters such as terrain separation,
- The GPWS was probably serviceable but failed to warn the crew of impending flight towards high ground because of the combination of elderly equipment and rugged terrain,
- Advice within the aircraft manufacturer’s operating manuals regarding pilot reaction to a GPWS warning was incomplete,
- The MEL was being breached in that PIA wen not supplying their CAA with the required carry-forward defect summaries for analysis, neither was the CAA requesting them.