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Crash of an ATR72-500 in Pokhara: 72 killed

Date & Time: Jan 15, 2023 at 1057 LT
Type of aircraft:
Operator:
Registration:
9N-ANC
Survivors:
No
Schedule:
Kathmandu - Pokhara
MSN:
754
YOM:
2007
Flight number:
YT691
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
68
Pax fatalities:
Other fatalities:
Total fatalities:
72
Aircraft flight hours:
28731
Aircraft flight cycles:
30104
Circumstances:
The airplane departed Kathmandu-Tribhuvan Airport at 1032LT on a schedule service (YT691) to Pokhara, carrying 68 passengers and a crew of four. On final approach to Pokhara Airport in excellent weather conditions, the airplane entered a slight pitch up attitude, rolled to the left up to 90° (the left wing apparently stalled) then crashed on the bank of the River Seti, bursting into flames. The airplane was totally destroyed and the wreckage was found about 1,9 km short of runway 12 of the new Pokhara International Airport that was open to traffic January 1st, 2023. Part of the debris were found on the top of the hill and others down in the river bed. No one is believed to have survived the crash.
Probable cause:
In a preliminary report, the Nepalese Authorities confirmed the following points:
- At 10:56:27, the PF disengaged the Autopilot System (AP) at an altitude of 721 feet Above Ground Level (AGL). The PF then called for “FLAPS 30” at 10:56:32, and the PM replied, “Flaps 30 and descending”. The flight data recorder (FDR) data did not record any flap surface movement at that time. Instead, the propeller rotation speed (Np) of both engines decreased simultaneously to less than 25%1 and the torque (Tq) started decreasing to 0%, which is consistent with both propellers going into the feathered condition. On the cockpit voice recorder (CVR) area microphone recording, a single Master Caution chime was recorded at 10:56:36. The flight crew then carried out the “Before Landing Checklist” before starting the left turn onto the base leg. During that time, the power lever angle increased from 41% to 44%. At the point, Np of both propellers were recorded as Non-Computed Data (NCD) in the FDR and the torque (Tq) of both engines were at 0%. When propellers are in feather, they are not producing thrust.
- When both propellers were feathered, the investigation team observed that both engines of 9N-ANC were running flight idle condition during the event flight to prevent over torque. As per the FDR data, all the recorded parameters related to engines did not show any anomaly. At 10:56:50 when the radio altitude callout for five hundred feet3 was annunciated, another “click” sound was heard. The aircraft reached a maximum bank angle of 30 degrees at this altitude. The recorded Np and Tq data remained invalid. The yaw damper disconnected four seconds later. The PF consulted the PM on whether to continue the left turn and the PM replied to continue the turn. Subsequently, the PF asked the PM on whether to continue descend and the PM responded it was not necessary and instructed to apply a little power. At 10:56:54, another click was heard, followed by the flaps surface movement to the 30 degrees position.
- When ATC gave the clearance for landing at 10:57:07, the PF mentioned twice that there was no power coming from the engines. At 10:57:11, the power levers were advanced first to 62 degrees then to the maximum power position. It was followed by a “click” sound at 10:57:16. One second after the “click” sound, the aircraft was at the initiation of its last turn at 368 feet AGL, the high pressure turbine speed (Nh) of both engines increased from 73% to 77%.
- It is noted that the PF handed over control of the aircraft to the PM at 10:57:18. At 10:57:20, the PM (who was previously the PF) repeated again that there was no power from the engines. At 10:57:24 when the aircraft was at 311 feet AGL, the stick shaker was activated warning the crew that the aircraft Angle of Attack (AoA) increased up to the stick shaker threshold.

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

Date & Time: Mar 12, 2018 at 1419 LT
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 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:

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:
2014
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:
A Dornier 228 aircraft, registration 9N-AHA, was planned to operate a flight from Tribhuvan International Airport (TIA), Kathmandu, to Tensing/Hillary Airport, Lukla with 16 passengers and 3 crews. The Commander was the Pilot Flying (PF) which was in accordance with common practice for flight crews operating this route. The 0020Z METAR for TIA reported calm wind, 3,000 m visibility in mist, scattered cloud at 2,000 ft AAL, broken cloud at 10,000 ft AAL, a temperature of 19° C and a QNH of 1017 HPa. ATC broadcast a change in the QNH to 1018 HPa at 0029 hrs. At 0028 hrs (0613 am), the Co-pilot asked ATC for taxi clearance and 9N-AHA taxied towards Intersection 2 for Runway 20. While taxiing towards the runway the flight crew carried out the before takeoff checklist during which the Commander confirmed that Flaps 1 was set and all four booster pumps were ON. There was no emergency brief or discussion about the reference speeds to be used during the takeoff. The flight crew changed frequency and contacted the tower controller who gave them clearance to enter Runway 20 from the intersection and wait for clearance to takeoff. The Commander asked for the line-up checks to be completed during which the Speed Lever was selected to HIGH. After lining up, the Commander said "THERE IS A BIRD" and, three seconds later "I WILL TAKE FLAPS TWO" which was acknowledged by the co-pilot. The aircraft was cleared for departure and began its takeoff run at 0032 hrs. Two seconds after beginning the takeoff roll, the Commander said "WATCH OUT THE BIRD". The Co-pilot called "50 KNOTS " as the aircraft approached 50 kt and the Commander replied "CHECK". Two seconds later, the co-pilot called "BIRD CLEAR SIR" as the aircraft accelerated through 58 kt. Approaching 70 kt, approximately 13 kt below V1 and Vr , the first officer called "VEE ONE ROTATE". The aircraft began to rotate but did not lift off the ground and the nose was briefly lowered again. As the aircraft reached 86 kt, it lifted off the ground and the landing gear was raised immediately. As the aircraft began to climb, it accelerated to 89 kt over approximately 2 seconds. It continued to climb to 100 ft above the runway over the next 11 seconds but, during this time, the speed decreased to 77 kt. The aircraft then flew level for 14 seconds during which time the following occurred: the speed decreased to 69 kt; the air traffic controller asked "ANY TECHNICAL?" to which the pilot replied "[uncertain]….DUE BIRD HIT"; it's heading changed slowly from 200 °M to approximately 173 °M; and the stall warning was triggered for three seconds as the aircraft decelerated through 71 kt. Two seconds after the stall warning ended, it was triggered again for approximately six seconds with the airspeed at 69 kt. The aircraft began a gentle descent at 69 kt with the stall warning sounding and the rate of turn to the left increased rapidly. It departed controlled flight, most probably left wing low, and crashed into a small open area 420 m south-east of the end of Runway 20. A runway inspection found the remains of a bird, identified as a "Black Kite", at a position 408 m from Intersection 2. No bird strike was reported in relation to any other departure.
Probable cause:
Causal Factors:
The investigation identified the following causal factors:
1. 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.
2. 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 investigation identified the following contributory factors:
1. 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.
2. The flight crew did not maintain the runway centreline which removed the option of landing the aircraft on the runway remaining.
Final Report:

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:
Nepalgunj – Kathmandou
MSN:
2191
YOM:
1988
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The single engine aircraft was performing an ambulance flight from Nepalgunj to the capital city Kathmandu with a patient, one accompanist, two doctors, a nurse and a pilot on board. It crashed in unknown circumstances in a hilly and wooded terrain 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:
Kathmandu - Kathmandu
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:
The aircraft was performing a special flight with tourists above the Himalayan mountains and especially a tour of the Everest in the early morning. While returning to Kathmandu-Tribhuvan Airport, the copilot (PIC) was cleared to descend to 6,000 feet for a landing on runway 02. In marginal weather conditions, he passed below 6,000 feet until the aircraft contacted trees and crashed in hilly and wooded terrain located near the village of Bishanku Narayan, some 6,7 km southeast of the airport. The aircraft was destroyed by impact forces and a post crash fire. A passenger was seriously injured while 18 other occupants were killed. Few hours later, the only survivor died from his injuries. The 16 tourists were respectively 10 Indians, 2 Americans, 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 5,000 feet MSL instead of 6,000 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 analyzed 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 5,000 instead of 6,000 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 6,000 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.

Crash of a De Havilland DHC-6 Twin Otter 300 near 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
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:
The twin engine aircraft departed Lamidanda Airport at 1508LT on a flight to Kathmandu. Shortly after departure, the crew was cleared to climb to 10,500 feet but ATC ask them to maintain 8,500 feet due to traffic. The captain disagreed with this ATC instruction and continued to climb. The copilot asked the captain to accept the ATC proposal so finally, the captain cleared 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, the aircraft entered clouds when the right wing impacted ground. The aircraft crashed in a rocky area located on the Palunge Hill, near Okhaldhunga. The wreckage was found the following morning. The aircraft was destroyed by impact forces and all 22 occupants were killed. 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. Controlled flight into terrain.

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 service to the Lukla-Tenzing-Hillary Airport. On approach to runway 06, the crew encountered poor visibility due to foggy conditions. Despite the pilot did not establish any visual contact with the ground, he continued the approach when, on short final, the aircraft struck a rock and crashed just below the runway 06 threshold, bursting into flames. The captain was seriously injured while 18 other occupants were killed, among them 12 Germans, 2 Australians and 5 Nepalese.
Probable cause:
Controlled flight into terrain after the captain decided to continue the approach under VFR mode in IMC conditions.

Crash of a Dornier DO228-201 in Lukla

Date & Time: Jun 30, 2005 at 0735 LT
Type of aircraft:
Operator:
Registration:
9N-AEO
Survivors:
Yes
Schedule:
Kathmandu - Lukla
MSN:
8010
YOM:
1983
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Lukla-Tenzing-Hillary Airport, the twin engine aircraft skidded then veered off runway and came to rest in a dirt ground. All 12 occupants escaped uninjured while the aircraft was damaged beyond repair.