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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 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 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.

Crash of a De Havilland DHC-6 Twin Otter 300 in Lukla: 3 killed

Date & Time: May 25, 2004 at 1356 LT
Operator:
Registration:
9N-AFD
Flight Type:
Survivors:
No
Site:
Schedule:
Kathmandu - Lukla
MSN:
651
YOM:
1979
Flight number:
YET117
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
While descending to Lukla Airport from the south following a cargo flight from Kathmandu, the crew encountered poor visibility due to clouds when, at an altitude of 11,600 feet, the aircraft struck the slope of a mountain located near the Lamjura Pass, in the Solukhumbu district. The wreckage was found west of the airport and all three crew members were killed.
Probable cause:
Controlled flight into terrain. The following factors were identified:
- Hazardous behaviour and attitudes of the captain such as overconfidence,
- The crew failed to comply with the approach routes, following a direct track,
- The crew failed to follow SOP's,
- The operator's policy for flying in adverse weather were incomplete and not up to date,
- Lack of communication by the operator,
- The operator was unable to perform internal investigations and execute corrective actions when required.

Crash of a De Havilland DHC-6 Twin Otter 300 in Simara: 10 killed

Date & Time: Dec 25, 1999 at 1502 LT
Operator:
Registration:
9N-AFL
Flight Phase:
Survivors:
No
Site:
Schedule:
Simara - Kathmandu
MSN:
796
YOM:
1982
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
10
Circumstances:
The twin engine aircraft departed Simara Airport at 1457LT on a schedule flight to Kathmandu with 10 people on board. Three minutes after takeoff, while climbing in marginal weather conditions, the aircraft struck the slope of Mt Burja Lek located few km from the airport. The aircraft disintegrated on impact and all 10 occupants were killed. At the time of the accident, the visibility was estimated to be 5 km with low ceiling.
Probable cause:
Controlled flight into terrain after the crew failed to follow the correct route after takeoff and continued at an insufficient altitude until the aircraft collided with terrain.

Crash of an Avro 748-501-2B in Kathmandu: 15 killed

Date & Time: Sep 5, 1999 at 1030 LT
Type of aircraft:
Operator:
Registration:
9N-AEG
Survivors:
No
Site:
Schedule:
Pokhara - Kathmandu
MSN:
1806
YOM:
1988
Flight number:
3Z104
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
15
Circumstances:
On approach to Kathmandu-Tribhuvan Airport under VFR mode, the crew encountered limited visibility due to a low cloud layer. On final, at an altitude of about 6,000 feet, the aircraft collided with a radio antenna (100 feet high) located on the top of a hill and owned by the Nepalese National Broadcasting Company. The aircraft went out of control and crashed seven km short of runway 02. All 15 occupants.
Probable cause:
Collision with obstacle on a VFR approach in limited visibility.

Crash of a Boeing 727-243F in Kathmandu: 5 killed

Date & Time: Jul 7, 1999 at 1951 LT
Type of aircraft:
Operator:
Registration:
VT-LCI
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Katmandu – New Delhi – Sharjah
MSN:
22168
YOM:
1981
Flight number:
LCI8533
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Aircraft flight hours:
43000
Aircraft flight cycles:
25000
Circumstances:
The aircraft departed Kathmandu-Tribhuvan Airport on a cargo flight to Sharjah with an intermediate stop in New Delhi, carrying five crew members and a load of 21 tons of woolen carpets. After takeoff from runway 20, the crew continued to climb but failed to realize his altitude was insufficient. The aircraft struck the slope of Mt Champadevi located 11 km southwest of the airport and disintegrated on impact. All five crew members were killed.
Probable cause:
The accident occurred as the crew after take off did not adhere to the published Standard Instrument Departure (SID) procedure for runway 20 at Kathmandu, Nepal.
The following contributory factors were identified:
- Incomplete departure briefing given by P1 while other cockpit activities were in progress,
- The unexpected airspeed decay to V 2 -3 during initial right climbing turn South of the VOR which occurred while P2 was busy with ATC,
- The improper power and climb profile used by P1 after rolling the aircraft out on a southwest heading following the initial airspeed loss,
- The inadequate intra cockpit crew coordination and communication as the aircraft proceeded to and across the KTM VOR 4 DME arc before recommencing a shallow right turn, and
- The incorrect and slow response to the initial and subsequent GPWS activation prior to the collision with the terrain.

Crash of a Pilatus PC-6/B2-H4 Turbo Porter in Namche Bazar: 1 killed

Date & Time: Nov 19, 1998 at 1538 LT
Operator:
Registration:
9N-ABK
Flight Type:
Survivors:
No
Site:
Schedule:
Kathmandu - Namche Bazar
MSN:
755
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Aircraft flight hours:
5762
Circumstances:
The pilot, sole on board, departed Kathmandu-Tribhuvan Airport on a positioning flight to Namche Bazar to pick up passengers. During the pre-flight briefing, he was informed about the good weather conditions along the route and at destination. But en route, these conditions deteriorated and upon arrival, clouds were present up to 3,600 metres. He made several circuits expecting weather improvement. Few minutes later, he saw a hole in the clouds and initiated a descent when the aircraft struck the slope of Mt Kongri Himal located 3 km north of the airfield. The aircraft was destroyed and the pilot was killed.
Probable cause:
Controlled flight into terrain.

Crash of an Avro 748-106-1A in Pokhara

Date & Time: Nov 6, 1997
Type of aircraft:
Operator:
Registration:
9N-ACM
Survivors:
Yes
Schedule:
Kathmandu - Pokhara
MSN:
1549
YOM:
1963
Location:
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
44
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing at Pokhara Airport, the hydraulic system failed. The crew lost control of the airplane that veered off runway to the right and collided with a parked Nepal Airways Avro 748 registered 9N-ACW. All 48 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of an Avro 748-352-2B in Meghauli

Date & Time: Apr 25, 1996 at 1158 LT
Type of aircraft:
Operator:
Registration:
9N-ABR
Survivors:
Yes
Schedule:
Kathmandu - Meghauli
MSN:
1771
YOM:
1979
Flight number:
RA155
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
27
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Kathmandu, the crew started the descent to Meghauli Airfield. On final, the aircraft was too high and landed too far down the runway, about 1,148 feet past the runway threshold (Meghauli Airstrip is 3,500 feet). Unable to stop on a wet grassy runway, the aircraft overran and came to rest in a ravine. All 31 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
Wrong approach configuration on part of the crew who landed the aircraft too far down the runway, reducing the landing distance available. Also, it was reported that the braking action was poor as the grassy runway was wet.