Thursday, June 05, 2014

Nepal Airline Corporation de Havilland DHC-6-300 Twin Otter (9N-ABB) crash report out

Shows crew members did not follow standard operating procedures‚ pilot-in-command disregarded co-pilot's suggestions 

KATHMANDU: Nepal Airline Corporation’s Twin Otter crashed at Dihidanda of Masinalek in Arghakhanchi district on February 16, as crew members failed to follow standard operating procedures and the pilot-in-command disregarded the co-pilot’s call ‘not to descend the aircraft’, a report prepared by a committee formed to investigate the air accident says.

The aircraft had left for Jumla from Pokhara at 12:43pm carrying 15 passengers and three crew members. The flight was made by Pilot-in-command (PIC) Shankar Shrestha and Co-pilot Rabindra Banjara after weather conditions at Pokhara and Jumla airports were said to be clear.

But after seven minutes into the flight, the weather condition deteriorated and the aircraft diverted from its normal route and headed south. The plane then gradually started ascending and reached an altitude of 10,500 feet, where the temperature fell to minus six degrees centigrade.

Although the PIC issued a warning about the falling temperature, no action was taken to prevent icing, says the report, which was handed over to Minister for Culture, Tourism and Civil Aviation Bhim Acharya today.

“Conversation between the PIC and co-pilot shows that the weather condition was adverse at that time. Yet, the PIC was more focused on completing the mission rather than returning to Pokhara,” said Buddhi Sagar Lamichhane, joint secretary at the Ministry of Culture, Tourism and Civil Aviation (MoCTCA), who is also member secretary of the committee.

Then after 23 minutes into the flight, the co-pilot complained about track becoming worse and the plane headed towards Dang. Two minutes later, the aircraft descended to an altitude of 8,500 feet, where the temperature was recorded at zero degree centigrade.

After about another three minutes, the aircraft again encountered bad weather condition. A minute later the pilot called for diversion of the plane to Bhairahawa.

“By that time, the pilot and co-pilot seem to have lost sense of direction. And the PIC must have assumed they had entered the Tarai region,” said Meghendra Kumar Shrestha, senior aeronautical engineer and a member of the committee. “As a result, the PIC started descending the plane.”

However, the co-pilot suggested that the PIC not descend the aircraft or make a turn. But the PIC did just that.

“At that time, the co-pilot should have insisted ... Insistence at that particular time was very necessary,” the report says.

Then as the aircraft made a turn, it slashed a branch of a tree and hit the sloppy ridge with a huge impact.

“The aircraft was totally damaged and disintegrated. Some parts were completely burnt. Different parts and pieces got scattered on both sides of the ridge,” says the report.

And all 18 on board got killed.

“Based on the evidence, it could be concluded that the nature of the accident was a ‘Controlled Flight into Terrain’,” says the report referring to the type of accident which occurs when an aircraft under full control of the pilot is flown into terrain, water or an obstacle. In such a condition, pilots generally become aware of the gravity of the situation after it is too late and usually are in no position to take preventive measures.

“This occurred because of serious lack of coordination among crew members, PIC’s faulty decision and inability on the part of the co-pilot to strongly intervene in the PIC’s wrong action,” the report says.

MoCTCA Joint Secretary Suresh Acharya said that airline companies must be more careful while pairing PICs and co-pilots, as senior pilots tend to turn a deaf ear to advices laid by junior pilots. He made the comment referring to the aircraft accident of Agni Air in Jomsom in May 2012, in which the PIC had failed to heed the suggestion of the co-pilot. At least 15 people were killed in the accident.

“Also, the Civil Aviation Authority of Nepal should ensure that all aircraft making commercial flights are equipped with the appropriate Terrain Awareness Warning System,” says the report.

- See more at:

Nepal Airlines,  de Havilland DHC-6-300 Twin Otter, 9N-ABB,  Flight RA-183

Nepal's history of plane crashes

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