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:

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 Dornier DO228-101 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, the crew encountered poor weather conditions. Unable to locate the runway, he decided to divert to Simara Airport. Unfortunately, the visibility at Simara Airport was insufficient and the crew eventually decided to return to Kathmandu. While descending to runway 02, a generator failed. The crew did not declare an emergency, contacted his maintenance base and was unable to switch to the backup generator. Shortly after the crew elected to reset the battery system, the aircraft entered an uncontrolled descent and crashed in a rice paddy field. The aircraft disintegrated on impact and all 14 occupants were killed, among them 4 Americans, one British and one Japanese. The wreckage was found about 30 km southeast of Tribhuvan Airport.
Probable cause:
Loss of control on approach following the failure of a generator for undetermined reasons.

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.

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 Harbin Yunsunji Y-12-II in Lukla

Date & Time: Sep 26, 1992
Type of aircraft:
Operator:
Registration:
9N-ACI
Flight Phase:
Survivors:
Yes
Schedule:
Lukla - Kathmandu
MSN:
0069
YOM:
1992
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll at Lukla-Tenzing-Hillary Airport, at a speed of 85 knots, the nose gear collapsed. Out of control, the aircraft veered off runway and came to rest in a ditch. All 14 occupants escaped uninjured while the aircraft was damaged beyond repair.
Probable cause:
It was determined that the nose gear tyre burst after hitting stones coming from a pothole in the runway surface. This caused the nose gear to collapse.

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

Date & Time: Jun 9, 1991 at 1010 LT
Operator:
Registration:
9N-ABA
Survivors:
Yes
Schedule:
Kathmandu - Lukla
MSN:
301
YOM:
1971
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
14
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While descending to Lukla Airport, weather conditions deteriorated and the captain decided to go-around and to follow a holding pattern. Few minutes later, as he thought weather conditions improved, he decided to attempt to land and initiated a second approach. On short final, the aircraft entered a layer of low clouds and the aircraft was not properly aligned when it struck the runway surface and bounced. Out of control, it veered off runway and came to rest in a ravine. All 17 occupants were injured and the aircraft was destroyed.

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

Date & Time: Oct 15, 1973
Operator:
Registration:
9N-ABG
Flight Phase:
Survivors:
Yes
Schedule:
Lukla - Kathmandu
MSN:
370
YOM:
1973
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances while taking off from Lukla-Tenzing-Hillary Airport. All six occupants escaped uninjured while the airplane was damaged beyond repair.