Region

Crash of a Canadair RegionalJet CRJ-200ER in Kathmandu: 18 killed

Date & Time: Jul 24, 2024 at 1113 LT
Operator:
Registration:
9N-AME
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Kathmandu – Pokhara
MSN:
7772
YOM:
2003
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
18
Circumstances:
The airplane departed Kathmandu-Tribhuvan Airport at 1111LT, carrying technical engineers and staff of the airline. The airplane was ferried to Pokhara to proceed with a C-check maintenance program. Less than two minutes after takeoff from runway 02, the crew encountered an unexpected situation when the airplane rolled to the right, went to an almost vertical attitude before it crashed 200 meters to the right of the runway centerline, bursting into flames. The captain was seriously injured while 18 other occupants were killed.

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
Captain / Total flying hours:
21901
Captain / Total hours on type:
3300.00
Copilot / Total flying hours:
6396
Copilot / Total hours on type:
186
Aircraft flight hours:
28731
Aircraft flight cycles:
30104
Circumstances:
On 15 January 2023, an ATR 72-212A version 500 was operating scheduled flights between Kathmandu (VNKT) and Pokhara International Airport (VNPR). The same flight crew operated two sectors between VNKT to VNPR and VNPR to VNKT earlier in the morning. For first sector, the aircraft landed on runway 30 of VNPR and thereafter departed from VNPR using runway 12. The accident occurred during a visual approach for runway 12 at VNPR. This was the third flight by the crew members on that day. As per the CVR recordings it was understood that the flight was operated by two Captains, one Captain was in the process of obtaining aerodrome familiarization for operating into VNPR and the other Captain was an instructor pilot. The Captain being familiarized, who was occupying the left-hand seat, was the Pilot Flying (PF) and the instructor pilot, occupying the right-hand seat, was the Pilot Monitoring (PM). The take-off, climb, cruise and descent to VNPR was normal. The weather was compatible with VMC enroute to the destination airport. During the first contact with VNPR tower, the Air Traffic Controller (ATC) assigned runway 30 for the aircraft to land. But during the later phases of flight the flight crew, without mentioning any reason for changing the allocated runway, requested and received clearance from ATC to change runway 30 to 12 for landing. At 10:51:36, the aircraft descended from 6,500 feet at fifteen miles away from VNPR and joined the downwind track for Runway 12 to the north of the runway. The aircraft was visually identified by ATC during the approach. At 10:56:12, the pilots extended the flaps to the 15 degrees position and 46 seconds later they selected the landing gears lever to the down position. 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 continue descent. 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% and the torque (Tq) started decreasing to 0%, which is consistent with both propellers going into the feathered condition . The feather condition is not recorded in the FDR parameters. On the cockpit voice recorder (CVR) area microphone recording, a single Master Caution chime was recorded at 10:56:36. As per CVR readout, the flight crew then carried out the “Before Landing Checklist” without identifying the flaps were not to the 300 position, before starting the left turn onto the base leg. During that time, the power lever angle increased from 41% to 44%. At that point, Np of both propellers was recorded as Non-Computed Data (NCD) in the FDR and the torque (Tq) of both engines was at 0%. When propellers are in feather, they are not producing thrust. When both propellers were feathered both engines of 9N-ANC were running in flight idle condition during the event flight as per design to prevent overtorque. As per the FDR data, the engine turbo machine were functioning as expected considering the propeller were feathered. At 10:56:50 when the radio altitude callout for five hundred feet was annunciated, another “click” sound was heard . The aircraft turned to the left and reached a maximum bank angle of 30 degrees. The recorded Np and Tq data remained non-computed, in line with propellers being in feather condition. The yaw damper was 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 moving to the 30 degrees position. When ATC gave the clearance for landing at 10:57:07, the crew did not respond to the tower, the PF mentioned twice that there was no power coming from the engines. The FDR data shows that at 10:57:11, the power levers were advanced first to 62 degrees then to the maximum power position in 2 seconds. 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 left turn at 368 feet AGL, the highpressure turbine speed (Nh) of both engines increased from 73% to 77%. It is noted that at 10:57:18, in the very last stage of flight, the PF handed over control of the aircraft to the PM. 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 shaker5 was activated warning the crew that the aircraft Angle of Attack (AoA) increased up to the stick shaker threshold. At 10:57:26, a second sequence of stick shaker warning was activated when the aircraft banked towards the left abruptly. Three seconds later, the radio altitude alert for two hundred feet was annunciated, and the cricket sound and stick shaker ceased. At 10:57:32, sound of impact was heard in the CVR. The FDR and CVR stopped recording at 10:57:33 and 10:57:35 respectively. The airplane was totally destroyed and all 72 occupants were killed.
Probable cause:
The most probable cause of the accident is determined to be the inadvertent movement of both condition levers to the feathered position in flight, which resulted in feathering of both propellers and subsequent loss of thrust, leading to an aerodynamic stall and collision with terrain.
The following contributing factors were identified:
- High workload due to operating into a new airport with surrounding terrain and the crew missing the associated flight deck and engine indications that both propellers had been feathered;
- Human factor issues such as high workload and stress that appears to have resulted in the misidentification and selection of the propellers to the feathered position;
- The proximity of terrain requiring a tight circuit to land on runway 12. This tight circuit was not the usual visual circuit pattern and contributed to the high workload. This tight pattern also meant that the approach did not meet the stabilized visual approach criteria;
- Use of visual approach circuit for RWY 12 without any evaluation, validation and resolution of its threats which were highlighted by the SRM team of CAAN and advices proposed in flight procedures design report conducted by the consultant and without the development and approval of the chart by the operator and regulator respectively;
- Lack of appropriate technical and skill based training (including simulator) to the crew and proper classroom briefings (for that flight) for the safe operation of flight at new airport for visual approach to runway 12;
- Non-compliance with SOPs, ineffective CRM and lack of sterile cockpit discipline.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 near Sanosware: 22 killed

Date & Time: May 29, 2022 at 1010 LT
Operator:
Registration:
9N-AET
Flight Phase:
Survivors:
No
Site:
Schedule:
Pokhara – Jomsom
MSN:
619
YOM:
1979
Flight number:
TRA197
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
19
Pax fatalities:
Other fatalities:
Total fatalities:
22
Captain / Total flying hours:
17500
Captain / Total hours on type:
13500.00
Copilot / Total flying hours:
520
Copilot / Total hours on type:
315
Aircraft flight hours:
41336
Aircraft flight cycles:
71338
Circumstances:
On 29 May 2022, Tara Air’s 9N-AET, Twin Otter (DHC-6/300) aircraft was scheduled for three flights on Pokhara-Jomsom-Pokhara sector. Tara Air had also filed flight plans for two additional Charter flights on the same sector. Among those five flights, four flights were to be conducted by a set of crews already positioned at Pokhara while the last flight was scheduled to be commanded by the PIC who had reached Pokhara from Kathmandu that very morning. Since Jomsom Airport was closed for operations due to bad weather, the PIC went to Tara Air crew camp and waited for the updates of weather improvement of Jomsom. After Jomsom Airport was open for operations at 0321 UTC, Tara Air operation decided to operate the first scheduled flight. However suspecting the next flight operation to Jomsom could not be operated, the original PIC assigned to the flight seated on board as a passenger to Jomsom for his scheduled business trip and the PIC assigned for the last flight took command. The Flight Plan was amended accordingly. At 0342 UTC, Summit Air’s 9N-AKZ, LET-410 took-off from Pokhara to Jomsom. At 0405 UTC, it reported an altitude of 12,500 ft and patches of cloud over Tatopani. At 0409 UTC, Summit Air’s second aircraft 9N-AMG, LET-410, took-off for Jomsom and subsequently, at 0410 UTC, 9N-AET of Tara Air (TRA197) took-off with 19 passengers and three crews on board. The Copilot had initially reported 3 crew and 18 passengers onboard to Pokhara Tower but later, revised the passenger figure was 19 prior to takeoff. 9N-AET was supposed to take-off before SMT 601 but the PIC seemed hesitant to commence the flight due to weather PIREP from 9N-AKZ that, the en-route weather was not favorable for VFR flights and critical around LETE and TATOPANI. All the crew members of TRA 197 and SMT 601 were in their respective cockpits and communicating with the preceding flight 9N-AKZ as well as with Pokhara tower for the updated information of en-route and destination weather. No flights had been conducted since morning and most of the passengers of Tara air and Summit Air were already at airport. In this situation it can be assumed that there was pressure to conduct flight from each angle. While listening to the CVR of TRA 197, it was observed that someone, either ground staff or some intimate passenger to the crew, advising strongly to the PIC to conduct the flight. Following the PIREP from 9NAKZ, both TRA197 and SMT 601 subsequently started their engines to commence the flights. The PIC of TRA 197 was still hesitant to conduct the flight for Jomsom even after the engine start and delayed the taxi as he was not yet convinced about the weather report received from preceding 9N-AKZ aircraft. In the meantime, SMT 601 lined up for departure to Jomsom. That was one of the most important pressure points to the PIC of TRA 197 to initiate departure. TRA 197 finally lined up and took off from Pokhara at 0410 UTC following the SMT 601 based on the en-route weather information (VMC) from 9N-AKZ, through Pokhara Tower. The en-route weather provided by Summit Air’s 9N-AKZ to Pokhara Tower and the crewmembers of TRA 197 and SMT 601 was not the same. Aircraft took off from Pokhara from runway 04 heading North. Tower instructed “report 5 DME northwest RW 04”. Then after departure at 90 climb power aircraft turned left to maintain a heading of 345 and planned to join heading 305 degree towards Ghodepani. After four minutes, TRA 197 reported, “Now on course…. 6000 climbing and ETA Jomsom 32” (0432 UTC). At 04:21 TRA 197 reported to Pokhara Tower as position approaching Ghodepani 12000 climbing for 12500. After 6 Seconds ATC Pokhara asked TRA 197, “confirm would like to change level and TRA 197 replied, “No Ma'am we have crossed Ghodepani and like to be on”. Pokhara Tower instructed, “Tara 197 contact Jomsom Tower 122.5” CVR recordings show that after TRA 197 crossed Ghodepani, the PIC was not comfortable with the en-route weather. However, the flight was continued following the advice of SMT 601. At 0426 UTC, TRA 197made the first contact with Jomsom AFS and reported its position to which Jomsom Tower conveyed the prevailing weather as “Wind South Westerly up to 30 kts, QNH 1019, Temp 18º”. The PIC of TRA 197 reconfirmed twice if the wind was maximum, up to 30 Kts and currently South Westerly-25kts. The crew was discussing about the bad weather being encountered and the PIC himself voiced his dissatisfaction about the behavior of other pilots who conduct VFR flights in such unfavorable weather. The CVR recordings reveal that the aircraft was encountering clouds and the PIC was trying his best to remain clear of the clouds. During the course of flight, TRA 197 hadn’t reported any abnormalities encountered and neither any technical defect on aircraft either to Jomsom tower or Pokhara Tower. As per CVR, PIC was searching for light and brighter areas and adamantly heading towards it. As per CVR and V2 tracker data, the aircraft was maintaining 12000 ft and was in a climbing attitude. During the continuous attempts of crew to avoid the clouds with Terrain Avoidance and Warning System [TAWS] inhibited, the aircraft met with an unfortunate CFIT accident into the rocky terrain at an altitude of 4050 meter AMSL at Sanusare Mountain, Thasang Rural Municipality, Mustang. As per V2 tracker, last position of 9N-AET was 7.7 nm SW of Jomsom Airport. The aircraft was completely destroyed by the impact and there were no survivors.
Probable cause:
The probable cause of this accident was the flight crew's failure to monitor and maintain the proper course while inadvertently flying in IMC conditions with the aircraft Terrain Avoidance and Warning System (TAWS) inhibited which resulted into a Controlled Flight Into Terrain (CFIT) accident.
The following contributing factors were identified:
1. The flight crew's failure to follow the SOP of company.
2. The aircraft flight operation with TAWS inhibited during deteriorating en-route weather condition.
3. Loss of situational awareness of crew.
4. Deteriorating en route weather.
5. Less experienced copilot for that sector and high crew gradient.
6. Poor CRM during the flight.
7. The whole cockpit duties [both PF and PM] were undertaken by the PlC, which likely impaired his performance.
8. Underutilization of the available Navigation instruments.
Final Report:

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 Cessna 208B Grand Caravan near Simikot: 2 killed

Date & Time: May 16, 2018 at 0645 LT
Type of aircraft:
Operator:
Registration:
9N-AJU
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Surkhet – Simikot
MSN:
208B-0770
YOM:
1999
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total hours on type:
414.00
Copilot / Total hours on type:
461
Aircraft flight hours:
15757
Aircraft flight cycles:
31540
Circumstances:
The single engine aircraft departed Surkhet Airport at 0612LT on a cargo flight to Simikot. At 0627LT, the crew made his last radio transmission with Nepalgunj Tower. About 18 minutes later, while cruising by night at an altitude of 12,800 feet, the airplane struck the slope of a mountain located near the Simikot Pass, some 12 km from Simikot Airport. The airplane disintegrated on impact and both crew members were killed.
Probable cause:
The Commission determines the most probable cause of this accident was to continue the flight despite unfavorable weather conditions resulting inadvertent flight into instrument
meteorological conditions and there by deviating from the normal track due to loss of situational awareness that aggravated the spatial disorientation leading to CFIT accident. The following contributing factors were reported:
- Possible effect of hypoxia due to flight for prolonged period in high altitude without oxygen supplement,
- Ineffective safety management of the company which prevented the organization from identifying and correcting latent deficiencies in risk management and inadequacies in pilot training.
Final Report:

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 PZL-Mielec M28-05 Skytruck in Bajura: 1 killed

Date & Time: May 30, 2017 at 1210 LT
Type of aircraft:
Operator:
Registration:
NA-048
Flight Type:
Survivors:
Yes
Schedule:
Surkhet - Simikot
MSN:
AJE003-02
YOM:
2004
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The crew departed Surkhet on a flight to Simikot but was unable to land at Simikot due to high winds and diverted to Bajura Airfield. Upon arrival, the twin engine aircraft crashed and came to rest upside down. The captain was killed and both other crew members were seriously injured.

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 BAe 4101 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:
1993
Flight number:
YT893
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
29
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach to Siddharthanagar-Gautam Buddha Airport was completed in good weather conditions with a wind from the southeast at 4 knots and a 8 km visibility. After touchdown on runway 28, the twin engine aircraft was unable to stop within the remaining distance. It overran, lost its undercarriage and came to rest in bushes, some 110 metres past the runway end. All 32 occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of a Pacific Aerospace 750XL in Chilkhaya: 2 killed

Date & Time: Feb 26, 2016 at 1305 LT
Operator:
Registration:
9N-AJB
Flight Phase:
Survivors:
Yes
Schedule:
Nepalgunj - Jumla
MSN:
160
YOM:
2009
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
9
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The single aircraft departed Nepalgunj at 1230LT bound for Jumla. About 35 minutes into the flight, the crew encountered an unexpected situation and attempted an emergency landing in a field. The aircraft eventually collided with an earth bank and came to rest near the village of Chilkhaya. Both pilots were killed and all 9 passengers were injured. The aircraft destroyed.