Scheduled Revenue Flight

The Twin Otter (DHC6/300) aircraft with registration number 9N-ABO, owned and operated by Nepal Airlines Corporation (NAC), departed Kathmandu to Pokhara for night stop on 15 May 2013 in order to accomplish up to 5 (five) Pokhara-Jomsom-Pokhara charter flights planned for the subsequent day on 16 May 2013. As per the programme, the aircraft completed first charter flight from Pokhara to Jomsom sector on 16 May 2013 morning after one and half hour waiting on ground due weather. For this second flight, the aircraft departed at 0225 UTC (08:10LT) from Pokhara to Jomsom in the command of Capt. Dipendra Pradhan and Mr. Suresh K.C. as co-pilot. There were 19 passengers including one infant and 3 crew members on board. The aircraft was operating under Visual Flight Rules (VFR). As per the CVR readout there was no reported difficulties and all the pre and post departure procedure and en-route portion of the flight were completed in normal manner. There was no indication of lacking of information and advice from Jomsom Tower. At first contact the co-pilot called Jomsom Tower and reported its position at PLATO (a compulsory reporting point) at 9 miles from Jomsom airport at 12500ft. AMSL. The Jomsom Tower advised runway 24 wind south westerly 08-12 KTS, QNH 1020, Temp 13 degree and advised to report downwind for runway 24.The co-pilot accepted by replying to join downwind for runway 24. There was no briefing and discussion between the two pilots regarding the tail wind at the airport. The PIC, then, took over the communication function from co-pilot and called Jomsom Tower, requesting to use runway 06 instead of runway 24, despite the advice of tower to use runway 24 to avoid tail wind effect in runway 06. Jomsom Tower repeated the wind speed to be 08-12 KTS for the runway 06, to which the PIC read back the wind and answered to have ”no problem”. As per the PIC request the Jomsom Tower designated runway 06 for landing and advised to report on final runway 06. The PIC did read back the same. The pre landing checklist was used, flaps with full fine in propeller rpm were taken and full flaps was also taken before touchdown. In the briefing of “missed approach” the PIC had answered to be “standard”. The aircraft touched down runway of Jomsom airport at 0245 UTC (08:30LT) at a distance of approximately 776 ft, far from the threshold of runway 06. After rolling 194 ft. in the runway, the aircraft left runway and entered grass area in the right side. The aircraft rolled around 705 ft in the grass area and entered the runway again. The maximum deviation from the runway edge was 19 ft. The Commission has observed that when aircraft touched down the runway, it was not heading in parallel to the runway centreline. After touchdown the aircraft rolled around 194ft on the runway, left the paved area and started rolling in the grass area in the right side. During the landing roll, when the aircraft was decelerating, the co-pilot had raised the flaps as per the existing practice of carrying out “after the landing “checks". As per the observation of passenger seated just behind the cockpit, after touchdown of the aircraft there was no communication between pilot and co-pilot. It seemed that pilot was busy in cockpit and facing problem. It was obvious that PIC was in dilemma in controlling aircraft. He added power to bring aircraft into the runway with an intention to lift up the aircraft. He did not brief anything to copilot about his intention and action. He started adding power with the intention of lifting up, but the aircraft was already losing its speed, due to extension of flaps by co-pilot without briefing to PIC and use of brakes (light or heavy, knowingly and unknowingly) simultaneously by the PIC. The accelerating aircraft with insufficient speed and lift to take off ran out of the runway 24 end, continued towards the river, hit the barbed fence and gabion wall with an initial impact and finally fell down into the edge of river. The left wing was rested in the mid of the river preventing the aircraft submerged into the river.

Shortly after takeoff from Sam Neua-Nathong Airport, while in initial climb, the twin engine aircraft collided with trees, lots height and crashed in a small river located 200 metres past the runway end. All 18 occupants were injured, five seriously. The aircraft was damaged beyond repair.

On 13 April 2013, a Boeing 737-800 aircraft, registered PK-LKS, was being operated by PT. Lion Mentari Airlines (Lion Air) on a scheduled passenger flight as LNI 904. The aircraft departed from Husein Sastranegara International Airport (WICC) Bandung at 0545 UTC to Ngurah Rai International Airport (WADD), Bali, Indonesia. The flight was the last sector of four legs scheduled for the crew on that day which were Palu (WAML) - Balikpapan (WALL) - Banjarmasin (WAOO) - Bandung (WICC) - Bali (WADD). The aircraft flew at FL 390, while the Second in Command (SIC) was the Pilot Flying (PF) and the Pilot in Command (PIC) was the Pilot Monitoring (PM). There were 2 pilots, 5 flight attendants and 101 passengers comprising 95 adults, 5 children and 1 infant making a total of 108 persons on board. The flight from the departure until start of the approach into Bali was uneventful. At 0648 UTC, the pilot made first communications with the Bali Approach controller (Bali Director) when the aircraft was located 80 Nm from BLI VOR. The pilot received clearance to proceed direct to the TALOT IFR waypoint and descend to 17,000 feet. At 0652 UTC, the Bali Director issued a further clearance for the pilot direct to KUTA point and descent to 8,000 feet. At 0659 UTC, the aircraft was vectored for a VOR DME approach for runway 09 and descent to 3,000 feet. At 0703 UTC, while the aircraft was over KUTA point, the Bali Director transferred communications with the aircraft to Bali Control Tower (Ngurah Tower). At 0704 UTC, the pilot contacted Ngurah Tower controller and advised that the aircraft was leaving KUTA point. The Ngurah Tower controller instructed the pilot to continue the approach and to reduce the aircraft speed to provide sufficient separation distance with another aircraft. At 0707 UTC, the Ngurah Tower issued take-off clearance for a departing aircraft on runway 09. At 0708 UTC, with LKS at approximately 1,600 feet AGL, the Ngurah Tower controller saw the aircraft on final approach and gave a landing clearance with additional information that the wind was from 120° at 05 knots. At 0708:47 UTC, the aircraft Enhance Ground Proximity Warning System (EGPWS) aural alert called “ONE THOUSAND”, the SIC said one thousand, stabilized, continue, prepare for go-around missed approach three thousand. The FDR showed that the pilot flown using LNAV (Lateral Navigation) and VNAV (Vertical Navigation) during the approach until disengagement of the Auto Pilot. The sequence of events during the final approach is based on the recorded CVR and FDR data, and information from crew interviews as follows: At 0708:56 UTC, while the aircraft altitude was approximately 900 feet AGL, the SIC commented that the runway was not in sight, whereas the PIC commented “OK. Approach light in sight, continue”. At 0709:33 UTC, after the EGPWS aural alert “MINIMUM” sounded at an aircraft altitude of approximately 550 feet AGL, the SIC disengaged the autopilot and the auto-throttle and then continued the approach. At 0709:43 UTC, the EGPWS called “THREE HUNDRED”. At 0709:47 UTC, the CVR recorded a sound similar to rain hitting the windshield. At 0709:49 UTC, the EGPWS called “TWO HUNDRED”. At 0709:53 UTC, while the aircraft altitude was approximately 150 feet AGL, the PIC took over control of the aircraft. The SIC handed control to the PIC and stated that he could not see the runway. At 0710:01 UTC, after the EGPWS called “TWENTY”, the PIC commanded for go-around. At 0710:02 UTC, the aircraft impacted the water, short of the runway. The aircraft stopped facing to the north at about 20 meters from the shore or approximately 300 meters south-west of the beginning of runway 09. Between 0724 UTC to 0745 UTC, three other aircraft took-off and six aircraft landed using runway 09. At 0750 UTC, the airport was closed until 0850 UTC. At 0755 UTC, all occupants were completely evacuated, the injured passengers were taken to the nearest hospitals and uninjured occupants to the airport crisis centre.

Following an uneventful flight from Sialkot, the crew completed the approach to Muscat-Seeb Runway 26L. After touchdown, while decelerating, the left main gear collapsed, causing the left engine to struck the ground. The aircraft slid for few dozen metres before coming to rest on the left edge of the runway. All 114 occupants evacuated uninjured while the aircraft was damaged beyond repair.

Following an uneventful flight from Casablanca-Mohamed V Airport, the crew started the approach to Tunis-Carthage International Airport Runway 19 and encountered marginal weather conditions. After touchdown, the aircraft rolled for a distance of 1,600 metres then deviated to the right. The aircraft veered off runway, rolled in a grassy area for 114 metres when the nose gear impacted the concrete perpendicularly runway 11/29. On impact, the nose gear was torn off and the aircraft rolled for another 130 metres before coming to rest. All 83 occupants evacuated safely while the aircraft was damaged beyond repair. At the time of the accident, strong crosswinds and heavy rain falls passed over the airport.

The Rome-Fiumicino Airport Runway 25 was closed to trafic due to work in progress so the crew was vectored and cleared for a landing on runway 16L. The approach was completed in good visibility with strong crosswinds from 250° at 28 knots gusting to 41 knots and windshear. On the last segment, the aircraft lost height and impacted ground 567 metres short of runway 16L threshold. The aircraft bounced three times, lost its right main gear, slid for few dozen metres and came to rest in a grassy area some 1,780 metres past the runway threshold. All 50 occupants were rescued, among them seven were slightly injured. The aircraft was damaged beyond repair.

Following an uneventful flight from Kokshetau, the crew started the descent to Almaty Airport and was cleared for an ILS approach (Cat IIIb approach) to runway 23R. At this time, the horizontal visibility was 200 metres, the vertical visibility 40 metres and the RVR for runway 23R was 275-250-225 metres respectively. Due to this poor weather conditions at destination, the captain got stressed, creating a strong emotional reaction. On short final, at an altitude of 180 metres, the captain decided to abandon the landing procedure and initiated a go-around manoeuvre. The automatic pilot system was deactivated and the TO/GA mode was activated. Four seconds later, the captain pushed the control column forward, causing the aircraft to descend. The EGPWS alarm sounded in the cockpit but there was no response from the flying crew. In a pitch angle of -16° and with a descent rate of about 20-30 metres per second, the aircraft impacted ground and disintegrated in a snow covered field. The wreckage was found some 1,400 metres short of runway. All 21 occupants were killed. Due to the actual weather conditions, the crew should perform a Cat IIIc approach.

On approach to runway 18 at Okiwi, New Zealand, the aircraft encountered windshear on short final as the pilot reduced power to land. The pilot was unable to arrest the descent rate and the aircraft landed heavily. Damage was caused to both landing gear oleos and one brake unit, with rippling found on the upper and lower skin of each wing. One passenger sustained a back injury, which was later identified as a fractured vertebra. The pilot was aware of fluctuating wind conditions at Okiwi and had increased the approach speed to 70 knots as per company standard operating procedures. The pilot reported that despite this, the airspeed reduced rapidly and significantly at 10 to 15 feet agl, leaving little time to react to the situation.

While taxiing to runway 18 for a departure to Neuquén, the twin engine aircraft went out of control, veered off taxiway to the left and rolled onto a soft ground four about 40 metres before coming to rest. The nose gear sank in soft ground, causing both propeller blades to struck the ground and to be partially torn off. The fuselage was hit by debris. All 33 occupants evacuated safely and the aircraft was damaged beyond repair.

Following an uneventful flight from Roatán, the crew started the approach to San Pedro Sula Airport Runway 04. After touchdown, the pilot applied brake when the aircraft encountered controllability problems. It veered off runway to the left, went through a grassy area, lost its undercarriage and came to rest with its nose in a drainage ditch located 40 metres to the left of the runway. All 19 occupants escaped uninjured and the aircraft was damaged beyond repair.