Nepal Airlines 9N-ABB Crash Press Conferece

1. SUBMISSION OF DRAFT
FINAL REPORT OF
TWIN-OTTER, DHC-6, 300
Crashed on – 16 February 2014
at
Dihidanda, Masinalek , Arghakhanchi District,Nepal.
TO
The Minister for Culture Tourism and
Civil Aviation
[2071/2/--/-/-/ 2014/06/--]
6/5/2014
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2. Introduction
Aircraft : 9N-ABB, DHC6-300, Double engine,
STOL Category
Owned and Operated by: Nepal Airlines
Corporation (NAC)
Engine Manufacturer : Pratt and
Whitney, Canada
Airframe Manufacturer : De Havilland
Canada.
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3. Composition of the Commission :
Former DG , CAAN, - Mr. Tri Ratna Manandhar
- Chairman
Senior Aero. Er.- Meghendra Kumar Shrestha--
Member
Senior Pilot (IP-DHC6)- Mr. Prabhakar Prasad
Ghimire-- Member
Joint Secretary, MoCTCA--Mr. Buddhi Sagar
Lamichhane--- Member Secretary
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4. Aircraft Crash and
CONSTITUTION OF COMMISSION
 Crashed on – 16 February 2014
 At the south sloppy ridge of Dihidanda
Masinalek, Arghakhanchi District, Nepal
 Altitude of the impact point is: 7190 Ft.
 The Government of Nepal on 17 February 2014
in accordance with the provisions of Civil Aviation
(Accident Investigation) Rules, 2024 B.S (1967)
constituted 4 Member Aircraft Accident
Investigation Commission’ to investigate and find
out the cause of the accident and recommend
remedial measures for the purpose of preventing
future aircraft accidents and incidents
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5. Crash Site
 Sloppy south ridge of Dihi Danada Masinalek ,
Arghakhanchi District, Nepal
 First impact point reference : N 27 deg 54’43’’ Latitude
E 83 deg 06’ 56'' Longitude
 Elevation: 7190 feet AMSL
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6. Aerial Photo first -- impact site
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7. History of Flight
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8. History of Flight
 PIC – Shankar Shrestha
 Co-pilot – Rabindra Banjara
 Air Hostess – Muna Maharjan
 Total Passenger on Board – 15
 Total person on board – 18 (3 +15)
 Cargo – Nil
 Survival -- Nil
 Fatality -- ALL
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9. Aeronautical route- direct and followed
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Crash site
POKHARA
JUMLA
KTM
Direct Track
Track Followed

10. History of Flight………
 On the day of accident flight was delayed due to bad
weather
 Departed from Kathmandu to Pokhara on the same
day at 0610 UTC (1155 LT)
 The flight from KTM-PKR was accomplished in
normal manner
 Flight Rule -- VFR
 The aircraft departed Pokhara at 0658 UTC to Jumla
 Weather at Pokhara and Jumla Airport
VFR Normal
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11. Flight Detail as submitted by 9N ABB TO PKR TWR
 Aerodrome of Departure: Pokhara
 EOBT: 0645 UTC
 Destination Aerodrome: Jumla
 Altitude: 10500ft
 Total Estimated Elapse Time: 0100 hour
 1st Alternate Aerodrome: Nepalgunj
 2nd Alternate: Surkhet
 Endurance: 02:30 HRS
 PIC: Capt. Shankar Shrestha
 Equipments: SD/N
 POB: TBN
 Flight Rule: VFR
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12. After the completion of Jumla flight,
the aircraft was scheduled to Night stop
at Nepalgunj. Next day it had a series of
shuttle flights from Nepalgunj.
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13. History of Flight……..
 Initially the PIC tried from direct track.
 Due to bad weather towards direct track the aircraft
followed south of track via Juliet
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14. Injuries to Persons
 Injuries Crew Passenger Total
 Fatal 3 15 18
 Total 3 15 18
Among Passengers
 [Adults - 17 ; Infant - 1]
 [ Danish – 1 ; Nepalese- 17]
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15. Damages to Aircraft and Third party
 The aircraft was totally damaged and disintegrated. Some parts
were completely burnt. Different parts and pieces were scattered
on both sides of the ridge where the accident took place.
 No damage to outside people and structures.
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16. Satellite Picture of weather pattern of Nepal
on that day around 2014-2-16, 7:32
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17. Findings
 The pilots were certified and qualified in accordance with the existing
Nepalese aviation regulations. Both the pilot and co-pilot were in
normal health condition and were certified as fit to fly.
 The crew had adequate rest and the duty times within the accepted
guidelines.
 The aircraft was maintained as per the existing rules and regulation.
Pre-impact failure and other mechanical malfunction was also not
found .
 There was no evidence of engine failure before impact.
 CVR was found in good condition and all the cockpit conversation
was recorded.
 The GPS installed was of old model and it does not have capability of
storing previous track data.
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18.  The 9N-ABB had departed Kathmandu to Pokhara (where
technical landing for refueling was planned) even when the
weather at destination airport Jumla was below VFR
Minima.
 Pilots encountered unfavorable enroute weather in the
direct track deviated to South with the way points aiming
JULIET and THARA.
 PIC had penetrated the visible moisture without having
proper anti-icing and De-icing facility equipped in aircraft
in violation to SOP as well as flight manual of DHC 6 – 300.
 Aircraft climbed up to 10500 ft with OAT -06 degrees
Celsius and again went down to 8500 ft whereby they
ultimately encountered zero degree temperature i.e.
without icing conditions.
 PIC found to be focused on completing the mission in spite
of adverse weather.
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19.  PIC did not brief co-pilot on descending from 8500 ft to
the lower level. Co-pilot had suggested PIC not to descend
but did not insist. Insistence on that particular time was
very necessary.
 While descending to altitude lower than 8500 ft and
maneuvering to get out of the adverse weather, 9N-ABB
was flying inside the visible moisture with no in-flight
visibility.
 PIC had started losing his situational awareness as a result
of which, he inadvertently started descent making turns.
Co-pilot, now monitoring, was suggesting again to PIC
not to descend and not to make turn.
 While initiating turn the aircraft was on north easterly
heading, initially slashed a small branch of a tree and hit
the sloppy ridge with the huge impact.
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20.  Based on the evident it was concluded that nature of
accident was a ‘Controlled Flight into Terrain’.
 Serious lacking in crew coordination especially in the
last critical part of the flight. PIC's faulty decision,
inability on the part of co-pilot to strongly intervene
the PIC's wrong action led to the catastrophic
accident.
 Company's Dispatch Policy as reflected in DHC6 SOP
is not implemented properly.
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21. Interim Safety Recommendations:
 "Operators shall immediately develop and
implement an appropriate surveillance
mechanism to ensure the effective monitoring of
the flying behaviors of the pilots and their
adherence to SOP including the violation of the
VFR rules."
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22. Causes of Accident
and
SAFETY
Recommendations
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23. Causes
 The Accident Investigation Commission has determined the
most probable cause
 " Loosing situational awareness on the part of PIC while
flying into instrument meteorological weather
condition to the extent of impact. leading to CFIT
accident."

 Contributory factors to the occurrence are;
 -inappropriate and insufficient crew coordination
while changing course of action,
 -the prevailing weather of cold front from the west
,unstable in nature and embedded CB.

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24. Safety
Recommendations
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25. SAFETY RECOMMENDATIONS TO
TheMinistry of Culture Tourism and Civil
aviation (MoCTCA)
 MoCTCA should establish an independent and
effective aircraft accident investigation mechanism
with the provision of adequate resources under the
Ministry of Culture, Tourism and Civil Aviation
(MoCTCA) for the effective investigations and also
for the continuous monitoring of the
implementation and compliance-status of remedial
safety measures.
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26. Safety Recommendations to
The Civil Aviation Authority of Nepal
 CAAN should further strengthen its surveillance and monitoring function
focusing on the critical safety areas including violation of SOP, proper
application of CRM, CFIT, and ensure effective enforcement mechanism by
collecting information on flight operational activities on daily basis.
 CAAN should ensure that all fleets operated by AOC holders are equipped
with the appropriate Terrain Awareness Warning System (TAWS) in
accordance with the provisions of Annex 6 .
 CAAN in coordination with Department of Hydrology and Meteorology
should develop a mechanism to obtain the real time weather data not only of
the airport stations but also from other parts of the country for the
information and analysis of en-route weather.
 Encourage airlines to install onboard aircraft equipment that will help for
real time tracking of the aircraft in flight.
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27. Safety Recommendations to
The Department of Hydrology and Metrology
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28. Safety Recommendations to NAC
 NAC should review and strengthen the training
requirements on Crew Resource Managements ( ground
and in flight), with special attention to the importance of
close coordination and cooperation between PIC and Co-
pilot and also emphasizing the situations requiring
interventions from co-pilot.
 In view of the significant fleet expansion in process , NAC
should systematically identify the hazards, changes in
system , operational environment and consequential safety
risk specially in the process of recruitment and training of
the operational and engineering personnel.
 NAC should enhance the flight dispatcher's capability to
enable them to fulfill their responsibility as per the
provisions of company SOP.
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29.  For the prevention of CFIT accident NAC should develop
the normal and alternate track (for weather reason) in its
company manual and strictly follow the policy of either to
fly VFR only or to fly at Minimum Safe Altitude (MSA)
developed for that particular route, if a flight could not be
conducted with visual references. Such MSA policy should
be reflected in SOP and Operational Flight Plan.
 NAC should review and further strengthen the effective
implementation of SMS process specially in the areas of
improved reporting system, hazard identification and risk
mitigation.
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30. ANIMATION OF FLIGHT
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31. 6/5/2014
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32. Comments / Questions
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