- 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 Draft Final Report,
9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 1
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. 6/5/2014 Draft Final Report,
9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 2 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 6/5/2014 Draft Final Report, 9N-ABB,Crashed at
Arghakhanchi, on 16 February 2014 3 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 6/5/2014 Draft Final Report, 9N-ABB,Crashed
at Arghakhanchi, on 16 February 2014 4 5. Crash Site Sloppy south
ridge of Dihi Danada Masinalek , Arghakhanchi District, Nepal First
impact point reference : N 27 deg 5443 Latitude E 83 deg 06 56''
Longitude Elevation: 7190 feet AMSL 6/5/2014 Draft Final Report,
9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 5 6. Aerial
Photo first -- impact site 6/5/2014 Draft Final Report,
9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 6 7. History of
Flight 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi,
on 16 February 2014 7 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 6/5/2014 Draft Final Report, 9N-ABB,Crashed at
Arghakhanchi, on 16 February 2014 8 9. Aeronautical route- direct
and followed 6/5/2014 Draft Final Report, 9N-ABB,Crashed at
Arghakhanchi, on 16 February 2014 9 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 6/5/2014 Draft Final
Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 10 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 6/5/2014 Draft Final Report, 9N-ABB,Crashed at
Arghakhanchi, on 16 February 2014 11 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. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at
Arghakhanchi, on 16 February 2014 12 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 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi,
on 16 February 2014 13 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] 6/5/2014
Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February
2014 14 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. 6/5/2014 Draft Final Report, 9N-ABB,Crashed
at Arghakhanchi, on 16 February 2014 15 16. Satellite Picture of
weather pattern of Nepal on that day around 2014-2-16, 7:32
6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16
February 2014 16 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. 6/5/2014 Draft Final
Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 17 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. 6/5/2014 Draft Final Report,
9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 18 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. 6/5/2014 Draft Final Report, 9N-ABB,Crashed
at Arghakhanchi, on 16 February 2014 19 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. 6/5/2014
Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February
2014 20 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." 6/5/2014 Draft Final Report,
9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 21 22. Causes
of Accident and SAFETY Recommendations 6/5/2014 Draft Final Report,
9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 22 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. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at
Arghakhanchi, on 16 February 2014 23 24. Safety Recommendations
6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16
February 2014 24 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. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at
Arghakhanchi, on 16 February 2014 25 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.
6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16
February 2014 26 27. Safety Recommendations to The Department of
Hydrology and Metrology 6/5/2014 Draft Final Report, 9N-ABB,Crashed
at Arghakhanchi, on 16 February 2014 27 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.
6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16
February 2014 28 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. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at
Arghakhanchi, on 16 February 2014 29 30. ANIMATION OF FLIGHT
6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16
February 2014 30 31. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at
Arghakhanchi, on 16 February 2014 31 32. Comments / Questions
6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16
February 2014 32