'Plane crash' at Nepal's Kathmandu airport

[Super VC-10]

Aircraft landed 5,600 feet iinto a 10,000 foot runway. :ugh:

[Heathrow Harry]

I think , given the published comms and probable path it's amazing they found any runway to land on at all TBH

[ironbutt57]

It doesnt appear he was aligned with the runway axis when he touched down, but rather touched down as he was crossing it at a rather severe angle, hence, his continuation across the runway, into obstacles, then down the slope

[birmingham]

Even with the confused coms, circling approach and VOR based let down, it is very hard to understand how an experienced crew in a modern type with fully functioning avionics did not realise that they wern't lined up with either 20 or its reciprocal.

[RAT 5]

Indeed; and the real crux of the final report that will be of interest is why they didn't land on the 10,000' that was presumably in front of them on the initial approach. That to me is the mystery, not all the ATC v pilot guff. You make an approach, are cleared to land, see the runway and then decide to do some fandango. Why? Let's wait and read.

[Livesinafield]

At VREF it will do approx 10-11 miles witha headwind in 6 mins maybe 12

[avionimc]

Is there a map of the flight path or track during the final moments of the flight, going around and circling, until the crash. I thought I saw one here, but cannot find it. No luck on flightaware or flightradar24 either.
Thank you.

[ATC Watcher]

The map showed in here previously in a post was a guesswork made by a newspaper . Not the actual track flown by the aircraft and It seems they also never made an actual go around . The final leg was not an approach as they hit the ground nearly perpendicular across the runway.

[avionimc]

Thanks ATC Watcher.
It would be interesting to see the actual or even an approximate flight/ground track.

[portmanteau]

Rat 5, its the ATC/pilot guff that must have played a large part in this accident. For Nepal Civil Aviation to say it was normal is frankly absurd. Both ATC and pilots made several contradictory and puzzling transmissions. It ended up with a pilot who was proceeding lefthand downwind for 20 later being instructed to join righthand downwind for 02.This required a 180 turn to the right which he appears at least to have started. Then ATC offer him 02 or 20, he elects for 20 and Tower says runway 02 cleared to land. Clear as mud. Aircraft then appears from the north as if trying to land on 20. CVR might reveal what actually happened.

[RAT 5]

Portmanteau: I'll wait for the final report. These quotes are taken from earlier posts & links. It would seem to me that the 'ATC/Pilot guff' started AFTER the a/c deviated from their clearance. So which party do you think caused the confusing conversation? If a B737 can land straight in with no problem I'll wait to hear why a turbo prop couldn't do the same thing. It seems it was the deviation from a 02 landing, as per approach & clearance, that started the chain of events. Why? That's the mystery

At the time there was a light tailwind component of six to seven knots. Landing direction was 02. The DHC-8-400 was following a Boeing 737-800 of Jet Airways (Flight JAI266 from Mumbai) that was landing about 3 minutes ahead of SB211 on runway 02.
According to transmissions by the Kathmandu tower controller, despite cleared to land on runway 02 the flight began deviating from its course.

BS211(female voice): „Good day, BanglaStar211 final runway 02.“
KTH-Tower: „BanglaStar211, tower. Wind 220 degrees eight knots, tailwind component seven knots, continue approach.“
BS211(female voice): „Continue approach BanglaStar 211.“
..
KTH-Tower: „BanglaStar211, wind 220 degrees seven knots, talwind component six knots, you’re cleared to land.“
BS211(female voice): „Cleared to land, BanglaStar 211.“
..
KTH-Tower: „BanglaStar211, tower?“
BS211(female voice): „Go ahead, sir.“
BS211(male voice): „Go ahead, mam‘.“
KTH-Tower: „BanglaStar211, you were given a landing clearance to runway 02.“
BS211(male voice): „Affirmative, mam.“
KTH-Tower: „You are going towards runway 20.“

[portmanteau]

I dont think either party "caused" the confusing conversation. Both ATC and pilots are expected to operate without making mistakes regardless of the circumstances.

[ScreenCap]

Both ATC and pilots are expected to operate without making mistakes regardless of the circumstances.

Speak to some HF people about the error rate of the typical human, and about TRM/CRM and stuff like that!

Retired-US Center ATC here, longtime lurker. If you want to get a picture of the reality of what LFAJ means, and how things really work, just skip over to the SWA1380 thread and listen to the two live atc recordings on pg 2 linked by mkenig. Several professionals who speak on these recordings make minor or major errors, some of the more significant of which are corrected by others. Many phraseology errors and colloquialisms are ignored by all. How it works is, we all watch each other and listen and correct each others' many errors, on the ground, in the air, and in all radio transmissions. That's what it means to be a group of mistake-prone human beings and do successful work related to the imminent safety of others. Seeing things in this light makes it even harder to guess how CRM was being utilized leading up to the sad US-Bangla crash (RIP and condolences to all those affected), and leads me to wonder if significant incapacitation of flight crew might somehow be involved. Most similar what-are-they-doing-it doesn't-make-sense incidents I observed in my career turned out to have involved incapacitation of one sort or another. Out.

[ATC Watcher]

Screen Cap absolutely. Same experience from my end. The capt voice on the R/T might give a clue , but there is also the possibility of uncontrollable aircraft in the end due technical issue or CG shift , which they are looking at. But it is all to be proven . One last point since we are taking about past experiences: mine are that there is very rarely a single simple cause to an accident. Most are a combination of factors happening at the same time. I suspect the same here .

[portmanteau]

Quote:
Originally posted by LFAJ: If anyone of us makes a mistake there are checks and balances to help to identify it and procedures to correct it.

Quote:
Originally posted by Screencap: How it works is, we all watch each other and listen and correct each others many errors, on the ground, in the air and in all radio transmissions.

Fine sentiments but can I point out there is no evidence that such co-operation existed between ATC and 211 Pilots in this accident. Both ATC and pilots failed to challenge a number of questionable transmissions.

But let us move on a bit. CAAN's dismissal of the R/T as "normal" suggests they will not analyse it any further nor does it seem likely they will share the CVR with us. We are left with trying to work out for ourselves what went wrong.

211 broke off an approach without advising ATC . They did not declare an emergency. These two facts should have alerted ATC that the aircraft had a problem and in my view they should have taken immediate action to clear the runway and other traffic in order to get the aircraft on the ground asap. The aircraft was seen in the lefthand downwind position for 20 and ATC should have facilitated his landing on 20 without any delay. ATC's priority is the safety of the aircraft passengers and crew. Was the crews' silence and behaviour due to someone threatening the crew? A technical problem? Incapacitation? ATC certainly didnt know, all the more reason to treat it as an emergency and act accordingly. Get the aircraft pax and crew down and investigate later. Instead ATC keeps him circling around with its tragic ending.

[ATC Watcher]

Portmanteau; Instead ATC keeps him circling around
You do not seem to understand how ATC works. Prime objective of a TWR controller is to prevent collisions when there is more than one aircraft in the air at the same time .
. You cannot have opposite runway operations , clearing the way is what they did , then offering both 02 and 20 to the 211 was the right thing to do . Most of us would have acted exactly this way
Last word of caution in judging a situation based on partial facts :
The recordings put on internet are recordings made by a hand held icom receiver from the ground, meaning that due line of sight many ground level and very
low level transmissions are missing.
The " squelch" noises on the tape are in fact transmissions.When you hear those , the picture changes.

[portmanteau]

ATC Watcher, I think you need a refresher course in basic ATC principles, one of which is to help aircraft in trouble. 211 clearly had problems and the sooner he was on the ground the better but it seems you would make him wait for his turn to land rather than assist him to land immediately. If you cannot understand this then further discussion is futile.

[ATC Watcher]

portmanteau : If you cannot understand this then further discussion is futile. Indeed . you should maybe change your name to Captain Hindsight .
Patanom : It's very strange track This is definitively not the actual flight path of the aircraft .

[RAT 5]

Flight in good visual contact with the runway. ATC. You are cleared to land, you choose the runway. What more can they do? Trying to shift this accident onto ATC is unjust. Making them wait their turn? Where do you get that from. Until the final report is out, indeed, further discussion is futile. It all starts with why they didn't land on 02 straight in.

[Yo_You_Not_You_you]

2018-08-27/exclusive-us-bangla-pilot-was-mentally-stressed-and-reckless

New report by Nepali investigators says the US-Bangla Flight BS211 captain’s past behaviour should have been a warning sign

CCTV footage obtained by the Post.Aug 27, 2018-The pilot of the US-Bangla plane that crashed at Kathmandu’s Tribhuvan International Airport in March, killing 51 people, appears to have lied to the control tower during the landing procedure and was smoking continuously inside the cockpit during the one-hour flight from Dhaka to Kathmandu.According to details of the official investigation led by the Nepal government, a copy of which was obtained exclusively by the Post, Captain Abid Sultan was going through tremendous personal mental stress and anxiety, and a series of erroneous decisions on his part led to the crash of the Flight BS211.Throughout the flight, Sultan was engaged in erratic behaviour that marked a departure from his usual character-signs that should have immediately raised red flags, Nepali investigators concluded in the report.

Six minutes before the landing time, Sultan had confirmed that the plane’s landing gear was down and locked. “Gears down, three greens,” the pilot said, according to the report, referring to the electrical indicator lights inside the cockpit.However, when co-pilot Prithula Rashid conducted a final landing checklist, the landing gears were not down. Minutes later, the plane carrying 67 passengers and four crew members burst into flames after missing the runway during its second landing attempt.The majority of the 22 Nepalis killed in the crash were medical students who had come home on a two-month leave before their final year results were published.

Only 20 passengers survived the crash.Investigators say Sultan had been smoking cigarettes frequently during the hour-long flight from Dhaka to Kathmandu. The former Bangladeshi Air Force pilot, who had clocked more than 5,500 flying hours, had not disclosed to the airlines that he was a smoker, leading investigators to conclude that Sultan was undergoing severe mental stress inside the cockpit.“When we analysed the conversation on the Cockpit Voice Recorder, it was clear to us that the captain was harbouring severe mental stress. He also seemed to be fatigued and tired due to lack of sleep,” investigators wrote in the report. “He was crying on several occasions.”

The voice recorder has captured nearly an hour-long conversation between the captain and his co-pilot in the cockpit, further demonstrating Sultan’s tensed mood throughout the flight and a complete lack of situational awareness.“I don’t f---ing care about safe flight, you f--- your duty,” Sultan said at one point inside the cockpit, according to the report.

It was not clear whom the pilot was directing the statement at, as the co-pilot was the only crew member present inside the cockpit during the flight.The report also shows that Sultan made multiple abusive statements toward a female colleague [another co-pilot in the company] who had questioned his reputation as an instructor, and their relationship was a major topic of discussion throughout the flight. Records show that Rashid, the co-pilot, was a passive listener to Sultan’s story throughout the flight.“A cockpit is a place where personal conversations between colleagues are strictly prohibited when the aircraft is preparing to land or take off,” said Captain Shrawan Rijal of Nepal Airlines. “It’s a strictly enforced cockpit rule, which instructs pilots to focus entirely on the aircraft’s operations.”The Sterile Cockpit Rule under the US Federal Aviation Administration regulation requires aircraft pilots to refrain from non-essential activities in the cockpit during critical phases of flight, normally below 10,000 feet.

The rule was imposed in 1981, after reviewing a series of accidents that were caused by flight crews who were distracted from their flying duties by engaging in non-essential conversations and activities during the flight.At one point during the flight, according to details from the audio recorder, the pilot broke down and said that he was “very upset and hurt by the behaviour of the female colleague” and that “she was the only reason he was leaving the company.” The captain had expressed his desire to resign a day before the accident, the report says, although he had not submitted any written documents. He said that he wished to continue on the job for three more months to complete training the co-pilots.Sultan had joined US-Bangla in 2015. Prior to flying commercial flights, he had served in the Bangladesh Air Force, and according to reports, had a history of depression.

While in the Bangladesh Air Force, back in 1993, he had been removed from active duty after a psychiatric assessment. But he was re-evaluated by a psychiatrist back on January 9, 2002, and had been declared fit for flying.The report said that Sultan’s detail medical history was not reviewed by US-Bangla Airlines when he was hired.

Kamrul Islam, general manager and spokesperson for the US-Bangla Airlines, declined the Post’s request for comment.However, the report clarifies that Sultan did not exhibit any recurring mental issues during the medical examinations from 2002 to 2018.“None of the medical reports that the committee reviewed from 2012 to 2017 mentioned any symptoms about depression,” the report said, adding that during his routine medical evaluations, he was declared fit and free from any symptoms of depression.The Civil Aviation Authority of Bangladesh conducts an annual medical evaluation of all of the country’s pilots. The airline staff can also visit any medical consultants on their own for any health issues.

A senior aviation expert told the Post many pilots refuse to seek treatment for mental health issues because they fear the medical assessment will have a negative impact on their career.“Broken relationships, personality disorders, work stress, alcohol and drug problems all spell disaster,” the expert, who asked to stay anonymous because of his proximity to the investigation, said. “And they try to manage their depression themselves, without proper attention and treatment.”“Those who do not seek timely help might see a recurrence of manifestations brought upon by their depression,” said Dr Khagendra Bahadur Shrestha, chief medical assessor of the Civil Aviation Authority of Nepal. Shrestha said he could not comment further before reviewing the report.

Aviation officials are expected to make a summary of the report public at the end of August.Sultan’s medical records also indicated inconsistent and unreliable responses about his smoking habit. In his self-declaration form from 2012 to 2014, he wrote that he had never smoked. In 2015, Sultan said he used to smoke but had quit in 2010. Then in his most recent medical evaluations in 2016 and 2017, he mentioned that he had never smoked.

HOW THE CRASH UNFOLDEDThe US-Bangla Airlines Flight BS211 flight departed from Shahjalal International Airport, Dhaka, at 12:30pm. About an hour later, the flight crew began preparations to land at Tribhuvan International Airport. At 1:50pm, the plane started its descent and the controls were handed over to the Kathmandu’s airport air control room, which directed the flight to descend to 13,500ft, and cleared the aircraft to hold over a point named “Guras.”At 2pm, the airport control tower instructed the flight to reduce its speed and descend to 12,500ft. The control tower cleared BS211 to approach the 02 runway (from the Koteshwor side).When the crew did not follow the control tower's instructions, the approach controller at TIA asked the pilots why they were not holding over Guras. At this time, based on the cockpit voice recordings, Sultan responded: “Holding will not be required in this case."According to the report, Sultan then lit a cigarette, when the aircraft had just under three minutes to start their initial approach.

This, the report says, demonstrated complacency and gross negligence of procedural discipline on the pilot’s part.At this time, the aircraft had lost its use of the plane’s auto-flight guidance system control. And strong westerly winds, blowing at an average of 28 knots, pushed the aircraft to the east.The tower informed the crew that they were clear to land via the 02 side of the runway, but instead the aircraft seemed to be headed for 20 (on the Boudha side). The report said that at this stage, there was a complete loss of situational awareness on part of the flight crew.That is when another supervisor controller from the airport tower took over the microphone and cleared the flight to land via 20, assuming that it was the crew’s intention to land from the Boudha side.

The aircraft, however, was struggling to locate the runway and continued flying northeast. When the aircraft descended to around 175 ft above ground level, a ground proximity warning system alarm went off.The tower immediately asked the flight crew about their intention. Sultan radioed his intention to land via 02. Then the air traffic control, while also handling the landing of another aircraft--a Buddha Air aircraft that was approaching from 02, cleared BS211 to land at 02.

The information was relayed to BS211 to caution them that there was traffic ahead of them.The aircraft then started to gain altitude. At this point, according to the report, the captain admitted to his co-pilot that he had made a mistake. Local pilots, who had been monitoring the development on the radar at the airport premises, raised concerns with the tower that the US-Bangla pilots appeared to be disoriented and lost. The tower then issued a landing clearance to the flight for either 02 or 20.The CVR revealed that both pilots made several statements that reflected that they had completely lost their orientation of the runway, but the issue was not communicated to the ATC.A few seconds later, the co-pilot reported sighting the runway. The captain, however, still appeared confused. Despite the runway in sight, the co-pilot made no callouts to discontinue the manoeuvre. Alarmed, the control tower hastily cancelled the landing clearance by saying “takeoff clearance cancelled.”

The ground proximity warning alarm sounded continuously in the cockpit while the aircraft flew as low as 45 feet, right over the domestic terminal building. Nepali airline officials at the time had expressed horror watching the plane fly so close to the tower--and had praised the pilot for skillfully avoiding hitting the tower and at least half a dozen fueled planes parked at the international airport’s parking bay.Airport officials at the control tower had described the scene that afternoon, before the crash, as “something like a war film”--a complete suicidal attempt that nearly blew the tower.

The aircraft then finally touched down on the ground, with only its right landing gear hitting the runway, and skidded to crash through the airport’s periphery before coming to a halt onto a nearby field.The impact started a fire within six seconds because the aircraft had 2,800kg of fuel onboard.The investigation commission said that because the crash had a low impact, passengers had high chances of survival, but the rapidly spreading post-crash fire prevented passengers from escaping.The accident was one of the deadliest aviation disasters involving an international carrier in Nepal since the Thai Airways and Pakistan International Airlines tragedies in 1992.

On July 1992, a Thai Airways flight from Bangkok crashed into a mountain outside Kathmandu, killing all 99 passengers and 14 crew members. Less than two months later, an Airbus operated by the Pakistani carrier crashed into another mountain while approaching Kathmandu. All 167 people on board were killed.The investigation of the US-Bangla Flight 211 concluded that the ATC’s handling of the flight was not a significant contributing factor to the crash. However, the report stated that some air traffic management procedural lapses were noted on the part of the crew at the control tower.As part of its key safety recommendation, the investigation is expected to ask the Civil Aviation Authority of Bangladesh to renew the licenses of permanently-grounded pilots due to medical reasons, following thorough physical and psychological tests.

[ATC Watcher]

This is a journalistic version of a technical report. Not bad per se but missing some other essential points that (I hope) will be mentioned on the final report .
Were there any indication when the report will be made public ?

[Sqwak7700]

Must have had the transcript, or a source who had seen or heard it.

[Yo_You_Not_You_you]

This is a journalistic version of a technical report. Not bad per se but missing some other essential points that (I hope) will be mentioned on the final report .
Were there any indication when the report will be made public ?

It says here that it will be made at the end of august .

[ATC Watcher]

It says here that it will be made at the end of august .
Thanks .

squawk7700 : Must have had the transcript, or a source who had seen or heard it.
May have been just one of the drafts , not the final version.

[aterpster]

About an hour later, the flight crew began preparations to land at Tribhuvan International Airport. At 1:50pm, the plane started its descent and the controls were handed over to the Kathmandu’s airport air control room,

Case closed. It was VNKT's airport air control room's fault.

Reporters! :}

[Joe_K]

May have been just one of the drafts , not the final version.

Seems to be. The Guardian has it as "draft copy of the final investigation report, seen by AFP" and "A source at Nepal’s tourism ministry, which led the investigation into the crash, confirmed the authenticity of the draft."

https://www.theguardian.com/world/2018/aug/28/nepal-plane-crash-caused-by-emotionally-disturbed-captain

Key paragraphs in that article seems to be:

"Investigators said the captain, Abid Sultan, wept during the flight after his skills had been questioned by a co-worker. “This mistrust and stress led him to continuously smoke in the cockpit and also suffer an emotional breakdown several times during the flight,” their report said."

"The captain’s constant monologue led to the “total disorientation” of the co-pilot, who was flying the plane when it crashed. Prithula Rashid had only recently qualified and had never previously landed at Kathmandu airport."

"During the short flight, Sultan – a former Bangladesh air force pilot who was also an instructor for the airline – talked non-stop as he tried to impress upon the junior co-pilot his competence and proficiency."

[akaSylvia]

A very contained leak, it seems. I rather expected to see a copy of it scattered around the interwebz by now.

[fdr]

Await with morbid interest the report. Sobering HF event.

[akaSylvia]

Still nothing on the Govt of Nepal website (http://tourism.gov.np/publications/10):
:sad:

[VGCM66]

Let's be honest, at the very least they have a year to finish the Final Report.

Cheers,

[aterpster]

Still nothing on the Govt of Nepal website (http://tourism.gov.np/publications/10):
:sad:

It will be forthcoming. They did a great job on the Turkish 330 crash.

[superliner]

Pilot smoking in the cockpit (https://www.news18.com/news/india/pilots-smoking-inside-cockpit-led-to-us-bangla-airline-crash-in-nepal-that-killed-51-2016053.html)led to the crash!? How common is that?

[His dudeness]

Probably depends on what you smoke. From tobacco seems far fetched.

The report says:

3.2.1 The Probable Causes

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.

3.2.2 Contributing Factors
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.
Failure to ARM the VOR to intercept the desired radial (Aircraft never intercepted the radial, rather it crossed over from left to right of the desired approach path of the runway while remaining on HDG Mode with AP ON);
Failure to adhere to the standard operating procedure. Failure to perform proper briefing.
Not noticing the unsafe gear warning horn by the crew until approaching the MDA.
PIC did not make corrective action to EGPWS warnings on time.
Failure to carry out a standard missed approach procedure in spite of the runway not being
visual at the MDA.
Failure to meet the stabilization criteria of the aircraft on approach.
Increased workload on the PIC as he was manually flying the airplane and communicating
with the ATC;
Loss of situational awareness due to miss-alignment with the runway during initial
approach, and eventually not being able to sight the runway;
High bank angle, rapid descent, excessive threshold speed, inadequate inner rudder input
contributed for hard contact of the right main landing gear to the runway.
The speed, altitude and the radial was never monitored during approach.
Lack of assertiveness on the part of Air Traffic controller in monitoring the flight path of
the aircraft and not issuing a clear instruction to carry out a standard missed approach
procedure.
Lack of clear understanding and acknowledgment on the part of both ATC and the crew to
clearly understand each other's communication regarding the landing runway.
Lack on the part of the ATC to alert the crew of their actual position.
Even though the copilot was operating to Kathmandu (CAT C) for the first time, the
provision of a safety pilot which was not given a importance could have been of a great
help in the situation.
Lack of simulator training dedicated to the visual approach for runway 20 to the PIC.


Didin`t see smoking in there...

Under medical/human factors they say:

3.1.7 Medical/Human Factor
The PIC was declared unfit to fly in 1993 due to his medical condition (depression). He was later cleared medically only in 2002.
Medical examination of PIC in successive annual medical was not focused on his previous medical condition of Depression; which seemed mandatory. This may have been missed as this was not declared in self-declaration form in annual medicals.
There was no evidence that the pilot suffered any sudden illness or incapacitation which might have affected his/her ability to control the aircraft.
Toxicological analysis was Negative for Insecticides, Narcotic drugs, Ethyl alcohol, and Methyl alcohol and Phosphine gas. However the toxicology testing did not include prescription medications that are commonly used to treat depression (e.g., anti-depressants) or anxiety (e.g., benzodiazepines, anxiolytics.
There is clear evidence that PIC was harboring severe mental stress. The effect of stress was evident with the fact that he was irritable, tensed, moody, and aggressive at various times. This is probably the reason for his undue aggressive behavior and anger aimed at ATC personnel as well as operation staff.
The foul language and abusive words he was using in conversation with a junior female FO was very inappropriate and certainly not expected from a level headed person.
PIC also seemed to be fatigued and tired due to lack of sleep the previous night as well as due to the stress he was harboring.
PIC 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. The financial insecurity may have augmented his stress.
FO asked PIC about Missed Approach Procedure of Kathmandu but PIC never briefed her, rather got engaged in unnecessary and personal talks. Failure to react after missing the runway for the first time, not doing standard go around procedures after missing the Missed Approach Point (MAP) and impaired decision making; all were probably due to stress.
The PIC seemed to have loss of situational awareness. He did not realize that they had crossed VOR and was under impression that they are still behind it.
Even in the last moments of flight, PIC had fixation to land at any cost and he never considered for go around procedure even after realizing that flight was not configured to land. One of the reasons could be him trying to prove FO that he is a very competent pilot and would be able to safely land the aircraft in any adverse situation.
A post-mortem examination of the pilot showed that MULTIPLE BLUNT TRAUMA TO HEAD AND CHEST in presence of Carbon Monoxide poisoning as likely cause of death. While post-mortem examination of the FO showed BLUNT FORCE INJURY HEAD as likely cause of death.

[superliner]

Probably depends on what you smoke. From tobacco seems far fetched.


Didin`t see smoking in there...



It's mentioned on page 22 of the report under section 2.2.1:
....
At times the Captain even seemed to have emotional breakdown as revealed in the CVR. This stress might have led him to smoke in the cockpit during the flight and this clearly is against the Company Standard Operating procedure. This state of mind with high degree of stress and emotional state might have led him to all the procedural lapses.
....

[krohmie]

. Nr. 12 "MULTIPLE BLUNT TRAUMA TO HEAD AND CHEST in presence of Carbon Monoxide poisoning"

[A0283]

http://tourism.gov.np//files/publication_files/284.pdf
The final report of 53 pages.

[ATC Watcher]

an Horrendous reading !
Likely to revive the "depression" debate we had after Germanwings ,as the one on putting MPLs after 150h on the right seat with a senior Cpt not performing .
But she was stressed and probably scared a swell when one read this : " the PIC again requested for the landing checklist for the third time where the FO again confirmed that it had already been completed regardless of the landing gear unsafe tone still stridently audible.
The whole operation seemed to be in disarray :

The proper preflight briefing by the dispatch including the recently introduced Bangladesh ADC number was not carried out
The first APP : All the critical items such as minimum sector altitudes, final approach inbound course, type of approach (CDFA), surrounding terrain with highest obstacle sectors, descent rate requirements, aircraft configuration schedule, speed control, stabilization criteria, missed approach point and procedure, minimum descent altitude and runway lighting etc. were never reviewed.

The PIC kept on assuming that the landing runway was still ahead of them, though the aircraft had already flown through the eastern part of the entire RWY at a position beyond the north east of RWY 20 threshold, approximately 3-4 NM northeast of KTM VOR. Autopilot was disengaged at 1.1 nm east of the VOR.
one oddity ( already mentioned) : PIC post mortem : Carbon Monoxide poisoning as likely cause of death. meaning he was alive after impact and died due to exposition to fumes ?

[Maninthebar]

On page 24 of the report describing the Approach segment "The PIC further demonstrated complacency and his gross negligence to procedural discipline by lighting up another cigarette"

[His dudeness]

It's mentioned on page 22 of the report under section 2.2.1:

Yeah sure, but NOT as a cause in any way, shape or form.

[superliner]

Yeah sure, but NOT as a cause in any way, shape or form.
Yes, agreed. My bad for posting only after glancing through the news article and not reading the report.

[pattern_is_full]

I would note that the lighting of the cigarette occured in the period when the PIC should have been deleting the HOLD previously entered in the FMC, since he had by then been cleared for the approach.

And accidentally entering the hold and turning away from the inbound course initiated the "circus" that just got worse and worse thereafter.

But it was a brief minor distraction during the 3 minutes or more the crew failed to correct that error - so yes, a symptom of complacency and loss of SA and focus even then, rather than a cause.

[ATC Watcher]

Well as a heavy smoker in the 70's, I remember that lighting a cigarette was often a way to try to relieve stress and accompanied stressful moments. Not a signal of relaxation as Hollywood movies wanted to portrait . Anyway there is far more stuff that went wrong on that flight that focusing on smoking " because it is prohibited" is frankly a bit ridiculous, but get people talking.. proof here :hmm:

[Passenger 389]

The reference to 'in presence of carbon monoxide poisoning' seems far more likely to be a result of the post-crash fire, not whether he smoked a few cigs during the flight.

See: 1.15 Survival aspects
The impact forces of the accident were survivable to most of the occupants seated to the right.
The passengers seated to the left most likely succumbed to death due to impact forces.
The immediate and rapidly spreading post-crash fire likely precluded the possibility of escape for remaining passengers who might have survived the impact.

[His dudeness]

Anyway there is far more stuff that went wrong on that flight that focusing on smoking " because it is prohibited" is frankly a bit ridiculous, but get people talking.. proof here :hmm:

Thats what I wanted to say.... this guy worked himself up about a comment about is abilities and then screwed up royally. A bitter irony in this one.

[aterpster]

http://tourism.gov.np//files/publication_files/284.pdf
The final report of 53 pages.

Interesting that the appendices are not included.

[India Four Two]

aterpster,

I was going to make the same observation. Looking at other Nepalese CAA reports, it seems that is their SOP.

[portmanteau]

Well we are not going to see the CVR chat on here and there's no reason to disbelieve what the investigators say about it so sadly this Captain was found wanting on this one day on far too many levels. The number of cockpit errors is almost unbelievable. Nepal included the shortcomings of their own ATC as well which is commendable. Though undoubtedly a shocking tragedy I think it can be said to be almost a unique event as regards a pilot's behaviour and is unlikely to ever be repeated.

[VGCM66]

Well we are not going to see the CVR chat on here and there's no reason to disbelieve what the investigators say about it so sadly this Captain was found wanting on this one day on far too many levels. The number of cockpit errors is almost unbelievable. Nepal included the shortcomings of their own ATC as well which is commendable. Though undoubtedly a shocking tragedy I think it can be said to be almost a unique event as regards a pilot's behaviour and is unlikely to ever be repeated.

Sorry but don't bet on it unfortunately.

Cheers,

[His dudeness]

Nepal included the shortcomings of their own ATC as well which is commendable.

I´d say that is an accident report should be: open and honest in all directions.

[aterpster]

I´d say that is an accident report should be: open and honest in all directions.
That would mean including the five appendices that were omitted.

[excrab]

I made a comment RE - this disaster- my comment was removed by the administrator. I think this will have the same fate.
This crash was Murder by the industry - how on earth can a child fly a Q400 with 390 flight time. Nothing to do with a smoking crying captain - Get your heads out of the sand.

Respect to those who lost family.

In 22 years in the LHS of various multi crew aircraft, including Q400 and larger and faster machines I have flown with numerous F/Os with 300 hours or less, and whilst they may have still had things to learn about operating the aircraft, as indeed I did and still do, I never had any doubt that they would use the words “go-around” and “I have control” as required.

At the risk of being taken as non pc, there are possibly some cultures where a more inherent respect for ones elders or superiors might mean that isn’t a good thing, but I’m pretty sure that’s not the case in Australia, any more than it is in Europe.

Whst that, plus a lack of proper CRM training (ASIT etc) may have had a bearing on this accident, it’s very unfair to suggest that is the case at every airline in the world which employs low houred first officers who haven’t spent years flying a C206 single crew around the Boondocks.

[BlueMax56]

US Bangla plane crash cctv footage at Kathmandu AirportVarious video angles of the crash just recently posted on youtube and is shocking to watch the plane fly over the terminal and apron area.
(don't have enough posts to place the URL here yet)

[Imagegear]

Bad situation:

Katmandu Bangla

IG

[Livesinafield]

That's incredible footage, especially the one over the terminal... video really shows what a mess these two made of the approach, can't quite work out how this happens, just trying to imagine what kinda of pilot can try and salvage this approach.

Truly Bizarre