'Plane crash' at Nepal's Kathmandu airport

[aterpster]

Originally Posted by akaSylvia

Still nothing on the Govt of Nepal website:

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

[superliner]

Pilot smoking in the cockpit 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

1. 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.
2. 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.
3. A very steep gradient between the crew.
4. Flight crew not having practiced visual approach for runway 20 in the simulator.
5. A poor CRM between the crew.
6. 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);
7. Failure to adhere to the standard operating procedure. Failure to perform proper briefing.
8. Not noticing the unsafe gear warning horn by the crew until approaching the MDA.
9. PIC did not make corrective action to EGPWS warnings on time.
10. Failure to carry out a standard missed approach procedure in spite of the runway not being
    visual at the MDA.
11. Failure to meet the stabilization criteria of the aircraft on approach.
12. Increased workload on the PIC as he was manually flying the airplane and communicating
    with the ATC;
13. Loss of situational awareness due to miss-alignment with the runway during initial
    approach, and eventually not being able to sight the runway;
14. 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.
15. The speed, altitude and the radial was never monitored during approach.
16. 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.
17. 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.
18. Lack on the part of the ATC to alert the crew of their actual position.
19. 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.
20. 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

1. The PIC was declared unfit to fly in 1993 due to his medical condition (depression). He was later cleared medically only in 2002.
2. 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.
3. There was no evidence that the pilot suffered any sudden illness or incapacitation which might have affected his/her ability to control the aircraft.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.
10. 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.
11. 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.
12. 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]

Originally Posted by His dudeness

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]

Smoking...

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]

Originally Posted by superliner

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]

Originally Posted by His dudeness

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

[Passenger 389]

'carbon monoxide poisoning' almost certainly was from post-crash fire

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]

Originally Posted by ATC Watcher

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

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]

Originally Posted by A0283

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]

Originally Posted by 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.

Sorry but don't bet on it unfortunately.

Cheers,

[His dudeness]

Originally Posted by portmanteau

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

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

[aterpster]

Originally Posted by His dudeness

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

That would mean including the five appendices that were omitted.