Not rushing to judgement is quite commendable but do you not feel there is a level of confusion which should simply never occur when flying a fully functional and instrumented aircraft during daylight hours with relatively clear sight of the ground and moderate haze?

Adopting a track to enter a traffic pattern for runway 20 when cleared to land 02 may be accepted as confusion.

Entering the left downwind when ATC clears you for the right (then right, then right, then left, then right) downwind is easily accepted as confusion, especially when ATC seem to be clearing you for whatever they guess you're planning to do next anyway.

Then they receive and understand 'cleared to hold?' They readback 'right orbit' then proceed to steadily lose height in the orbit until - I'd guess - an EGPWS warning shakes them out of their fugue state. They abort the orbit into an approximate (climbing, of course!) left base leg, overshoot the runway they apparently can't see (probably due to being too high), 180 left turn into... well, it's high key, isn't it? Followed by the usual which turns out not to work so well in an ATR.

I see a lot of confusion in the initial stages, but in the later stages I see a certain 'I know exactly what to do, now I just have to get the airplane to do it' certainty of purpose that's something quite different entirely and much more dangerous. Confused people aren't dangerous if they know they're confused. They hold, they put the autopilot on, they pause. The danger starts when people suddenly snap out of their confusion, believe they're in a familiar and tolerable situation and begin a tactical approach from high key. In an ATR. Wouldn't you say?

Except it was in a Dash not an ATR

As requested METAR

VNKT 120850Z 26007KT 140V300 7000 FEW015 FEW025CB SCT030 BKN100 21/10 Q1015 NOSIG CB TO SE AND S=
VNKT 120820Z 28008KT 240V320 6000 TS FEW015 FEW025CB SCT030 22/11 Q1015 NOSIG CB TO SE S AND SW=

in hindsight a go-around instruction from the tower would not have been a bad thing.

but they probably assumed the plane had some kind of problem and didn't want to add to it.

Thank you. So there would appear to be no weather problems over the airfield. Reasonable visibility with circuit level dotted cloud and light winds. So why did the straight in not work? The root cause lies well before the chaos of 'buzzing the tower & apron' in a seemingly 'where am I and what am I supposed to do' quandary.

Apart from the specifics of this particular accident, how many countries are there in the world that allow scheduled VFR flights in transport category/heavy turboprops?

Captain had landed 100+ times at this airport.
All very strange.
Seeing the final track and the tightening left turn I actually wondered if something was amiss w the left engine right at the end.

Hypoxia
 

I still lean towards some sort of hypoxia incident here, and I wouldn't normally jump straight to that conclusion as there should have been plenty of warning signs.

However if you are hypoxic, might not recognize them. Although the masks would have dropped based on cabin altitude if that was the case.

Even though I just speculated I'm not a big fan of speculation in aviation so FDR/CVR should help here.

We can all speculate until the cows come home. There comes a time when speculation needs to give way to some patience for the facts to emerge.

FYI most Q4s don’t have drop down masks in the cabin it’s an optional extra for max ceiling of FL270

Also we cannot talk about track that drawing/sketch is purely made from eye witness accounts would say it has very very little accuracy.

Does KTM have radar? If not any military stations? be nice to see a radar track

Possible "fuming incident"? Loss of situational awareness....

Just my two cents

You know, I've started flying to VNKT in a heavy pretty recently. I do it regularly now. It's a Capt's landing and take off as per my company SOP's. After my first two approaches there, where I found myself 'busy' mentally, with FO's from a culture that have a hard time speaking up to and correcting the Capt. (no- I'm not an a....in the cockpit) I decided to let the FO fly the approach the last few times. My reasoning; I want to be 100% concentrated on exactly where we are and what comes next. And not be busy pushing buttons. I've found myself much more at peace and ahead of the game, going into VNKT, monitoring and guiding the approach, in min. weather at Kathmandu. Breaking the SOP's? Yes I am.:ouch:

Looking at the path it seems to me a reasonable explanation is a series of attempts to circle to land on 20... none of them are good and seem to have been affected by too tight/maybe fear of terrain,

As it goes on the excursions get bigger and the turns tighter

probably finally total loss of awareness (but still fear of nearby terrain) and overcooks the turn and stalls in

I agree with that. But it doesn't seem that there's an obvious problem (i.e. declaration of emergency) that warrants flying something without requesting it first, or at least a short while after starting to doing it (that last bit as a sort of a benefit of doubt in case of a hectic cockpit for whatever reason). ATC is the first to notice they're deviating from their clearance. IMO they failed to do any of those three "golden rules" in a proper manner. They shouldn't crash if they've done them properly, but FWIW, initially at least, I think they attempted to aviate but failed to navigate and communicate (efficiently anyway).

@eternal: I don't get it mate. Why would they suffer from hypoxia (at 5-6k ft anyway!) and, based on what has been said here, after a considerable amount of flight time (around 1hr). Plenty of things should have happened before if that was the case.

My first questions would be:
- What happened with the first approach? Everyone else seems to have managed it. There isn't an obvious sign of why they botched/missed it
- What happened in the cockpit after missing that first approach, regarding decision-making, PF/PM duties?

Everything else after that I think is just the consequence/poor execution of these decisions/actions

Having read the transcripts and also the comments relating to slurred speech, confusion, and erratic communication combined with the miss handling of the aircraft it struck me the pilot flying may well have suffered a medical problem, specifically the possibility of a TIA (transient ischemic attack) prior to and during the approach.

Sometimes Occam's razor can cut.

In all the cases where people have suggested incapacitation, fumes, hypoxia etc in order to explain otherwise inexplicable flying, I don't think a single one has been found to involve such an event after the formal investigation.

The simpler explanation is that the human brain is fallible, gets overloaded, loses SA and never regains it. Remember that these are rare 1 in 10 million events, most pilots will never experience such a degree of mental "lockup" through their whole career.

Really good post and points

I think you are right - I've "locked up" once and seen it happen to others (all in non-flying/driving situations thank God)

Its very weird and normally caused by the brain just getting so much conflicting information WHEN KNOW YOU NEED TO REACT FAST -you just shut down,... might be 10 seconds, might be 15 minutes........... You remeber what was happening - you just can't make any decisions

Kindred spirit - good decision.. Never understood the bull**** of Captains Only airfields. Captain can make the decision about who is flying but if they can't make that decision in the best interests of the flight they shouldnt be captain!

"bull****" well the regulatory body of the airline most certainly won't see it that way....

Nor will the insurance company.

If a company mandates that one or other pilot needs to handle on the basis that somehow that improves the liklihood of a successful landing then they are completely negligent in allowing a multi crew aircraft to operate there. It should be absolutely clear that either pilot should be capable of making an approach and landing the aircraft at any airfield that the company operate into. If it is the case that one or other pilot is not capable of handling an approach and landing into an airfield, what are they doing sitting in the pilots seat! If you can't make the approach and landing yourself, how can you competently be pilot monitoring?

The choice of who handles and who monitors is a crew and ultimately captains decision. If the best crew member to handle is the FO because it gives the best SA to the Captain then the company are deliberately reducing safety margins by taking away that option.

Glen, im sorry but you are talking complete rubbish.First of all it is the operators right to decide this issue in the interests of safety.Quite often the demanding nature of any particular operation (take off or landing) requires a high level of experience to ensure a safe level of handling.This is not the Captains choice but the operators im afraid.In general it is the PIC who has this required level of expertise, not the effoh.

What is very often overlooked is that the pilot monitoring (copilot when the PIC MUST be the PF) has a very very important and demanding role.....of monitoring what the PF is doing.Many Captains are good handling pilots but, poor at PM.Leave this function to the F/O.Often they are much better at this role.

This is possibly getting off the original subject, but in my maybe limited experience of Cat C airports it isn't about one pilot being better than the other, it is often down to training costs.

To take the example of VNKT which is what the thread is about, the simulator training takes about 5 hours, most of which is devoted to the circling approach and the single engine go around from various points in the valley.

The captain is designated as PF and does the flying, most of which is hand flown.
Halfway through the detail it is normal to switch F/Os, as they are not PF, so they spend half the detail as PM and half observing in the back of the sim.

If F/O s were also checked out as PF it would double the cost of training in the sim, and also need more line trainer's time for the initial airfield visits.

Strangely enough, in all of the times I have flown into VNKT none of the F/Os, ranging from 300 hour cadets to 10000 hr ex turboprop captains, have expressed any regret at not being allowed to fly a steep NPA, with a tailwind, at night, to an upsloping runway in a black hole surrounded by 15000 ft mountains. There are plenty of other difficult places on the network that they can fly to if they feel a need to prove themselves.

The RNP AR Rwy 02 tames the approach substantially.

As SLF, I think I'd be happier if the flight diverted from a captains only airport if either pilot was incapacitated.

Totally agree with the first part, however I disagree with the second part:
I remember transitioning as PIC to a different type and on my first trip after OE/linetraining, had a late evening arrival with gusty winds into San Sebastian (LESO), special training required but both PIC and FO can land. The FO was new (less than a year). I decided to be PM, because I knew I would definitely call the GA if I wasn't comfortable with the approach, but I was not sure if a inexperienced FO would call the GA on an "experienced" PIC (I was experienced, just not on type/destination). My brother is merchant marine, the captain never holds the control but always monitors.

ps: Also have to take big issue with "Many Captains are good handling pilots but, poor at PM. Leave this function to the F/O.Often they are much better at this role". After 20 years I have much more experience than most of the FOs I fly with. I can let them fly the plane, and know that if needed I can suggest/direct/take over if needed. I fly with a lot of new FOs, so I am definitely better at handling, but that does not make them better at monitoring. If you want to be a good captain you let your FO be the PF as much as possible, he will learn much more from doing than watching, if you can't be a good PM as PIC you are doing something wrong.

Hello Hans

I am confused. Are you arguing for or against the company deciding who handles into an airport? Your decision is exactly the right one in my opinion and the same as the decision I made operating into LESO. Lovely place, got filmed departing (youtube 9H-COL). I think you have identified one reason why it is important that the crew decide who is PF and who is PM... Your ability to assess the approach and decide if it should be discontinued is based on your ability to fly it. Your cockpit and aeroplane is safer as a result
https://www.pprune.org/images/smilies/thumbs.gif

the point is folks, if your company has nominated an airport as "Captains only", then the legal ability of the Captain to make the decision has been removed, conducting the operation in any fashion contrary to the operational policy, except in an emergency, would fall into the "wilful violation" category, and is technically against the law laid down by the operator's regulatory authority...simple really

I agree completely with hans brinker and tommoutrie. Also with Ironbutt57 though. Ironbutt; actually my Policy manual says "Capt's landing'...so in order to satisfy the legal heads, I might just to the Big Airways thing next time, and take over when runway is in sight :-) I still find it much better for MY decision making and SA, to let the FO fly the APPROACH into VNKT though...

I think to some extent people are comparing oranges to clementines here, Hans Brinker and Tommoutrie are talking about a Category B airfield on the coast of Spain. We also fly into plenty of Cat B airfields, and for them either pilot can land there, the decision about who does so being made by the crew (ultimately the PIC) on the day after reviewing the weather conditions.

Cat C is a bit more involved, and the rules are generally not even a decision by the operator alone, but involve the company's flight ops inspector as the representative of whichever national regulatory body grants the company AOC.

For Sptraveller, if you are referring to my post, then no, that isn't what was said. What was said was that the F/O was given five hours of training at VNKT (split equally into observer and PM), so they know exactly what the PF is doing. They also have an airfield visit with a line training captain flying the
aircraft, and before they do any of that they need to have 500 hours on type.
So there is no reason to think that they can't effectively monitor what the PF is doing. I would never have any worries about whether any of our F/O's would tell me to go around if I was making a dog's breakfast of it, I know that they are all perfectly capable and prepared to do that for any approach, anywhere.

Also, looking at it from the passenger's perspective, if you were going into VNKT at night, in turbulence, with visibility and cloud base at minimas, in the pouring rain, with your family sitting next to you, who would you rather have flying the aircraft, the five, six, seven (or seventeen) thousand hour captain, or the seven hundred hour F/O because the Captain wanted to be pilot monitoring.

Finally, just saw MD drivers post. Our ops manual is quite specific, "Captain's only approach, landing and take-off". So no monitored approaches and taking over at MDA in VNKT for us.

I should also point out that this is an enormous amount of thread drift...the training the airline I fly for gives is not necessarily the same as that given by
the airline involved in this crash, as we do not know what is in their ops manual and agreed with their regulator.

As a SLF but with ex RAF Dad, I always thought that PF v PM effectiveness had much to do w the relationship between left and right, which can have all kinds of angles including seniority, culture, gender. We may have all three happening here, contributing to a Jr FO maybe being less willing to correct a senior Captain or call for a GA.

Bit of a thread creep but still interesting. All those who determine "Captains only" means exactly that are correct. Develop the thread and suggest that FO could/should fly the approach but still let Capt land are technically correct but not in the spirit of the ruling.


Long time ago, Funchal in Madeira was Capt Only and Cat C. The visual, curved approach was such that on finally levelling wings on completion of the "approach" there was very little time to decide whether a landing could be met, let alone a last minute switch of handling. Better let Capt do the whole thing. That is, actually, the spirit of the regulation.


Now, we don't want to go to far into the old BEA monitored app. For Cat 3, "blind in the fog" landings, RHS did the approach but with typical DH of 50ft, Capt response to "Decide" was "Land" but with the latter calling the shots and George now continuing to land. Oh yeah, confused ? Watch those guys in cavok at LHR and it was a larf a minute. RHS always did the app. Capt Always did the landing. DH call would be around 200ft but success was pretty well anticipated many miles out. Yet, we still did the "soft shoe shuffle" at 200ft with some interesting minor divergences leading to a thump in the guts as we "arrived".


Creeping back to thread ; I too been into & out of Kat many times. Wouldn't dream of a monitored approach. I too hated dipping my nose into the valley, higher rate of Descent, often tail wind, upsloping runway, on limits and getting it all right for the touch was better handled by someone handling all the way. GA needed to be well rehearsed and briefed as, I recall, it was a turn in one direction if all donks were running and, in a twin, a opposite direction turn if you happen to be on one. I got a very funny look from my initial Trainer when I asked what do we do if a donk fails during a two-engine GA.


Capt Only airfiields are just that & as Ironbutts correctly exhorts, It is a Regulatory requirement, adopted in the SOPs. Stick your head above ground, like one Poster, who claims he regularly breaks the Company SOPs and you are headed towards a Court appearance.

That scenario alone would make me question why any airline would want to risk VNKT unless they can fly the RNP AR RWY 02 approach. Nepal understands this issue; that’s why they spent the resources to get RNP AR capability for the airport early on.

RNP AR 3-D 2.80 degree path to a DA of 4,621’ (300’ Height Above Touchtown).

VOR Rwy 02 5.31 degree path to an MDA of 4,950’ (629’ Height Above Touchdown) with a demanding 6 DME stepdown fixes from the FAF to the VOR, and with the following cautionary note:

the RNP AR has been fairly recent, and it takes you a bit west of the VOR final approach course through a valley where quite often a thunderstorm is happily doing it's thing, our airline had a CDA style procedure for the VOR flown in either FPA on the Airbus, or VS on the Boeing, scalloping was experienced but very slight, the visual sector of the approach was on a standard PAPI, never felt it was particularly demanding or otherwise...

The VOR radial goes directly over a 7,680' terrain point. The RNP AR track is 2.5 miles west of that point. Not much of a difference when TRWs are popping.

I have no doubt experienced pilots that are very familiar with the airport handle the VOR approach quite well. Nonetheless, it is archaic compared to the RNP AR approach. And, 1,100 meters vs. 2,800 meters visibility for CAT C is also significant, especially when the rain is coming down in a habitually polluted valley.

If the company makes it a captain only airport, only the captain can be PF, no discussion. However the company I flew for believed in equal qualifications for FO and PIC, so both would be able to be PF. This applied to all category C airports we flew into (and we flew into a lot of dodgy places including unpaved strips in central Africa for UN evacuation flights, and Afghanistan/Kazachstan aso).

At one time I worked for a carrier whose base was 8000 feet amsl.After quite a few take off and landing tailstrikes on the big jets, only Captains were allowed to conduct landings.There were still landing tailstrikes going on however the frequency reduced by 75%.As I was/am a quite experienced instructor, I let some copilots do the landing, once I had observed them and determined that they were competent.I immediately understood why the Managers put this policy in place.Several times, I had to take control during the flare or earlier as the required touchdown accuracy was not going to be met plus the pitch atttitude was creeping up too close to the tailstrike range.I stopped this "act of kindness" and just did all the landings myself.These types of operations are best conducted not only by the most experienced pilot (usually the PIC), but also by the pilot with the most exposure to doing it.

Totally in agreement. But it should not be mandated by the company as it is not always the case. It should be decided by the crew. You, as captain, are not necessarily a better handling pilot. You are a more experienced pilot and you make the decision about who flies the leg. If your decision is that its best if you handle, handle. We are all different - some captains will be very happy to monitor an FO landing at a more challenging airport, some won't. That ability to assess our own attributes and those of our crew is part of what makes us good commanders.
Consider this. How many of the FOs you flew with actually had a tailstrike while you were flying? How much did they benefit from flying with you and understanding how it had got out of shape when you took over and explained it to them afterwards. Talk to them now - some of what you let them "discover learn" will have prevented them making the same mistake now they are in the left seat. That learning goes away when companies dictate that you only become a competent handling pilot when you are also capable of command.

GlenQuagmire,

With all due respect there is a huge difference in what can be done in a corporate operation with a small pilot force who all know each other (been there and done that), and an airline. Even if an airline Captain wants to break the rules and ignore company SOPs, how is she or he supposed to decide if the first officer they are flying with, one of several hundred in the same base, who the captain has never flown with before, is the better or worse handling pilot in order to decide who should do the landing at the Cat C airport they are inbound to?

The only sensible answer to that question is that they can't, so therefore SOPs
are put in place based on the fact that Captain is capable of landing there, and it doesn't matter if the F/O is or not.

In the airlines I've worked for I have never considered being qualified for Cat C airfields to be an indicator of my skills, instead it is a pain in the a*rse as you end up (in Europe) working every weekend doing ski charters to horrible places or being a target for crewing for more standby call outs because you are the only one available who can go there.

Getting a bit closer to the original topic, the VOR approach to VNKT if flown in LNAV / VNAV really isn't that difficult, and weather wise one day the CBs might be in the way of that approach and the next day where the RNP approach takes you....however flying the VOR approach in VORLOC and VS with a tailwind might be a bit harder....my guess is they got high on the approach and tried to cobble together some sort of visual approach without briefing it or planning it, rather than fly the missed approach, divert and end up at the alternate, possibly out of duty hours to get home. Just a guess , as is most of what has been posted on this thread about the original topic.

Back to the original discussion and reference the earlier speculation that the controller who said " confirm you are VFR" could have meant VMC.
I got confirmation that the tower controller did meant VFR and not VMC . When spotted the position of the aircraft was roughly 1000ft AGL East of the runway which corresponded roughly of the downwind position for the VFR East pattern for 20. Hence the question. The controllers had visual with the aircraft.