Probe blames 'serious judgment error' for Jomsom crash
KATHMANDU, SEP 10 -
A loss of situational awareness that caused a 'serious judgmental error' by pilots and a failure to react effectively to technical problems led to the crash of the Agni Air-owned Dornier-228 aircraft in Jomsom in May, a panel formed by the government to investigate the crash said on Sunday.
A chartered Pokhara-to-Jomsom flight struck a small rock on the hill at 2,827 metres, 0.2 nautical miles north-west of Jomsom Airport, on May 14, killing 15 people, including two crew members, on board. Six persons survived the crash.
Two other causes--inadequate flying hours of the pilot-in-command (PIC) with the Dornier type aircraft and flying under stress and being de-motivated with job--has also been attributed to the crash.
Pilot-in-command Prabhu Sharan Pathak and co-pilot Suman Dongol Maharjan and 13 Indians died in the crash. Among the six survivors were two Danes, three Indians and air hostess Roshani Haiju.
A report released by the panel outlined how the pilots failed to respond effectively to problems when the plane reported the 'light indication problem'. The PIC and the assisting pilot were busy in the cockpit after the problem surfaced, and suddenly things started to go wrong when both of them engaged to fix it, making them unaware of the situation outside, the report said. The aircraft took its course itself for a while.
At normal weather conditions, the aircraft took off from Pokhara at 9:30 am and was told to land at the 06 runway at Jomsom Airport. The same moment, the pilot requested to use runway-24 instead of 06. However, the aircraft continued its descent from runway-06. After arriving at the 06 threshold, the PIC reported the problem and decided to divert the plane back to Pokhara.
The PIC's last contact with Jomsom Airport was recorded at 9:45 am and the crash took immediately after a minute.
According to the report, the crew encountered the problem after the landing gear lever was selected down. “After the cockpit crew failed to sort out the problem, the PIC decided to divert to Pokhara,” the report said. Then, the pilots responded to the situation by executing a sharp left U-turn at a very low speed and altitude.
The speed and altitude of the aircraft was at its lowest (73 Knots = 84.01 miles/hour) and 9,172 ft that went into a sustained stall, signaled by a warning message, the report said. Subsequently, the left wing of the aircraft stuck a small rock on the hill, disintegrating the aircraft.
The stall warning was continuously 'on' during the last phase of the flight, up to the last 12 seconds prior to the impact. “The subjected sharp turn and climb was not enough to avoid the cluster of muddy hills on the northern side of Jomsom Airport,” the report said. The co-pilot had meekly raised his concern regarding the insufficient radius.
“The total flying hours of the PIC was 5,776.07 hours, but considering the Dornier aircraft, it was very low at 596.48 hours,” said Sunil Pradhan, a member of the panel entrusted to investigate the operational aspects.
In the last six months before the crash, the PIC had flown the Dornier for only 19 hours. The PIC was also a senior instructor pilot employed with the Civil Aviation Authority of Nepal (CAAN).
However, on the other hand, the PIC's assistant pilot had flown the Dornier for 316 hours in the last six months, which is considered a relatively good experience. On the medical aspect, the report said the PIC was flying under stress and was de-motivated with his job. The PIC was on his third flight for the day.
The investigators have made 14 safety recommendations that include single fleet policy to be strictly adhered to at the earliest. They also said CAAN pilots should maintain sufficient flying hours on the type of aircrafts, especially on the STOL fields.
The panel further recommended an independent unit as a permanent body to carry out air accident investigations effectively and efficiently.
Posted on: 2012-09-10 02:00