US-Bangla DH8D at Kathmandu on Mar 12th 2018, landed across the runway and fell down slope
Last Update: January 28, 2019 / 15:18:02 GMT/Zulu time
Incident Facts
Date of incident
Mar 12, 2018
Classification
Accident
Airline
US-Bangla Airlines
Flight number
BS-211
Departure
Dhaka, Bangladesh
Destination
Kathmandu, Nepal
Aircraft Registration
S2-AGU
Aircraft Type
De Havilland Dash 8 (400)
ICAO Type Designator
DH8D
Rescue services took 39 occupants to hospitals, however, eight of them were pronounced dead upon arrival at the hospital. 31 bodies were recovered from the wreckage.
The Ministry of Tourism reported 39 people died in the accident, 31 were rescued alive.
Later in the evening Nepali Police reported that 22 people are in hospital care, 31 bodies were recovered from the wreckage, 18 people were pronounced dead at the hospitals, 49 people died in the accident.
Ground observers reported the aircraft turned suddenly left, overflew two aircraft, came very close to the control tower and went out of sight. A large plume of smoke began to rise seconds later.
The airport reported the aircraft veered right off the runway and slid for about 300 meters until coming to a rest on a soccer field and burst into flames. The airport later added: "The plane flew past just above the air-traffic control tower during its descent for landing. It touched down the ground just next to a parked plane, a Thai Airways, and ploughed through a fence on the east side of the airport, and plunged into the lower ground."
The airline complained tower "gave the wrong signal" to the aircraft and thus caused the accident. On Mar 14th 2018 the airline added, that the captain of the flight, an experienced ex-military captain, had received training for Kathmandu and had flown into Kathmandu at least a hundred times.
Nepal's government have appointed an accident investigation commission to investigate the accident.
A Thai Airways Boeing 777-200 registration HS-TJR was parked at Bay 2 of Kathmandu Airport. The aircraft had arrived as flight TG-319 about one hour prior to the accident and was able to depart Kathmandu about 3 hours after the accident.
The aerodrome is elevated by about 10 meters above the surrounding terrain including the soccer field.
After contacting Kathmandu Approach the aircraft was cleared to descend to 13,500 feet and proceed to GURAS Hold via the ROMEO standard arrival. The Aviation Herald was unable to hear the actual approach clearance to BS-211, however, all other approaches were cleared for the VOR approach runway 02, BS-211 was later instructed to "continue approach" before being handed off to tower.
On Mar 14th 2018 Nepal's CAA reported that the black boxes have been recovered, an accident investigation commission consisting of six people has been formed. Bangladesh as well as the aircraft manufacturer are participating in the investigation led by Nepal's CAA.
On Mar 14th 2018 a ground observer located just west of the international terminal reported he observed the aircraft on a southeasterly heading near the southern edge of the international terminal heading for taxiway D (connecting runway and parallel taxiway just south of the international apron, perpendicular to the runway). Seconds later the plume of smoke began to arise.
On Mar 14th 2018 other ground observers (supported by a video having surfaced on Mar 14th 2018) reported the aircraft had been in an orbit north of the aerodrome near Kapan about 2nm northnorthwest of the aerodrome (as if holding in a right hand traffic pattern to runway 20 where the turn to base would occur). It subsequently appeared to turn towards the south of the aerodrome possibly for a left hand visual traffic pattern to runway 02.
According to extended ATC recordings another aircraft, Buddha Flight 282, was trailing the Dash 8 on approach to runway 02 and was advised of the Dash 8 ahead by approach control before being handed off to tower. After the Dash turned left to join a right hand traffic pattern for runway 20 at 08:29Z - against clearance to land on runway 02 - a conflict arose between the Dash 8 and the Buddha flight. Tower told the Dash 8 about the Buddha on short final to runway 02 two miles out and instructed the Dash to enter a right hand orbit stressing to not land on runway 20. The Buddha aircraft landed on runway 02, tower advised the Dash that the runway was clear again and cleared the Dash to land on runway 20, however, when asked about having runway 20 in sight the crew denied which led tower to clear the aircraft to land on runway 02. The crew reported to have runway 02 in sight and queried whether they were cleared to land, which tower affirmed. Soon after tower informed other aircraft about an aircraft accident and sent all arrivals into holds.
On Apr 10th 2018 Nepal's AAIC released their preliminary report reporting the aircraft touched down about 1700 meters down runway 20, travelled on the ground towards the southeast, went off the runway, broke through the inner perimeter fence, moved down along a rough downslope and stopped after a ground travel of 442 meters at the eastern side of the runway (editorial note: the coordinates of touch down point and final position do not match the narrative). The aircraft caught fire and was destroyed. All 4 crew and 47 passengers perished, 20 passengers survived with serious injuries. Initially 22 passengers were rescued alive from the crash site, two later succumbed to their injuries. The cockpit voice and flight data recorders were recovered and were dispatched to the Transport Safety Board Canada (TSB) together with other aircraft components like PSEU, EGPWS, EMU and QAR.
On Aug 27th 2018 Nepal's Kathmandu Post claimed to have received exclusive access to the investigation report by Nepalese accident investigation and described the report portrays the captain having acted under severe mental stresses throughout the flight and acting highly erratic throughout the flight as well as abusive towards the female first officer. The newspaper report however was immediately challenged by the Bangladeshi investigators participating in that investigation stating that they have no such information as reported in the newspaper. US Bangla called the newspaper report "fiction".
On Jan 28th 2019 Nepal's AAIC released their final report concluding the probable causes of the accident were:
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.
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.
The AAIC reported the crew had prepared for the VOR 02 approach in their FMS, initially they were instructed to descend to 13500 feet and hold at waypoint GURAS, the crew thus programmed the FMS with the hold at GURAS. The crew was subsequently cleared to descend to 11500 feet and was cleared for the VOR 02 approach, however, forgot to remove the hold out of the FMS due to being involved in unrelated discussions. Upon reaching GURAS the aircraft thus unexpectedly turned left, captain and first officer noticed the deviation and counteracted, approach control also noticed the deviation and queried the crew. The captain selected a heading of 027 degrees to intercept the radial 202 again, 5 degrees off the approach course. The aircraft passed the VOR and maintained heading 027 deviating to the right of the approach course (and extended runway center line). Kathmandu Tower alerted the crew their landing clearance was for runway 02, however, they appeared to be tracking for runway 20. The crew advised their intention was to land on runway 02 and turned right. Tower instructed the aircraft to join downwind runway 02 (no mention of whether left or right downwind in the report), instead of joining the left downwind for runway 02 the aircraft continued the turn towards the northwest, tower instructed the aircraft to remain clear of runway 20 as a Buddha Aircraft was just landing on runway 02. After the Buddha aircraft had landed tower cleared the US-Bangla Dash to land on runway 20 or 02, but the aircraft again made a right hand orbit northwest of runway 20. While turning through the southeast the commander reported he had the runway in sight and requested landing clearance, tower cleared the aircraft to land (not stated for which runway), the aircraft was still turning and very close to the threshold runway 20 at that point. Subsequently tower spotted the aircraft maneouvering very close to the ground and not aligned with the runway and hurried to transmit "takeoff clearance cancelled" (instead of instructing go around). Within the next 20 seconds the aircraft pulled up in a westerly direction, and turned left at a high bank angle. The AAIC continued:
The aircraft ... flew over the western area of the domestic apron, continued on a southeasterly heading through the ATC Tower and further continued at a very low height, flew over the domestic southern apron area and finally attempted to align with the RWY 20 to land. During this process, while the aircraft was turning inwards and momentarily headed towards the control tower, the tower controllers ducked down their heads out of fear that the aircraft may hit the tower building. Missing the control tower, when the aircraft further turned towards the taxi track aiming for the runway through a right reversal turn, the tower controller made a halfhearted transmission by saying, “BS 211, I say again...”.
At around 0834 UTC the aircraft touched down at coordinates N27041'48", E085021'34", 1700 meters down the threshold with a bank angle of about 15 degrees and an angle of about 25 degrees with the RW axis (approximately heading Southeast) and on the left of the center line of RWY 20, then veered southeast out of the runway through the inner perimeter fence along the rough down slope and finally stopped at coordinates N27041'41", E085021'32" about 442 meters southeast from the first touchdown point on the runway. All four crew members (2 cockpit crew and 2 cabin crew) and 45 out of the 67 passengers onboard the aircraft were killed in the accident. Two more passengers succumbed to injury later in hospital during course of treatment. The aircraft caught fire after 6 seconds of touchdown which engulfed major portions of the aircraft.
The captain (52, ATPL, 5,518 hours total, 2,824 hours on type) was pilot flying, the first officer (25, CPL, 390 hours total, 240 hours on type) was pilot monitoring.
The AAIC analysed that the first officer was "trying continuously to pivot the situation by enquiring about the radio frequencies, navigation topics and reminding that the briefing from the PIC was due." However, only a very brief and incomplete briefing of the approach followed, the AAIC stating: "The Captain never carried out a complete briefing on VNKT RWY 02 approach, which requires a very high degree of flight deck preparation, orders and understanding of the very challenging operations environment. This might indicate his complacency as he had performed this approach several times before and not realizing that the First Officer was operating this flight for the first time."
The AAIC continued analysis: "In summary, the flight crew failed to conduct a complete approach briefing which was unstructured and inconsistent. The first officer also made several statements that indicated she had an incorrect understanding of the procedures to follow during approach and her confusion over the missed approach procedure in VNKT was never resolved by the PIC, asserting that he would brief the remaining items later."
The AAIC analysed:
Having received the expected approach time of 08:26UTC by previous controller and holding instructions over GURAS, the crew discussed on the published holding pattern and procedures. Emphasizing to the clearance, the PIC coached the FO on setting up the NAV and “Arming the hold in their Flight Management System”. Various aspects of LNAV, VNAV, FMS, Power setting, Altimeter setting etc. were discussed at this moment. At 0813:41UTC, KTM Approach instructed the flight to reduce the speed to minimum clean and cleared to descent to 12500ft. As of the current profile, the aircraft would arrive position GURAS at 08:20UTC, 6 minutes earlier from the assigned estimated approach time of 0826UTC and therefore the holding mindset was definite to the pilots and the FMS was programmed accordingly. In contradiction to the previously assigned expected approach time of 08:26UTC and holding instructions, the Approach Controller cleared BS 211 to descent to 11500ft and cleared for VOR Approach RWY 02 at 0816:13 UTC.
Though acknowledged the instructions the crew overlooked the preprogrammed FMS settings and missed to disarm the HOLD inputs. The PIC further demonstrated complacency and his gross negligence to procedural discipline by lighting up another cigarette at this stage when the aircraft was just under 3 minutes to arrive the initial approach fix “GURAS”. In the meantime, the approach checklist was also conducted ambiguously by the crew. The CVR also revealed that during this phase the FO was holding the power lever where the PIC corrected her to leave it as he was the pilot flying for the sector and reminded to keep the heading bug on top, which was 017 degrees, corrected for westerly winds.
At 08:20:04 UTC, the pilots received the cabin secured message from the cabin crew and after the ALT star FMA annunciation, the FO reported position GURAS at 11500ft to the ATC at 08:21:06 UTC. The flight was cleared to continue by the controller. This particular moment becomes the triggering factor for distraction and temporary confusion between the crew when the aircraft suddenly starts entering the hold over GURAS as programmed in their FMS, which was caught out of surprise as the hold input was erroneously not disarmed. This error was apparently realized by both pilots and was also alerted by the Approach controller also. The PIC hurriedly selected the Heading mode to 027 degrees towards the final approach inbound track overriding the autopilot FMS LNAV guidance in an attempt to continue the approach as cleared, keeping 5 degrees of intercept angle to the published the course towards west in an attempt to enter the hold over GURAS as programmed. This action on the FGCP led to become the primary cause of losing the FMS Auto Flight Final Approach lateral navigation guidance capability of the aircraft, where the command to autopilot was demanded to fly in “Heading Mode”.
The airborne air data computer registered winds aloft data during this phase revealed strong westerly winds from 270 to 280 degrees at an average of 28 knots, seemingly drifting the flight path towards east with heading correction set at 027 degrees by the pilot in heading mode. In the meantime, the vertical flight profile had also deviated to be high as the descent was due; the PIC was distracted and the aircraft had gone to pitch hold mode reversion due to heading selection in HSI. The PIC commanded descent inputs in the FGCP pitch wheel to approximately 1300 feet per minute (fpm) to initiate descent.
AS per the airline’s Operation Manual Part C guidelines sec 1.2, the aircraft should have already attained the full landing configuration with the landing checklist completed before the initial approach fix “GURAS” to meet the stabilization criteria. The initial flap 5 was requested at 15 DME after crossing the IAF. At 0822:5 UTC, the PIC requested for flap 15 and the landing checklist while crossing 13 DME on the approach. During the challenge and response sequence of the landing checklist which was conducted by the FO, the PIC confirmed the landing gears to be down by stating “gears down three greens” without checking to confirm the position of the landing gears which were actually not in down and locked position, this was also overlooked by the FO as well. At 0823:41UTC, the FO reported 10 miles final where the CVR also recorded the landing gear unsafe tone over the flight deck speakers continuously which was constantly disregarded by both the pilots.
At 08:23:45 UTC, the flight was handed over to KTM Tower and the initial contact with the tower was established at 0824:39 UTC, and was cleared to continue approach and the gear unsafe tone continuously sounding in the cockpit. At 8 DME, the PIC erroneously set the minimums at 4688ft instead of 4950ft as published, though the radio altimeter was set to 629ft to receive the “100ft above” auto callouts above the correct minimums and the PIC (PF) possibly had no approach charts displayed in front of him to refer to. The PIC requested for the landing checklist again and the FO affirmed that it was already completed even though the landing gear unsafe tone was still active. During the final descent, the FO made call outs of the altitude constraints for the segments, and kept prompting the PIC that they were 500ft to 600ft high on profile.
With the noisy flight deck where the landing gear unsafe tone was continuously active and in an already rushed situation where the crew were dealing with correcting a significant vertical flight path deviation, the crew seemed so preoccupied that the interception of the final approach course 022 degrees by the aircraft in Heading mode at 7 DME went undetected to both the pilots and hence the flight path deviation started towards the East of final course as no attempt was made to rearm or reengage the FMS LNAV mode or select the VOR mode. The aircraft continued drifting east of final course in heading mode with heading still set at 027 degrees where the air data computer registered winds from 272 degrees at 24 knots at that altitude. The CVR did not revealed any evidence of ATC controllers providing any alert to the flight crew of the aircraft deviation to the right of the approach path. The CVR revealed that the PIC was having difficulty in understanding what the FO was saying due to the high noise levels inside the flight deck. Exhibiting his confirmation bias, 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.
At 0825:25 UTC, the aircraft arrived the missed approach point in visual meteorological condition with descent rates as high as 1700 feet per minute and off the final approach course, followed by EGPWS “sink rate and too low gears” callouts. The tower reported winds from 220 degrees at 7 knots with tailwind component of 6 knots and cleared the flight to land RWY 02. On the other hand, regardless of the aerodrome environment not being visual to the crew and the stabilization criteria not being met in IFR operations, no attempt was made by the flight crew to carry out a standard missed approach procedure. At this point only, the FO realized that the landing gear was not actually down and initiated its extension under the instruction of the PIC.
The PIC once again requested for the landing checklist for the fourth time. The further conversation between the crew, as revealed by the CVR, led to an ambiguous expectation of when they would acquire visual contacts with the runway environment while being unaware that the aircraft was already flown past and parallel way along the eastern side of the runway towards northeast direction. 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.
When the aircraft was at this position, at 08:27:30 UTC, KTM Tower contacted BS211, being concerned by observing that the aircraft had flown to the northeast of the airfield, whereas it should have landed by then, informed the flight crew that they had been issued a clearance to land on RWY 02 but instead they were going for RWY 20. This time the PIC replied that he thinks he is continuing for RWY 02. At this moment the tower OJT controller was replaced by the Tower Duty Controller who took over the microphone and mistakenly cleared the flight to land on RWY 20 on share assumption, in considering with the aircraft’s current visual flight position that it could be pilots’ intention to land on RW 20 though the PIC deliberately transmitted that he would land on RW 02. Soon after this time, the tower duty controller was replaced by the Tower Supervisor Controller who was present at the tower control.
While struggling to find the runway, the flight continued towards the northeast sector on the same heading. The CVR recorded continuous EGPWS warnings with various flight parameters exceeded. At around 6 DME northeast from the VOR the PIC started maneuvering the aircraft on a right hand orbit while sighting the dead end rising terrain ahead of them. During the maneuver the aircraft descended to as low as 175 ft above ground level with bank angles of up to 35-40 degrees triggering various EGPWS alerts and warnings. Desperate to find the landing runway and still unaware of their position, compounded by threatening high terrain all around and multiple EGPWS warnings, the commission concluded that there was a complete loss of situational awareness on the part of the flight crew at this stage. At 0829:02UTC, KTM tower inquired the crew about their intention and tried to reconfirm if they were still VFR. The PIC affirmed and radioed his intention to still land on RWY 02. In relation with the aircraft’s current position towards northeast from RWY 02, the ATC cleared the flight to join the right hand downwind for RWY 02.
The ATC was also handling another domestic traffic, Buddha 282 which was approaching 2 miles final for RWY 02 and had been cleared to land. This traffic information was passed on to BS211 cautioning them again that there was a landing traffic on short final for RWY 02 sequenced before them which was acknowledged by the PIC. In conflict to the clearance given, the ATC sighted BS211 proceeding towards RWY 20 instead of joining the right downwind for RWY 02. The ATC warned BS211 not to proceed towards RWY 20 as there was a landing traffic on RWY 02 and cleared to perform an orbit at their present position. At this time, the aircraft had already flown past north abeam threshold RWY 20 on a westerly heading of 280 degrees at 3.2 DME north from the VOR at 6000 ft. The aircraft continued to climb to 6500ft until when the PIC then again started maneuvering the aircraft on a steep right hand orbit, on the northwest sector and admitting to the FO that he had made a mistake as he was constantly talking to her.
During the turn, the bank angles reached up to 45 degrees with descent rates over 2000 feet per minute triggering the EGPWS warnings again. While the aircraft was maneuvering, the CVR also recorded another local pilot from the ground raising concern to the ATC that these pilots seemed to have been disoriented and lost and also informed the ATC that the surrounding visibility towards hillside was marginal. The reported visibility at this moment was still 6000m. Until this moment the CVR recorded no statements from either pilot of BS211 to have located the RWY environment though they were flying in the vicinity of threshold RWY 20. At 08:31:52 UTC, the tower issued a landing clearance to the flight for either runway (02 or 20) to their comfort realizing their confusion over the position and assured that the RWY was clear.
The PIC replied that he would like to land on RWY 20 now though till this moment the RWY was not in sight to either crew. In spite being pilot flying, the PIC himself was communicating with ATC the entire time inflating his flight deck duties in an already overloaded situation. The aircraft now exiting the orbit and flying on a southeasterly heading of approximately 160 degrees at an altitude of 5400ft. The PIC rolled out of the turn and maintained this heading of 160 degrees momentarily to find the runway in the front because of the FO stating that the runway could be in front of them. Both the pilots were anxiously trying to locate the runway. The CVR revealed that both pilots made several statements which reflected that they had now completely lost their orientation of the runway, but this was not communicated to the ATC. At 0832:34UTC, the ATC tried to confirm with BS211 if the RWY was still not in sight and advised them to turn right in an attempt to assist the pilots in finding runway 20 as the aircraft position was just northeast abeam the threshold RWY 20 on a southeasterly heading.
At 0832:43UTC, the First Officer finally sighted the threshold RWY 20 at their 3 O’clock position at an altitude of 5500ft, 4.1 DME from the VOR and approximately 1.8 nm from the threshold RWY 20. Though it appeared unmanageable to land the aircraft on RWY 20 from the current position, attitude and altitude; for some undetermined reason, the PIC initiated desperate maneuvers in an attempt to put the aircraft on ground and requested landing clearance again affirming that he had the RWY in sight now. The Flight directors were set to standby at this point and the PIC reconfirmed the landing checklist was done again for the sixth time now. Still to his confusion he requested the FO to give him the heading bug of 022 degrees and set the same on her side, though the practical setting would have been 202 degrees for RWY 20. The FDR data shows that the aircraft overflew the threshold RWY 20 at 450ft above the ground on a westerly heading of 255 degrees and left bank angles of 40 degrees at an IAS of 150 knots. Distressed and panicked by the PIC’s engagements, the FO made no callouts for go around or discontinue the maneuver.
At 0833:27UTC, spotting the aircraft carrying out reckless and irresponsible maneuvers at very close proximity of the ground within the aerodrome periphery and alarmed by the situation, the ATC hastily cancelled the landing clearance by saying "Takeoff clearance cancelled". At that critical moment ATC was confused sighting the unusual and abnormal maneuver of the aircraft and could not be assertive. The PIC still requested for clearance in a calm and content tone. But the aircraft was flying on improper attitude.
The EGPWS warnings “bank angle and sink rate” sounded continuously in the cockpit while the aircraft overflew the TIA domestic apron, cleared the hanger side and domestic passenger terminal by barely 45 feet as per the radio altimeter and FDR data. The ATC viewed all these unusual maneuvers of the aircraft and at one time the controllers, out of fear, ducked down themselves down below their table level. Thereafter, Overflying the TIA international parking bay, the aircraft finally made this time a right reversal right turn to align with the runway and eventually touching down on its right main landing gear 1700 meters past threshold RWY 20 (between intersection Charlie and Delta) left side of the RWY centerline with right bank angle. The aircraft hit the runway at an IAS of 127 knots and a heading of 190 degrees and immediately departed the runway surface towards the southeast direction in an uncontrollable manner further impacting the inner periphery fence, descending downslope and finally bursting into flames.
With respect to human factors the AAIC analysed:
The effect of stress was evident with the fact that he was irritable, tensed, moody, and aggressive at various times. He 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. The PIC's impulsive and inappropriate behavior, or concentration, incomplete task as not completing before landing checklist, mentioning all 3 green for landing gear down in spite of not actually all 3 being green, repeatedly asking for before landing checklist in an obsessive manner; all was due to excessive stress he was harboring.
PIC seemed very unsecure about his future as he had planned to resign from this company. He said he did not have any job and does not know what he is going to do for living in future. The future financial insecurity may have augmented his stress.
The PIC was engaged in unnecessary conversation which was beyond the norms and violating the company SOP. This distraction as well as stress may have led tounstabilized approachspeed not under control, aircraft not fully configured and check list not completed. He had many opportunities to correct the maneuvers, if he had followed the SOP during descend and approach phase. It seems that the PIC was trying to prove to the FO that he was indeed a good pilot, good teacher and competent in flying skill also and would be able to safely land the aircraft in any adverse situation.
The PIC’s decision to land the aircraft at any cost after sighting the runway at a very close proximity, way off the final approach course, at very low altitude and decision for not initiating a go-around even after realizing that flight was not stabilized, is a very poor decision making on part of PIC.
...
This flight was her first to Kathmandu as a crew and during flight she showed utmost interest to learn. She also was keen to clear her doubts about flying and tried to learn in every step during the flight.
However, steep crew gradient, FO’s inexperience in the sector and higher authority of PIC probably disallowed FO from being assertive even though she was effectively monitoring the progress of the flight and suggested/initiated corrective actions.
Metars:
VNKT 120950Z 31011KT 280V350 7000 TS FEW015 FEW025CB SCT030 BKN100 20/10 Q1015 NOSIG CB TO SE NW N AND E=
VNKT 120920Z 27005KT 230V320 7000 TS FEW015 FEW025CB SCT030 BKN100 20/10 Q1015 NOSIG CB TO SE W N E AND OVERHEAD=
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=
VNKT 120750Z 25007KT 200V300 6000 FEW015 FEW025TCU SCT030 22/10 Q1016 NOSIG=
VNKT 120720Z 31006KT 6000 FEW015 SCT030 22/10 Q1016 NOSIG=
VNKT 120650Z 31008KT 6000 FEW015 SCT030 21/10 Q1017 NOSIG=
VNKT 120620Z 27005KT 230V340 5000 HZ FEW015 SCT030 21/09 Q1018 NOSIG=
VNKT 120550Z 29004KT 5000 HZ FEW015 20/10 Q1019 NOSIG=
VNKT 120520Z 00000KT 4000 HZ FEW015 19/11 Q1019 NOSIG=
Incident Facts
Date of incident
Mar 12, 2018
Classification
Accident
Airline
US-Bangla Airlines
Flight number
BS-211
Departure
Dhaka, Bangladesh
Destination
Kathmandu, Nepal
Aircraft Registration
S2-AGU
Aircraft Type
De Havilland Dash 8 (400)
ICAO Type Designator
DH8D
This article is published under license from Avherald.com. © of text by Avherald.com.
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