Lao AT72 at Pakse on Oct 16th 2013, went into Mekong River during go-around

Last Update: November 28, 2014 / 19:30:45 GMT/Zulu time

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Incident Facts

Date of incident
Oct 16, 2013

Classification
Crash

Aircraft Registration
RDPL-34233

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

On Nov 28th 2014 Lao's Ministry of Transport released a summary of the final report, the actual final report has not surfaced in public so far, concluding the probable causes of the crash were:

The probable cause of this accident were the sudden change of weather condition and the flight crew's failure to properly execute the published instrument approach, including the published missed approach procedure, which resulted in the aircraft impacting the terrain.

The following factors may have contributed to the accident:

- The flight crew's decision to continue the approach below the published minima

- The flight crew's selection of an altitude in the ALT SEL window below the minima, which led to misleading FD horizontal bar readings during the go-around

- Possible Somatogravic illusions suffered by the PF

- The automatic reappearance of the FD crossbars consistent with the operating logic of the aeroplane systems, but inappropriate for the go-around

- The inadequate monitoring of primary flight parameters during the go-around, which may have been worsened by the PM's attention all tunneling on the management of the aircraft flap configuration

- The flight crew's limited coordination that led to a mismatch of action plans between the PF and the PM during the final approach

The Ministry summarized: "The crew started the approach to runway 15 while a thunderstorm was in the vicinity of the aerodrome. After passing the MAP, the crew decided to perform a go-around and initiated a right turn at an altitude of about 600ft. During the missed approach the aircraft descended which resulted in an aural warning from the TAWS. The aircraft then climbed and started to descend again before impacting an island located on the Mekong River." detailing a bit further: "On 08 h 50 UTC, the pilot started the approach facing South East. A local thunderstorm was around the airport. It was raining but the pilot continued the approach and lastly decided to go-around at an altitude below the MAP in a steep right tum. It impacted the trees on an island located in the Mekong, the fuselage stroke the bank and plunged into the river."

The captain (57, ATPL, 5,600 hours total, 3,200 hours on type) was assisted by a first officer (22, CPL, 400 hours total, no hours on type provided). Overall the summary summarized: "The Pilot in Command was experienced and skilled on this type of aircraft. The First Officer was qualified and trained in France. His overall flight experience was not very high but his training was fresh in mind."

The Ministry released following key sentences of analysis:

"Under IMC conditions, with no reference to the ground, the SOPs lead to conducting an instrument approach. In Pakse the VOR DME approach procedure is in force. There is no radar service. The flight crew has to fly to the initial approach fix or the intermediate fix at an altitude above 4600ft, then start the descent to 2300ft until final approach fix. Finally the flight crew descends to the minima (990ft), if visual references with the ground are available and sufficient the flight crew may continue until touchdown. If ground visual references are not available or not sufficient, the flight crew may level off up to the missed approach point and then must start the missed approach procedure. From the FOR data, the flight crew set 600 ft as the minima. This is contrary to the published minima of 990 ft. Even if the flight crew had used the incorrect height as published in the JEPPESEN Chart at that time the minima should have been set to 645 ft or above. The choice of minima lower than the published minima considerably reduces the safety margins. Following the chart would lead the flight crew to fly on a parallel path 345 ft lower than the desired indicated altitude. The recordings show that the flight crew initiated a right turn according to the lateral missed approach trajectory without succeeding in reaching the vertical trajectory. Specifically, the flight crew didn't follow the vertical profile of missed approach as the missed approach altitude was set at 600 ft and the aircraft system went into altitude capture mode. When the flight crew realized that the altitude was too close to the ground, the PF over-reacted, which led to a high pitch attitude of 33°. The aircraft was mostly flying in the clouds during the last part of flight."
Incident Facts

Date of incident
Oct 16, 2013

Classification
Crash

Aircraft Registration
RDPL-34233

Aircraft Type
ATR ATR-72-200

ICAO Type Designator
AT72

This article is published under license from Avherald.com. © of text by Avherald.com.
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