Tara DHC6 near Pokhara on Feb 24th 2016, aircraft impacted terrain

Last Update: January 19, 2018 / 18:49:50 GMT/Zulu time

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Incident Facts

Date of incident
Feb 24, 2016

Classification
Accident

Flight number
TA-193

Destination
Jomsom, Nepal

Aircraft Registration
9N-AHH

ICAO Type Designator
DHC6

A Tara Air Viking DHC-6-400 Twin Otter, registration 9N-AHH performing flight TA-193 from Pokhara to Jomsom (Nepal) with 20 passengers and 3 crew, departed Pokhara at 07:47L (02:02Z) and was enroute about 10 minutes into the flight when radio contact with the aircraft was lost. The aircraft has not arrived at the destination or any airport in reach so far. The aircraft was later found near Rupse Chhahara at Soleghopte cliff in Dana VDC at position N28.5759 E83.6153 at an altitude of 10,982 feet. There were no survivors.

Nepal's police reported, a search for the aircraft has been initiated, two helicopters have departed Pokhara in the search for the missing aircraft. Police is also responding to reports of villagers of a fire near Rupse Chhahara, 18nm northwest of Pokhara and 15nm south of Jomsom, which could be the aircraft. Later the day police reported that the wreckage was found crashed and burned, there were no survivors.

The airline released a passenger manifest containing 23 names including three crew. 21 occupants are Nepalese citizens, one Chinese and one Kuwaiti. The aircraft was new and joined Tara's fleet in September 2015.

Nepal's Prime Minister reported the aircraft was found crashed with no survivors and offered condolences to the families. The bodies are being recovered and handed to the families as soon as possible. A high level probe panel is being formed to investigate the crash.

Dana VDC is located at WGS84 coordinates N28.54 E83.62. The crash site is located about one hour walk outside the center of Dana VDC at Soleghopte cliff.

The weather along the route was generally good, however, there were clouds of dust in the area following landslides on the south flank of Annapurna.

In the evening of Feb 25th 2016 Nepal's Army reported that all bodies have been recovered from the crash site at 4900 meters (16,070 feet) above sea level, helicopters took the bodies to Pokhara.

Late Feb 25th 2016 Nepal's Civil Aviation Authority reported that the cockpit voice and flight data recorders were recovered and handed over to the investigation panel.

On Aug 1st 2016 Nepal's Ministry of Transport reported, that the accident investigation commission have handed over their final report into the crash reporting that the crew had diverted to the left of the planned route due to the valley/route being in cloud. While deviating the aircraft however entered cloud, a GPWS warning occured, but the aircraft collided with terrain. The flight was conducted under visual flight rules, entering cloud thus was not permitted. When the crew encountered cloud enroute the aircraft climbed to 12,000 feet and deviated to the left, however, still entered a cloud and descended to 10,000 feet in an attempt to descend out of cloud. At 10,200 feet the GPWS sounded about a minute prior to impact while still in cloud. There was no immediate reaction to the warning. The aircraft began to climb again but impacted a cliff at 10,700 feet and came to rest of an altitude of 10,982 feet. The commission reported that ignoring the GPWS had become habit with flight crews, previous flights had received a GPWS alert at that location in normal flight, too. The captain had accumulated 20,800 flight hours total.

In Jan 2018 the final report surfaced on Nepals tourism website concluding the probable cause of the crash was:

The Commission concludes that the probable cause of this accident was the fact that despite of unfavourable weather conditions, the crew¡®s repeated decision to enter into cloud during VFR flight and their deviation from the normal track due to loss of situational awareness aggravated by spatial disorientation leading to CFIT accident.

The Nepal Accident Investigation Commission (NAIC) reported the sequence of events in the cockpit:

As per the cockpit conversation, the crew were comparing the base of the cloud which was higher than the day before and proposed to continue climb to 12,500 ft if not on-top of the cloud at 10,500 ft. Around 5 miles before Ghorepani passing 10,100 ft, the captain (54, ATPL, 20,108 hours total, 18,500 hours on type) told that cells were still present so advised F/O (30, CPL, 760 hours total, 560 hours on type) to continue climb to 12,000 ft and told that they will proceed till TATOPANI and decide to continue or divert. At 02:14 approaching GHOREPANI and passing 11,400 ft, Captain told F/O to maintain level to be in between the cloud layers and briefed F/O that if they had to divert it would be a left turn. At the same time captain asked repeatedly to F/O if his side was raining for which F/O told and confirmed not visual, after which captain told they would see and decide (regarding continuation of flight).

At 02:14:50 while over Ghorepani area at 11,500 ft the EGPWS TERRAIN alert and at 02:14:52 PULL UP warning came while they were not visual and at 02:15:01 it was stated that they were visual and by 02:14:53 the warning stopped. At 02:15 while maintaining 11,500 ft the captain reported ATC that they are at Ghorepani at level 10,500 ft after which frequency changeover to Jomsom tower was given. At 02:15:27 the captain instructed F/O to maintain heading of 330° and flight level just below the cloud, after which a shallow descent was initiated. At this time captain asked F/O if his side was visual, in response F/O replied somewhat visual. The Captain then instructed F/O to descent to 10,000 ft. Once the descent was started at 02:15:55 passing 11,000 ft an OVERSPEED warning sounded in the cockpit for 2 seconds as the speed reached 152 knots.

At 02:16 while passing 10,700 ft captain advised F/O to make a left turn so that it would be easy to turn ifrequired as he was able to see his side. Then F/O asked if left side was visual for which the captain informed that not that side (towards the track) but somewhat visual to the left of him and told that the TRACK TO GO was TO THE LEFT whereas they were actually left of the track and had descended to 10,300 ft.

At 02:17:58 EGPWS TERRAIN alert sounded when the aircraft was at 10,200 ft and descending on heading of 321° with right bank angle of around 3°. At 02:18:06 when the aircraft had descended to 10,100 ft the PULL UP WARNING sounded for which the captain said not to worry and at 02:18:12; when the aircraft was at 10,000 ft the captain took-over the control, continued descent and asked F/O if his side was visual. The F/O informed that right side was not visual at all by which the aircraft had continued shallow descent on heading 325° with right bank angle reaching up to 13° at 2:18:19 and by 02:18:23 the aircraft once again returned back to 0° bank angle. At 02:18:23 the captain started left bank followed by right bank again while still on a shallow descent until 02:18:27. Upon reaching 9,850 ft (lowest altitude) the aircraft started very shallow climb. At 02:18:35 when aircraft was 9,920 ft the captain told F/O that they reached Landslide (a checkpoint which is on track to Jomsom on the right side of the Kali-Gandaki River).

At 02:18:44 when aircraft reached 10,150 ft captain told "what I will do is now I will turn to heading of LETTE" (another way point on route to Jomsom); while the PULL-UP warning was continuously sounding. At 02:18:49 when the aircraft was at 10,300 ft right bank angle increased up to 16° with pitch up attitude of 7°. At 02:18:52 the captain told that he would start climb when the aircraft had reached 10,350 ft; pitch attitude of 10° and still on right bank. The aircraft reached zero degree bank at 02:18:53 and started shallow left bank with pitch attitude of 12° nose up. By 02:18:57 the bank angle reached 20° left with pitch attitude of 11.8° and altitude of 10,550 ft and captain was still questioning F/O about the visibility towards his side but F/O informed his side not visible completely. The last data recorded in FDR was at 02:19:03 when the altitude had reached around 10,700 ft; pitch attitude of 7° nose up and left bank angle of 25° heading of 335° with EGPWS PULL-UP warning ON.

The commission analysed that there was no mechanical issue prior to first impact with terrain. The commission analysed. The commission wrote: "There is a tendency amongst crew to disregard the alternate weather condition or the weather of the departing aerodrome. This was evident from the fact that on 23rd despite Pokhara was opened for departure only due to bad weather and alternate aerodrome, Bhairawaha, was also closed due to bad weather, the crew decided to conduct flight from Pokhara to Jomsom."

The commission analysed:

Last 3 minute of the FDR data showed that the aircraft frequently changed its pitch and roll attitude in an attempt circumvent cloudy weather. Following picture illurates the actual flight path flown by the aircraft on the day of the accident (Green Coloured line) in comparision to the flight path of the aircraft the day before (Magenta Colour line). The CVR revealed the fact that the pilot had assumed the track to follow was to the left, which could be due to the wrong interpretation of the Track and Heading function of the EFIS.

...

Aircraft was flown left of the usual track to Jomsom. As per FDR and CVR data the decision to turn to left heading assuming that they have reached landslide (a waypoint after tatopani en-route to Jomsom created by the airline) was totally wrong in the real world, as the aircraft had never reached the said (landslide) waypoint. Furthermore, the crew continued descended as low as 9500 ft in an attempt to maintain visual condition in between the cloud layers despite the fact that the EGPWS warning was active, until they reached a point after which it was not possible to maintain VMC. The crew continuing on Northwesterly heading while inside the cloud, wanted to make right turn to return back but as there was weather on the right side turned left but during the turn the aircraft hit the ground first with the belly near the tail section which was then detached from the main fuselage. After the detachment of the tail portion from the fuselage, the aircraft slammed the ground.
Incident Facts

Date of incident
Feb 24, 2016

Classification
Accident

Flight number
TA-193

Destination
Jomsom, Nepal

Aircraft Registration
9N-AHH

ICAO Type Designator
DHC6

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