Status: | Accident investigation report completed and information captured |
Datum: | zondag 16 februari 2014 |
Tijd: | 13:30 |
Type: |  de Havilland Canada DHC-6 Twin Otter 300 |
Luchtvaartmaatschappij: | Nepal Airlines |
Registratie: | 9N-ABB |
Constructienummer: | 302 |
Bouwjaar: | 1971 |
Aantal vlieguren: | 43947 |
Aantal vluchten: | 74217 |
Motoren: | 2 Pratt & Whitney Canada PT6A-27 |
Bemanning: | slachtoffers: 3 / inzittenden: 3 |
Passagiers: | slachtoffers: 15 / inzittenden: 15 |
Totaal: | slachtoffers: 18 / inzittenden: 18 |
Schade: | Vernield |
Gevolgen: | Written off (damaged beyond repair) |
Plaats: | 7 km (4.4 mijl) NW of Sandhikhark ( Nepal)
|
Fase: | Kruisvlucht (ENR) |
Soort vlucht: | Binnenlandse lijnvlucht |
Vliegveld van vertrek: | Pokhara Airport (PKR/VNPK), Nepal |
Vliegveld van aankomst: | Jumla Airport (JUM/VNJL), Nepal |
Vluchtnummer: | 183 |
Beschrijving:A de Havilland Canada DHC-6 Twin Otter operated by Nepal Airlines was destroyed when it impacted a mountainside near Sandhikhark, Nepal. All 18 on board sustained fatal injuries.
Flight RA183 was a domestic flight from Kathmandu to Jumla with a refueling stop at Pokhara. The airplane took off from Pokhara at 12:43. Upon leaving Pokhara Control Zone, the pilot in command realized that the direct track was not possible due weather and decided to proceed via a more southern track. During the flight the pilots were experiencing uncomfortable flying environment due to unfavorable weather conditions. Attempting to avoid the weather, the pilots had to fly up and down and changing the heading. Finally being unable to penetrate the weather ahead, the captain decided to divert to Bhairahawa, the nearest airport. However, the captain did not take into consideration the surrounding terrain and continued descent turning right.
The aircraft initially slashed a small tree and finally impacted a ridge. Due to the heavy impact the left wing was first disintegrated and then the front part of the aircraft toppled over beyond the ridge with several subsequent impacts.
The cockpit voice recorder showed that the copilot had warned the captain not to descend or turn.
The wreckage was located the following morning at an altitude of 7190 feet (2192 m). There were no surivors.
Probable Cause:
Causes:
After detail investigation and thorough analysis of the circumstances and evidences, the Commission has determined that the most probable causes of the accident is the
"Losing situational awareness on the part of PIC while flying into instrument meteorological weather condition to the extent of Collision with terrain."
The contributing factors to the occurrence are;
- Deteriorated weather associated with western disturbance, unstable in nature and embedded CB.
- Inappropriate and insufficient crew coordination while changing course of action.
Accident investigation:
|
Investigating agency: | AAIC Nepal  |
Status: | Investigation completed |
Duration: | 190 days (6 months) | Accident number: | Final report | Download report: | Final report
|
|
Bronnen:
»
ekantipur.com» Nepali Times
» Hemant Arjyal
»
SKYbrary
Veiligheidsmaatregelen
Nepal AAIC issued 11 Safety Recommendations
Issued: 25-AUG-2014 | To: MoCTCA | 9N-ABB (1) |
MoCTCA should establish an independent and effective aircraft accident investigation mechanism with the provision of adequate resources under the Ministry of Culture, Tourism and Civil Aviation (MoCTCA) for the effective investigations and also for the continuous monitoring of the implementation and compliance-status of remedial safety measures. |
Issued: 25-AUG-2014 | To: Nepal Airlines | 9N-ABB (10) |
NAC should develop special program and policy for the prevention of CFIT accidents. |
Issued: 25-AUG-2014 | To: Nepal Airlines | 9N-ABB (11) |
NAC should review and further strengthen the effective implementation of SMS process especially in the areas of improved reporting system, hazard identification and risk mitigation. |
Issued: 25-AUG-2014 | To: Department of Hydrology and Meteorology | 9N-ABB (2) |
Department of Hydrology and Meteorology in coordination with CAAN shoulddevelop a mechanism to obtain the weather data not only of the airport stations but also from other parts of the country for the information and analysis of en-route weather. |
Issued: 25-AUG-2014 | To: CAAN | 9N-ABB (3) |
CAAN should further strengthen its surveillance and monitoring function focusing on the critical safety areas including violation of SOP, proper application of CRM, CFIT, and ensure effective enforcement mechanism by collecting information on flight operation activities on daily basis. |
Issued: 25-AUG-2014 | To: CAAN | 9N-ABB (4) |
CAAN should ensure that all fleets operated by AOC holders are equipped with the appropriate Terrain Awareness Warning System (TAWS) in accordance with the provisions of Annex 6. |
Issued: 25-AUG-2014 | To: CAAN | 9N-ABB (5) |
CAAN in coordination with Department of Hydrology and Meteorology should develop a mechanism to obtain the real time weather data not only of the airport stations but also from other parts of the country for the information and analysis of en-route weather. |
Issued: 25-AUG-2014 | To: CAAN | 9N-ABB (6) |
Encourage airlines to install onboard aircraft equipment that will help for real time tracking of the aircraft in flight. |
Issued: 25-AUG-2014 | To: Nepal Airlines | 9N-ABB (7) |
NAC should review and strengthen the training requirements on Crew Resource Managements (ground and in flight), with special attention to the importance of close coordination and cooperation between PIC and Copilotand also emphasizing the situations requiring interventions from copilot. |
Issued: 25-AUG-2014 | To: Nepal Airlines | 9N-ABB (8) |
In view of the significant fleet expansion in process, NAC should systematically identify the hazards, changes in system, operational environment and consequential safety risk especially in the process of recruitment and training of the operational and engineering personnel. |
Issued: 25-AUG-2014 | To: Nepal Airlines | 9N-ABB (9) |
NAC should enhance the flight dispatcher\'s capability to enable them to fulfill their responsibility as per the provisions of company SOP. |
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Foto's

accident date:
16-02-2014type: de Havilland Canada DHC-6 Twin Otter 300
registration: 9N-ABB

accident date:
16-02-2014type: de Havilland Canada DHC-6 Twin Otter 300
registration: 9N-ABB
Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft
niet de exacte vliegroute weer.
De afstand tussen Pokhara Airport en Jumla Airport bedraagt 213 km (133 miles).
Accident location: Exact; as reported in the official accident report.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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DHC-6 Twin Otter
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