1.SUBMISSION OF DRAFT FINAL REPORT OF TWIN-OTTER, DHC-6, 300 Crashed on 16 February 2014 at Dihidanda, Masinalek , Arghakhanchi District,Nepal. TO The Minister for Culture Tourism and Civil Aviation [2071/2/--/-/-/ 2014/06/--] 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 1

2. Introduction Aircraft : 9N-ABB, DHC6-300, Double engine, STOL Category Owned and Operated by: Nepal Airlines Corporation (NAC) Engine Manufacturer : Pratt and Whitney, Canada Airframe Manufacturer : De Havilland Canada. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 2 3. Composition of the Commission : Former DG , CAAN, - Mr. Tri Ratna Manandhar - Chairman Senior Aero. Er.- Meghendra Kumar Shrestha-- Member Senior Pilot (IP-DHC6)- Mr. Prabhakar Prasad Ghimire-- Member Joint Secretary, MoCTCA--Mr. Buddhi Sagar Lamichhane--- Member Secretary 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 3 4. Aircraft Crash and CONSTITUTION OF COMMISSION Crashed on 16 February 2014 At the south sloppy ridge of Dihidanda Masinalek, Arghakhanchi District, Nepal Altitude of the impact point is: 7190 Ft. The Government of Nepal on 17 February 2014 in accordance with the provisions of Civil Aviation (Accident Investigation) Rules, 2024 B.S (1967) constituted 4 Member Aircraft Accident Investigation Commission to investigate and find out the cause of the accident and recommend remedial measures for the purpose of preventing future aircraft accidents and incidents 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 4 5. Crash Site Sloppy south ridge of Dihi Danada Masinalek , Arghakhanchi District, Nepal First impact point reference : N 27 deg 5443 Latitude E 83 deg 06 56'' Longitude Elevation: 7190 feet AMSL 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 5 6. Aerial Photo first -- impact site 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 6 7. History of Flight 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 7 8. History of Flight PIC Shankar Shrestha Co-pilot Rabindra Banjara Air Hostess Muna Maharjan Total Passenger on Board 15 Total person on board 18 (3 +15) Cargo Nil Survival -- Nil Fatality -- ALL 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 8 9. Aeronautical route- direct and followed 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 9 Crash site POKHARA JUMLA KTM Direct Track Track Followed 10. History of Flight On the day of accident flight was delayed due to bad weather Departed from Kathmandu to Pokhara on the same day at 0610 UTC (1155 LT) The flight from KTM-PKR was accomplished in normal manner Flight Rule -- VFR The aircraft departed Pokhara at 0658 UTC to Jumla Weather at Pokhara and Jumla Airport VFR Normal 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 10 11. Flight Detail as submitted by 9N ABB TO PKR TWR Aerodrome of Departure: Pokhara EOBT: 0645 UTC Destination Aerodrome: Jumla Altitude: 10500ft Total Estimated Elapse Time: 0100 hour 1st Alternate Aerodrome: Nepalgunj 2nd Alternate: Surkhet Endurance: 02:30 HRS PIC: Capt. Shankar Shrestha Equipments: SD/N POB: TBN Flight Rule: VFR 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 11 12. After the completion of Jumla flight, the aircraft was scheduled to Night stop at Nepalgunj. Next day it had a series of shuttle flights from Nepalgunj. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 12 13. History of Flight.. Initially the PIC tried from direct track. Due to bad weather towards direct track the aircraft followed south of track via Juliet 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 13 14. Injuries to Persons Injuries Crew Passenger Total Fatal 3 15 18 Total 3 15 18 Among Passengers [Adults - 17 ; Infant - 1] [ Danish 1 ; Nepalese- 17] 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 14 15. Damages to Aircraft and Third party The aircraft was totally damaged and disintegrated. Some parts were completely burnt. Different parts and pieces were scattered on both sides of the ridge where the accident took place. No damage to outside people and structures. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 15 16. Satellite Picture of weather pattern of Nepal on that day around 2014-2-16, 7:32 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 16 17. Findings The pilots were certified and qualified in accordance with the existing Nepalese aviation regulations. Both the pilot and co-pilot were in normal health condition and were certified as fit to fly. The crew had adequate rest and the duty times within the accepted guidelines. The aircraft was maintained as per the existing rules and regulation. Pre-impact failure and other mechanical malfunction was also not found . There was no evidence of engine failure before impact. CVR was found in good condition and all the cockpit conversation was recorded. The GPS installed was of old model and it does not have capability of storing previous track data. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 17 18. The 9N-ABB had departed Kathmandu to Pokhara (where technical landing for refueling was planned) even when the weather at destination airport Jumla was below VFR Minima. Pilots encountered unfavorable enroute weather in the direct track deviated to South with the way points aiming JULIET and THARA. PIC had penetrated the visible moisture without having proper anti-icing and De-icing facility equipped in aircraft in violation to SOP as well as flight manual of DHC 6 300. Aircraft climbed up to 10500 ft with OAT -06 degrees Celsius and again went down to 8500 ft whereby they ultimately encountered zero degree temperature i.e. without icing conditions. PIC found to be focused on completing the mission in spite of adverse weather. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 18 19. PIC did not brief co-pilot on descending from 8500 ft to the lower level. Co-pilot had suggested PIC not to descend but did not insist. Insistence on that particular time was very necessary. While descending to altitude lower than 8500 ft and maneuvering to get out of the adverse weather, 9N-ABB was flying inside the visible moisture with no in-flight visibility. PIC had started losing his situational awareness as a result of which, he inadvertently started descent making turns. Co-pilot, now monitoring, was suggesting again to PIC not to descend and not to make turn. While initiating turn the aircraft was on north easterly heading, initially slashed a small branch of a tree and hit the sloppy ridge with the huge impact. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 19 20. Based on the evident it was concluded that nature of accident was a Controlled Flight into Terrain. Serious lacking in crew coordination especially in the last critical part of the flight. PIC's faulty decision, inability on the part of co-pilot to strongly intervene the PIC's wrong action led to the catastrophic accident. Company's Dispatch Policy as reflected in DHC6 SOP is not implemented properly. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 20 21. Interim Safety Recommendations: "Operators shall immediately develop and implement an appropriate surveillance mechanism to ensure the effective monitoring of the flying behaviors of the pilots and their adherence to SOP including the violation of the VFR rules." 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 21 22. Causes of Accident and SAFETY Recommendations 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 22 23. Causes The Accident Investigation Commission has determined the most probable cause " Loosing situational awareness on the part of PIC while flying into instrument meteorological weather condition to the extent of impact. leading to CFIT accident." Contributory factors to the occurrence are; -inappropriate and insufficient crew coordination while changing course of action, -the prevailing weather of cold front from the west ,unstable in nature and embedded CB. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 23 24. Safety Recommendations 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 24 25. SAFETY RECOMMENDATIONS TO TheMinistry of Culture Tourism and Civil aviation (MoCTCA) 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. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 25 26. Safety Recommendations to The Civil Aviation Authority of Nepal 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 operational activities on daily basis. 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 . 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. Encourage airlines to install onboard aircraft equipment that will help for real time tracking of the aircraft in flight. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 26 27. Safety Recommendations to The Department of Hydrology and Metrology 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 27 28. Safety Recommendations to NAC 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 Co- pilot and also emphasizing the situations requiring interventions from co-pilot. In view of the significant fleet expansion in process , NAC should systematically identify the hazards, changes in system , operational environment and consequential safety risk specially in the process of recruitment and training of the operational and engineering personnel. NAC should enhance the flight dispatcher's capability to enable them to fulfill their responsibility as per the provisions of company SOP. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 28 29. For the prevention of CFIT accident NAC should develop the normal and alternate track (for weather reason) in its company manual and strictly follow the policy of either to fly VFR only or to fly at Minimum Safe Altitude (MSA) developed for that particular route, if a flight could not be conducted with visual references. Such MSA policy should be reflected in SOP and Operational Flight Plan. NAC should review and further strengthen the effective implementation of SMS process specially in the areas of improved reporting system, hazard identification and risk mitigation. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 29 30. ANIMATION OF FLIGHT 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 30 31. 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 31 32. Comments / Questions 6/5/2014 Draft Final Report, 9N-ABB,Crashed at Arghakhanchi, on 16 February 2014 32