Kathmandu ulykken for to og et halvt år siden - Rapport ute - ATW

 Timeline har vært vanskelig å redigere og er ikke perfekt. (Red)

Complete Loss Of Situational Awareness: Timeline Of The US-Bangla Airlines Crash

February 10, 2020

Four crewmembers and 47 of the 67 passengers on board a US-Bangla Airlines Bombardier Q400 died on March 12, 2018, when their scheduled flight crashed and burned at Tribhuvan International Airport (VNKT), Kathmandu, Nepal, while maneuvering for a VFR landing.

The Nepalese government convened an investigation commission (NAIC). Its findings are unusual and worthy of consideration:

The probable cause of the crash, said the commission, was “disorientation and a complete loss of situational awareness” on the part of the pilot. Contributing to this was his attempt to recover from a misaligned approach path by maneuvering “in a very dangerous and unsafe attitude.”

The landing “was completed in a sheer desperation” after the pilot sighted the runway at very close proximity and low altitude. He made no attempt to go around, even though a go-around was possible until “the last instant before touchdown on the runway.”

Take a look at the timeline below detailing the key events of the crash. To read the full analysis, take a look at the original article 'An Approach So Awful, The Tower Controllers Ducked Out Of Fear'.

 

The crew began to prepare for its arrival into the VNKT area. 

While monitoring ATIS and performing other flight duties, said 

investigators, the pilots were busy “discussing their personal issues 

and worries.”

The first officer reported MONDA at FL 240 to Kolkata Control and was instructed to report establishing contact with Kathmandu Control. Between contacts, the captain was showing the first officer how to set up the FMS, FGS and other avionics. He did this “with great passion, calmness and professional efficiency,” said the Commission. The captain then asked the first officer if she was comfortable with all he had explained, and she replied, “Yes, very comfortable, sir.”

The aircraft made initial contact with Kathmandu Control. At 0807:49, the first officer requested descent clearance, and Kathmandu cleared the aircraft to FL 160 with an estimated approach time of 0826, which she acknowledged.

The flight was handed off to Kathmandu Approach.

The approach controller instructed the aircraft to descend to 13,500 ft. and hold over GURAS (17 nm southwest). The crew inserted the GURAS hold in the FMS. The reported weather at the time was VFR — 6,000 meters visibility; wind, 210 deg. at 6 kt.; few clouds at 1,500 ft.; scattered clouds at 3,000 ft.; temperature 22C; and dew point 10C. Elevation of Tribhuvan Airport is 4,390 ft. Its single runway — 2/20 — is 10,007 ft. long. MDA on the approach is 5,120 ft. (807 ft. AGL). ATC instructed the aircraft to reduce speed and descend to 12,500 ft. 

Approach instructed the aircraft to descend to 11,500 ft., and cleared it for the VOR RWY 2 approach, maintaining minimum approach speed. Neither pilot remembered to cancel the HOLD previously entered into the FMS because they were still engaged in unnecessary conversation. Upon reaching GURAS, the aircraft turned left to enter the holding pattern. The captain noticed the excursion and made an immediate correction. (ATC was alerting the crew to the situation at the same time.)  
The captain selected the HDG mode and dialed in a heading of 027 deg. —  a 5-deg. intercept angle for the desired 202-deg. inbound radial to VNKT. The local wind was out of the west at 28 kt. The aircraft continued the approach in heading mode and crossed the 202-deg. radial at 7 DME. The aircraft then continued on the 027-deg. heading, thus deviating to the right (east) of the final approach course. Although VMC prevailed, the crew never saw the airport as they passed it, ending up 2- to 3-nm northeast of the complex. 

Kathmandu Tower alerted the crew that the landing clearance was for Runway 2, but the aircraft seemed to be circling to Runway 20.

The tower controller asked the crew of their intentions, to which the captain replied the flight would be landing on Runway 2. The aircraft then made an orbit to the right. So, the controller instructed the crew to join downwind for Runway 2 and report when sighting a Buddha Air aircraft that was on final for the runway. However, instead of joining the downwind leg for Runway 2, the US-Bangla Q400 continued its right turn to a westerly heading northwest of Runway 20. The controller instructed the aircraft to remain clear of Runway 20 and continue to hold at its present position because a Buddha Air aircraft was landing at Runway 2 (from the opposite side) at that time. 

The tower cleared US-Bangla BS211 to land on either Runway 2 or 20, but the aircraft again made an orbit to the right. While continuing with the turn, the captain reported that he had the runway in sight and requested clearance to land. The tower controller cleared the aircraft to land. The aircraft continued to turn and approached very close to the threshold of Runway 20 on a westerly heading and unaligned with the runway.

The tower controller became alarmed by the situation and canceled the landing clearance by saying, “Takeoff clearance canceled.” (He obviously misspoke.)

Within the next 15-20 sec., the aircraft pulled up in a westerly direction and turned left with a very high bank angle and overflew the western area of the domestic apron, continued on a southeasterly heading past the control tower and continued at a very low height over the domestic southern apron area and finally attempted to align with Runway 20 to land. (While the aircraft was heading toward the control tower, the controllers ducked out of fear that it would hit the tower building.) “When the aircraft further turned toward the taxiway aiming for the runway through a right reversal turn, the tower controller made a halfhearted transmission by saying, ‘BS211, I say again . . . ,’” said the commission. 

The aircraft touched down 1,700 meters from the threshold in a 15-deg. bank at a 25 deg. angle to the centerline. It then veered southeast off the runway through the inner perimeter fence along a rough downslope and finally stopped about 442 meters southeast of the touchdown point. The aircraft broke up into number of sections along the rough downslope before coming to a stop.

 

Some 2,800 kg (6,200 lb.) of fuel was on board at touchdown; fire broke out within 6 sec. The commission concluded that most of the occupants would have survived the impact, but the immediate and rapidly spreading post-crash fire likely precluded the possibility of escape for most of those who died. The airport fire brigade vehicle movement was initiated within 16 sec. of impact.

Management and most fellow pilots opined that the captain was a very friendly, soft-spoken and gentle person. He was levelheaded, they said, and would behave nicely with his colleagues and junior staff. He was well-spoken and would not use foul language in conversations. His attitude and behavior toward company, authority, colleagues and juniors was good and he was liked by most of them. He was also a very good teacher and instructor. Most of the students were satisfied with his teaching techniques. The captain never consumed alcohol, was happily married and had a teenage son.

The commission said it seemed the captain was obsessively worried over a female colleague’s criticism of his competency. Most of the conversation in the cockpit during the accident flight was directed toward and aimed at the woman who apparently was telling others that the captain was not a good instructor and he could not teach properly.

“The captain’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 the decision for not initiating a go-around even after realizing that flight was not stabilized, is very poor decision making on the part of the PIC.”