Tara Air flight 193 crash report: Pilots violated standard operating procedure
Aug 1, 2016-
Pilots of Tara Air Flight 193, which crashed at Myagdi’s Solighopte in February killing all 23 onboard, deliberately entered cloud while operating under the visual flight rules and deviated from the normal track due to the loss of situational awareness, the government’s fact-finding committee said on Sunday.
Visual flight rules are a set of regulations under which a pilot operates an aircraft in weather conditions generally clear enough to allow the pilot to see where the aircraft is going. Entering cloud under the visual flight condition is violation of standard operating procedure.
A crash report submitted to the Tourism Ministry after five-and-half-month-long investigation pointed out that the crew had to contend with poor visibility and fog on the Pokhara-Jomsom route, one of the treacherous routes, after the plane reached an altitude of 7,000 ft.
The Pokhara airport had cleared the aircraft under 5,000m visibility, but the visibility report provided by the metrological office was 4,000m, according to the report. Flights are operated when the visibility is 5,000m in Pokhara. The flight was under the command of co-pilot Dikesh Nemkul.
After travelling 5 miles at 10,100 ft, before the Ghorepani passing, Captain Roshan Manandhar, who was acting as pilot monitoring, had said: “Cloud cell still present.”
Manandhar then advised Nemkul to continue to climb to 12,000 ft and told him that they will take chance till Tatopani and decide whether to continue or divert, the report said.
Due to adverse weather condition on the flight path, the flight crew had avoided the normal route of Kaligandaki and deviated to the left. Suddenly, over the Ghorepani area, the cockpit started to buzz with ground proximity alert—“terrain...terrain; pull up...pull up”, the report said. The aircraft was flying in dark clouds. “However, for a few second, the visibility outside the cockpit had improved,” the report states.
The captain then instructed the flight commander to descend and subsequently a shallow descent was initiated. Again, the captain asked: “Whether you can see the visual.” Nemkul replied: “Somewhat visual.”
Nemkul was then instructed to descend to 10,000 ft. Again, an “over speed” warning sounded in the cockpit for 2 seconds. Then, the terrain alert sounded when the aircraft was at 10,200 ft. However, the captain responded not to worry about it, the report said. “The captain did not respond to the repeated warnings,” said Captain Shrawan Rijal, a member of the government’s committee.
Finally, at the critical point, a minute before the crash, Captain Manandhar decided to take the control. He then started to climb the aircraft. But the aircraft’s belly hit the terrain at 10,700 ft and was destroyed completely by the impact. It rested at an altitude of 10,982 ft. The captain had 1:05 minutes to react, but he did not consider it seriously, the report said.
However, there were also other reasons for Manandhar hesitance to react. “Based on previous flight data recorder of the same aircraft, the area used to witness repeated ground proximity alert in the normal flight situation too,” said Rijal. “They had become habitual of the alert so it was not considered seriously.”
However, being an experienced pilot, who had 20,800 hours of flying experience, it was “skill error” or “judgemental error” of the captain, the report said. Rijal said there are other areas as well where such types of alerts are persistent and it’s a serious issue.
After the submission of the report, a new debate has surfaced whether co-pilots or junior captains should be allowed to fly on treacherous route.
The investigation committee had issued an interim safety recommendation to the Civil Aviation Authority of Nepal (Caan) to enforce a mechanism to stop the tendency of pilot-in-command acting as pilot monitoring and junior pilots or co-pilots as flight commander during critical circumstances or on treacherous routes under the visual flight condition in the domestic sector.
However, some pilots said such a decision would prevent juniors to be experienced on difficult terrain and condition.
The committee has recommended that the Caan devise a mechanism to study en-route weather to ensure safe operation. It has recommended that the Department of Hydrology and Meteorology develop facilities to provide en-route weather information along various routes, particularly for aircraft flying on remote areas.
It has also recommended airlines ensure compliance with the provision of visual flight rules as an aircraft entering cloud under visual flight is considered a crime.
Published: 01-08-2016 09:30