Loss of situational awareness of crew primary factor for crash

Kathmandu, January 27

The Accident Investigation Commission formed to probe the US-Bangla Airlines’ plane crash at the Tribhuvan International Airport on March 12 last year submitted its report to the government today citing ‘loss of situational awareness of crew member’ as the primary factor behind the fatal crash killing 45 out of the 67 passengers on board.

The US-Bangla scheduled flight DHC-8-402, S2-AGU, BS-211 was flying from Dhaka to Kathmandu.

Though the committee, which was led by former tourism secretary Yagya Prasad Gautam, mentioned that some confusion in communication within the terminal area between the crew and the air traffic controller (VNKT Tower) regarding intentions of the flight crew and clearances for runways 02 and 20 was revealed through the Cockpit Voice Recorder, a complete loss of situational awareness due to negligence in the basic procedural discipline and non-adherence to Standard Operating Procedures (SOP) was evidenced in the part of the flight crew.

“The Pilot in Command (PIC) was also flying the plane under stress and was emotionally disturbed as he felt that the female colleague of the company questioned his reputation as a good instructor. This together with the failure on the part of both the crew to follow the standard operating procedure at the critical stage of the flight contributed to loss of situational awareness to appreciate the deviation of the aircraft from its intended radial that disabled them sighting the runway,” states the report.

“This loss of situational awareness indulged the PIC into some dangerous manoeuvres of the aircraft at a very low altitude in the hilly and mountainous terrain around TIA. Finally, when the crew sighted the runway, they were very low and too close to runway 20 and not properly aligned with the runway,” the report added.

After impact on the ground the uncontrolled aircraft ran out of the runway, hit the runway perimeter fence and rolled down the slope onto the grass field and caught fire which engulfed the aircraft.

Other contributing factors to the fatal crash of the US-Bangla aircraft included the improper timing of the pre-flight briefing and the commencement of the flight departure in which the operational pre-flight briefing was given in early morning but the flight departure time was around noon and there were four domestic short flights scheduled in between, PIC flying under stress due to the behaviour of a particular female colleague in the company and lack of sleep the preceding night, a very steep gradient between the crew, flight crew not having practised visual approach for runway 20 in the simulator and poor Crew Resource Management (CRM) between the crew, as per report.