SANGAM PRASAIN
KATHMANDU, NOV 22 -
Human error appears to be the cause behind the crash of Agni Air's Dornier aircraft on August 24 during a scheduled passenger flight from Kathmandu to
Lukla, according to an Agni Air's accident report made public here on Sunday.
The investigation commission report said that the technical aspect of the twin-engine plane was a secondary cause. However, human errors -- not following the flight checklist and lack of advice to deal with the emergency -- were found to be the major cause of the accident.
Although the pilot had an option to prevent technical errors, he was unable to get suggestions from the ATC and Agni Air's pilots in such a critical situation that were in communication with him. "But nervousness ruled more in the last hour making the pilot take his independent decision and made him forget regular checklist procedures," a source said. "We assumed that the captain forgot to switch off the battery before lowering the landing gear," said engineer Sharada Bhakta Rajbhandari, presenting the technical aspect of the report.
When the two generators of the aircraft were died, its battery could provide power for about 30 minutes. "However, the battery lasted for only 13 minutes as a result of bringing the landing gear down using the electric hydraulic pump without switching off the battery power that had consumed maximum power," Rajbhandari said. As soon as the landing gear was lowered, the aircraft lost speed and balance that made the aircraft uncontrollable and it nosedived to the ground. The investigation commission determined that the accident took place due to spatial disorientation of the flight crew, after the loss of altitude indication because of the total loss of battery power causing the aircraft go into an uncontrolled dive to the ground. Weather at the time was severe in terms of rain, cloud and visibility. Visibility was less than 500 m.
On August 24, the Agni Air’s aircraft crashed at Bastipur of Sikharpur VDC in Makwanpur district killing 14 passengers
on board. The aircraft dived from an altitude of 11,500 ft and impacted the ground at an elevation of 1,760 ft and disintegrated completely.
The investigation commission report also said that there was no emergency declared despite using the emergency checklist for double generator failure, which required the aircraft to land (Aviation Safety Action Program) ASAP. "If the flight captain was able to declare an emergency after knowing that both generators had failed, it should be a different story," said Rajbhandari.
The flight had contacted Agni Air's instructor pilots and the ATC after problems were seen in the aircraft. "The ATC lacked proper information about the technical status of the aircraft and thus failed to understand the gravity of the situation." Agni Air's instructor pilots who were in communication with the aircraft failed to provide suitable suggestions to handle the situation, the report said.
The investigation commission for the Agni Air crash said that there was no recording of
the initial 15 minutes after take-off in the Cockpit Voice Recorder (CVR), which they said was a serous issue.
Meanwhile, minister for Tourism and Civil Aviation Sharat Singh Bhandari said that his ministry was committed to making an in-depth study of air crash reports. "Reports of past air accidents will also be studied and appropriate remedies implemented to make the Nepali skies more reliable,” he said.
Findings
• The aircraft had dual generator failure and was powered for about 13 minutes
on battery
• The landing gear was found extended in the aircraft
• Language spoken in cockpit was ambiguous and non-standard
• No emergency was declared despite using the emergency checklist for double
generator failure
• Agni Air's instructor pilot who were in communication with the aircraft failed
to provide suitable suggestion
• The aircraft was released by maintenance personnel for IFR operations despite its lacking of proper standby power supply
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