Investigation Summary
The flight was an unscheduled domestic service carrying 18 passengers, primarily Indian pilgrims, and 3 crew members. During the approach to Jomsom's runway 06, the crew lowered the landing gear and received a fault indication suggesting the wheels might not be properly locked. After failing to resolve the indication, the crew initially requested to land on the reciprocal runway 24 but then decided to abort the landing entirely and return to Pokhara. At approximately 9,200 feet MSL, just after crossing the runway 06 threshold, the captain initiated a sharp left turn. This maneuver was performed at 73 knots, a speed insufficient for the bank angle and radius required to clear the surrounding mountains. The aircraft entered a continuous stall warning state for the final 12 seconds of flight. The left wing struck a rocky outcrop on a hill, causing the aircraft to stall and impact a muddy slope nose-first. The flight attendant and five passengers survived the impact and were subsequently airlifted to Pokhara for treatment.
Final Conclusions
The investigation concluded that the primary cause was the captain's decision to execute a sharp left turn at low airspeed (73 KIAS) without regard for the aircraft's turn radius or the proximity of rising terrain. This maneuver was contrary to all published standard operating procedures for Jomsom Airport. The investigation also noted that while the captain was a senior flight instructor for the Civil Aviation Authority of Nepal, he had relatively low experience on the Dornier 228 type. The first officer had expressed concern regarding the turn radius during the maneuver, but these concerns were not acted upon.
Photographic Evidence (1)
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Senior flight instructor for CAAN.
Systems & Failure Modes
Landing Gear Indication System
The crew received a fault indication after extending the gear, leading them to believe the wheels might lock up or were not secure for landing.
Stall Warning System
The system provided a continuous warning for the final 12 seconds of flight as the aircraft's speed dropped to 73 knots during a steep turn.
Interesting Facts
- 01The aircraft was a Dornier 228-212 built in 1997, previously operated by Hornbill Skyways.
- 02The crash site was located approximately 270 meters north of the aerodrome near Marpha village.
- 03The captain was a senior flight instructor employed by the Civil Aviation Authority of Nepal (CAAN).
- 04Six survivors, including the flight attendant, were rescued from the nose section which remained relatively intact on the slope.
- 05Weather at the time of the accident was reported as clear, though Jomsom is known for high winds later in the day.
Safety Actions & Advisories
Jomsom Approach Procedures Review
Investigators highlighted that the accident could have been avoided if the crew had followed standard missed approach procedures or turned right toward lower terrain instead of left into the hills.