Investigation Summary
The flight was the second leg of a domestic route, with the First Officer designated as the Pilot Flying (PF) and the Captain as the Pilot Monitoring (PM). During the approach to Heho, the crew encountered 'distinct fog' with visibility reported at 3,000 meters. Despite the airline's SOPs prohibiting a First Officer from flying landings in visibility less than 3,000 meters, the Captain allowed the junior pilot to continue. The crew initiated a non-precision NDB approach to runway 36 but turned prematurely, requiring heading corrections. As the aircraft reached the MDA of 530 feet, the crew lacked visual contact with the runway environment but failed to initiate a missed approach. Instead, they continued the descent. When the EGPWS issued low-altitude alerts, the Captain attempted to engage the autopilot's altitude hold mode rather than performing a go-around. The aircraft was already too low to recover, striking 66 KV power lines and trees before coming to rest in a paddy field across a road.
Final Conclusions
The Myanmar Accident Investigation Bureau (MAIB) concluded the primary cause was the crew's decision to descend below the MDA of 160 meters (530 feet) without the runway in sight. Contributory factors included the Captain's inadequate risk assessment in assigning the First Officer as PF under the prevailing weather conditions, and increased perceived pressure to land due to other aircraft following them in the approach sequence. The investigation also noted high pilot workload and a loss of situational awareness during the final stages of the flight.
Photographic Evidence (1)
Video Analysis
The Airline That Didn’t Care About Safety | Air Bagan 011 — A detailed look at the Christmas Day 2012 crash of Air Bagan Flight 011, examining the pilot errors and procedural violations that led to the CFIT accident.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Pilot Monitoring (PM) during the accident leg. 49 years old.
First Officer
Pilot Flying (PF) during the accident leg.
Systems & Failure Modes
EGPWS
The Enhanced Ground Proximity Warning System provided multiple aural alerts as the aircraft descended toward the terrain, which were ignored by the crew until the final seconds.
Autopilot Altitude Hold
The Captain attempted to use the altitude hold function at approximately 100 feet above ground level to arrest the descent instead of executing a manual go-around.
NDB Approach
A non-precision approach using a Non-Directional Beacon, which requires pilots to strictly adhere to Minimum Descent Altitudes (MDA) as it provides no vertical guidance.
Interesting Facts
- 01The aircraft was a 21-year-old Fokker 100 that had previously served with British Midland Airways.
- 02One passenger died in the aircraft, and one motorcyclist was killed on the ground by falling debris and fuel.
- 03The Captain had 5,937 total flight hours, while the First Officer had only 849 total hours.
- 04The aircraft had passed a major maintenance check in November 2012 and a line check two days before the crash.
- 05Two emergency exits over the right wing were not used during evacuation because that side of the aircraft was on fire.
Safety Actions & Advisories
MAIB Recommendations
Source ↗The Myanmar Accident Investigation Bureau issued three safety recommendations: Air Bagan must ensure pilots strictly adhere to SOPs and MDA requirements, improve CRM training regarding the designation of Pilot Flying in adverse weather, and the Department of Civil Aviation should enhance oversight of airline training programs.