Investigation Summary
The flight was a scheduled cargo service carrying 21 tons of textiles and carpets. Following a departure from Runway 20, the crew was required to follow a specific SID to clear the high terrain surrounding the Kathmandu valley. However, the investigation found that the Captain (P1) provided an incomplete departure briefing while other cockpit activities were underway, leading to poor situational awareness. As the aircraft entered a shallow 10-degree right bank, the airspeed decayed to V2-3 while the First Officer (P2) was preoccupied with ATC communications. The Captain then used an improper power and climb profile after rolling out on a southwest heading. The aircraft crossed the 4 DME arc at approximately 7,500 feet, well below the required minimum altitude of 9,500 feet for that area. Although the GPWS sounded and a stick shaker activated as speed dropped to 171 knots, the crew's response was insufficient to prevent the collision with the Champadevi Hills.
Final Conclusions
The Nepalese investigation concluded the primary cause was the crew's failure to adhere to the published SID for Runway 20. Contributory factors included an incomplete departure briefing, inadequate intra-cockpit coordination (CRM), improper power management during the climb, and a slow, incorrect response to GPWS warnings.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Systems & Failure Modes
Ground Proximity Warning System (GPWS)
A system designed to alert pilots if their aircraft is in immediate danger of flying into the ground or an obstacle; in this event, the crew responded too slowly to multiple alerts.
Stick Shaker
A mechanical device that rapidly and noisily vibrates the control yoke to warn the crew of an imminent aerodynamic stall; it activated 11 seconds after the GPWS.
Standard Instrument Departure (SID)
A published flight procedure followed by aircraft on IFR departure; the crew failed to follow the specific SID for Runway 20, leading them into terrain.
Interesting Facts
- 01The aircraft was carrying 21 tons of cargo, primarily woolen carpets and textiles.
- 02The flight was operated by Hinduja Cargo Services on behalf of Lufthansa Cargo.
- 03The crash site was located approximately 11 kilometers (6 nautical miles) southwest of the Kathmandu VOR/DME.
- 04Weather at the time of the accident was drizzly with a ground temperature of 22°C.
- 05The aircraft was 17 years old at the time of the accident.
- 06The flight was scheduled to stop at New Delhi before continuing to its final destination in Sharjah.
Safety Actions & Advisories
CRM and SOP Adherence
The investigation emphasized the necessity of strict adherence to Standard Operating Procedures (SOPs) and effective Crew Resource Management (CRM), particularly during high-workload departure phases in mountainous terrain.