Investigation Summary
The accident occurred during the second of five planned charter flights between Pokhara and Jomsom. Although Jomsom Tower advised using Runway 24 due to south-westerly winds of 8 to 12 knots, the Captain requested Runway 06, which resulted in a tailwind landing. The aircraft touched down approximately 776 feet past the threshold and immediately veered right, departing the runway and rolling 705 feet through a grass area. During this excursion, a critical breakdown in Crew Resource Management (CRM) occurred. The First Officer, following routine procedure for a successful landing, retracted the flaps to the up position. Simultaneously, the Captain, without briefing his intentions, applied power to attempt a takeoff from the grass to return to the runway or go around. Because the flaps were retracted and the Captain was also applying brakes, the aircraft could not gain the necessary lift. It overran the airport perimeter, crashed through a barbed wire fence and a gabion wall, and fell into the Gandaki River. The left wing submerged, but the fuselage remained on the riverbank, preventing a total submersion and likely contributing to the lack of fatalities.
Final Conclusions
The Civil Aviation Authority of Nepal (CAAN) released its final report on February 18, 2014. The investigation determined the probable cause was the PIC's inappropriate conduct of STOL (Short Take-Off and Landing) procedures and landing techniques, specifically the attempt to take off again without sufficient airspeed, lift, or runway length. A major contributory factor was the total absence of CRM, characterized by a lack of communication and coordination regarding the PIC's actions during the post-landing phase, which led to the First Officer retracting flaps while the PIC was attempting to accelerate.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Dipendra Pradhan, 39 years old, Nepali citizen
First Officer
Suresh K.C., 29 years old, Nepali citizen
Systems & Failure Modes
Flaps
High-lift devices used to increase lift at lower speeds; their retraction by the First Officer during the Captain's attempted emergency takeoff prevented the aircraft from becoming airborne.
Braking System
The PIC was reportedly using brakes while simultaneously adding power to take off, further hindering the aircraft's ability to accelerate.
Interesting Facts
- 01The aircraft was a 1979-built DHC-6 Twin Otter that had been with Nepal Airlines since its manufacture.
- 02There were 19 passengers on board, including one infant; 8 were Japanese tourists.
- 03The Captain had over 8,000 hours of experience on the DHC-6 type.
- 04The aircraft was written off following the accident, leaving Nepal Airlines with only two operational domestic aircraft at the time.
- 05Nepal Airlines continues to use the flight number 555 for the Pokhara-Jomsom route.
Safety Actions & Advisories
CRM Training Emphasis
The final report emphasized the need for improved communication and coordination (CRM) between crew members, particularly during non-standard maneuvers or emergency transitions between landing and takeoff.