Buddha Air crash: Report blames pilot error, 'distractions' for crash

KATHMANDU, MAR 02 - An official investigation report has blamed the pilot suffering from 'sleep inertia', improper communication and other distractions for the crash of the Buddha Air's Beechcraft B-1900D in Lalitpur, which killed 22 people on September 25.

The report submitted to the Ministry of Tourism and Civil Aviation (MoTCA) on Friday said that the pilots, tired and irritated by comments made on the cockpit by the ground pilot, were unable to give their 100 percent to the flight that ultimately led to a judgment of error of the crew.

Ten Indians, two US nationals, one Japanese and six Nepalis had died in the crash. The report also indicates "interpersonal relationship" between Pilot-in-Command (PIC) JB Tamrakar and first officer Padma Adhikari before the take-off. However, Adhikari was found to have been made the pilot-in-command.

"Tamrakar's tiredness could be the reason for him to entrust the responsibility to the junior pilot," an investigation committee member said.

The report said Tamrakar was on duty at 6:00 am to prepare for a mountain view flight on September 25, 2011. "On September 24, the day before the crash, Tamrakar was on 12 hours' duty flying other aircrafts," the report said.

The report also said that the ground pilots had irritated the flying crew with unnecessary comments several times and sometimes even 'teasing' them. The flight had to return midway due to weather problems.

"Although, no evidence has been recorded on the personal affair between the two flying crew, and Tamrakar's frequent advice to Adhikari instead of commanding her for necessary procedures has raised doubts on their interpersonal relationship," a member of the investigation panel said.

"Personal comments between the ground pilots and the flying crew kept them distracted," said Dr Ranjit Singh Baral, an investigation committee member who looked after the human factor of the crash. However, Baral refused to comment on the interpersonal relationship between the two crew.

While Adhikari had a mere 18-hour flight experience with seniors, she was not in a position to take up the PIC job.

Amid all the distraction, things took an ugly turn as the aircraft prepared to land at the TIA, and it was away by two minutes. The airport had a six-km visibility while there were clouds in the southern skies of the airport. The aircraft was flying at 5,000 ft although it was required to maintain a 6,000-ft elevation.

The crash occurred when the aircraft was turning south for landing at Runway 02 and suddenly entered a cloud. After entering the cloud formation, Adhikari requested Tamrakar to look for the runway on her right.

"Although, the aircraft descending to 5,000 ft was the major cause of the crash, it could have been avoided had Adhikari followed the panel and instructions inside the cockpit," said the panel member.

What actually led to the crash was both the flying crew's decision to look for the runway, the report said, adding that Adhikari instead should have followed the panel and the instructions.

"It was too late when Adhikari, making her first landing, tried to react when the ground proximity warning system warned 'Terrain Terrain-Pull up, Pull up' three second before the crash. "Had the PIC been Tamrakar, the situation would have been different."

The investigation panel has made nine "interim safety" recommendations including pilot training as per Nepal's terrain, implementation of a single fleet policy, internal safety audit and installation of visual aids.