Helicopter Accident Investigation Commission …s3.amazonaws.com/zanran_storage/ Report of Accident...

Final Report of Accident Investigation of helicopter 9N-AHJ

Page No. 1

Helicopter Accident Investigation Commission Kathmandu, Nepal.

FINAL REPORT

Accident of Shree Airlines (P) Ltd. Helicopter 9N-AHJ (MI-8 MTV-1)

Accident Date : 23rd September 2006

Accident Site : Lelep V.D.C.- 9 Phaledanda, Taplejung

Submitted to,

The Government of Nepal

on 4th December 2006


Page No. 2

The Accident Investigation Commission :

In Nepal Accident Investigation Commission for aircraft accident investigation is formed under

Civil Aviation (Accident Investigation) Rules, 2024. Commission to Accident Investigation for 9N-AHJ

MI-8MTV1 of Shree Airlines (Pvt.) Ltd. was constituted as per the decision of Nepal Government on 25th

September 2006. The responsibility of the Commission is to find out the cause of the accident and give

recommendations for the prevention of accident of similar nature in future.

Composition of the Commission:

Hon. Keshari Raj Pandit, Justice, Court of Appeal, Patan, Lalitpur Chairman

Mr. Puspa Raj Koirala, Joint Government Attorney, Member

Office of the Attorney General

Col. Pramod Kumar Lama, No. 11 Brigade, Gaucher Member

Mr. Sanjeev Shrestha, Engineer, Simrik Airlines (P.) Ltd. Member

Mr. Bijaya Kumar Vaidya, Deputy Director General,

Department of Hydrology and Meteorology Member

Brig. (Retd.) Dr. Khagendra Bahadur Shrestha Member

Mr. Yajna Prasad Gautam, Joint Secretary,

Ministry of Culture, Tourism & Civil Aviation

Member - Secretary


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Synopsis On 23rd September 2006, the ill-fated MI-8 MTV-1 helicopter 9N-AHJ owned and operated by

Shree Airlines Pvt. Ltd., was on chartered flight to Ghunsa, Taplejung. It departed from Fungling,

Taplejung at 09:32 LT and weather was cloudy with light drizzle. The helicopter during flight reached

maximum altitude 3400 m. and reported on ground Ghunsa at 09:51 LT.

The flight was in command of Capt. Klim Kim and this was his first flight to Ghunsa. The

weather at Ghunsa was cloudy. The helicopter, with 4 crew members and 20 passengers and TOW 10,344

kg, took-off at 10:45 LT (0500 UTC) and entered into cloud while clearing Ghunsa valley. Then

helicopter climbed up to 3885 m. with air speed 62 km/hr in 2 min 30 seconds and flight was into clouds.

At this moment, pilot observed that helicopter was only 60 m. above the ground, which indicated that

peak was somewhere around them. Flying in IMC, he decreased the airspeed and tried to achieve high

rate of climb with application of maximum power. Helicopter reached up to 4033 m. and this moment

speed dropped to 31 km/hr. The combined effect of speed below 31 km/hr, low main rotor RPM,

helicopter weight at that altitude and flying into the cloud (IMC) contributed to sink the helicopter from

4033 m. In 13 seconds, the helicopter descended to 3990 m. with further drop in airspeed of 12 km/hr and

main rotor RPM 91% and faced impact in steep rugged mountain terrain. Fire was immediately registered

in helicopter. All other parts were found in limited area in burnt conditions. No survival was found.

The Commission has determined the primary contributing factors for this accident are entering the

cloud intentionally in the unfamiliar terrain of high altitude mountains, poor crew coordination and poor

area map information. This helicopter was certified only for Visual Flight Rules (VFR).

The Commission has presented its safety recommendations needed to be adopted by the Civil

Aviation Authority of Nepal, Shree Airlines and other Airlines. The objective of these recommendations

is the prevention of the accident of this nature in future.

Injuris to Person FATAL Seriously injured Minor injured Non injured

Crew - 04 00 00 00

Passenger - 20 00 00 00

Other - 00 00 00 00


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1. Factual Information

1.1 History of the Flight

At about 0500 UTC on 23rd September 2006, a MI-8 MTV 1 helicopter with registration 9N-AHJ

of Shree Airlines (P.) Ltd, departed Ghunsa, Taplejung on a charter flight to Fungling, Taplejung in the

eastern part of Nepal with 4 crew members and 20 passengers on board and crashed at Lelep V.D.C-9

Phaledanda. The actual flight plan was not submitted as the helicopter was taking-off from an unmanned

helipad.

9N-AHJ had departed Kathmandu on 22nd September 2006 for Taplejung with the intention of

making the flight from Fungling to Ghunsa on the next day. On the way to Taplejung it was to land at

Rampurtar, Okhaldhunga to pick up Hon. State Minister Gopal Rai but could not land at Rampurtar and

instead landed at Okhaldhunga due to weather. Later the helicopter arrived at Taplejung on the same day.

The main programme of charter party World Wildlife Fund (WWF) was launched at Fungling on 22nd

September 2006 and the helicopter made a night stop at Fungling. Throughout the day the weather

condition at Taplejung was frequent rain and cloudy.

On 23rd September 2006 also the weather condition was not good. It was totally overcast with

frequent light rain. The commander of helicopter 9N-AHJ intended to complete the planned flight to

Ghunsa when he felt a little improvement of weather. After getting listed passengers on board, the

helicopter departed Fungling at about 0932 LT for Ghunsa and arrived there at 0951 LT. As per eye

witnesses after reaching Ghunsa, the passengers proceeded to the programme venue, completed their

programme within a short period of time and then came back to the helipad for departure. As per local

people, weather condition at Ghunsa and surrounding was cloudy with frequent rain and drizzle. All the

surrounding hills including hill tops and also foothills to east, west and south were completely covered up

but north side hilltops were partially visible. The helicopter took-off from Ghunsa at or about 10:45 LT

i.e. 0500 UTC with an approximate load of 10334 kg. The eye-witnesses told the Commission that within

a few moment of take-off the helicopter disappeared into clouds. Then approximately about 3 minute

after take-off an unusual sound like 'Bang' was heard by the local people at Ghunsa and after few minutes


Page No. 5

later another big sound was heard but nothing was observed visually. Following the events, the local

people of Ghunsa called Fungling and gave the detail information. The message was relayed to

Kathmandu and Rescue Co-ordination Center (RCC) at Tribhuvan International Airport was activated

immediately on 23rd September 2006 at 1400 LT. Air Dynasty Helicopter 9N-AGU flying in Taplejung

area was requested to attempt search for 9N-AHJ but it could not fly the probable area due to bad

weather.

On 24th September 2006 with no improvement in weather, a ground search team was sent to

Ghunsa including a 15 member team from Nepal Mountaineering Association along with local people.

Finally the ground Search and Rescue team located the crash site at Lelep V.D.C.-9 Taplejung (Co-

ordinates 273845 N 0875411 E) at 3990 m. from sea level on a steep rocky terrain and found the aircraft

completely destroyed into several pieces and totally burnt. There was no survival and almost all except

one body was found in a burnt and charred condition. The rescue team recovered dead bodies and FDR

but could not find the CVR. All the dead bodies and body parts including FDR were dispatched to

Kathmandu subsiquently. FDR read out was done at Russia.

1.2 Injuries to persons:

Injuris to Person FATAL Seriously injured Minor injured Non injured

Crew - 04 00 00 00

Passenger - 20 00 00 00

Other - 00 00 00 00

1.3 Damage to aircraft:

The helicopter caught fire upon impact with rocky terrain. Main rotor blades and tail rotor blades

were broken into pieces and scattered around the site. Nose landing gear was detached from the airframe.

All other parts were found in a limited area without much scattering. Cockpit, central part of fuselage and

some parts of tail boom were found totally burnt to ashes and the remaining parts were found in a

damaged condition.


Page No. 6

1.4 Other Damages:

The accident site consisted of steep rugged cliff without any habitation and vegetation at an

altitude of 3990 m. So no damage was caused to private property and persons.

1.5 Personal Information:

Capt. Klim Kim

Captain : Male Date of Birth : 10.03.2054. Nationality : Kyrgyzstan Republic License : 00018 Issued by : Kyrgyzstan Republic Validity : 16.06.2007 Rating at type, and instructor : MI-17 (MI-8 MTV, MI-8 AMT) Nepalese License : 143 Authorization by : Civil Aviation Authority of Nepal Validity : 16/12/2006 Last Medical : 16/06/2006 Pilot Proficiency Check : 20/11/2005 Previous accident/incident : None

He had received the following trainings and attended the following courses in Kathmandu:

i. Training in Aeronautical Information Publications (AIP), Nepal from 30 August 2005 to 04

September 2005, conducted by Civil Aviation Authority of Nepal,

ii. Passed English Language Skill test with remarks ‘satisfactory’ on 13 September 2005, taken

by Civil Aviation Authority of Nepal

iii. Passed Pilot Proficiency & Upgrading Check on 20 November 2005 with remarks

‘Satisfactory’,

iv. 6-hours training course in CRM on 21 November 2005

v. Refresher Course in Flight Operation Regulation (FOR) on 24 November 2005,

vi. Refresher Course on Transport of Dangerous Goods on 25 November 2005.

vii. Technical & Performance Refresher Course in MI-17 helicopter from 22 November 2005 to

25 November 2005,

viii. High Altitude Familiarization/Practice carried out on 01.12.2005 and 02.12.2005 with

Instructor pilot Captain Koleniscov Vladimir at Syangboche, Everest Base Camp area


Page No. 7

He also had following special remarks (Restriction/Rights) from his country and valid up to 26

May 2006:

i. Rated for Radiotelephony operation in English,

ii. Helicopter MI-8T/MI-8MTV, sling cargo ferry over plain, mountain area,

iii. Helicopter MI-8T/MI-8MTV-1, cargo dumping and parachute landing,

iv. Helicopter MI-8T/MI-8MTV-1, cross country flight & airborne air field selection up to

altitude 4500 m,

v. Helicopter MI-8T/MI-8MTV-1, cross country flight & airborne air field selection up to

altitude 5000 m

Flight hours total 11977:36

Flight hours on Type 3777:36

Hours flown in last three months 122:47

Hours flown in last 30 days 88:46


Professional Training Flight Training, Russia

Aircrafts flown MI-8T, MI-8MTV, MI-AMT

Date of joining Shree Airline 25 August 2005

Career Progression Senior Captain

Earlier Professional Experience Flying in Kyrgyzstan

Co-pilot, Capt. Mingma Tshering Sherpa

Captain : Male Date of Birth : 15.11.1972. Nationality : Nepalese License : ATPL 17 (H) Issued by : Civil Aviation Authority of Nepal Rating at Type, Pilot in command, Day only, July 2003

MI-17-IV (MI-8MTV)

Validity : 30/09/2006 Pilot Proficiency & Upgrading Check : 21.03.2006 Last Medical : 22.09.2005 Previous accident/incident : None


Page No. 8

i. Successfully completed High Altitude Training flight up to 13000 ft. on 10.02.2006,

13.03.2006 and 17.03.2006 in Heli Hansa, Instructor A. Tchirva, Syangboche Airfield.

ii. Route Check, satisfactory, KEP to DUNAI, 30.09.2005, in Heli Hansa, Instructor V.

Koleniscov

iii. Recurrent Training, found proficient, 29.04.2005, in Heli Hansa, Instructor V. Koleniscov

iv. Successfully completed Refresher Ground Class Training, Technical and Performance, on Mi-

17 Helicopter on 28 02.2005, Simrik Air

v. Successfully completed Refresher Ground Class Training on Company Resource Management

(CRM), Flight Operations Requirements (FOR), and Transport of Dangerous Goods 03 – 05,

March 2005, Simrik Air

Total Flight hours 3476:20





Professional Training CPL Training in Kremenchug, Ukraine in 1995

Aircrafts flown MI-17-1V

Date of joining Shree Airline 17 September 2006

Career Progression Captain

Earlier Professional Experience

Co-pilot in Asian Airlines after coming back from Russia

Joined Heli Hansa from Sept, 2004

Then Shree Airlines on from 17 September 2006

He was overweight. He had undertaken Glucose tolerance tests in Sept 2004 and they were in

normal range. He was considered to be a good, knowledgeable, experienced and safety conscious

pilot. He had flown together with Capt Klim for the first time only from 21 Sept 2006.

Flight Mechanic (Flight Engineer) F/E Safronov Valeriy

F/E : Male Date of Birth : 1959 Nationality : Russian Flight Mechanic License : 006819 Issued by : Federal Aviation Authority of

Russia Validity : 01.06.2005


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Nepalese License : F/E 123 Authorization by : Civil Aviation Authority of Nepal Validity : 01.06.2007 Rating at type : MI-17 (MI-8 MTV, MI-8 AMT) Last Medical : 16/06/2006 Pilot Proficiency Check : 12.04.2006 Previous accident/incident : None

Ratings Flight Engineer Instructor

Helicopter MI-8 MTV/AMT – 26.06.2000

Flight Engineer Instructor MI-171 – 26.05.2004

Flight Engineer MI-8 MTV – 29.11.1999

Special Remarks:

Approved for Flight Engineer Instructor – MI-8 MTV/AMT – 26.06.2000

Approved for High Altitude Flight -04.07.2000

Approved for Rescue Operation over sea – 04.07.2000

Approved for Night Flight - 04.07.2000

Approved for Sling Operation – 20.04.2001

Approved for international flight – 20.04.2001

Approved for Test Flight – 25.07.2003

Approved for Search and Rescue Flight – 15.06.2003

License issued in accordance with ICAO Standard – 29.11.1999

Simulator Training, KTV mi-8 MTV/AMT 31.05.2006 & 01.06.2006 – Excellent

Recurrent Training F/E First Class Mi-8&T/MTV/AMT 01.06.2006 – Excellent

NCAR Examination conducted by Airworthiness Inspection Division, CAAN 14.06.2004 – Pass

Flight hours total 6163:06





Aircrafts flown MI-8MTV, MI-AMT, MI-171

Date of joining Shree Airline 06 June 2004

Career Progression Instructor flight training

Earlier Professional Experience Flying in Russia


Page No. 10

He was considered to be an experienced flight mechanics

1.6 Aircraft Information

1.6.1 Airframe

Helicopters type MI are designed by MIL Moscow Helicopter Plant, Russia. As per helicopter log

books and documents submitted by Shree Airlines, helicopter MI-8 MTV-1 with Registration No. 9N-

AHJ was manufactured by Kazan Helicopter Plant, Russia on 11th April 1984. Initially this helicopter

was equipped with two TV3-117 MT engines and helicopter type was MI-8MT (MI-17).

This helicopter was modified from MI-8MT to MI-8 MTV-1 in July 1998 as per service bulletins

and 'Decision' issued by designer "MIL Moscow Helicopter Plant" and manufacturer "Kazan Helicopter

Plant". This modification work was carried out by maintenance organization 'ERDAS' in Kazan, Russia.

This helicopter was converted to 'Passenger Version' from 'Cargo Version' by AEROTECH SLOVAKIA

Company, Bratislava in 17.10.2003 with authorization from "MIL Moscow Helicopter Plant".

Helicopter 9N-AHJ was imported to Nepal from Germany by Manang Air Pvt. Ltd. (Nepal) after

issuing a Certificate of Registration by CAAN on 24th October 2003. Before its operation started in

Nepal, the helicopter had been operated for 52 hours since last overhaul and total time since new was

only 798 hours. The helicopter was transferred to Shree Airlines on 25th August 2006. Shree Airlines

operated this helicopter for 76 hours within 28 days of purchase till the date of accident on 23rd

September 2006.

Out of the total service life of 7000 hours and/or total calendar life of 25 years of MI-8 MTV-1

helicopter, as per present documents the ill-fated helicopter had completed 2145 hours of service life and

22 years 5 months of total calendar life.

Aircraft Manufacturer : Kazan Helicopter Plant Designer : MIL Moscow Helicopter Plant

Aircraft Owner : Shree Airlines (P) Ltd.

Aircraft Operator : Shree Airlines (P) Ltd.


Page No. 11

Present user : Shree Airlines (P) Ltd.

Aircraft Registration Mark : 9N-AHJ

Aircraft Model : MI-8 MTV1

Aircraft Serial No. : 93590

Time since overhaul : 1398 hours

Total Time Since new : 2145 hours

1.6.2 Engines

1.6.2.1 Engine History

MI-8MTV-1 helicopter 9N-AHJ was equipped with two TV3-117VM engines manufactured by

"Motor Sich", Ukrane. Engines were Turboshaft-free turbine type with maximum power 2200 SHP each.

S.N. Description Engine 1 Engine 2

1. Make Motor Sich, Ukrane Motor Sich, Ukrane

2. Type TV3-117VM TV3-117VM

3. Serial Number 7087852703217 7087883200146

4 Date of Manufacture 02.06.1987 24.09.1992

5. Modification from TV3-117V __________

6. Overhauled by Lugansk Aviation Repair

Plant, Ukraine in 07.02.2001

Ural Overhaul Plant, Russia in

26.10.2004

7. Time Since Overhaul 920 Hours 815 Hours

8. Total Time Since New 2011 Hours 2513 Hours

9. Installation Date 21st February 2006 7th January 2005

10. Remaining Life to next overhaul 580 Hours 685 Hours

1.6.2.2 Engine Operating Parameters

Output Shaft

Horsepower

Power Without

DPD

With

DPD

installed

Maximum

Gas

Generator

Turbine

Speed, %

Maximum

Engine Gas

Temperature,

ºC

Main

Rotor

RPM, %

Time of

Continuous

Operation, Min.

Contingency 2200 2100 101.15% 990ºC 93±1 ____

Take-off 2000 1900 101.15% 990ºC 93±1 6 Min.


Page No. 12

-10

Max. Continuous 1700 1700 99.0% 955ºC 95±2 60 Min.

Cruising 1 1500 1500 97.5% 910ºC 95±2 Not limited

Cruising 2 1200 1200 95.5% 870ºC 95±2 Not limited

Idle 200 200 as per graph 780ºC 55+15 20 Min.

1.6.3 Main Gearbox History

Main Gearbox of this helicopter MI-8 MTV-1 was manufactured by Perm Motors, Russia.

S.N. Description Main Gear Box

1. Part No. VR-14

2. Serial Number 1040141103074

3. Perm Motor, Russia

4 Date of Manufacture 13th March 1991

5. Overhauled by Ural Overhaul Plant, Russia in

29.07.2005

6. Time Since Overhaul 431 Hours

7. Total Time Since New 3449 Hours

8. Installation Date 15th October 2005

9. Remaining Life to next overhaul 1169 Hours

1.6.4 Aircraft Schedule Inspections and Maintenance Status

The Accident Investigation Commission examined in detail the history of recent maintenance

works on helicopter 9N-AHJ. This consisted of reviewing of maintenance records and extensive

interviews of maintenance personnel associated with the maintenance works. Additionally, the past one

year record along with helicopter logbooks, engine logbooks, main gearbox logbook and component

cards were examined.

Last major inspection carried out in this helicopter was "500 hours TBO prolongation Inspection"

by authorized engineers from MIL Moscow Helicopter Plant, Russia on 28th October 2005. This

inspection was conducted in Nepal and service life till next major inspection was extended to 1500 hours

and calendar life up to 17th October 2006. So the remaining service life was 102 hours and/or calendar

life for 25 days till next major inspection.


Page No. 13

Last Schedule Inspection was carried out on 21st September 2006 in the volume of "100 hours

Inspection" by engineers of Shree Airlines at TIA, Kathmandu.

Last Daily Inspection of helicopter was carried out by engineers of Shree Airlines on 21st

September 2006 at 5 P.M. Pre-flight inspection of helicopter was conducted by engineers of Shree

Airlines at 7:00 A.M. on 22nd September 2006.

The maintenance record showed that maintenance and schedule inspections were carried out in

this helicopter as per schedule inspection programme while operating in Nepal.

1.6.5 Aircraft Maintenance History

Maintenance Manual, Overhaul Manual, Service Manual and Maintenance Instructions of

helicopter MI-8 MTV-1 were issued by the manufacturer 'Kazan Helicopter Plant, Russia". Shree

Airlines Pvt. Ltd. has developed Maintenance Procedure Manual in April 2005 for the maintenance of

their MI-8 MTV helicopter and this manual was approved by Civil Aviation Authority of Nepal on 15th

May 2005. Subsequent Maintenance recommendations such as Service Bulletins, service letters,

Decisions etc. are issued by Manufacturer or designer "MIL Moscow Helicopter Plant".

Normal maintenance works carried out in MI-8 MTV-1 helicopter are as follows:

A. Inspection Procedures classified as per "Maintenance Procedure Manual" are:

(i) Pre-flight Inspection

(ii) Daily Inspection

(iii) 50 hrs./100 hrs/200 hrs. or 300 hrs. Schedule Inspection

(iv) Storage Inspection

Last Schedule Inspections carried out in this helicopter is mentioned in 1.6.4

B. Rebuild and Reconstruction Work (RRW) is carried out by designer "MIL Moscow Helicopter

Plant" or approved Maintenance Organization with permission of Civil Aviation Authority.

This type of maintenance was not carried out in this helicopter.


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C. Overhaul of the helicopter is carried out by approved Maintenance Organization in Overhaul

Plant in Russia.

This helicopter was overhauled by Maintenance Organization "ERDAS" in Kazan, Russia on

18th July 1998.

D. Local modification works are carried out with permission of and in coordination with Civil

Aviation Authority.

GPS, ELT and Digital FDR installation in this helicopter were carried out as Local

Modification with permission of and in coordination with CAAN.

E. TBO prolongation inspection works for Airframe TBO service life/Calendar life prolongation

are carried out by designer "MIL Moscow Helicopter Plant" with permission and approval of

Civil Aviation Authority.

MIL Moscow Helicopter Plant conducted 500 hours TBO prolongation inspection on 28th October

2005 after completion of 1000 hours given after overhaul with permission of and in

coordination with CAAN.

This helicopter was in almost complete storage position without any flights in the years 1995,

1996, 1997 and 1998. But it was overhauled in July 1998 and modified from MI-8MT to MI-8 MTV by

an approved Maintenance Organization, ERDAS with change or overhaul of major components. This

overhaul work was certified and approved by the designer MIL Moscow Helicopter Plant and the

manufacturer Kazan Helicopter Plant.

1.6.6 Helicopter Speed Limitations

IAS Limits, Km/hour

13000 kg take-off weight 11100 kg take-off weight Altitude, M

Maximum Minimum Maximum Minimum

Up to 1000 Meter 230 km/hr 60 km/hr 250 km/hr 60 km/hr

2000 Meter 195 km/hr 60 km/hr 230 km/hr 60 km/hr



4800 Meter 100 km/hr 60 km/hr ______ 60 km/hr


Page No. 15

5000 Meter ______ ______ 130 km/hr 60 km/hr

6000 Meter ______ ______ 100 km/hr 60 km/hr

The Helicopter 9N-AHJ was flying with a take-off weight 10344 kg and flying at an altitude of

4033 meters just before the crash. For this take-off weight and altitude, the minimum air speed is 60

km/hr.

1.7 Meteorological Information :

Nepal experiences seasonal rainfall from June to September called Summer Monsoon. In Nepal,

about 80% of the total annual rainfall occurs during the monsoon. Generally the monsoon enters Nepal on

10th June and ends on the fourth week of September. This year due to formation of depression at the Bay

of Bengal, the monsoon was active on 22nd and 23rd September 2006. During monsoon season, monsoon

depressions (low pressure areas) form over the Bay of Bengal with highest sustained winds of up to 34

knot (64km/hr) in the circulation. The life period of the depression is about 6 to 7 days. For a few days

they normally move in a westerly direction. Later they either weaken or continue to move west and

recurve towards north and north-east direction. On an average 2 to 3 depressions are usually formed over

the Bay of Bengal every year during the monsoon.

This year, at the end of monsoon over Nepal, the weather over eastern and central region of the

country was deteriorating till 25th Sept. 2006 due to the northward movement of depression that was

initially formed over the northern part over the Bay of Bengal on 20th Sept. 2006. After its movement, the

center of the low pressure field or depression lay over Bihar on 23rd Sept. 2006. Due to the effect of this

large scale system, the central and eastern part of the country was covered with low clouds and poor

visibility extending from Kathmandu to Taplejung on 22nd and 23rd Sept. 2006. The position of the low

pressure system from 20th to 26th September is shown in appendix.

On the satellite imageries of 22nd to 25th Sept. 2006, consecutive cloud mass extended well to the

north of Bay of Bengal covering Bihar, central Nepal, eastern Nepal, Sikkim and Bhutan. Particularly on

22nd and 23rd Sept. 2006, the cloud cover was dense over eastern Nepal and the adjoining Bihar plains.

The successive satellite imageries of 05:45 LT (0000 UTC) and 11:45 LT (0600 UTC) of 22nd and 23rd

September 2006 are shown in appendix.


Page No. 16

Fungling, Taplejung is the nearest meteorological station from Ghunsa. The meteorological record

of Taplejung showed (shown in the table below) that there was complete cloud coverage with drizzle and

rain on 22nd and 23rd Sept. 2006 from 0545 LT (0000 UTC) to 1745 LT (1200 UTC). Also the record

shows that the 24 hours rainfall was 5.2 mm ending at 0845 LT (0300 UTC) and 1.7 mm of rainfall from

0845 LT (0300 UTC) to 1745 LT (1200 UTC) with 200 m and 500 m visibility at 0545 LT (0000 UTC)

and 1445 LT (0900 UTC) on 23rd September 2006.

According to local people at Ghunsa, the weather at Ghunsa at the time of departure of 9N-AHJ

was cloudy with drizzle and the surrounding mountains were not completely visible due to cloud. The

temperature at Ghunsa at time of departure (10:45 LT) was estimated at about 11ºC.

As part of its regular service Meteorological Forecasting Division (MFD) issues 24 hrs weather forecast

with satellite images on 22nd and 23rd Sept. 2006 indicating bad weather due to depression centered over

Bihar through its website www.mfd.gov.np for the users. MFD issues the same forecast over Radio Nepal

and Nepal Television by FAX for broadcasting over the radio and television for those who are interested

in weather. Also MFD issues mountaineering forecast everyday at 6 P.M. This forecast is given with

wind direction, wind speed and temperature at altitudes of 3km, 5.5km, 7.0km and 9.0km at western,

central and eastern region through its website and is also transmitted after the 8 P.M. English news of

Radio Nepal. This forecast of 22nd Sept. 2006 is shown in appendix.

As regards the meteorological information at Tribhuvan International Airport (TIA) for domestic

flights, only on some rare occasions do airline representatives enquire verbally about the weather by

telephone.

At TIA, MFD also provides regular meteorological service for aviation. The regular

meteorological service to cover the flights within the Kathmandu Flight Information Region (FIR) and

the flights in International air routes between Kathmandu and other International Aerodromes are as

follows:

a. Observational Data : METAR (Name of the code for an aviation routine weather report issued at

an hourly or half hourly interval), SPECI (is the name of the code for an aviation special weather

report issues at any time when certain criteria are met), TAF (Aerodrome Forecast) and other

observations as required.


Page No. 17

b. Meteorological Briefing : Oral briefing for current flight operation and for advance operational

planning of its international flights as well as for domestic flights is provided in person with the

help of the available meteorological aids to the crew.

c. Flight Documentations : Flight Documentation for International flight consisting of en-route

forecast as well as the other information as demanded by ICAO/WMO regulation.

d. Additionally Department of Hydrology and Meteorology (DHM) has meteorological office at

Biratnagar, Pokhara, Simara, Bhairawa and Nepalgung airports to issue hourly weather report for

aviation purposes. At present about 30 domestic airports of Nepal are operating without

meteorological services from DHM but visual weather information is provided by ATC. DHM is

the authorized responsible agent for meteorological service in Nepal.

Weather Record of Taplejung (elevation:1732 m) on 22nd and 23rd Sept. 2006

Date Time (LT)

Wind

Visibility (Km)

Cloud Amount (Okta)

Temp (ºC)

Rainfall (mm) Weather

0545 Calm 8 8 16.0 Continuous rain (slight)

0845 ,, 6 8 17.0 3.0 Slight rain intermittent

1145 ,, 8 8 19.2 Slight drizzle Intermittent

1445 ,, 6 8 19.4 Slight rain intermittent

22 Sept. 2006 Max. Temp: 23.3ºC Min. Temp: 16.0ºC

1745 ,, 10 8 19.6 0.3 Continuous (slight) rain

0545 Calm 0.2 8 16.5 Recent drizzle 0845 ,, 10 7 17.4 5.2 Cloudy 1145 ,, 6 8 18.8 Drizzle 1445 ,, 0.5 8 19.6 Continuous rain


1745 ,, 2 8 18.5 1.7 Recent shower of rain

Note : Cloud Amount = 8 (complete coverage of cloud in the sky.)

Weather Record of Kathmandu (elevation:1337 m) on 22nd and 23rd Sept. 2006

Date Time (LT)

Wind (direction/

speed)

Visibility(Km)

Cloud Amount/ (Okta)

Temp (ºC)

Rainfall (mm) Weather

0545 Calm 12 8 19.5 Cloudy 0845 Calm 8 8 21.4 1.1 Slight rain 1145 Calm 12 8 23.4 Slight rain 1445 W /03 knot 7 8 22.8 Moderate rain


1745 Calm 8 8 20.6 0.4 Recent Drizzle


Page No. 18

0545 Calm 8 8 18.9 Rain 0845 Calm 7 8 20.0 7.2 Rain 1145 Calm 10 8 22.2 Cloudy 1445 W /05 knot 10 7 23.6


1745 W /04 knot 10 7 22.8 0.3 Cloudy

(Refer to appendix No. ...... . )

1.8 Aids to Navigation

Helicopter 9N-AHJ was equipped with the following Navigation equipments:

a. Automatic Direction Finder (ADF) type ARK-15M

b. Global Position System (GPS) type GPSMAP 196

c. Distance Measurement Equipment (DME) type KN0062

Ghunsa helipad is an unmanned station where no navigation and communication facilities are available

for the flight.

Map of Ghunsa :

1.9. Communication


Page No. 19

9N-AHJ helicopter was equipped with two VHF Radio Sets type 'BAKLAN-20' and one HF

Radio Set type 'YADRO-1A'. Pilots had possibility to communicate with nearest stations (Taplejung,

Biratnagar, Bhojpur, Tumlingtar and with Kathmandu also) on the same HF networks. On 22nd

September, while helicopter was flying from Kathmandu to Okhaldhunga and then Fungling it was in

contact with Kathmandu and other stations en-route on VHF. On 23rd September 2006 helicopter 9N-AHJ

planned sector was Fungling-Ghunsa-Fungling. While departing from Fungling to Ghunsa, helicopter

made contact on HF with Bhojpur and Kathmandu and reported altitude and ETA Ghunsa. While landing

at Ghunsa, helicopter had reported 'On ground Ghunsa and ground time 1 hour' on HF again to Bhojpur

and Kathmandu.

Communication Between Bhojpur Tower and Helicopter on 23rd September.

Time

(UTC) To From Details

0355 VNBJ 9N-AHJ 9N-AHJ Taplejung-Ghunsa 100 Ghunsa 0410

9N-AHJ VNBJ Roger

9N-AHJ VNKT Roger

0404 VNBJ 9N-AHJ 9N-AHJ Onground Ghunsa, Ground time 0100 hrs.

9N-AHJ VNBJ Roger

9N-AHJ VNKT Roger

Communication recorded by domestic aeronautical fixed service (EAST), TIA on 23rd September.

Time

(UTC) To From Details

0355 9N-AHJ Taplejung-Ghunsa 100 climbing ETA Ghunsa

0410

VNKT Roger. passed to Area Control Centre

0406 9N-AHJ Onground Ghunsa, Ground time 0100 hrs.

VNKT Roger.

On departure from Ghunsa to Fungling leg, no communication log was found with any stations.

So, actual time of departure and estimates could not be received. Taplejung Airport tower was not found

'watch on' while helicopter 9N-AHJ was flying in that region on 22 and 23 Sept. 2006. Taplejung airport

is an manned station and equipped with HF/VHF communication.


Page No. 20

1.10. Helipad Information

(a) Point of Departure : Location : Ghunsa, Taplejung

Elevation : 3145 m. AMSL

Co-ordinates : N 27º 39'24"

E 087º 55'48"

(b) Crash Site : Location : Lelep V.D.C-9, Faledanda, Taplejung


Co-ordinates : N 27º38'45"

E 087º 54'11"

(c) Destination : Location Fungling, Taplejung


Co-ordinates : N 27º 21'19"

E 087º 39'53"

1.11 Flight Data Recorder (FDR)

The helicopter was equipped with Digital Flight Data Recorder type 'SDK-8'. It registers flight

information for 26 hours with the following 13 analog parameters and 12 signals:

S.N. Parameters Signals

1. Pressure Altitude 1. Failure of Main Hydraulic System

2. Indicated Airspeed 2. Duplicate Hydraulic System off

3. Pitch Altitude 3. Master Warning 'FIRE'

4 Main Rotor Speed 4 High Vibration Right Engine

5. Roll Altitude 5. High Vibration Left Engine

6. Collective Pitch Position 6. Minimum Fuel

7. Engine Gas Temperature, Right Engine 7. Anti-icing System Right Engine ON

8. Engine Gas Temperature,Left Engine 8. Anti-icing System Left Engine ON

9. Power Right Engine (RPM) 9. Low Oil Pressure Right Engine

10. Power Left Engine (RPM) 10. Low Oil Pressure Left Engine

11. Swash Plate Assembly Inclination 11. Low Oil Pressure Maine Gearbox

12. Heading 12. Fuel Pump Unserviceable


Page No. 21

13. Radio Altitude

FDR was recovered from the crash-site and it was sent to Interstate Aviation Committee, Russia

for read out. FDR read out graphs of flights conducted by 9N-AHJ on 22nd and 23rd September 2006

were provided to the Commission. The FDR read out graphs were analyzed by the Commission.

(a) FDR read out of flights of the helicopter 9N-AHJ of Kathmandu-Okhaldhunga sector on 22nd

September 2006 is analyzed as below:

5 min. 40 seconds after engine start up, the helicopter took off from Kathmandu and landed with an

air time of 34 minutes 20 seconds and engines were switched off 4 min. 20 sec. after touch down at

Okhaldhunga. So block time of this sector was 44 minutes 20 seconds and all helicopter systems

operated normally. Engine parameters are normal and no failures are observed.

(b) Okhaldhunga-Fungling sector on 22nd September 2006 is analyzed as below:

After 7 minutes from engine start up at Okhaldhunga, the helicopter took off and landed after 38

minutes 35 seconds of air time at Fungling. Engines were switched off after 2 minutes 40 seconds

of touch down on the helipad. Block time of this sector was 48 minutes 15 seconds and all

helicopter systems and engines operated normally.

(c) Fungling-Ghunsa sector on 23rd September 2006 is analyzed as below:

The helicopter engines were in operation for 3 minutes 20 seconds in Fungling helipad before take

off. The helicopter landed at Ghunsa after 16 minutes 20 seconds of flying time. Engines were

switched off after 2 minutes 10 seconds of touch down at Ghunsa helipad.

Both engine parameters were normal and smooth. The flight parameters of helicopter in respect of

heading, climb, cruise and speed throughout the flight was stable and smooth.

Analysis of FDR Read out Graph of Flight in Sector Fungling-Ghunsa

S.N. Time (Min:Sec)

Helicopter Flight

Position

Left Engine RPM,

%

Right Engine RPM,

%

Left Engine EGT

ºC

Right Engine EGT

ºC

Main Rotor RPM,

%

Air Speed

V, Km/Hr

HBar Meter

HG Meter

Heading

1. 00.00 Hover 96% 96% 860 860 93% 0 1744 2 360º

2. 01.00 Climbing 97% 97% 845 845 93.6% 160 1875 300 50º

3. 02.00 ,, ,, 97% 97% 856 856 93.6% 200 2100 700 25º

4. 03.00 ,, ,, 97% 97% 856 856 93.6% 205 2250 610 25º

5. 04.00 ,, ,, 97% 97% 856 856 93.6% 205 2400 600 25º


Page No. 22

6. 05.00 ,, ,, 97% 97% 856 856 93.6% 200 2600 500 25º

7. 06.00 ,, ,, 97% 97% 856 856 93.6% 210 2750 56 25º

8. 07.00 ,, ,, 97% 97% 856 856 93.6% 205 2850 750 26º

9. 08.00 ,, ,, 97% 97% 856 856 93.6% 210 2950 320 28º

10. 09.00 ,, ,, 97% 97% 856 856 93.6% 205 3050 50 35º

11. 10.00 ,, ,, 97% 97% 856 856 93.6% 165 3250 600 30º

12. 11.00 ,, ,, 94% 94% 770 770 93.6% 150 3400 400 0º

13. 12.00 ,, ,, 96% 96% 790 790 93% 65 3300 400 46º

14. 13.00 Descending 96% 96% 840 840 93% 65 3290 180 44º

15. 14.00 ,, ,, 95% 95% 800 800 93% 45 3250 80 20º

16. 15.00 ,, ,, 96% 96% 856 856 93.6% 22 3200 60 180º

17. 16.00 Landed 95% 95% 760 760 93.6% 0 3145 0 190º

Note : 1. Ground Time before take-off = 03:20 2. Ground Time after landing = 02:10 3. Air Time = 16:20 4. Total Block Time = 21 min. 50 second.

(d) FDR read out for Ghunsa to Fungling sector on 23rd September 2006 is analyzed as below :

Both engines were started and the helicopter was on ground for 3 minutes 50 seconds at an

altitude of 3145m and then the helicopter was hovered at a height of 2m. with engines in take off

power and 91% main rotor RPM (normal rating is 93±1). The helicopter took off on a heading of

310º with translational lift and gained an air speed of 62 km/hr. Then the helicopter accelerated up

to 154 km/hr and climbed to 200 m. with a rate of climb of 3 to 4 m/s in 1 minute 20 seconds after

take off. Then the helicopter climbed and reached 3600m on a heading of 170º with airspeed of 60

km/hr in 1 min. 50 sec. After 30 seconds the heading was 175º and the helicopter climbed to

3800m with a rate of climb of 6.8 m/s and the radio altimeter showed 200 meters from ground.

Then the helicopter speed was gradually decreased to 60 km/hr at 2 min. 30 second at an altitude

of 3885 m. but at this time the radio altimeter showed 60 meters from ground which 10 seconds

earlier was 200 meters. Then after 10 seconds, the helicopter speed dropped to 36 km/hr and main

rotor RPM dropped to 88%. It shows the helicopter flight behavior as abnormal with possibly

panic and loss of orientation in bad weather for a further 18 seconds till first impact with terrain.

Its speed decreased abnormally as 36→32→25 then 12 km/hr (minimum speed at this altitude is

supposed to be 60 km/hr) and main rotor RPM fluctuated as 88%→86%→91%→89% and then to

0% (normal main rotor RPM in flight 95±2%). At this point the helicopter made impact, 'Fire in

Helicopter' was registered simultaneously and it came to a final stop. At an altitude of 3990

meters "Minimum oil pressure in Main Gearbox" was also registered just after the impact which

showed that the main rotor and Main Gearbox was damaged. "Main Hydraulic System Failure"


Page No. 23

signal was also registered. After one minute 10 seconds of impact, the FDR registered "Low Fuel

Pressure in Left Engine", "Low Fuel Pressure in Right Engine", after 2 min 15 seconds of impact

"Minimum Fuel" signal was also registered and FDR stopped to function after 4 minutes 34

seconds.

Analysis of FDR Read out Graph of Sector Ghunsa-Taplejung

S.N. Time (Min:Sec)

Helicopter Flight Position/Phase

Left Engine RPM,

%

Right Engine

RPM, %

Left Engine EGT ºC

Right Engine EGT ºC

Main Rotor

RPM, %

Air Speed

V, Km/Hr

HBar Meter

Heading (º)

HGeogr. Meter

1. 00.00 GT

Helicopter in Ghunsa, Engine Started for Ghunsa-Taplejung

Normal Normal Normal Normal Normal 0 3145 86 0

2. 03:00 GT

Helicopter Engines in right correction

Normal Normal Normal Normal 0 3145 160 0

3. 03:50 GT

00:00

Helicopter Hovering before take off 100% 100% 913 913 91% 0 3147 356 2

4.

03:55 GT

00:05 AT

Helicopter take off with Transition lift 100% 100% 913 913 91% 62 3170 310 25

5. 00:10 AT

Helicopter climbing 913 913 91% 22 340 45

6. 00:50 Helicopter climbing 98% 98% 870 898 92% 50 200 190 7. 01:20 Helicopter climbing 98% 98% 875 900 92% 154.3 3350 170 200 8. 01:50 Helicopter climbing 100% 100% 885 912 91.5% 60 3600 170 584

9. 02:00 Helicopter low climbing 99% 100% 885 912 92% 75 3632 187 515

10. 02:10 Helicopter climbing 99% 100% 885 912 92% 84 3700 187 400 11. 02:20 Helicopter climbing 99% 100% 885 912 92% 84 3800 175 200 12. 02:30 Helicopter climbing 99% 100% 913 925 92% 62 3885 200 60

13. 02:40 Helicopter climbing with some panick 100% 100% 915 930 90% 33 4020 222 80

14. 02:45 Helicopter Sink 100% 100% 925 935 88% 30 4033 230 103

15. 02:50 Helicopter initiation for stability to avoid sinking

100% 100% 925 935 91% 25 4012 225 95

16. 02:55 Helicopter again started to sink (Panick)

100% 100% 920 930 90% 15 4000 208 62

17. 02:58 Helicopter first imact after sink 83% 80% 880 900 0% 12 3990 193 0

18. 03:00 Helicopter hit finally to rocky surface and stopped

80% 69% 800 900 0 0 3990 150 0

19. 04:20 Helicopter Burning 0% 0% 460 230 0 0 3990 148 0

20. 07:34 Stop of Operation of FDR 0 0 460 460 0 0 3990 148 0

1.12. Wreckage information

The helicopter was found almost completely burnt and toppled on its left side with scattering of

its parts in a limited area.


Page No. 24

A. Cockpit : Both instrument panels, wind shields, seats, control sticks, auto-pilot, circuit

breaker, system indicators, electrical blocks in cockpit were also burnt completely.

Most of these parts were found in the form of ashes. Cockpit frames were also

found in the condition of ashes or in a melted down condition.

B. Central part of Fuselage : Central part of fuselage of helicopter MI-8MTV-1 consist of 23 frames.

First 10 frames were found in the conditions of ashes or in a melted down condition.

Frames, stringers, floors, passenger seats etc. were completely burnt. Remaining

frames after 10th frame were also burnt. Last row seats were partially burnt. Rear

portion of external fuel tanks were not completely burnt. Some maintenance

accessories (funnel, ladder etc.) were found unburnt. Rear clam-shell doors of the

helicopter was found in pieces in a partially burnt condition. Rearmost part of

central section of fuselage was found in a partially burnt condition.

C. Tail Boom : Out of 17 frames of the tailboom, initial frames were completely burnt and

remaining part including stabilizer, tail guard were found unburnt but in a damaged

condition.

D. Pylon : Pylon was found in a damaged condition but unburnt.

E. Landing Gears : Nose Landing Gear along with its shock absorber was found about 28 meters away

to the rear and to the left of the wreckage. Main Landing Gear tyres were burnt

completely and shock absorbers with brace struts were found partially burnt.

F. Main Rotor and Tail Rotor : Main rotor blades were found with 70% of its length scattered in

different directions. Remaining 30% of its length attached with the hub were found

in a burnt condition.

G. Engines : Both engines TV3-117VM engines of helicopter were found burnt completely

except engine exhaust pipe. Components of engines were left in the form of ashes or

in melted down condition.

H. Main Gear Box : Main Gearbox of helicopter was completely burnt down to ashes and melted down.


Page No. 25

I. Flight Data Recorder : FDR was recovered with its casing in a partially burnt condition in the rear

side of fuselage.

J. Cockpit Voice Recorder : CVR was searched with several attempts but it was not recovered.

1.13 Medical and Pathological Information

Identification: Medico-legal investigation of all the bodies, body parts and remains retrieved from the

crash site were done in Kathmandu Autopsy Centre/Department of Forensic Medicine, Institute of

Medicine, Tribhuvan University, Maharajganj. Further expert assistance was provided by Finnish-US

team composed of two members, a Detective Chief Inspector and a Senior Forensic Pathologist, of the

Finnish-DVI team and two specialists, a Forensic Odontologist and a Senior Forensic Anthropologist

from the US, JPAC Central Identification Laboratory.

Only one body was in good condition. Few were substantial body parts, others were only limited body

parts and yet others were only teeth and a few bones. All of them, except one were severely burnt and

charred.

Only 10 of 24 occupants could be identified. Of them seven were identified on the basis of recognizable

facial features, personal belongings and jewelry present with the bodies. Five had positive dental

identification and of them four had only dental identification from the very limited remains. One was

identified on DNA analysis only.

Injuries to the Occupants: Only one occupant, found outside the helicopter was in good condition

though he had laceration on the scalp and multiple closed fractures of the ribs on the left side. Rest of the

occupants were inside the helicopter. They all received very severe injuries due to high decelerative force

during the final impact. Those substantial bodies received fractures of the skull and facial bones

extruding the brain tissue, fractures and dismembering of distal parts of upper and lower limbs, fractures

of chest cage and vertebrae and in some exposing lung tissue, and abdominal injuries with opening and

exposure of and injury to organs. Others consisted of only torso or portion of body part and some only

teeth and adjoining bone structures with some tissue. All of them except one lying outside the helicopter

received severe burn and were extensively charred.

Autopsy findings of Decedents of Shree Airlines 9N-AHJ Helicopter Accident at Ghumsa

Body/

Remains Head, Face &

Neck Torso Upper Limbs Lower Limbs


Page No. 26

A – DB 1 Mingma Norbu Sherpa - Identified at site by local people; facial features & clothes

Laceration, 5 cms A-P scalp over mid top, muscle deep right upper eyelid; Contusion inner aspect upper lip; Abrasions multiple punctuate & linear right cheek bone,

Multiple closed fracture left anterior lateral aspect of rib cage; Abrasion left shoulder, left scapular region; No external injuries in the abdomen and pelvis

Contusion right thigh, left fore arm; Abrasion, multiple punctuate dorsum right hand

Contusion posterior mid 3rd of right thigh, left knee

C – DB 3 Ms Jennifer Lynn Hedley – identified by sex, physical characteristics, personal item (ring) and dental identification

All bones of skull missing;, head burst open, brain tissue missing; extensive 1st to 3rd degree burn, face and neck

Multiple fractures vertebral column, anterior rib cage; 1st to 3rd degree burn chest, both clavicles burnt, right lung; Left breast tissue present in anterior chest; Whole of posterior rib cage burnt with multiple burns, fractures of left half; Abdomen burst open, 1st to 3rd degree burn, exposing liver and abdominal contents, Multiple fractures of pelvis, both ilio-sacral dislocation; sacral region of vertebral column fracture

Multiple fractures, Missing Right arm below mid humerus; Left burnt & fracture of mid humerus; burn left forearm and dorsum of hand with burn

Multiple fractures; Missing Right below mid tibia, whole right thigh burn, Right leg burn exposing burnt bones; Whole Left. thigh burnt, Left leg burnt exposing burnt lacerated muscles and fractured bones; dorsum of Left. foot burnt and fractured, attached to leg by a muscle flap only

D – DB 4 Dr. Tirtha Man Maskey – Identified by necklace & locket

Head & face completely charred, scalp missing from the top and back, remaining scalp charred

Muscles of anterior chest missing, anterior left rib cage charred exposing underlying cooked lungs; vertebral column fractured at lumbar region with attachment only by a strap of muscle, liver and gall bladder not discernible due to charring;Genital organs missing, Left half of pelvis fractured; all soft tissues of pelvic region cooked

Right shoulder joint dislocated; upper limbs heat contracture

Upper half of both thighs cooked, both femurs charred and broken at the middle, Parts distal to mid third on both sides missing

F – DB 6 Dr. Bijnan Acharya, Identified based on DNA analysis

Skull bones fragmented and burnt, with cooked brain tissue; broken remains of cervical spines; some fragments of jaw bones with some teeth attached, burnt

Left scapula with charred flesh attached; portion of upper spine & ribs, 6 pieces of vertebrae, burnt; Abdomen and pelvis missing

Humeral head only, rest missing

Missing

H – DB 8 Min. Gopal Rai, identified by clothes and facial features, though burnt

Closed fracture bones of cranial and facial skul; Face and neck 1st to 2nd degree burn; upper jaw right 1st premolar burnt,

Upper half of anterior chest 1st to 2nd degree burn, lower half below nipples charred; Both clavicles and ribs on both sides of anterior chest multiple closed fracture; Whole of

Right, 1st to 3rd degree burn; soft tissue of dorsum of distal arm and forearm missing, dislocation of elbow joint, and heat

Both, muscles of superior two-third avulsed; all parts distal to two-third of thighs are missing


Page No. 27

right canine and 2 incisors fractured, 2nd left incisor fractured

posterior trunk charred; Multiple fractures posterior rib cage; Abdomen burst open with viscera exposed and partially burnt, Perinium burnt, genitalia charred

contracture of wrist and fingers; Left, 1st to 3rd degree burn, compound fracture and dislocation of wrist

T – DB 20 Capt. Klim Kim - Identified by the watch in his wrist

Not present Not present Left upper limb with scapula, charred; arm exposed to muscle layer; distal phalanges of all fingers missing (metal wire entangled between the fingers).

Not present

Dr. Harkha Gurung - Identified on the basis of dentures

Soft tissue of scalp avulsed from top of the head to the anterior; parts of both parietal bones missing,

Neck charred;, Chest charred; Genitalia, penis & scrotum burnt

Fingers of both hands burnt

Muscles of both thigh extensively lacerated and charred, Left. femur fracture;, avulsed lacerations both legs; dorsum of both feet missing from distal 3rd of leg

Mr. Pauli A. Mustonen, Dental identification

Teeth, Missing Missing Missing

Mr. Matthew Stewart Preece, Dental identification

Teeth Missing Missing Missing

F/E Safronov Vallery, Dental identification

2 pairs of crown & bridge

Missing Missing Missing

Followings could not be identified from the examination of body parts and remains

Ser.No. Name Ser.No. Name 1. Mrs. Mina Rai 8. Mr. Bijaya Kumar Shrestha 2. Dr. Damodar Prasad Parajuli 9. Dr. Chandra Prasad Gurng 3. Mr. Narayan Prasad Poudyal 10. Mr. Hem Raj Bhandari 4. Mrs. Yeshi Lama 11. Dr. Jill Bowling Schlaepfer 5. Mr. Dawa Tshering Sherpa 12. Ms. Margarate R. Alexender 6. Mr. Sunil Prasad Singh 13. Capt. Mingma Tshering Sherpa 7. Mr. Sharad Kumar Rai 14. C/A Guruwar Tandul


Page No. 28

Biochemical and Toxicological Examination: Biochemical and toxicological examination in the crew

could not be done due to unavailability of proper tissue.

Fire: There was post impact fire which devoured the passenger compartment and cockpit along with most

of the occupants, leaving behind extensively burnt and charred bodies or remains and ashes.

1.14. FIRE' in Helicopter :

As per flight data recorder read out, 'FIRE' was registered by FDR simultaneously with impact on rocky

cliff 2 minute 58 seconds after take-off from Ghunsa.

As per the technical documents, fire Extinguishing System in MI-8MTV-1 Helicopter 9N-AHJ includes

the following:

(a) Four compartments of the helicopter are protected by the system :

(i) Left Engine,

(ii) Right Engine,

(iii) Main Gearbox and APU,

(iv) Kerosene Heater

(b) 'FIRE' Detection Process : (i) Altogether 42 fire detectors are placed in the above mentioned four

compartments for the detection of 'FIRE'.

(ii) When the temperature in any compartment reaches above 150ºC or the

rate of increase of temperature in any compartment is more than

2º/second then the fire detector sends the signal of 'FIRE' in the

respective compartment to 'FIRE Warning System SSP-FK'.

(c) FIRE Warning Process : It includes a block SSP-FK for warning purposes when it receives a signal of

'FIRE'. This system sends the signal of 'FIRE' in the respective compartment

to the following systems:

(i) Master warning signal "FIRE" in left instrument panel;

(ii) Voice warning system 'RI-65' gets the signal of 'FIRE' and it warns

crew members "Fire in ........... compartment" with a voice warning;


Page No. 29

(iii) Red signal lamp of respective compartment comes 'ON' in fire

extinguishing system panel;

(iv) Flight data recorder receives signal of 'FIRE';

(v) Cockpit voice recorder receives signal of 'FIRE';

(d) Fire Extinguishing Process : Two balloons (filled with freon) each of 4 litre capacity are placed in the

MGB compartment for fire extinguishing purposes. One balloon is for

automatic release and the second balloon is for manual release.

When the fire warning system sends a signal of "Fire in ......compartment", simultaneously the

channel of that compartment is opened from the balloon for automatic release. If necessary, the flight

engineer then depresses the button for manual release of 2nd balloon.

The helicopter 9N-AHJ impacted terrain 2 minutes 58 seconds after take-off. So the APU would

have been switched off at that time because normally the APU is switched off before take off or just after

take-off.

The accident took place on 23rd September, at around 10:48 LT. Normally at an altitude of 3200

m. at this time of day and month, the outside air temperature is around 11ºC. At this outside air

temperature the kerosene heater is normally not used. Kerosene heaters are normally used when

temperature is below 3ºC.

So, possibility of 'FIRE' signal from "MGB and APU compartment", or "Kerosene Heater

Compartment" is very remote. Therefore the 'FIRE' signal registered by the FDR was possibly from

either "one of the engine compartments' or "both engine compartments" upon impact.

As the helicopter 9N-AHJ with a take-off weight of 10,344 kg faced first impact, the nose landing

gear was detached and frames were also deformed and damaged due to the high impact. Such a huge

impact can easily disturb and damage the engine attachments with the airframe and engine modules e.g.

combustion chamber, free turbine. In case of damage to engine supports around the combustion chamber

or free turbine (4th or 5th support) and damage in compressor turbine blades or free turbine blades can

cause the ejection of flame from the combustion chamber to the compartment and to outside of the engine

compartment.


Page No. 30

Regarding the wreckage analysis, the central part of fuselage from 1st frame to 11th frame was

totally burnt and the helicopter had toppled and was resting on its left side with left external fuel tank

(≈400 liter fuel) below the engines and right external fuel tank (≈400 liter fuel) above the engines.

Engines are attached with the 2nd frame and its location is up to the 7th frame of central part of fuselage.

Hence, 'Fire' in helicopter was started simultaneously upon impact with terrain and most probably from

engines with fuel poured from external fuel tanks with the helicopter in an inclined position. The

helicopter was extensively burnt resulting in most of its parts in the condition of ashes or in a melted

down condition.

The accident site is at an altitude of 3990 m. in remote mountainous area and inaccessible to the

ordinary people. Therefore Fire Fighting Services was not possible at the time of accident.

1.15 Survival Aspect

Survival Aspects: This was an un-survivable accident as seen by the extent of injuries and mutilations

inflicted on the occupants. The death must have been instantaneous. The burn and charring was post-

mortem. There was no smoke or combustion in the trachea in some bodies where it was looked into.

1.16 Examination of Helicopter Components:

The accident of the helicopter 9N-AHJ took place in a mountainous area of an elevation of 3990

m. The status of the several components were found as below:

Engines : The helicopter was equipped with two TV3-117VM engines. Both engines were

burnt completely. So no functional or any test/examination could be possible. As

per FDR read out analysis, both engines functioned normally till the impact.

Main Gearbox : The helicopter was equipped with VR-14 gearbox. The gearbox was found totally

burnt. So no test of this component was possible. As per FDR report, the function of

Main Gearbox till the accident was normal.


Page No. 31

FDR : The helicopter was equipped with Digital Flight Data Recorder type 'SDK-8', which

was recovered and read out.

CVR : As per aircraft document the helicopter was equipped with CVR type P-503B but it

could not be found after several search attempts. So, CVR information could not be

obtained.

Autopilot System : The helicopter was equipped with AP-34 type autopilot System. Components of the

system were not identified as most of them were completely burnt. However, no

evidence was found to indicate that there were any problems in autopilot system.

1.17 Additional Information

Eyewitnesses at Ghunsa, the organizing charter party, search and rescue workers, maintenance

engineers, friends of pilots, persons familiar with the crew of the helicopter, CAAN personnel, media

persons and forensic specialist etc. were invterviewed in the process of investigation. Photos and video

materials related to the accident were also collected from different organizations and analyzed. The

Commission also interacted with ICAO study team on aviation safety led by Capt. Roger Mulberge from

Asia Pacific Office, Bangkok.

1.18 Organization and Management Information

Present Shree Airlines was registered on 2055/10/07 B.S. in Nepal as Air Ananya Pvt. Ltd. for the

purpose of operation domestic air service in Nepal. Its head office is located in Tripureshwor in

Kathmandu. It started its operation on 2056/01/04 B.S. with MI-8 MTV 1 and MI-8 AMT helicopters.

Company changed its name as Shree Airlines Pvt. Ltd. on 2059/11/30 B.S. Presently company has 3 such

helicopters.

2. Analysis 2.1 Introduction


Page No. 32

The analysis of the event that led to the accident of helicopter 9N-AHJ began with a brief

summary of the factual evidence gathered during the investigation. Finding the cause of the accident is

usually a deduction from known set of facts. Discussions were held about the violation of regulation with

conducting IFR flight with VFR certified helicopter in unfamiliar terrain without proper flight planning

which could lead to the probable cause of the accident.

2.2 Methodology The following methodologies were employed to find out the probable cause(s) of the accident of

MI-8MTV-1 helicopter 9N-AHJ of Shree Airlines :

(a) Accident Site Visit :

This accident took place in mountainous terrain with steep rugged cliff at 3990 m at Lelep

V.D.C-9, Faledanda of Taplejung. The accident site could be reached only by the professional

climbers using mountaineering climbing equipments. The members of the Commission

visited the Ghunsa helipad and studied the route followed by helicopter 9N-AHJ. Due to

inaccessibleness of crash site, members of committee inspected the site by air. The wreckage

distribution area and position of wreckage were also observed.

For proper analysis of the site and wreckage, photographs and video materials taken by the

rescue team members (professional climber of Nepal Mountaineering Association) were

collected by the Commission.

(b) Interview and Statements :

Flight crew flying that area, local witness of Ghunsa and Taplejung were interviewed. Search

and rescue team, representative of WWF, ATC officer of Taplejung, forensic specialist were

also interviewed to gather information of helicopter, crew and passengers.

(c) Documents, Log Book and Records :

Aircraft logbooks, engine log books, component cards and helicopter journey logbook were

checked. Maintenance and modification records of helicopter were also studied. Pilot record,

flight records were also observed.

2.3 Mechanical and External Factors


Page No. 33

2.3.1 Incapacitation of Pilot

The pilots possessed good physical health. The crew didn't have any history of 'mental' illness.

The pilots flying records showed that both pilots were highly experienced. Thus possibility of

incapacitation of pilot had been ruled out.

2.3.2 Engine Failure :

The helicopter 9N-AHJ was equipped with two TV3-117VM engines with max power of 2200

SHP each. As per FDR analysis of 22nd and 23rd September 2006 flights of sectors Kathmandu-

Okhaldhunga-Fungling-Ghunsa and from Ghunsa to Fungling (accident recorded sector), both

engines were operating normally in all sectors. Until the impact of the helicopter, the engines

were functioning normally. Even after impact, the engines were operating for 1 min. 10 seconds.

Hence the possibility of the engine(s) failure is ruled out.

2.3.3 Failure of Helicopter System :

As per FDR read out, "Fire" was registered only after the impact of helicopter with terrain.

Hydraulic system failure was also not registered in the flight till impact as per the FDR read out

graph. Hence failure of helicopter systems e.g. fire, hydraulic, flight control, pneumatic can be

ruled out.

2.3.4 Tail Rotor/Transmission Failure :

In case of tail rotor failure or transmission shaft breakage during flight, the helicopter flight path

changes suddenly with rotation in its vertical axis and the pilot normally switches off the engines

following the failure. In this case as per the FDR read out graph, the engines were operating

normally till impact and the heading of the helicopter had not changed suddenly to show rotation

in its vertical axis. Hence the tail rotor or transmission failure is ruled out.

2.3.5 Major Components Failure :

No evidence of abnormality was found regarding loss of main rotor control as 'high vibration'

or "MGB oil low pressure" was not registered in that flight in FDR read out graph. Main rotor

RPM and longitudinal movement of swash plate shown in FDR read out indicates that major

component failure can be ruled out.


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2.3.6 Explosion in Flight :

In the case of an explosion in flight, wreckage is usually scattered in larger area. As per FDR

read out, all helicopter systems and engines were operating normally till the impact of

helicopter with terrain and all wreckages were concentrated in a limited area. Hence, the

explosion as the cause of accident can be ruled out.

2.3.7 Maintenance Lapses

The commission examined the maintenance history of the helicopter and found that all the

airworthiness directives and service bulletins had been complied with as per maintenance

requirements within the prescribed time frame. The technical logs and log books show that

the maintenance works, major inspection works and modifications were carried out as per

approved maintenance program or bulletins. No technical defects were found in technical

logbook prior to its flight.

2.3.8 Weather Condition :

The actual weather observation on 23 Sept. 2006 at Taplejung, Okhaldhunga and Biratnagar

at 0545 LT (0000 UTC) and 0845 LT (0300 UTC) was cloudy with rain. According to

eyewitnesses at Ghunsa, the weather at the time of departure of the helicopter in the morning

was cloudy with drizzle and the surrounding mountains were not completely visible.

Weather at Ghunsa was deteriorating due to the influence of the depression whose low

pressure centre was situated at Bihar, India. The eyewitnesses at Ghunsa told to the

commission that at the time of take-off of the helicopter the weather was very bad and within

few minutes the helicopter was disappeared into the clouds. Hence departure from unmanned

station to fly on high altitude with maximum take-off weight in such a bad weather is the

main contributing factor for this accident.

2.3.9 Flying over Unfamiliar Terrain

Ghunsa is situated in a very narrow valley at an altitude of 3145 m. All the surroundings are

high altitude mountains. Normally Ghunsa is a single approach helipad from south and for

departure pilot has to follow the Ghunsa river for south on completely VFR condition. This


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was the first time that Captain had been to Ghunsa and his Co-pilot was also not been there

for long period. So, they were not familiar with the terrain and its surrounding hills. The

possibilities of change of weather and wind patterns were not familiar to them. The pilot's

decision to enter clouds in the region where the terrain was unfamiliar to them was one of the

major contributing factors for the accident.

2.3.10 Violation of Regulation

MI-8MTV-1 Helicopter 9N-AHJ was certified for Visual Flights Rules (VFR) only. On that

day while being at Ghunsa, pilots were completely aware of surrounding weather. It was

completely covered up with low clouds having poor visibility. But pilot intentionally decided

to take-off and entered into the clouds just after the take-off clearly violating the Flight

Operations Regulation.

2.3.11 Crew Coordination

The weather of Ghunsa was not advisable for VFR flight. The Flight Engineer had already

started the APU (possibly under the instruction of Captain). As per eyewitnesses, Co-pilot and

cabin attendant were out of the helicopter at that time and later they entered to helicopter

when engines were already started as well as the passengers were on board.

Both pilots were of Captain status, so the trans-cockpit authority gradient was flat. This

situation could inhibit non-flying pilot interfering with or objecting flying captain's decision

or action, thus affecting crew coordination and communication adversely.

.

There is possibility that unhealthy relationship between Russian (foreign) crew and Nepalese

crew existed. Generally there appears to be an unhealthy working environment between

Russian crew (Captain and Flight Engineers) and Nepalese crew (mostly Co-pilots). the

Russian crew's intention is to delay the Nepalese pilots’ upgrading to Captain thus insuring

their jobs security whereas Nepalese would like to be assisted towards their career promotion

to Captain. So there is likelihood of not getting optimal communication and interaction

between the Russian crew and Nepalese crew.

So possibility of crew coordination regarding weather, pay load, surrounding obstacles, route

plan etc. prior to departure is very remote.


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2.3.12 Communication

As per communication log sheet, Taplejung Tower was not found 'watch on' on 22nd and 23rd

September 2006 at the time of flight. 9N-AHJ could not communicate its flight details to

Ghunsa and position report on VHF communication. So actual flight details and plan level

could not be logged in. But while flying on Fungling to Ghunsa leg, pilot had reported its

altitude and ETA Ghunsa and also 'on ground Ghunsa' on 5805.5 KHz to Bhojpur and

Kathmandu. But it failed to report its flight details and departure message to any station on

return leg.

2.3.13 Take-off weight

As per nomogram of flight manual, the take-off weight 10,344 kg from Ghunsa (H=3145 m,

OAT=11ºC) was within the limit. But this take-off weight to fly in bad weather in higher

altitude in narrow valley would not allow maximum rates of climb.

If pilot had judged its take-off weight and the surrounding weather, he should have to wait for

the improvement of weather. Hence the Commission is of the opinion that crew did not

analyze pay load regarding the weight of the take-off considering the possible high rate of

climb in such bad weather condition.

2.3.14 Inappropriate Decision

As per Flight Data analysis of Fungling-Ghunsa sector, it was found that helicopter conducted

flight from 1771 m (Fungling) then smoothly climbed to 3400m and landed at Ghunsa (3145

m). While flying from Fungling to Ghunsa, pilot was facing the overcast and drizzling

condition of Fungling but he started flight for high altitude helipad without analyzing the high

altitude weather condition. Also on way to Ghunsa, pilot didn't make proper operational plan

for his return leg in same route.

Just after departure from Ghunsa, the helicopter flew towards north and then to southerly

direction. It entered into clouds over the Ghunsa valley with a speed of 150km/hr. The Pilot

might have thought that he would be in VFR condition after crossing the valley but it turned


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out to be a wrong decision. The weather in such valleys during monsoon can change very

rapidly. This decision to enter cloud at this speed was inappropriate.

2.3.15 Hypoxia

a. As per the Company S.O.P. Manual flight crew are required to use oxygen above 4000 m or

13000 ft AMSL. Though mask headset with a communication cable of the flight crew is

fitted through tube with oxygen which are to be plugged to the oxygen port. However flight

crew do not plug in the oxygen tube during high altitude flights. According to ICAO and

CAAN Regulation flight crew member shall use breathing oxygen continuously above 3000

m if the flight above 3000 m amsl. In the Company Standard Operating Procedure (SOP)

Manual flight crew are required to inhale oxygen in altitude above 4000 m amsl.

b. The crew would not be using oxygen during this flight. This could cause hypoxia. Even with

mild degree of hypoxia, thinking may be dulled, judgment may be skewed, problem solving

abilities and normal motor skill may begin to fail and reflex reaction may slow down. To

make matters worse the flight crew are usually unaware of these failings and instead they can

become euphoric and over-confident.

c. At Ghunsa the helicopter had stayed at Ghunsa for nearly 45 minutes and then took off

climbing until it crashed at an altitude of 3990 m AMSL.

d. The hypoxia due to high altitude must have affected the flight crew on their thinking process,

judgment, problem solving abilities and normal motor skill and reflex reaction adversely.

2.3.16 Flight Analysis

The flight programme was from Ghunsa to Fungling on 23rd Sept. 2006. After departure time of 2

min. 58 seconds, helicopter faced impact at rocky mountain at 3990 m. This flight is analyzed in 3

phases :

(a) From take-off time to 2 min. 30 seconds.

The helicopter first hovered and took-off with translational lift to north and then to south. It entered

to cloud while leaving valley. The speed of helicopter was first increased upto 150 km/hr and then


Page No. 38

gradually decreased. The main rotor RPM was approximately 92% and engines power was in take-

off.

(b) Flight from 2 min. 30 seconds to 2 min. 45 seconds (flight with panic).

Crew observed from radio altimeter that they are only 60 m. above the ground in 2 min. 30 seconds

after departure from Ghunsa. They were flying in IMC condition and they were probably panic as

they felt that the peak was somewhere around them. This time they had 62 km/hr speed, 91% main

rotor RPM and 3885 m. elevation. Pilot decrease the speed and applied maximum power to achieve

high rate of climb. They reached to 4033 m. in 2 min. 45 seconds and air speed was 31 km/hr.

(c) Flight from 2 min. 45 seconds till impact (2min. 58 sec.)

Collective pitch was raised to its maximum to achieve maximum power causing maximum pitch

angle of main rotor blade. Which resulted drop in main rotor RPM to 90% and sometime 89% also.

The main rotor RPM in maximum power should be 92% to 94%. The air speed was only 31 km/hr

when helicopter was at 4033 m. Then helicopter started to sink due to combine effect of drop in air

speed, drop in main rotor RPM, helicopter weight and flying in IMC. Then helicopter descended

with rate 3 to 4 m/s and just before impact the air speed was 12 km/hr and main rotor RPM 90%.

2.3.17 Factors contributing to influence pilots to depart Ghunsa in bad weather

(a) The Daily Inspection (DI) of 9N-AHJ was carried out at 5 PM of 21st Sept. 2006. The validity

of the DI is for 48 hours. Therefore the validity would have expired at 5 PM on 23rd Sept. 2006.

The crew members may have intended to reach Kathmandu before the validity of the DI expired.

(b) Since Ghunsa is at an altitude of 10,700 ft. (above 10,000 ft.) it would not have been an

appropriate location to spend the night due to the high altitude that could adversely affect the

elderly passengers and due to the lack of comfortable lodges available for the dignitaries.

(c) Some of the foreign dignitaries had further programmes to Sauraha, Chitwan in the afternoon of

23rd Sept. 2006 and this information was passed to the crew members by WWF officials which

could have contributed to influencing the crew members to depart Ghunsa inspite of the

unfavorable weather.


Page No. 39

3. Conclusion

3.1. Findings

1. Weather condition of Fungling, Taplejung at the time of departure was cloudy with frequent

drizzle.

2. Weather condition of Ghunsa was cloudy with light rain. The visibility was poor and surrounding

hills were completely covered up except to the north where the visibility was slightly better.

3. Ghunsa helipad being an unmanned station, further details of weather and communication with

the helicopter was not possible.

4. This was the first flight of Capt. Kim to Ghunsa so he was not familiar with the terrain and its

surroundings.

5. 9N-AHJ had reported its position to Bhojpur and Kathmandu on HF while it was flying from

Fungling to Ghunsa. But it didn't call any station for the departure from Ghunsa to Fungling

6. Without analysing the weather condition, the helicopter took-off from Ghunsa and intentionally

entered into the cloud.

7. The helicopter was not certified for Instrument Flight Rules (IFR). So entering into cloud

intentionally in high mountainous area is not only the wrong judgment but also the violation of

Flight Operations Requirement (FOR).

8. After 2 min 58 seconds from take-off, the helicopter faced impact on steep rugged surface terrain

at the altitude of 3990 m. and immediately caught fire.

9. Pre-flight briefing and proper crew coordination among crew members were not found to be

followed.

10. Location of crash-site is a rocky steep cliff and ordinarily inaccessible.

11. Cockpit and passenger compartment of helicopter was completely burnt.

12. Though the take-off weight for the flight from Ghunsa was not out of limit, take-off from high

altitude helipad with high rate of climb in such bad weather condition late morning with

unpredictable wind condition was poor judgment on the part of crew members.

13. As per FDR report, the power plant and helicopter systems were functioning normally till the

impact.

14. As per helicopter documents, the helicopter was equipped with a Emergency Locator Transmitter

(ELT) but the signal of ELT was not received by any stations.

15. As per technical documents, all maintenance works were carried out as per Approved Schedule

Inspection Program and service Bulletins of designer.

16. Pilots were certified and qualified in accordance with present regulations.


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17. The flight crew were physically and mentally fit and had passed the medical assessment.

18. Flight crew were adequately rested and had normal breakfast in the morning.

19. It is not confirmed that the flight crew had used oxygen at Ghunsa and during flight.

20. There is no evidence of unlawful interference.

3.2. Causes

The Commission has concluded that the probable cause of the accident is the cumulative effect of

the followings :

a. Without analyzing the local weather condition, pilot took-off from Ghunsa helipad in poor

visibility and immediately disappeared into the cloud and continue flight in bad weather on IMC

condition violating the visual flight regulation in such weather.

b. This was first flight of Capt. Kim, so he was not familiar to the terrain around Ghunsa and local

weather condition mainly in rainy season.

c. Pilot could not maintain the normal rate of climb and speed after reaching to 4033 m. though the

engine power was maximum. The combined effect of low speed, low main rotor RPM, helicopter

weight at that altitude and flying into cloud (IMC) resulted the helicopter to sink and finally hit

the rocky cliff at 3990 m. The helicopter was severely damaged and burnt and all 4 crew

members and 20 passengers died in this accident.

d. Lack of crew coordination among the pilots and lack of situational awareness, pilot took-off from

Ghunsa and climb for high altitude and hypoxic effect.

4. Safety Recommendation

4.1 TO CAAN

1. Every pilot should take refresher training as per FOR. CAAN should ensure the effectiveness of

these trainings.

2. CAAN should ensure the installation and serviceability of FDR, CVR, ELT, GPS in aircrafts.

3. Most of the accidents occurred in Nepal were in monsoon seasons especially by flying IMC

condition by VFR certified aircrafts. To prevent this, CAAN should develop a format for daily

performance report of the pilot and circulate it to the airlines and make periodic audit.

4. CAAN should instruct the helicopter company to issue the supplement in their Operation Manual

to calculate the pay load with further safe margin rather than calculating from nomogram for

flight, in monsoon with possibility of high rate of climb over difficult terrain.


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5. On the basis of analysis, findings and recommendation of "serious incident" or "accident"

investigation reports, CAAN should conduct awareness programmes with the respective airlines

operating same type of aircraft.

6. FOR should include oxygen use in high altitude flights. CAAN should scrutinize the company

Flight Manual and SOP Manual and make uniform regulation regarding oxygen use in high

altitude flights.

4.2 TO Shree Airlines

1. Pilot should be aware of Standard Operation Procedure (SOP) and Operation Manual of their

company through an awareness program conducted by the concerned airline preferably every 3

months. This should include the followings:

(a) Flying in IMC by a helicopter certified for VFR should be strictly prohibited.

(b) Preflight planning by the crew should first be conducted on the ground at the place of origin

before undertaking any flight, which should cover the entire information regarding the

route, weather, altitude, terrain, obstacles and helipad characteristics specially those flights

to difficult helipads and the helipads where the crew members have never been before.

(c) Detailed study of concerned area map should be carried out and discussed among crew

members before take-off.

(d) The pay load of the helicopter during monsoon at high altitude helipads should be

calculated taking into consideration the possibility of high rate of climb and increase bank

angles in narrow valleys.

(e) Communication with stations to be established compulsorily prior to take-off, en-route and

landing.

(f) Engineer should be available for Daily Inspection of helicopter, if it is going to make night

stop other than the base for more than 24 hours.

2. Company should provide their pilots refresher classes of FOR, CRM, Meteorology and

technical/performance of helicopter by instructors authorized by CAAN.

3. Company should review their SOP for monsoon and high altitude flight and they should conduct

interaction programme for their pilots in every 3 months interval.

4. Operation Director, Chief Pilot and Safety Director should monitor the flight performance and

behaviour of their pilots regularly. If any pilot is found to conduct flight in IMC, it should be

investigated internally. Such a case should be taken as 'incident' and must be strictly discouraged.

Pilots should be encouraged to report in writing ‘near misses’ or ‘events’ or even ‘violation of

regulations and reason to do so’ without fear of having punitive actions from management.

5. Engineering and Quality Assurance Department should improve the documentation process and

validity of any inspection period should be strictly followed with.


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4.3 For all Concerns

(a) Aircraft certified for Visual Flight Rules (VFR) should not enter into cloud.

(b) Flight details before departure and landing report from unmanned airport/helipad should be

reported to the nearest airport.

(c) Flight at high altitude during monsoon and bad weather condition should be conducted by

experienced pilots familiar with terrain and weather condition.

(d) Meteorological Forecasting Division (MFD) at TIA provides weather forecast for next 24 hour

and mountain weather forecast in their web site www.mfd.gov.np with satellite image. Aircraft

flying high altitude helipads in monsoon and bad weather should be provided weather forecast

report by Airlines.

(e) The commanding pilots of domestic flights must get Met briefing from TIA Met Weather

Briefing especially during bad weather situation.

(f) Meteorological Office must be established in important aerodromes such as Lukla, Syangboche,

Taplejung, Jomsom and others for which CAAN should take initiative as required.

(g) Airline should regularly conduct CRM courses, dealing theoretical aspects and practical or role-

playing in various situations.

4.4 To the Ministry of Culture, Tourism and Civil Aviation

1. The Civil Aviation (Accident Investigation) Rules, 2024 B.S should be amended in the context of

open sky policy of the Government, the establishment of CAAN and the Nepali commitment in

the international forum.

2. The Rules should incorporate the formation of the Accident Investigation Commission, its

accountability, minimum qualifications of the members, compensation for their services, etc.

3. Expert Development Program should be initiated in the field of aeronautical engineering, aviation

security, aviation medicine, meteorology, air law and investigation techniques, etc. and a roster of

Accident Investigation Experts should be maintained in the Ministry.

4. Accident Investigation Management Unit should be established in the Ministry to monitor the

implementation of the Commissions’ recommendations and to maintain the archives.

5. As to conduct the Accident Investigation is the State obligation, instead of levying the cost to the

concerned operator, Ministry should provide logistics, budget and other essentials to the

Commission.

6. A clear national policy should be developed to regulate the helicopters certified to Cargo Version

for transporting revenue passengers to enhance their safety.

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