Disoriented pilot trying to land in 'sheer desperation' led to crash of US-Bangla plane: Report

The US-Bangla Airlines plane (Flight BS211) from Dhaka crashed on its second landing attempt at the Kathmandu's Tribhuvan International Airport on March 12, 2018. Fifty one people were killed and 20 others injured in the crash. Among the dead, 28 were Bangladesh nationals, 22 Nepalese and one Chinese. The pilot and co-pilot also died in the crash.

The 43-page investigation report, compiled by Nepalese officials and released on Monday, said the probable cause of the crash was the pilot's "disorientation and loss of situation awareness".

Contributing to this, the Bombardier Dash 8 Q400 turboprop aircraft was offset to the proper approach path that led to maneuvers in a very dangerous and unsafe altitude to alight with the runway, it said, adding that landing was completed in a "sheer desperation" after sighting the runway, at very close proximity and very low altitude.

Nepali investigators also cast a spotlight on the history of mental health of pilots in the final report on the crash and recommended that before the renewal of licence of any permanently grounded pilot due to a medical reason, a thorough periodic physical and psychological status should be assessed.

It said a system should be adopted to monitor the medical condition closely in all subsequent medical examinations as well. The investigation commission recommended that all airline pilots should undergo a psychological evaluation as part of the training or before entering into service.

The report, submitted to Tourism Minister Rabindra Adhikari on Sunday, said the pilot, Abid Sultan, had been released from the Bangladesh Air Force in 1993 due to depression and was only allowed to fly civilian planes from 2002 after a detailed medical evaluation.

The Nepali investigators said the flight captain's past behaviour should have been a warning sign.

Sultan's detail medical history was not reviewed by the US-Bangla Airlines when he was hired, the report said, adding that medical examination of the pilot in successive annual medicals was not focused on his previous medical condition of depression, which seemed mandatory.

As per the US Federal Aviation Administration rules, captains are required to have a first-class medical certificate renewed every year if the pilot is under 40 years of age and every six months if the pilot is 40 years or older. Psychological checks are not required.

"Many pilots refuse to seek treatment for mental health issues because they fear the medical assessment will have a negative impact on their career. This may have cost the passengers lives as well as the airlines," Buddhi Sagar Lamichhane, member-secretary of the investigation committee was quoted as saying in the Kathmandu Post.

The investigators said there was clear evidence that the flight captain was harbouring severe mental stress.

"The effect of stress was evident with the fact that he was irritable, tensed, moody, and aggressive at various times," the report said.

Few minutes before the landing, Sultan had confirmed that the plane's landing gear was down and locked. "Gears down, three greens," the pilot said, according to the report, referring to the electrical indicator lights inside the cockpit.

However, when co-pilot Prithula Rashid conducted a final landing checklist, the landing gears were not down.

According to the report, the pilot was worried about one particular aspect and was thinking about it all the time.

"This was about one particular female colleague's criticism on his competency. Most of the conversation in the cockpit was directed towards and aimed at the female colleague who apparently was telling others that the pilot was not a good instructor and he could not teach properly," it said.

"Lost in the conversation, the landing was completed in sheer desperation after sighting the runway, at very close proximity and very low altitude. There was no attempt made to carry out a go-around when it seemed possible until the last instant before touchdown on the runway," the report said.

Both pilots were anxiously trying to locate the runway. Both pilots made several statements that reflected that they had completely lost their orientation of the runway, but that was not communicated to the air traffic controller, it said.

As the pilot was smoking continuously inside the cockpit during the one-hour flight from Dhaka to Kathmandu, the investigators also recommended that airline operators should reinforce firm "No Smoking" policy during flights and have a system in place to monitor it and take actions.