The plane, German built Dornier Do 228 with 21 people on board, crash into a hill side near Jomsom Airport in Mustang district on May 14, 2012 killing 15 people including two crew members.[break]
Medini Prasad Sharma, chairman of the commission to investigate the accident, handed over the report to the government on Sunday.
"The major cause of the accident was the decision of the captain to divert to Pokhara without considering the required radius of turn and the rising surrounding terrain." Sharma said. He said the subjected turn and climb of the ill-fated aircraft was not enough to avoid the cluster of muddy hills and its left wing struck a small rock on the 2,827 m high hill.
According to the report, the other contributing factors include insufficient Cockpit Resource Management (CRM) and lack of situational awareness which caused a serious judgmental error as both the crew members were bogged down in trying to resolve the landing gear light indication problem. Pilot Prabhu Sharan Pathak had quickly decided to divert the aircraft to Pokhara after finding out the problem in landing gear light.
Although co-pilot S.D Maharjan had warned about the sharp turn while diverting the aircraft, Pilot Pathak was found ignoring the warning, according to voices in Cockpit Voice Recorder (CVR).
Suresh Acharaya, joint-secretary of Ministry of Culture, Tourism and Civil Aviation and the member secretary of the commission said the lack of decision making for situational avoidance had caused the fatal accident. “Findings suggest that Pilot Pathak had obligation to return back to Pokhara and was also under stress and de-motivated with his job,” said he. Pathak who was an instructor pilot at Civil Aviation Authority of Nepal (CAAN) had flown only 16 hours in Dornier aircraft in last three month.
The six-member commission has also suggested all the operators to analyze the flight recorder on a timely basis as the cockpit area microphone of the aircraft was found not working. As the decision of the pilot was not according to standard operating procedure (SOP), the commission has recommended all the operators to ensure and establish a mechanism to monitor their adherence to the directives of company SOPs.
Likewise, the authority has been asked to strictly adhere single fleet policy at the earliest.
Six of the 21 people on board- three Indian nationals, the two Danish and airhostess Roshani Haiju survived the crash. Those who died were 13 Indian pilgrims and two Nepali crew members had died in the crash near Jomsom airport in Mustang district on May 14, 2012.
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