P_7878

The Himalayas - no room for cockpit confusion!

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The rugged and majestic beauty of the Himalayan mountains is un-paralleled on the earth, But, at the same time, it's one of the most inhospitable and dangerous territories for aviation (ETOPS restrictions apply to this region). There are inevitably catastrophic and unforgiving consequences to errors made in flight. This is one such story.

On 31st July 1992, Thai International Airways Flight 311 (an Airbus A310-300) lifted off from Bangkok's Don Mueang International Airport at 10:30 local time with 99 pax and 14 crew destined for Kathmandu's Tribhuvan International Airport (VNKT). After reaching Nepalese airspace, the pilots (Captain Preeda Suttimai (41), and FO Phunthat Boonyayej (53)) contacted the ATC and were cleared for SIERRA approach to Runway 02 from the South. Please note, here, the age difference between Captain/FO, and, reported, possible, psychological implications of Captain's "authority" over the FO's "experience". For navigational reference, please also see the "Romeo" fix (on the AS/FSC MAP screenshot below), the fix being 41nm south of Kathmandu VOR (KMT) along radial 202 degrees, and note that SIERRA approach starts 25nm north of the "Romeo" fix i.e. 16nm south of (KMT) VOR on the same radial. Nepalese ATC at the time was not equipped with radar (BTW, in a strange coincidence, this lack of radar facility, and also the navaid name "Romeo" sound familiar from one of my earlier stories!).

Shortly after reaching the starting point of SIERRA approach, the aircraft called ATC asking for a diversion to Calcutta (India) because of a "technical problem" (a fault was experienced in the workings of the inboard trailing flaps). The decision to divert was in keeping with both Company and performance requirements, which necessitated the use of full flaps for the type of steep final approach to VNKT. Twenty one seconds after making this request, at a distance of approximately 12nm from the Kathmandu VOR, the crew rectified the flap fault by retracting and then re-selecting the flaps. However, the crew determined that it was no longer possible to continue the straight-in approach to Runway 02, due to the steep descent angles required. So, they stated to the control tower that they wished to start their approach all-over again and requested a left turn back (south) to the "Romeo" fix.

After further dialogue with the controller, which included (four) repeated, but un-responded requests for a left turn, when the flight was about 7 nm south of the Kathmandu VOR, the crew unilaterally initiated a right turn (please see picture below and my FSX MAP loop-track) from the aircraft's 025 degree heading and simultaneously climbed from an altitude of 10,500 feet to FL180. The flight, then, commencing a descent while still in the turn, inexplicably completed a full 360-degree turn (NOTE: instead of proceeding south to the intended fix "Romeo"), and started heading, again, unfortunately, to the north at 025 degrees directly towards the high-mountains (see FSX Terrain MAP). To truly perceive the gravity and danger of this move, please note that my FSC MAP is showing Mountain Everest, world's tallest mountain (29,029'), barely 60-70 miles to the west of this fateful track, and the plane has already descended to 11,500' during the turn. Mount Everest is the tiny dotted circle at top RHS corner of the FSC Screenshot.

Then, at about 16nm north of Kathmandu VOR, the heading was altered slightly (reason unknown) to the left to 005 degrees. Approximately one minute later, at 12:45 local time, the Ground Proximity Warning System (GPWS) warnings sounded, engine noise was increased, and the aircraft impacted a steep rock face in a remote area at an altitude of 11,500 feet (of a 16,000-foot peak) with a ground speed of 300 nautical miles per hour. All 113 people on board perished in the collision. The accident site was located on the 015 radial at 23.3 nm from the Kathmandu VOR.

It remains a mystery why the crew had allowed the full 360 degrees turn back north (again) towards the Himalayan mountains, instead of proceeding further south to the fix "Romeo" for re-starting their approach to Runway 02. It's believed that the crew's (entire) focus on the FMS for trying to insert the "Romeo" fix and possibly resultant confusing (FMS) outputs may have degraded the crew's position awareness (BTW, these facts are also eerily coincidental to those of my earlier story, where the crew could not find the correct navaid "Romeo" on their FMS (it was not a "fix" there, but a "NDB", but of the same name!)).

Official investigations (jointly) carried out by the Nepalese Aviation Authority, Airbus Industrie, and the Transportation Safety Board of Canada, identified the following among the (57) probable causes of the accident.

  1. Loss of situational awareness and terrain separation (proceeding in a northerly direction which was opposite to the ATC-cleared fix "Romeo" to the South)
  2. Language barrier between ATC and Crew (ATC's poor grasp of English and non-standard (ATC) communications language)
  3.  Ineffective cockpit coordination by the crew (the FO seemed to have advised the captain to turn back before the impact, but not forcefully enough to change his thinking)
  4. Lack of sufficient (Airline) Simulator training for the complex and high-terrain Kathmandu Approach
  5. The misleading depiction of "Romeo" on the operator's approach chart used by the flight crew (seemingly the crew were having trouble entering data for the "Romeo" fix into the FMS)
  6. The flap fault, although corrected (required that the initial approach be discontinued)

So, here below, please find images of a flight using a faithful representation of the livery of the actual aircraft (thanks to TFS A310), but please excuse the registration "HS-TIC" here (instead of the actual "HS-TID"). I've made this flight pass through the aforesaid "Romeo" fix, following through the 360 degrees turn 7nm south of Kathmandu VOR (shots of it below including one FSX MAP shot of my tight-loop), and then heading north at 025 degrees (later changed to 005 degrees). I've applied some cloud-cover, and, for your reference, on several of the shots, I've inserted an Info-gauge (displaying true altitude, IAS, and heading - in that order), a NAV/DME gauge showing (continuous) aircraft-distance from the Kathmandu (KTM) VOR (112.20), and also a radio altitude gauge (below the DME gauge) - to monitor flight progress. Here is an admission that I did not have to make in my earlier such stories: As you can see, in the final shot, the DME gauge is reading 23.3nm, exactly what was reported in the actual case. The RA gauge at that point shows 1100', but, before I had a chance to collect another shot at RA=500', the plane had already collided with the mountain, indicating a steep side to this mountain, a fact that was also reported. Thanks for reading/viewing this story which is a unique combination of mechanical and human factors resulting in the tragedy - hopefully not to re-occur ever again (under similar circumstances and probable causes). [(FW) Aircraft/Gauges, AS/FSC, REX]

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Although I like the screenshots forum, I feel dwelling on accidents and using screenshots to illustrate them is the wrong venue for a website that celebrate's aviation.  It makes us look like those who orchestrated 9/11, recreating accidents with our simulators instead of using them for personal flight engagement and positive words, and encouraging thoughts to ease the pain and suffering of the passengers, and crew and jobs lost from any bad accident.  And picking on a foreign airline, when we have had our share of incidents in the US too, I do not like.  That's my opinion, I've stated it, and I will not reply to any replies here.

John

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John: No worries...your opinion, I especially respect here...whether the outcome of such events is uplifting or tragic, I've tried to mix both in the past, this will be my last such post....thanks...

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Posted (edited)

I always appreciate the amount of effort you put into preparing your posts. And I applaud your decision.

John F (the "other" John)

Edited by John F

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Posted (edited)
4 hours ago, John_Cillis said:

Although I like the screenshots forum, I feel dwelling on accidents and using screenshots to illustrate them is the wrong venue for a website that celebrate's aviation.  It makes us look like those who orchestrated 9/11, recreating accidents with our simulators instead of using them for personal flight engagement and positive words, and encouraging thoughts to ease the pain and suffering of the passengers, and crew and jobs lost from any bad accident.  And picking on a foreign airline, when we have had our share of incidents in the US too, I do not like.  That's my opinion, I've stated it, and I will not reply to any replies here.

John

John...I respect and understand your opinion, although there is obviously a love of aviation and desire to learn from past mistakes in the OP. What often sends these threads south imho is unnecessary hyperbole in responses, as in saying such a post "makes us look like those who orchestrated 9/11..." I applaud P_7878 for not reacting to that association and hopefully what you wrote is not what you meant to imply. I thought the OP's motives and purpose for the post were very clear and in no way resembled the comparison.

Edited by cimgrp501
clarity
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What a great article and I hope you keep them coming and dont listen to the nonsense by other posters if they dont like they dont need to read it. There is a guy on you tube that does the same thing except he shows the plane flying following exactly the same course and tells the story in captions and he uses xplane I think, he does a great job to

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John et al.:

Many thanks for the comments and also if you liked it...

When younger, many many years ago, I'd actually visited Kathmandu....although nearly 100 miles from the Mount Everest, there, you already get the unique sensation of being so near to this massive mountain ranges. I recall then asking one gentleman who had taken a trip much closer to the ranges, "How was it?". He had just replied, "If you see these things close, you'll know how small you are in God's creation...". I used to have classmate here who would tell me about the rich history of Nepal/Kathmandu, and even taught me a smattering of Nepali...

The Himalayas are more than just fascinating...just to imagine it has 50 peaks over 23500'...I've only visited the foothills of it. Plus, the Himalayas have been enriched in mythology and spirituality since the ancient the ages...

So my interest in it always peaks whenever aviation is added....🙂...

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I don't know how much time real world pilots peruse the details of recent or historic accidents.  But it is certainly advantageous to them to devote a good deal of time learning what pilots may have done, or failed to do, (least that current pilots become too over-confident in so-called routine flights). 

So, I think these type of analytic posts do more overall good than to offend anyone's sensitivities...

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I always enjoy your posts and the effort you put into them. This was very interesting, and I think there's just as much enjoyment that comes out of learning from other's real-aviation mistakes to better inform our own understanding of aviation. Learning about our hobby is half the enjoyment.  Aviation is dangerous. I would be sad to see you stop posting what you want when you want, just because someone doesn't approve. It would be a different story if a moderator told you these posts were in appropriate, but that didn't happen, so please consider keeping up with this theme if you want to. 🙂 

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15 hours ago, P_7878 said:

John et al.:

Many thanks for the comments and also if you liked it...

When younger, many many years ago, I'd actually visited Kathmandu....although nearly 100 miles from the Mount Everest, there, you already get the unique sensation of being so near to this massive mountain ranges. I recall then asking one gentleman who had taken a trip much closer to the ranges, "How was it?". He had just replied, "If you see these things close, you'll know how small you are in God's creation...". I used to have classmate here who would tell me about the rich history of Nepal/Kathmandu, and even taught me a smattering of Nepali...

The Himalayas are more than just fascinating...just to imagine it has 50 peaks over 23500'...I've only visited the foothills of it. Plus, the Himalayas have been enriched in mythology and spirituality since the ancient the ages...

So my interest in it always peaks whenever aviation is added....🙂...

I enjoyed two movies that showed the area around Nepal and Tibet, the humorous "Golden Child", after Daddy Day Care my favorite Eddie Murphy Movie, and "Seven Years in Tibet" about escaped POW's I believe bonding and becoming friends.  It was panned by critics but when a movie is panned by critics I like to watch it in the sense of judge not, lest ye not be judged. 

After all these actors are pushed by their producers and directors to churn out on site movies, which is quite tough.  I managed a hotel in Napa that was home to the Falcon Crest cast and I met, spoke, ate and drank with all of them.  Ana Alicia was a sweetheart and because of her I fell for a Mexican woman, Ada, the mother of my daughter.  I would of could of asked Ana out, but that would have ended my job at the hotel, since we had to decide whether to woo the guests or keep our job, lol.  I found her, and another cast member, Della Reese, to be the warmest people in the world I have met, except for my ex wife, who after my recent getting run over gave me a very warm phone call, I know there is still love in her heart for me and I will cherish it always.

There is a "evil" heart in the Latina women because of the way Europeans came to the America's which created long grudges, but if you can see thru that, you will see they are indeed some of the best mothers in the world.  I knew that because my best friend, Mike Hubert and his family, was like me a mixed race family--his Mom was the sweetest Mexican Mother one could ever know, and when I was sick with appendicitis in '72 and recovering from a very serious surgery, it wasn't simple back then as it is now, his mother and he would come to me, or they would invite me into their home, so I could just rest--they were very spiritual and loving people. 

When they moved away, that best family of friends, it broke my heart, they moved to Oregon because at that time California's property taxes were eating homeowners alive.  Finally they had a revolt, someone named Howard Jarvis motivated our families to bring those taxes down, which saved my family home and created the wealth that eventually allowed me to learn how to fly, some thirty years' later.  So I love cultural context in screenshots posts, the salvation of things I disagree with, because we learn from each other.

JC

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***Fantastic*** Another Quality Post,Thank You

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1 hour ago, Phantom88 said:

***Fantastic*** Another Quality Post,Thank You

Indeed, Thank you and keep them coming.

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Posted (edited)

Thanks all.

I was just thinking, cannot remember back exactly when, that I may have been the 1st to pick-up a copy of FS2004 from the "Walmart"...there were not the umpteen on-line SIM retailers that we see these days. But, life's stories (good and bad) got in the way....just as for many of us. I simply amaze myself at some of you folks how persistently and continuously you have maintained your connection to the SIM!

Anyway, time to see next what beautiful scenery Filou comes up with...🙂...on that flat landscape, but we certainly don't need high-mountains (that I'm personally fond of) to make it look any more beautiful...

Edited by P_7878

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To the OP - just wanted to reiterate i really enjoy your posts, and hope to see more of them.  I see them as a great learning tool.

 

Richard

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