Aviation Safety Report 2018 Civil Aviation Authority of Nepal Published by: Civil Aviation Safety Regulation Directorate Civil Aviation Authority of Nepal Head Office, Babarmahal Kathmandu, Nepal June 2018 Phone : +977-1-4262387, 4262518, 4262326 Fax : +977-1-4262516 Website: www.caanepal.org.np © Civil Aviation Authority of Nepal Foreword With diverse virtues such as bringing people assessments, validations, inspections and closer, promoting economic growth and enforcement. facilitating tourism and trade, aviation plays a crucial role in the wider economic development Management of safety, thus, is the joint of society. So as to ensure that air transport responsibility of CAAN and all the service continues to play a major role in driving providers. The journey towards a continuously sustainable economic and social development, safer aviation demands shared paces. CAAN is continuous improvement in aviation safety is committed to put its best efforts in promoting essential. As a regulator of civil aviation activities safety and inculcating safety as a culture among in the country, the Civil Aviation Authority of all concerned. Nepal (CAAN) is responsible for ensuring safety in Nepalese aviation arena. The Standards and This Safety Report is the second edition of the Recommended Practices (SARPs) stipulated in Aviation Safety Report, 2016. This Report has Annexes to the Convention on International Civil corrected some accidents data and also inserted Aviation are the basis of uniformly establishing a few data after verifying with ICAO and other safety in all contracting States. Based on these international publications. This Report is based SARPs, CAAN develops requirements, on guidance from Global Aviation Safety Plan, directives, manuals and procedures for the ICAO USOAP Audit Reports, Accident maintenance of aviation safety in acceptable Investigation Reports and Mandatory and level. Voluntary Reports. It provides a brief overview of updates on safety indicators including the accidents that occurred during the last ten years The air transport industry needs to deliver safe (2008-2017) together with Nepal's status in services in accordance to these regulatory USOAP Audit, safety priorities and safety framework set up by CAAN. For delivery of challenges of Nepal. safe services, an effective safety management system needs to be in place so that inherent risk can be identified and managed to an acceptable level. CAAN, as part of its oversight activities, verifies that the aviation industry complies with (Sanjiv Gautam) the regulatory framework through certifications, Director General Contents Foreword Executive Summary 1 1. Aircraft Operation in Nepal 4 2. Air Traffic Movement 5 3. Aircraft accident in Nepal 7 3.1 Accident of Multi-engine aircraft 8 3.2 Accident of Helicopters 9 3.3 Accident by area of operation 10 3.4 High Risk Category (HRC) accident 11 4 Safety Reporting 12 4.1 Incident reporting in 2016 and 2017 13 4.2 Incident analysis of the year 2016 14 4.3 Incident analysis of the year 2017 15 5. Universal Safety Oversight Audit Programme (USOAP) 16 5.1 ICAO Coordinated Validation Mission (ICVM), 2017 17 5.2 Overall EI score after ICVM 2017 18 5.3 USOAP current vs initial result 18 5.4 Open USOAP protocol findings 19 5.5 Safety deficient CEs and Areas 19 5.6 Nepal Safety Oversight Margin 20 5.7 Comparative EI Level in Audit Areas 21 5.8 Nepal Vs Global EI in CEs 21 6. Implementation of Safety Recommendations 22 7. Acronyms 25 8. Appendices 8.1 Appendix- 1: Accident of Nepalese registered multi-engine Aeroplane 26 8.2 Appendix- 2: Accident of Nepalese registered Single- engine Aeroplane. 28 8.3 Appendix- 3: Accident of Nepalese registered helicopters 29 8.4 Appendix- 4: Accident of foreign registered aircraft in Nepal 30 8.5 Appendix- 5: Accident of Nepalese registered recreational aircraft 30 Executive Summary Executive Summary Aviation in Nepal, with its diverse topography claimed 173 lives. Turbo Prop multi - engine as well as weather, has its own constraints and aircraft with seat capacity of more than 19 did challenges. Heterogeneity of aircraft in the not witness any fatal accident during that period. domestic operations varying from small Cessna Turbo-prop multi-engine aircraft with seat to bigger jets such as CRJ operated by 19 different domestic airline companies has added to these capacity 19 or less met with 13 accidents claiming challenges. Small turbo-prop aircraft including 150 lives and single -engine turbo prop aircraft DHC-6 300/400, LET 410, D228 and single had 3 accidents resulting in 2 fatalities. Similarly, engine Cessna- 208B operate mostly in the there were 10 helicopter- accidents with 16 airports that are located in narrow valleys or hill fatalities and 3 recreational aircraft accidents tops. with 5 fatalities. The diversity of weather patterns The movement of aircraft in domestic operations together with hostile topography are the main registered a significant increase from 2015 to challenges surrounding aircraft operations in 2016 by 33.04 % and a notable increase of 13.51 Nepal due to which, the number of accidents % took place from 2016 to 2017. related to small aircraft having 19 seats or less and operating in STOL airfields seems During the period of 2008 to 2017, Nepalese registered aircraft witnessed 30 accidents which comparatively higher. Aviation Safety Report 2018 1 As guided by ICAO Global Aviation Safety Plan, safety. Similarly, the second highest number of total aircraft accidents (except recreational flights) incident reports received, in 2016 and also in from 2008 to 2017 in Nepalese sky have been 2017, was related to wildlife strike. The lowest classified into six categories as: Controlled Flight number of incidents reported was related to laser into Terrain (CFIT), Loss of Control in Flight strikes in 2016. In 2017, lowest number of (LOC-I), Mid-Air Collision (MAC) Runway incidents reported was about ground incidents Incursion (RI), Runway Excursion (RE), and and laser strikes. Wildlife Strike (WS). The highest risk of accident in Nepalese civil aviation is CFIT as it accounts Nepal has shown significant progress in the for 37 % of total accident, LOC-I accounts for improvement in its safety oversight capability. 33% and Runway Safety (incursion and Significant Safety Concern (SSC) issued by excursion) accounts for 29% to stand as second ICAO after ICVM in July 2013 has been and third risk factors respectively. resolved. Similarly, Effective Implementation (EI) of ICAO safety standards and guidance has In 2016 total number of incidents reported was also been raised above the global average. The 192 whereas it was 159 in 2017. In both the effective implementation (EI) by CAAN was years, the incidents related to Air Operation and 43%, 55% and 66.08% in 2009, 2013 and 2017 Maintenance was found to be higher than other respectively. ICVM 2017 identified CE4 and categories viz. ANS, wildlife strike, runway CE8 as safety deficient critical elements and incursion and excursion, laser strike and ground ORG, AIG and ANS were identified as safety 2 Aviation Safety Report 2018 deficient Areas in the state oversight capability In the context of growing activities in air system. transportation, and in light of anticipated increases in air travel, it is imperative to maintain a very The implementation status of Recommendations strong focus on initiatives that will further issued by Accident Investigation Commission improve safety outcomes in the future. CAAN formed by Nepal Government in between 2008 to 2017 reveals that 81.17% of the total 154 is therefore continuously developing and refining recommendations have been complied, 8.44% more proactive methods to further reduce the have been partially complied, 7.79% not accident rate and contribute in building safer complied and 2.60% are not applicable. sky. Aviation Safety Report 2018 3 1. Aircraft Operation in Nepal Out of thirty international airline operators carrying out scheduled flights, three are Nepalese carriers namely Nepal Airlines Corporation, Buddha Air Pvt. Ltd. and Himalaya Airlines. Recreational International Domestic Domestic Helicopter Ultra lights (Sch.) (Sch.) ( Non Sch.) 4 11 3 9 1 Paragliding 59 - Nepal Airlines Corporation Schedueld International - Buddha Air (International) - Himalaya Airlines - Nepal Airlines Coorporation - Yei Airlines - Tara Air - Buddha Air Scheduled Domestic - Simrik Airlines - Sita Air - Summit Air - Saurya Air - Shree Airlines - Makalu Air Non -Scheduled (dom.) Shree Airlines Simrik Air Fishtail Air Air Dynasty Mountain Air Manang Air Helicopter Altitude Air Heli Everest VVIP Kailash Helicopter Prabhu Helicopter 4 Aviation Safety Report 2018 2. Air Traffic Movement Domestic The chart below depicts the movement of aircraft in domestic operations from 2008 to 2017, which shows an increase in aircraft movement in years 2009, 2010, 2011, 2016 and 2017. There was a significant increase from 2015 to 2016 by 33.04 % and a notable increase of 13.51 % took place in 2017 over 2016. The highest downturn in air traffic movement recorded for 2014-2015 can be attributed to the massive earthquake that hit the country in April 2015 impacting the entire tourism industry significantly. Aviation Safety Report 2018 5 International International aircraft movement shows annual decrease of 2.36 % from 2014 to 2015. Though the figure of 2014 surpasses the figure of 2013 by 12.46 %, the decrease in international aircraft movement in 2015 is also attributed in part to the devastating earthquake of April 2015. There is a significant increase of 23.02% in aircraft movement in 2017 over the year 2016. 6 Aviation Safety Report 2018 3. Aircraft Accident in Nepal Review of accident from 2008 to 2017 (Nepalese Registered Aircraft Only) Nepalese registered aircraft witnessed 30 accidents which claimed 173 lives during the period of 2008 to 2017. Turbo Prop multi - engine aircraft with seat capacity of more than 19 had one non fatal accident during that period. Turbo-prop multi-engine aircraft with seat capacity of 19 or less witnessed 13 accidents with 150 fatalities, single -engine turbo prop aircraft met with 3 accidents resulting in 2 fatalities.