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"I don't want any more Sarahs to die"



The latest airliner crash in Nepal has underlined the danger of monsoon flying in the Himalaya. Nepali Times gathered a panel of experts on Monday to discuss Nepal's appalling aviation safety record, and to suggest remedial measures.

DAMBAR KRISHNA SHRESTHA
Participants:

Capt PJ Shah: has been flying in Nepal since the age of the DC-3s and spent 40 years as a senior captain with Royal Nepal Airlines and then Emirates. His nephew, Capt Lucky Shah, was commanding the Agni Air flight that crashed on Monday.

Hemant Arjyal: engineer, aviation analyst and a member of the Nepal National Aviation Council.

Dorji Tsering Sherpa: airline entrepreneur who was with Yeti Airlines, Lumbini Airways and Skyline, and now Air Kasthamandap. His daughter, Sarah Sherpa, was on her first flight as an Agni Air flight attendant when she was killed in Monday's accident.

Binod Kumar Gautam: Deputy Director at the Civil Aviation Authority of Nepal (CAAN).

Sanjiv Gautam: Head of Air Traffic Control Division, CAAN.


Hemant Arjyal: Statistically, if you look at the record since the first crash in the 1950s, you see that most accidents happened in the monsoon and most of them have been classified as Controlled Flight into Terrain (CFIT), which means a perfectly good plane in full control of the pilot hits a mountain in cloud. Therefore, human factors are involved. It could be that there is complacency about the dangers of mountain-flying in the monsoon season, over-confidence, and pressure on pilots to fly in bad weather from passengers or the company.

PJ Shah: The preliminary indications are that the Agni Air crash was not a CFIT, as the nature of the impact suggests the pilot was not in control of the aircraft. The crash should be a warning, but we seem not to have learnt from previous crashes. We need a complete structural overhaul of the civil aviation regulatory environment.

Dorji Tsering Sherpa: I feel like I have come full circle in the airline business with the death of my daughter. Earlier, I had lost relatives in the Thai Airbus crash in 1992. Capt Lucky was one of the most experienced pilots around, a very safety-conscious commander. I went to the airport on Monday morning and asked why the Lukla flights were allowed to take off in such bad weather. It seems there was competition among the private operators to lift out the tourists stranded in Lukla. Someone has to say enough is enough. I don't want any more Sarahs to die.

PJ Shah: There are four components to the airline business. The manufacturer, the operators, the regulator, and the travelling public. Safety has to be the primary concern for all four, and the emphasis must shift to the passengers, without whom there would be no airline business. Unfortunately, in our country the most valuable sector, the passengers, are not treated well. Only VVIPs are given importance.

Dorji Tsering Sherpa: I agree, passenger safety has to be the ultimate goal. Even after this accident there will be a committee, there will be a report and no one will really know what happened or whether remedial measures were taken. I have been involved in the search and rescue of previous crashes. In two of them, planes crashed into mountains during the monsoon, but crew conflict was a factor. You have to respect the monsoon; maybe there should be a moratorium on flying to certain airports in the monsoon.

PJ Shah: You can't change the weather. I don't think you can stop flying in the monsoon; there are periods even in August when the weather is good. Nepal is a very difficult place to fly, but there have to be methods and proper procedures. We should also discourage fusion between the regulators and the operators. They should be separate, otherwise maintenance standards will be compromised.

Dorji Tsering Sherpa: The nature of Nepal's domestic airline business and tariffs is such that it is very difficult with current CAAN rules for an investor to sustain a fleet of multi-engine aircraft. Which is why I have always been a proponent of single-engine equipment for remote airports: they are easier and cheaper to maintain and operate. The other aspect is that even a small airline with only one aircraft is required to maintain an engineering department, whereas operators with the same aircraft should be able to pool maintenance and crew. But CAAN has no such mechanism.

Binod Kumar Gautam: I think we are a long way from pooling engineering departments. Two airlines with the same Jetstream or Beechcraft equipment don't even help each other out with engine or landing gear spares.

PJ Shah: There is no point imposing more rules, we have the world's best regulations, but let's face it, there is a problem with implementing them. There is a 'who cares' attitude among airline staff. There is a culture to compromise by cutting corners on safety matters.

Hemant Arjyal: If there is a crash every monsoon, you have to plan accordingly, and learn from the previous years. When can Air Traffic Control clear a plane for takeoff, what is the trend at the destination airport? We have to maintain minimum equipment and provide for air crew training. If there is a pattern of crashes and we know the causes, we have to be prepared.

Dorji Tsering Sherpa: CAAN has to do something about search and rescue coordination. It was chaos at the airport on Monday morning.

Sanjiv Gautam: We have a search and rescue unit as per ICAO requirements, it comes into operation only when something happens. It involves the army, police and civil police. What we need is more communication equipment, maps, charts, procedures, an MoU with the army in a permanent centre at TIA. If most accidents happen in the monsoon, we need rules on visibility, established norms for monsoon flying, and better coordination among pilots, Air Traffic Control and airlines. There has to be a balance between service and safety: if we insist on safety alone, the airlines will go bankrupt.

Binod Kumar Gautam: They say the history of aviation is written in blood, and in Nepal we have to address the human factor since this is the cause in most crashes. Pilots go through three phases: first they feel invincible, then with experience they think they know everything and in the third phase they think "it will happen to someone else, not me". Cockpit dynamics and bureaucratic and peer pressure to fly in bad weather are important issues. We have a confidential reporting system now that has already yielded results.

Sanjiv Gautam: Accidents happen and we try to look for someone to blame. But the cause is always a combination of factors. There is always risk, the question is can we keep the risk at a tolerable level, minimise it, and examine and eliminate the potential contributing factors?

PJ Shah: If most accidents are human error, we have to address the what, when, where, how and why, and plan accordingly.

Binod Kumar Gautam: Our main constraints at CAAN are insufficient technical manpower for maintenance inspections and remuneration of staff. We follow ICAO procedures, but just because an aircraft has passed our certification doesn't absolve the operator from responsibility. Financial regulations for the import of spares also need to be revamped. You have to wait three days to open a Letter of Credit (LC) for an urgently needed spare part. How do you keep the plane flying in that time?

Dorji Tsering Sherpa: The hassles in getting permits and LCs for spares need to be removed. Also, the process for visas and work permits for expat personnel need to be streamlined. Over-regulation is no regulation.

Hemant Arjyal:  Safety has to be a culture, not a requirement. But this can't happen overnight.

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1. Rasta
The history of tragic accidents in Nepalese civil aviation is a result of unscrupulous businessmen and unscrupulous Civil Aviation officials colluding in their pursuit for money. Nepal's mountainous terrain and the monsoon should not be used as an excuse any more. There are enough safety margins in the Standard Operating Procedures (SOPs) for flights in our terrain during the monsoon to avoid accidents. Are these SOPs being observed? The Civil Aviation Authority of Nepal is utterly incompetent when it comes to ensuring that the private operators are following proper maintenance practices.

2. Nepali Lad
You people have puppets you need for your paly, the commodities rely and still its always the same thing over and over again. Please STOP blaming each other and act as a human. What if you had your relative on that flight?
With the shiny designation name on you and yet you could not stop the tragedy. How would you feel?

Please be advised to follow "ALWAYS" a good measurement


3. Torts
Can the surviving family members of the bideshis who died sue Agni Airlines in a US or a British court for gross negligence, i.e., for flying despite the bad weather signals?  

4. Ram babu

You need to set highet standards. To get me of this mess make a committed decision to raise CAAN's standards. Make your standard higher then ICAO Requirements. The only question that matters for setting your standards is this:  Are you doing your best?  If the answer is yes, you�ve got nothing to be ashamed of, regardless of how your results stack up.

Raise your standards.  Can CAAN perform now a little better than DCA and CAAN did till date?  And can CAAN do the same thing tomorrow and the next day?  Follow that trail, and CAAN�ll come to discover just how incredible CAAN's best really is. 



5. DRC
"Action speaks louder than words". However, it seems you guys are only building castle out of air with no sustantive changes from the prospect of aviation industry. Big meetings, big people, and big talks doesn't help. Almost all of the airlines in Nepal is operating with the second hand rejected fleet of flights from other countries. Isn't it the biggest safety issue in Nepal? Corruption and bribery has given everybody a slack on everything from safety to operation. How about the trainning and qualification of the safety engineers? Are they really qualified to inspect and certify the flights taking off from the airport?  Start grounding and firing people for not doing their job and being corrupt and substandard then we can tell that, you guys have done something concrete about the safety of the others. Otherwise, don't waste your time and our lives, we already have so much in our plate and we are tired of too many cats with rats dancing on your heads.

6. Sherap Sherpa
Thank you Kunda and Nepali Times for putting together such a crucial discussion regarding flight safety which CAAN should have been doing every week. There is dirty competition prevalent everywhere in Nepal from small cyber cafes to big banks to airlines. CAAN needs a complete overhaul. It has to be kept away from political pressure. Since it is responsible for thousands of flight passengers and crew everyday, only experts should be hired to oversee the operation. I strongly agree, we can't afford to loose another Sarah Sherpa or another Lucky Shah. In a country like ours where even road travelling is often unpredictable, having airline service with good safety record is a must. Whether you are a tourist flying to your trekking region, or a local person returning back to be united with his family, safety must come first. It is high time that personnels and authorities concerned at CAAN must do something to bring the change and install positive win-win competition among our airline companies. When the weather is bad it mean BAD and no  airline should be allowed to take off. It is ok to be Mr. Late than Late Mr.


7. Vija Srestha

Reading the above articles about the reasoning why the Agni Air crashed and everyone pretending and not see the main reason behind it.It is a shame.

I am not a specialist in this field ,but I believe Nepal aviation has enough professional and capabable heads to understand why planes crash in Nepal so often.One word for it is Irresponsibility and Greed for Money .Until these have not been brought forward as the only human error,the planes are gone to crash as often as now.Weather conditions,common even the lower staff of airlines know that and everyone blaming it on bad weather,sounds even disgusting,technical problems,every engineer knows it,and again the only reason to these are Greed for Money and not being able to withstand the pressure .

Even doctors ,who have given the Oath , that one sincerely intends to do what one says , a solemn attestation of the truth or inviolability of one's words ,do not attend the patient ,until one has not paid money .

In aviation the reality is even much more simplier,in case anything happens,weather conditions and many other second importance excuses are always there.

Therefore I agree that only positive win-win competition among  airline companies may work ,because companies are brought to Nepal as a one way of doing bizness and any bizness needs to earn living even in the name of greater good,but not overlooking safety and who are they carrying on their board.Those are human lives,not wooden logs.If one wants to argue that to bring 100% safety on airline flights many lives will be lost on the way,then better think twice.Safety should not be a culture like one of the above writers mentions, it must be a requirement.Irresponsibility and Greed for Money is 99% reason to any of the acccidents happening in Nepal and one needs to be totally ignorant to believe all the reasoning  given above.

Strip of the company of the licence.

Maybe if airlines would be promoted only if they have a very good safety record of flights allowed to continue operate in Nepal ,the many owners would think twice,letting fly for whatever reason ,the main responsibilty must be on the owner of the company and only,but many owners just have few specialists at front desk and are let to buy and fly planes,but of course there ar other areas in the CAAN where lots of regulations and improvements must be made,like for example helping each other out ,or receiving and delivering needed very important parts and installing them on time etc.And again ,behind all of it is Irresponsibility and Greed for Money and not any other reason.

Well,if one cannot accept that,forget about other reasons.That's the truth and the reality ,and this is where we need to focus our attention,how to make it work and have a win-win situation with only priority,Safety .



8. Dorji Tsering Sherpa
Yes we need to thank gentlemen like Kunda for taking up the responsibility of researching and publishing in-depth details of what goes on in the aviation sector. I personally felt gratified by the pertinent questions for which i could express my feelings to so many people through Himal Khabar Patrika and Nepali times.There is no shortage of rules and regulation in Nepal, it is the will and the honest men that is lacking to implement them. Rule of law seems have totally disappeared in Nepal.. General public must take up the issue from all corners to have some positive results. Thank you.  

9. Vija Srestha

Dear Reader,

Yes,I totally agree that Mr.Dixit is one of those people in Nepal who cares and thinks ,and tries.He is doing his job.Everyone should ask himself a question.What legacy will I live behind myself?I was powerful and had all the riches to support my family ,is that all I can do?We can do more.Thank you Mr.Dixit for leading us.

Why it is the will and the honest men that is lacking to implement them?

The problem is much deeper than we allow to see.Not even irresposibility,because we punish the irresponsible and people are already used to that,just one reason,MONEY ,it is a question for millions of Nepalese,because work is being paid in money and how much one has is a ticket to many possibilites for millions of people in the whole country. They are adults and everyone knows and you Mr.Sherpa know the right from wrong,and everyone knows reason behind it,even you Mr.Dorji Tsering Sherpa,this is again one of those articles that brings up a discussion which ends with open minded question.I truly believe Nepal has enough professional staff to do the job well,not just in the aviation field ,but in many other spheres,the question is ,who will take the responsibility and put a full stop to all those atrocious acts. It should be an owner and only.A plane is a one kind of transport,it belongs to someone,that someone has rights and responsibilities.

But the problem will be solved approximately like this.

My opinion ,I think ,simply the insurance company will pay out anything it considers the right amount as long as the involved will be able to provide believable reasons.Harsh reality.

I thank you for reading the responses,but I think everyone would be more interested in responses of professionals involved.Not stating what is seen to everyone ,but what will be done to improve the situation.

What will be done?

Folloow through and let the public read and know the actions taken by the aviation.That could be the first step towards responsibility,even if as a group.

But as usual,everyone around is considered not to be professional enough to understand the complexity of problems and therefore soon the discussion will end.

Let's give a chance to every person ,each of us has a goodness in their heart ,bring it out,use it,don't give it just to the family,there are lots of people who need it and by having you where it counts,will sow a grain of kindness,honesty,so much needed in Nepali society.

 



10. jeev
Expert comments aside, 
Flying in Nepal is not nearly as safe as it can be.
Any comments suggesting regulations as being enough or them being enforced proper is a bunch of lies. 
Our regulators comply with the minimal and mandatory requirements and look out for ways to avoid the recommended practices, unless it has bearings to some 'old' commercial player. 
Our regulations are so misaligned with the thrust in the larger international aviation scene, any forward thinking and creative entrepreneur hoping to enter this business usually opts out in dismay.
The approach to safety is more pitch than any real action, cases relating to the 'regulators' turning a blind eye to less than perfect performance, both from the hardware and 'human ware' are so plenty, you'd have to blind not to see them. 
The infighting between the regulators themselves, and the pressure 'money' provided by the 'conservative' operators to eek things their way is plenty to be had.
What needs to be way forward is a complete overhaul on the way things are. Trying to supplement a diseased and failing organisation and expecting it to reap yields in plenty is not the way forward.



11. Vija Srestha

Good morning to everyone,

It is really upsetting to read about our indifference.

Regulations specially where the technology is involved is a must to follow,whether it is at international standard or local.One must not let fly if the technical problems are seen and just hoping ,must not be accepted and specially when the weather conditions are not perfect for flying.The only reason for this flight to have sad ending is a technical condition of an airoplane and responsibility of that lies on the companies owner,unless he doesn't even know that much.Did anyone check the plane before it took off ,since the plane was not in Kathmandu.Where is the technical check up of the plane at the other end,specially if it was not in operation for few days due to bad weather conditions as no plane could take off for almost a week ,recordings of technical check ups ,dated .....

It is not our job to do the inspections and find the proof,it is seen.Read the findings of last 26 minutes ,which is still accesable on the newspaer pages.

And yes,I would only be satisfied knowing what the responsible and involved people in this case are going to do and who will make a follow up how the promises are implemented,through the newspaper.A person should walk his talk and newspaper gives him this opportunity and we are waiting.

Nothing is a bunch of lies if you believe in doing your best and in this case too,it is following through the instructions,regulations and moral grounds.Is it a lot to ask?

No one is interested in infighting among the regulators and this is not a measure we need to follow,those people there are to do their professional job and the responsibilties what comes with it and only that must be a measurement .

But the sad ending is already there.We can not bring back people.We must work the best we know and can in a team,the only measure to follow in such complicated situations is one's own moral grounds and taking decision based on that would bring much better results.

We can talk about the reasons,all around the ups and downs,forces,technical problems etc,we press the buttons,don't we?

Accept the responsibility,follow through ,let us know what have you done ,make a personal promise,if you need,but do not pour the water,it is a waste  and disrespect to any thinking person.

Sincerely,

Vija

 



12. Vija Srestha

Dear Reader,

I was really looking forward for somebody to take a stand as the article itself raises a lots of unaswered questions,but the only response will be a black box, contains of which will not be disclosed to the public.

1.I would like to quote

Let me explain what is complacency <

 A feeling of contentment or self-satisfaction, especially when coupled with an unawareness of danger, trouble, ...

Is it really a good enough reason to let a pilot fly? I do not believe that sentiment like this would make any pilot  fly in  mountains and bad weather conditions with passengers on board.

The question to the owner and the company.

Since when the passengers decide when it is good enough to fly ?Since the company operates the plane in such weather conditions ,I think it is the reponsibility of the company and owner as the licence holder of the kind of transport one owns.

However ,responses on this article from the professionals involved are not satisfying and certainly are not responsible if one can read asnwers and reasoning like this. I will quote here words used in the arcticle.

2.The pilot started a flight as the Controlled Flight into Terrain 

because

< the article states the pilot switched of the instruments >,he had to use them as it was raining and bad visibility was present at least from Kathmandu.We all understand ,the weather can change in minutes,therefore flying using only, would be impossible. 

3.Between 7.10.a.m and 7.18 weather and equipment malfunction,all happens in these 8 minutes and the plane is almost half way from Lukla,as the map shows,which means just approximately 10 more minutes and it would reach the destination.

Generator malfunctioning ,the captain didn't declare emergency because he knows there is a backup generator,batery and there are instruments on which he would rely in case of visual landing.

So there are two generators,one of which works only for 8 minutes or even less,as in those eight minutes the pilot receives or sees bad weather conditons near Lukla,he needs to give information to the team and he also needs to follow the instructions received from Kathmandu .What exactly was said in these minutes,it is on the conscience of the team,because everything is mentioned ,but only one sentence is missing.

4.My question is,aren't both generators suppose to be in working condition when the plane takes off?

Why do we need two Mr.Dorji?In case one of them becomes malfunctioning .

There are two,one works not more than 5-8 minutes and the pilot knows about it since he is telling it is malfunctioning.The other even doesn't switch on.For instruments to be read ,one needs generator and batery in working condition ,even the once which pilot would use in case of visual landing.None of them work.There is a chain of questions and the reading you may find in a check up book before the plane took off as in my understanding all these three important parts must be in a working condition  before the flight takes off,but it is clear they were not.You have regulations and technical rules to follow.It may not be a deadly mistake if the weather conditions were good,but it is a must to have all these three components in a working condition before the flight is given a green light and working on 100% ,not just for 5 minutes ,the other generator was just an extra luggage ,if that was not important enough to maitain in 100% operational condition.

We may try to blame on weather conditions and rain doing damage ,during the flight ,so the engine and fuel would be the reason,but even then ,if that happened,was the plane checked well before the green light?It was not ,if that could be the case.

5.What is a battery?Every primary school child knows that parents use it at home when there is not enough of electricity at home.Why was the battery not working properly?Was it old,was it charged properly?

The article states ,He then said he was trying to 'recycle' the battery pack. Generators supply power to cockpit instruments, and without it most avionics shut down and the pilot is flying without direction or distance-measuring equipment.

The pilot saw the terrain and he was ready to land the plane using visual approach,so he knew direction, and distance measuring  to exact metre is not that important ,is it,which means his eyes and artificial horizon.That is needed for a pilot to direct the flight .

I am sure you have played computer games for kids and you know what is an artificial horizon. The article states ,most avionics shut down >

Which ones usually do not shut down?

Here I can only imagine,<,human visual reading>As the pilot states,he sees a terrain and will shoot down using visual reading.So what instrument in the cockpit does that?There must be one ,but seems even that was not in working condition ,because the pilot could not understand where he was.

In my understanding all instruments need some supply to be in working condition.

It is clear ,that none of the above mentioned important componets or parts were  in working condition according to the even minimal standards needed for such a short 20-25 minute flight.

You can take into account any reasoning ,but if you are to find one,it is people,their irresponsibility and greed for money.

One wanted to fly ,he is experienced,well paid,even though the weather conditions are not sunny,the ground personal are not doing their jobs upto standards requirred,how to keep the planes flying in a meantime when there are no spare parts supplied to change them in time and passengers and goods are waiting at the other end.......

It is a morale responsibility for everyone who serves and works for the people and only this should be a standard in making decisions to fly in such extreme conditions,but in this case ,I see only technical condition of the plane is a reason for a crash.

My sincere condolences to the families ,I hope and pray these are the last families to go through such pain in such a beautiful country.

 

 Sincerely,

Vija



LATEST ISSUE
638
(11 JAN 2013 - 17 JAN 2013)


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