US-Bangla Airlines Flight 211 was a scheduled international passenger flight from Dhaka, Bangladesh, to Kathmandu, Nepal, that crashed on 12 March 2018 while landing, killing 51 of the 71 people aboard. The aircraft, a 76-seat Bombardier Dash 8 Q400 operated by US-Bangla Airlines, burst into flames after the crash, and the 20 surviving passengers were seriously injured from the impact and the fire. At the time of the accident, it was the deadliest aviation disaster involving a Bangladeshi airline, and the deadliest incident involving the Bombardier Dash 8 Q400.

A commission appointed by the Government of Nepal investigated the accident and issued a report that concluded that the probable cause of the crash was pilot disorientation and a loss of situational awareness on the part of the flight crew. The report was criticized by the airline and by the Bangladeshi representative to the commission, who felt that the air traffic controllers at Tribhuvan International Airport in Kathmandu had not done their job properly and could have prevented the accident.

Aircraft

The aircraft was a Bombardier Dash 8 Q400, configured with a seating capacity of 76 passengers, and registered as aircraft S2-AGU. It was first delivered to Scandinavian Airlines in 2001, and flown by three airlines before being purchased by US-Bangla Airlines in 2014. It had already been involved in a minor incident in 2015, when it skidded off the runway in Saidpur resulting in minor damage to its right-hand main wheels. At the time of the crash, the aircraft had flown a total of 28,649 takeoff cycles for a total of 21,419 hours and was current on its maintenance.  The impact forces of the crash and the post-crash fire completely destroyed the aircraft.

S2-AGU, the aircraft involved, seen in July 2014

Passengers and crew

The aircraft was carrying 65 adult passengers, 2 children, and 4 crew members, for a total of 71 on board. Of the passengers, 33 were from Nepal, 32 were from Bangladesh, 1 was from China, and 1 was from the Maldives. All of the crew were from Bangladesh. There were 51 passengers and crew members killed in the accident; 22 from Nepal, 28 from Bangladesh, and 1 from China. Most of the Nepalis killed in the crash were medical students who were returning home during a break from school. There were 20 passengers who survived with serious injuries.

The captain of the flight was 52-year-old Abid Sultan, a former Bangladesh Air Force pilot. Sultan had 22 years of flying experience, with more than 5,500 hours of flight time, and more than 1,700 hours of experience flying the Q400. He had worked for US-Bangla since 2015 and was also an instructor for the airline. He was experienced with the flight to Kathmandu, having flown it more than 100 times, He had resigned from the airline before the flight, but as part of the airline’s code of conduct, he was required to continue working until he had been discharged. He suffered multiple blunt force trauma to his head and chest, initially surviving the crash, but he died of his injuries the next day.

The first officer was 25-year-old Prithula Rashid, the first female pilot of the airline. She joined the airline in July 2016 and had a total of 390 hours of flight experience, 240 hours in the aircraft type. This was her first time flying into Kathmandu. She died of her injuries, described as blunt force injury to her head.

The two cabin crew members, Khwaza Hossain Mohammad Shafi and Shamim Akter, died after the crash.

Abid Sultan – Prithula Rashid

The aircraft, operating as flight number BS-211, departed Shahjalal International Airport in Dhaka, Bangladesh, at 06:51 UTC (12:51 p.m. Bangladesh Standard Time) bound for Tribhuvan International Airport in Kathmandu, Nepal. BS-211 was a regularly scheduled flight that operated four times a week between the two cities.

At 08:10 UTC, the first officer contacted Kathmandu Approach, who told the flight to descend to 13,500 feet and hold over a navigational waypoint. Long approach delays were common at Kathmandu due to a lack of airport capacity and high volumes of traffic into and out of the airport. The pilots expected to spend several minutes in a holding pattern at that point, so they discussed the navigational elements of the holding pattern, and configured the flight management system for the hold. However, before the aircraft had arrived at the target waypoint, the approach controller cleared the flight to descend and proceed directly to the approach for runway 02, instead of entering the holding pattern. The pilots did not reconfigure the flight management system for the approach, so when the aircraft arrived at the next waypoint, the autopilot began a left-hand turn of the aircraft as it had been configured for the holding pattern. Realizing that the plane was off course, the pilot quickly changed the aircraft heading selector to a course that would intercept the correct approach, and manually selected a rate of descent. Those manual inputs disengaged the flight management system that controlled the course and the rate of descent.

The crew performed the landing checklist, with the pilot erroneously stating that the landing gear was down and locked. The pilots had difficulty adjusting for the correct rate of descent because the flight management system was disengaged. The first officer repeatedly called out that they were 500 ft to 600 ft too high on their approach altitude. Meanwhile, a gear unsafe alert tone sounded continuously in the cockpit, unacknowledged by the pilots. With their attention focused on trying to adjust to the correct rate of descent, and distracted by audible warnings, the crew failed to notice that the plane was still off course, and had by this time flown to the right of the desired approach path, descending at rates as high as 1,700 feet per minute. Audible warnings of “MINIMUM”, “SINK RATE”, “TERRAIN”, and “TOO LOW-GEARS” sounded, adding to the confusion. The first officer noticed that the landing gear was not down and lowered it, but by this time the aircraft had already passed the runway and neither pilot was aware of it. The tower contacted the flight crew and informed them that they had been cleared to land on runway 02, but they appeared to be heading to runway 20, the opposite end of the single runway, and asked the pilot’s intention. Still unaware that they had already passed the runway, the pilot responded that he intended to land on runway 02. Seeing high terrain ahead of them, the pilot performed a sharp right-hand turn, during which the aircraft descended to as low as 175 feet above the ground, and reached bank angles of up to 35 to 40 degrees. This triggered additional alerts and alarms of “PULL UP”, “TERRAIN”, and “BANK ANGLE” in the cockpit. After flying to the west without spotting the runway, the pilot calmly admitted to the first officer that he had made a mistake and had become distracted by talking to her, and performed another steep right hand turn, with bank angles as high as 45 degrees and descent rates of over 2,000 feet per minute.

Aerial view of Tribhuvan International Airport (TIA)

Eventually, with air traffic controllers on the radio still trying to clarify where the aircraft was going and the plane flying in a southeasterly direction, the first officer spotted runway 20 at the aircraft’s 3 o’clock position, approximately two nautical miles (2.3 mi; 3.7 km) away, and the pilot made a sharp and abrupt right turn back to the west in an attempt to return to the approach end of the runway. The aircraft overflew the end of runway 20 on a heading of 255 degrees, 450 feet above the ground, turning left with a bank angle of 40 degrees. Alarmed by the actions of the aircraft, the air traffic controller hastily cancelled the flight’s landing clearance, erroneously calling out “takeoff clearance cancelled”. The aircraft flew over the airport’s domestic passenger terminal less than 50 feet over the roof, and controllers in the tower ducked down out of fear. The aircraft made another sharp turn in an attempt to line up with the runway before touching down at an angle 1700 meters along the runway with its right main landing gear. The aircraft skidded off the runway, slid for 300 meters, crashed through a fence on the edge of the airport, came to a stop in a football field, and burst into flames.

After the crash, the Government of Nepal formed an Aircraft Accident Investigation Commission to determine the cause and the circumstances of the accident. The six-member commission was also assisted by Captain Salahuddin Rahmatullah, the head of the Aircraft Accident Investigation Group of the Civil Aviation Authority of Bangladesh, and Nora Vallée, senior investigator for the Transportation Safety Board of Canada, where the aircraft was manufactured.

The commission released a preliminary report on 9 April 2018. The report was a brief synopsis of the accident and stated that the aircraft had touched down 1,700 meters down runway 20 heading southwest before going off the runway. It said the cockpit voice and flight data recorders had been recovered and had been sent to the Transportation Safety Board of Canada for analysis along with other aircraft components.

On 27 August 2018, Nepal’s Kathmandu Post newspaper reported that a source had leaked details from the still ongoing official investigation. The source said that the commission was planning to assign blame for the crash on Captain Abid Sultan, and said that he was smoking continuously in the cockpit, lied to the control tower during the landing, and engaged in erratic behavior. The airline and the Bangladeshi representative to the commission dismissed the newspaper report as “baseless”, stating that the story was filled with false information, designed to make the airline and its employees look bad.

The final investigation report released on 27 January 2019 concluded that pilot disorientation and a lack of situation awareness led to the crash.

When we analyzed the conversation on the Cockpit Voice Recorder, it was clear to us that the captain was harbouring severe mental stress. He also seemed to be fatigued and tired due to lack of sleep — he was crying on several occasions.

— Final accident report by the Civil Aviation Authority of Nepal

The report also shows that Sultan made multiple abusive statements toward a young female pilot who he had trained, and who had questioned his reputation as an instructor. Their relationship was a major topic of discussion throughout the flight. He also spoke of a rumor that he and the trainee pilot had engaged in an extramarital affair, which had forced him to resign from the company. When telling this, he cried and wondered aloud where he would be able to find another job and stated that he had been so worried that he had not slept the previous night. Records show that Rashid, the co-pilot, who was on her first flight to Kathmandu and showed interest to learn at every stage of the flight, was a passive listener to Sultan’s story throughout the flight.

The sole Bangladeshi representative on the investigative panel was publicly critical of the final report, saying that it left out the fact that air traffic controllers at the airport did not execute their duties properly. He said that the controllers could have provided navigational assistance to the pilots once it became apparent that they were disoriented, but they did not. He said that if the controllers had done so, the accident could have been averted.

Final report

Key:

F UBG211: US-Bangla Airlines Flight 211 (Female Voice)
M UBG211: US-Bangla Airlines Flight 211 (Male Voice)
M VNKT TWR: Kathmandu ATC (Male Voice)
F VNKT TWR: Kathmandu ATC (Female Voice)
BHA282: Buddha Air Flight 282

The Transcript was, as follows:

M VNKT TWR:
Bangla-Star 211, can you reduce your speed further?

F UBG211:
Affirmative, Bangla Star 211.

M VNKT TWR:
Roger, descend to 12,500 feet and reduce your speed to minimum clean.

F UBG211:
Descend to 12,500 and reduce speed to minimum clean, Bangla Star 211.

M VNKT TWR:
Bangla Star 211, confirm holding over GURAS?

F UBG211:
Negative, sir. We are proceeding.

M VNKT TWR:
Roger, continue approach.

F UBG211:
Continue approach, Bangla Star 211.

–Short Pause–

Kathmandu Tower, Bangla Star 211, final runway 02.

F VNKT TWR:
Bangla Star 211, Tower. Wind 230 degrees 8 knots. Tailwind component 7 knots. Runway 02, continue approach.

F UBG211:
Continue approach, Bangla Star 211.

F VNKT TWR:
Bangla Star 211, wind 220 degrees 7 knots. Tailwind component 6 knots. Runway 02, cleared to land.

F UBG211:
Cleared to land, Bangla Star 211.

–Another Pause–

F VNKT TWR:
Bangla Star 211, Tower?

F UBG211:
Go ahead, Ma’am.

M UBG211:
Go ahead, Ma’am.

F VNKT TWR:
Bangla Star 211, you were given landing clearance to runway 02.

M UBG211: 
Affirmative Ma’am.   

F VNKT TWR:
You are going towards Runway 20.

BHA282:
Kathmandu Tower, Buddha 282.

M UBG211:
…to Runway 02.

—Pause—

M VNKT TWR:
Bangla Star 211, runway 20, cleared to land. 

M UBG211:
Cleared to land.

M VNKT TWR:
Bangla Star 211, Kathmandu Tower.

M UBG211: 
Go ahead.

M VKNT TWR:
Bangla Star 211, request your intentions.

M UBG211:
We’d like to land on 02.

M VKNT TWR:
Bangla Star 211, confirm you are VFR?

M UBG211:
Affirmative.

M VNKT TWR:
Bangla Star 211, join… right downwind runway 20.

M UBG211:
Copied.

M VNKT TWR:
Correction, right downwind runway 02. Break, break, Buddha 282, descend to minimum safe altitude. Runway 02, cleared to land.

BHA282:
Runway 02, cleared to land, descend to safe altitude, Buddha 282.

M VNKT TWR:
Bangla Star 211, traffic on final at runway 02 at 2 miles. If visible, report in sight.

M UBG211:
Copied, sir. We will be approaching runway 02.

M VNKT TWR:
Confirm that you’re tracking towards runway 20?

M UBG211:
Affirmative.

M VNKT TWR:
Join left, right downwind runway 02. I say again, Bangla Star 211, traffic is on final runway 02. Landing runway 02.

M UBG211:
Copied, sir.

BHA282:
Buddha 282.

M VNKT TWR:
Buddha 282, go ahead.

BHA282:
Confirm cleared to land runway 02?

M VNKT TWR:
Buddha 282, affirm. Runway 02, cleared to land.

BHA282:
02, cleared to land, Buddha 282.

M VNKT TWR:
Bangla Star 211, I say again, do not proceed toward runway 20. Cleared to hold at your present position.

M UBG211:
OK, we are making an orbit to the right. Copied?

—Pause—

Tower, 211 making a right holding. Right holding for runway 02.

M VNKT TWR:
OK, that’s approved. But do not land. Traffic is on short final runway 02.

M UBG211:
Roger that, sir. Copied.

M VNKT TWR:
Bangla Star 211, runway, cleared to land and runway’s vacated. Either runway 02 or 20. Confirm you need a vector.

M UBG211:
Affirm, we’d like to land on 20.

M VNKT TWR:
Okay, runway 20, cleared to land. Wind 270 degrees 6 knots.

M UBG211:
260, copied, cleared to land.

M VNKT TWR:
Bangla Star 211, confirm you have runway in sight?

M UBG211:
Negative, sir.

M VNKT TWR:
Bangla Star 211, turn right and you have runway. Confirm you have runway not in sight yet? 

M UBG211:
Affirmative, we have runway in sight, requesting clearance to land, sir.

M VNKT TWR:
Bangla Star 211, cleared to land.

M UBG211:
Cleared to land runway 02, Bangla Star 211.

M VNKT TWR:
Roger. Runway 02, cleared to land, Bangla Star 211.

—Pause—

Bangla Star 211, I say again, turn…

?: Unknown
VNKT GND: Kathmandu Ground
M VNKT TWR: Kathmandu ATC (Male)

?:
(Unknown)

VNKT GND:
Go ahead.

?:
The runway is closed, correct?

VNKT GND:
Airport closed, yes sir.

?:
Copied, sir.

VNKT TWR:
We suggest you either divert to either Lucknow or Varanasi. The airport is closed for all operations. Undetermined delay due to a crash at the airport. 

(Pause)

It will close for all operations due to crash at the airport. Delay not determined. We suggest you divert to either Lucknow or Varanasi.

(Pause)

I have repeated the same message three times. Four times now. THe airport is closed for all operations due to crash at the airport.

—End of Recording—

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