1 year after US-Bangla crash, fingers point to pilot

One year after the horrific crash in Kathmandu of US-Bangla Airlines Flight BS211, new evidence confirms the captain was mentally unstable and unfit to fly. But this is of little consolation to the relatives of the 51 who perished in a tragedy that was easily preventable if safety standards had been met.

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20 by 02, Kanak Mani Dixit

Individual tragedies, and a national loss, Monika Deupala

Capt Abid Sultan was abusive, erratic and incoherent even before the plane took off from Dhaka on a flight to Kathmandu on 12 March, 2018 with 67 passengers and 4 crew. A full transcript of the Cockpit Voice Recorder (CVR) obtained by Nepali Times shows that the mental state of the Captain was much worse than first indicated in an ATC (Air Traffic Control) tape, and should have set off alarm bells even before the plane took off.

https://www.youtube.com/watch?v=oDAvHQJZK_M&t=22s

On approach to Kathmandu the Bombardier Q400 turboprop twisted and turned over the airport before crashing and bursting into flames off the runway. The government’s Accident Investigation Commission released its report in January, concluding that Capt Sultan was ‘stressed and emotionally disturbed’ about another female pilot in his company. Actually he was more than that, he was excessively obsessed with her. 

The transcript (below) begins with conversation between US-Bangla Operations while still on ground in Dhaka. Sultan is volatile and explodes into foul language for no reason at all. First Officer (FO) Prithula Rashid, on her first route proving flight to Kathmandu must have already been terrified by the outbursts. But crew gradient seems to prevent her from reacting to her senior instructor.

Capt Sultan talks nonstop during the flight with angry monologues about another young female pilot whom he had trained, Farhat Lamia Khaled. He is obsessed about her alleged comments doubting his competency to be an instructor. 

Read also: Ashna isn't coming home, Sikuma Rai

https://www.youtube.com/watch?v=vEXAlqaGmxU&feature=youtu.be

US-Bangla crash Kathmandu airport CCTV footage. Video: shailendra @theshailen (Twitter).

Sultan’s hostility towards Lamia also seems to be personal – in sentences peppered with bilingual obscenities he casts aspersions on her morality and disparages her appearance. Halfway through the flight, citing rumours about their involvement Capt Sultan breaks down and starts weeping openly, telling his copilot that he was quitting the company because of Lamia.

As they start their descent, Capt Sultan temporarily regains his composure and in a professional and calm voice resumes his role of an instructor pilot, preparing the trainee pilot for approach and go-around procedures for Kathmandu. Throughout the transcript he alternates between being polite and kind to her one moment, even complimenting her airmanship, and then reverting to abuse-laden tirades the next.

The plane is cleared for approach, and Capt Sultan confirms landing gears are down, when they are not. In the course of the next few minutes he asks FO Rashid five times if she has completed the Pre-landing Checklist even though she confirms it every time. All the while, the landing gear error audio warning is sounding in the background. 

Kathmandu Radar hands the flight to tower frequency and it is cleared for the standard VOR-DME approach. But when the plane should be on finals, it is actually 3km to the east of the approach path at rooftop level. 

Margie Donahue is an American educator living in Balkot, and remembers seeing the plane with a blue tail flying very low and fast over her house. “I thought it would hit our roof and I waited for a big bang because I was sure it was going to crash,” she told Nepali Times. 

In the ATC tape, a female controller then comes on the radio to alert the flight crew: “BanglaStar211, you were given landing clearance to runway 02 … You are going towards runway 20.” Seeing the plane so far to the east, the controller appears to have thought the flight was entering downwind to make a circling approach to Runway 20 from the north side. After confirming the pilot is visual, a male controller takes over to instruct the plane not to land yet because of another traffic on finals.

The CVR transcript indicates Capt Sultan mistakenly thinks the VOR beacon is ahead of him when the plane is already flying northeast of the airfield straight towards Shivapuri mountain. There are miscues, misinterpreted intentions, language problems and lack of assertiveness on the part of controllers. 

After reviewing the CVR, a shocked Airbus 320 commander told us Kathmandu Radar should have first warned the plane he was deviating from the approach path, and failing that immediately ordered the plane to carry out a standard missed approach procedure when it overshot the runway. Instead, the Tower let the disoriented pilot blunder on.

Meanwhile in the cockpit, the EGPWS (Enhanced Ground Proximity Warning System) is going off loudly and continuously as the plane approaches Shivapuri. To avoid hitting the slope, Capt Sultan puts the plane into a steep turning climb (see map, right). Probably sensing that his co-pilot is nervous, he reassures her, admitting calmly that he has made a mistake, adding, “It happens, isn’t it?” 

https://www.youtube.com/watch?v=BBgcC3OlqfQ

At Gagalphedi village at the base of Shivapuri, locals hurriedly gathered to watch the Q400 descend dangerously low, and at the last moment pull out of the dive with both its landing lights on, and main gears down. A mobile video posted on YouTube is a key piece of evidence showing how close the plane already was to a crash. (Video clip above)

Two pilots on domestic flights are then heard on the ATC tape warning the tower in Nepali that the Bangladesh plane seemed lost: “He looks disoriented, doesn’t know where he is going. Vector him out of here.”

The plane makes an orbit at base leg northwest of the field at 6,500ft while both pilots look out of the runway. When he sees the airfield, Capt Sultan descends steeply in an abnormal and dangerous approach, banking steeply left, and missing the hangar roof by only 45ft. 

In the Tower, shocked air traffic controllers duck when they see the plane come straight at them. The Q400 then flies over the international apron narrowly missing a fully-loaded 777, and several 737s and 320s. The plane is at a 15o angle to the runway heading when its right landing gear hits the tarmac hard before veering off, and down the slope. 

Driving to the airport on the Ring Road, frequent flier Arnico Panday saw what he thought was an ATR-72 make a tight turn over the hangar, nearly hit the tower and disappear. “Moments later I saw the plume of black smoke,” Panday recalls.

Most of the passengers on the left side of the plane were either killed by the impact or the ensuing fire. Many who survived were sitting on the right side, or towards the front. 

The Investigation Committee Report concludes: ‘The PIC (Pilot in Command) was under stress and emotionally disturbed as he felt that the female colleague of the company questioned his reputation as a good instructor. This together with the failure on the part of both the crew to follow the standard operating procedure at the critical stage of the flight contributed to loss of situational awareness to appreciate the deviation of the aircraft from its intended radial that disabled them sighting the runway.’

All audio warnings on the flight deck are going off simultaneously in the last few seconds of the CVR: “Terrain, Terrain”, “Sink Rate, Pull Up, Pull Up”, “Bank Angle, Bank Angle”. 

The Radio Altimeter warning calls “100 Minimums”, then “50”. The last words heard are of FO Rashid, sounding alarmed: “Sir, Sir!”

With reporting by Sharad Ojha

"Sir! Sir!"

The Accident Investigation Commission set up by the Ministry of Tourism and Civil Aviation in January presented its report containing the graphic transcript of translated conversation picked up by the Cockpit Voice Recorder on US- Bangla BS211. Till now, clues about the state of mind of the pilot in command had come from the Air Traffic Control tape posted on the Internet on the day of the crash. This transcript shows that Captain Abid Sultan’s state of mind was much more unstable than first thought. Excerpts:

Read also: US-Bangla plane crashes at TIA

CODES
Internal cockpit conversation, with transmissions to Ground in bold
Time in UTC
Numbers in bold correspond to yellow boxes in map of the flight path
["SQUARE BRACKETS"] are audio cockpit warnings                                                             FO: Flight Officer                                                                                                                   OPS: US-Bangla Operations

PIC: Pilot in Command
Bangla: Conversation translated from Bangla
KTM: Kathmandu
ADC: Air Defence Clearance 
FIC: Flight Information Centre
Romeo: Waypoint southeast of Kathmandu

Guras: Waypoint 12 miles south of Kathmandu
VFR: Visual Flight Rules
EGPWS: Enhanced Ground Proximity Warning System
DME: Distance Measuring Equipment (miles from beacon)
VOR: Visual Omni-directional Range beacon
ROD: Rate of Descent

FO: 0636:20.2 Dhaka Ground BS211 good afternoon
Dhaka Ground: 0636:20.2 BS211 good afternoon, go head ma'm 
FO: 0636:34.8 BS211 standing at 28 South flight for KTM FL 240 

PIC: 0642:24.0 Do you have the ADC number? (Bangla)                                                       FO: 0642:25.9 No Sir, I have one number 2177 

PIC: 0642:25.9 Operations, BS211, how long will you take to respond, I want the ADC and FIC. (Angry tone)                                                                                                                      

OPS: 0643:31.5 KTM FIC for 211 is 1171 ADC KX 848 and for 212 FIC                                   PIC: 0643:39.7 I don’t want f--k 212, I want 211 (Very angry) … I don’t want to f--k you, read you, again? Keep your f---ing mouth shut.

PIC: 0650:10.5 Got the clearance?                                                                                            FO: 0650:09.1 Yes sir, line up is due. 
PIC: 0650:16.0 Don’t be scared, I am going to stay for another 3 months, I am going to    f--k these people right and left.

Dhaka Tower: 0650:25.7 BS211 clear line up runway 14                                                        FO: 0650:30.4 Clear line up, clear line up runway 14, BS211 

PIC: 0651:03.5 Bismillah, have we done the takeoff checklist? (Bangla) 
FO: 0651:40.5 80 kts, power set, V1 rotate, positive rate 
PIC: 0652:32.5 Look out for birds                                                                                           PIC: 0652:44.9 Autopilot engaged, 1,000, turning right. Perform the flow check (Bangla) 

Dhaka Tower: 0652:49.9 BS211 airborne 52, call turning right                                            FO: 0652:46.4 We are turning right BS211                                                                          Dhaka Tower: 0652:57.5 Roger re-cleared to 240, call passing 4,000                                      FO: 0652:57.5 Recleared to 240, we’ll call out of 4,000 

PIC: 0653:31.5 Even I am abusing others, you don’t be afraid, Buri, I am addressing you as Buri to show my affection for you. (Bangla) 

PIC: 0656:14.5 Operations BS 211?                                                                                          OPS: 0656:17.5 BS 211 Operations, go ahead Sir -- 
PIC: 0656:32.5 Why the hell you need the onboard fuel? Why do you ask me the onboard fuel? Tell me the reason you want to do with onboard fuel, let me know now … I want written f---ing explanation before I come back to Dhaka

OPS: 0659:27.5 Copied Sir, Wilco, Safe flight Sir                                                                  PIC: 0659:34.5 I don’t f--k care about the safe flight, you f--k your duty … Don’t talk to me unless I call you 

PIC: 0700:04.5 Okay, after takeoff checklist done? (Normal tone)                                      FO: 0700:07.5 Sir, yes, Sir done                                                                                                PIC: 0700:09.5 Mother f---er, piglets, son of bitch (Bangla, low voice)

PIC: 0715:33.5 (Paraphrased and shortened from transcript) Lamia was the worst trained in US-Bangla, now in Biman Bangladesh talks ill of US- Bangla instructors including me. They said we f---ed in the cockpit. Lamia is not even worth approaching, she is ugly, fat with obnoxious appearance…what the f--k is she, the beauty queen of the world? My wife is far more beautiful, I don’t need Lamia. If I intend to buy sex, I can do that with 100 dollars. Because of the mother f---er Lamia, only Lamia, I decided to resign. She talks big, what she knows about flying … if this impression goes to my wife and imagine if you were my wife, if you learn that your husband is fooling with another girl, how would you feel? 
FO: 0715:33.5 Oh no, oh my God. 
PIC: 0717:40.5 That f---er, that son of a gun, bitch, she asked to fly 100 hours with me. With no intention that she has big boobs nor she would do sex with me. If I want to f--k her, I can f--k her in the hotel. And you know that your friend is f---ing too horny. She has a… she does sex with 6-7 guys I know. You note it, she is not a virgin … So, your friend Lamia is a prostitute. (Bangla) 
FO: 0720:46.5 Sir, shouldn’t I switch on the radar?
PIC: 0804:52.5 That f---er Lamia, she made me… look at my f---ing eyes… weeping … crying… where did I do mistake (crying)? I take the blame and resigned. What is my next source of income? At least look at me f---er (crying and blowing nose) Do I need to cry like this? 
FO: No, no Sir. 
PIC: Look at me now (crying, choking and blowing nose). So, it is my problem that I have not been able to teach you. 
PIC: 0806:08.5 Okay, let us do the descent checklist (Bangla). 
FO: Yes Sir, it is time (Bangla)
PIC: 0806:55.5 I have suffered a lot, my child (bursts out crying, blowing nose)
FO: Sir, please forget. The God is above us. Even if you find it hard to forgive her, please forgive her. 
PIC: How can I forgive her. The girl for whom I have taken so much pain. We don’t know f--k how do I accept that, tell me (crying and blowing nose) PIC: 0807:42.5 We will do approach checklist at Romeo, okay (Bangla)? 
FO: Yes Sir
PIC: Ask, request for descent 

FO: 0807:49.5 Kathmandu, BS211 ready for descent 
KTM Control: 0807:49.5 BS211, descend to FL 160 

PIC: 0810:17.5 Do you know that I have not slept during the whole night and I cried a lot (Bangla). I have received so much pain … you have seen me now. I have cried enough my daughter, cried a lot. 

KTM Approach: 0813:41.5 BS211, Reduce to minimum speed and descend to 12,500 ft      FO: 0813:45.5 Descend to 12,500 and reduce speed to minimum BS211 

PIC: Good job my daughter. 
FO: Sir
PIC: 0819:03.5 I have dropped my cigarette, let me find the thing, do you know where I have dropped it … it is on the left. There is possibility of catching fire. 
FO: 0819:22.5 Sir, we are getting into cloud
PIC: Forget it. Okay adjust the pitch control of Weather Radar … Okay we don’t need this now out of cloud (Bangla) … Why are you holding the power levers? I am the pilot flying, idiot, I should be holding. What is our QNH 1015 okay? Okay put your HDG bug on top. 

KTM Approach: 0822:15.5 BS211, confirm holding over Guras? 
FO: 0822:15.5 We are continuing approach 

PIC: 0822:57.5 How much will it be at 13 DME? 9,800. Is it okay? Pumps on, Flaps 5
FO: Okay. Speed good for flaps… Flaps 5 PIC: 0823:00.5 Flaps 15 … Do the Before Landing Checklist … Do it 
FO: 0823:17.5 Landing Gear
PIC: Down Three Green
FO: Flaps
PIC: 15 set
FO: Sir, not yet set [LANDING GEAR UNSAFE WARNING] ... Sir, Speed Speed Speed
PIC: No worry, no worry [GEAR UNSAFE WARNING] KTM Approach: 0823:46.5 BS211, Position 10 Miles, contact Tower 118.1 [GEAR UNSAFE WARNING CONTINUES] FO: 0824:37.5 Kathmandu Tower, BS211, Finals RW 02 [GEAR UNSAFE WARNING] 

KTM Tower: 0824:45.5 BS211, Kathmandu Tower, wind 230 degrees 8 knots, tail wind component 7 knots, runway 02, continue approach 

PIC: Okay do Before Landing Checklist now (Bangla)
FO: Sir, have done Before Landing Checklist
PIC: What altitude at 5 DME
FO: At 5 DME 6,640
PIC: 6,640 So let me increase the ROD
FO: Yes Sir, the ROD needs to be increased … 4 DME, Sir we are 600 ft high
PIC: I do not understand what you are saying, say slowly. (Bangla) [“MIMINUMS, MIMINUMS] [GEAR UNSAFE WARNING] 
PIC: 0825:46.5 Have we seen the runway? (Bangla) 
[EGPWS “MINIMUM” “SINK RATE”] [“TOO LOW-GEARS”] [GEAR UNSAFE WARNING CONTINUES]. KTM Tower: 0826:33.5 BS211, wind 220 degrees 7 knots, tail wind component 6 knots, runway 02, clear to land. [EGPWS SOUND] [“TOO LOW-GEARS”] [GEAR UNSAFE WARNING CONTINUES] 
FO: 0826:37.5 Clear to land, BS211 
FO: 0826:46.5 Sir, Gear not yet down! (Bangla) 
[GEAR UNSAFE WARNING] [“TOO LOW – GEAR”] [“TERRAIN”] 
PIC: Okay put the gear down. Flaps 15, and Before Landing Checklist
FO: Landing Checklist done Sir
PIC: Done? Okay set the Go Around Altitude 10,500
PIC: 0827:17.5 Have we seen the runway (Bangla)?
FO: No not yet (Bangla) 
PIC: Not seen yet? (Bangla) No problem, it will be in front. 

1

KTM Tower: 0827:43.5 BS211, Tower…. you were given landing clearance to runway 02
PIC: 0827:45.5 Affirmative Ma’am                                                                                          KTM Tower: 0827:48.5 You are going towards Runway 20 

PIC: 0827:53.5 I think we are going to Runway 02 

KTM Tower: 0828:01.5 Ok, BS211, runway 20 clear to land                                                  PIC: 0828:03.5 Clear to land 

2

PIC: 0828:08.5 Can we see the Runway? We have set up everything, all done but we are not seeing the Runway
FO: No
PIC: That means the runway is to our right [“TERRAIN”] So, we have crossed the VOR, is not it, okay? (Bangla) [EGPWS “TERRAIN, TERRAIN, PULL UP, PULL UP”]. Let us turn right then, okay (Bangla)? [EGPWS “PULL UP, PULL UP, PULL UP]. So, we have gone past (Bangla) we will approach runway 02, 002 [EGPWS “TERRAIN, TERRAIN, TERRAIN, PULL UP, PULL UP, PULL UP”] 
FO: Okay (Scared voice) [EGPWS “PULL UP, PULL UP, PULL UP”] 

3

KTM Tower: 0829:07.5 BS211, Kathmandu Tower, request your intention [EGPWS CONTINUOUS “PULL UP”] 
PIC: 0829:09.5 I would like to land on 02                                                                              KTM Tower: 0829:14.5 BS211, and confirm you’re VFR                                                          PIC: 0829:14.5 Affirmative                                                                                                      KTM Tower: 0829:20.5 BS211, join the... (Garbled) … right downwind runway 20              PIC: 0829:21.5 Copied 

4

PIC: 0829:33.5 We have crossed and that’s why we have not being able to make it (Bangla)
FO: Sir, how have we missed the runway?
PIC: No worry, no worry. We are going to VOR. [CONTINUOUS EGPWS WARNING] 

KTM Tower: 0830:12.5 Join left ... right downwind, runway 02 … BS211, I say again, do not proceed towards runway 20. Clear to hold your present position                                    PIC: Copied Sir

PIC: So, our VOR is on to the left, is it not? Okay, Before Landing Checklist is done? 
FO: Yes everything done
PIC: 0830:37.5 Tower, Ok we are making an orbit to the right
FO: Sir, this is runway
PIC: Have you seen the runway, where is it? 

KTM Tower: 0831:00.5 Ok that’s good, but do not land. Traffic is on short final runway 02 PIC: 0831:12.5 We know that sir. Copied, let us know Sir once the aircraft lands

PIC: So I have done mistake, it happens isn’t it? It can happen since I was talking to you! Where is our VOR, gone left isn’t it, so let me make a turn 15 degrees to come back to the final. 
FO: Okay (More confident voice)   

KTM Tower: BS211 runway ah… clear to land … runway is vacated. Either runway 02 or 20. Confirm you need vector? [“BANK ANGLE, BANK ANGLE”]                                            PIC: 0832:07.5 Sir, we would like to land RW 20 [“BANK ANGLE, BANK ANGLE”] 
KTM Tower: 0832:09.5 Ok, runway 20 clear to land. Wind 270 degrees 6 knots PIC: 0832:10.5 260 copied clear to land 

5

PIC: 0832:16.5 We have to now find the runway isn’t it? We are 4 miles now. Which side should the runway be? (Bangla)                                                                                                  FO: 12 O’clock                                                                                                                            PIC: Where is the runway? [EGPWS “TERRAIN, TERRAIN PULL UP, PULL UP, PULL UP”. Unidentified voice in Nepali: 0832:31.5 02 gayo jasto cha khoi? (May have gone to 02, where is it?) 

KTM Tower: 0832:38.5 BS211, confirm you have air… runway in sight?                            PIC: 0832:40.5 Negative Sir

PIC: Where is the runway? (Bangla) 

KTM Tower: 0832:44.5 BS211, turn right and uh… you have runway… confirm you have a runway not in sight yet? 

FO: 0832:44.5 Sir runway, runway. Sir 3 O’clock. [“BANK ANGLE, BANK ANGLE”] 

PIC: 0832:47.5 Affirmative, we have runway in sight, request clear to land Sir                KTM Tower: 0832:52.5 BS211 Cleared to land 

PIC: 0832:55.5 Okay put the Flight Director Standby … keep the Heading Bug Zero … Okay, Landing Checklist Done? 

Unidentified voice in Nepali: 0833:11.5 Jahaj dekhira Chaina? Dekhira chha Sir. Downwind ma chha. Tei ta, yo ta purai almaliyo. Pheri orbit garyo Sir. (Can you see the plane? Yes, he is downwind, it is completely confused. He is making another orbit, Sir.) 
PIC: 0833:23.5 Have you given 022 [RADIO ALTIMETER CALL “100, MINIMUMS”] 

6

KTM Tower: 0833:26.5 BS211, that is not the runway… over… that’s not the runway. BS211, that is not the runway I say again. Take off clearance cancelled. [EGPWS “SINK RATE, PULL UP”]                                                                                                                                    PIC: 0833:35.5 We have the runway in sight Sir. Are we cleared to land? 

FO: 20 … Oh my God, Sir [“BANK ANGLE”]
KTM Tower: BS 211, I say again turn … [“BANK ANGLE, BANK ANGLE, BANK ANGLE, SINK RATE, SINK RATE”] [“50”] [“BANK ANGLE, BANK ANGLE”] 

FO: 0834:04.5 Sir! Sir! (Very alarmed)

7