Vientiane - Pakse

A first approach procedure to runway 15 was aborted by the crew due to insufficient visibility. On the circuit to complete a second approach in bad weather conditions, the ATR72-600 crashed some 8 km short of runway and was completely submerged in the Mekong River. None of the 49 occupants (44 pax and 5 crew) survived, among them 7 French citizens and 6 Australians. Aircraft left Vientiane at 1445LT and should arrive in Pakse one hour later. Aircraft was built and delivered to Lao Airlines in March this year. First crash involving an ATR72-600 series. Up to date, worst accident in Laos. The Laotian Authorities released the following key sentences of analysis: "Under IMC conditions, with no reference to the ground, the SOPs lead to conducting an instrument approach. In Pakse the VOR DME approach procedure is in force. There is no radar service. The flight crew has to fly to the initial approach fix or the intermediate fix at an altitude above 4600ft, then start the descent to 2300ft until final approach fix. Finally the flight crew descends to the minima (990ft), if visual references with the ground are available and sufficient the flight crew may continue until touchdown. If ground visual references are not available or not sufficient, the flight crew may level off up to the missed approach point and then must start the missed approach procedure. From the FOR data, the flight crew set 600 ft as the minima. This is contrary to the published minima of 990 ft. Even if the flight crew had used the incorrect height as published in the JEPPESEN Chart at that time the minima should have been set to 645 ft or above. The choice of minima lower than the published minima considerably reduces the safety margins. Following the chart would lead the flight crew to fly on a parallel path 345 ft lower than the desired indicated altitude. The recordings show that the flight crew initiated a right turn according to the lateral missed approach trajectory without succeeding in reaching the vertical trajectory. Specifically, the flight crew didn't follow the vertical profile of missed approach as the missed approach altitude was set at 600 ft and the aircraft system went into altitude capture mode. When the flight crew realized that the altitude was too close to the ground, the PF over-reacted, which led to a high pitch attitude of 33°. The aircraft was mostly flying in the clouds during the last part of flight."

Flight / Schedule

Vientiane - Pakse

Aircraft

ATR72-600

Registration

RDPL-34233

MSN

1071

Year of Manufacture

2013

Operator

Lao Airlines

Date

October 16, 2013 at 03:55 PM

Type

CRASH

Flight Type

Scheduled Revenue Flight

Flight Phase

Landing (descent or approach)

Crash Site

Lake, Sea, Ocean, River

Crash Location

Pakse Champasak Province

Region

Asia • Laos

Coordinates

15.1134°, 105.8151°

Crash Cause

Human factor

Narrative Report

On October 16, 2013 at 03:55 PM, Vientiane - Pakse experienced a crash involving ATR72-600, operated by Lao Airlines, with the event recorded near Pakse Champasak Province.

The flight was categorized as scheduled revenue flight and the reported phase was landing (descent or approach) at a lake, sea, ocean, river crash site.

49 people were known to be on board, 49 fatalities were recorded, 0 survivors were identified or estimated. This corresponds to an estimated fatality rate of 100.0%.

Crew on board: 5, crew fatalities: 5, passengers on board: 44, passenger fatalities: 44, other fatalities: 0.

The listed crash cause is human factor. A first approach procedure to runway 15 was aborted by the crew due to insufficient visibility. On the circuit to complete a second approach in bad weather conditions, the ATR72-600 crashed some 8 km short of runway and was completely submerged in the Mekong River. None of the 49 occupants (44 pax and 5 crew) survived, among them 7 French citizens and 6 Australians. Aircraft left Vientiane at 1445LT and should arrive in Pakse one hour later. Aircraft was built and delivered to Lao Airlines in March this year. First crash involving an ATR72-600 series. Up to date, worst accident in Laos. The Laotian Authorities released the following key sentences of analysis: "Under IMC conditions, with no reference to the ground, the SOPs lead to conducting an instrument approach. In Pakse the VOR DME approach procedure is in force. There is no radar service. The flight crew has to fly to the initial approach fix or the intermediate fix at an altitude above 4600ft, then start the descent to 2300ft until final approach fix. Finally the flight crew descends to the minima (990ft), if visual references with the ground are available and sufficient the flight crew may continue until touchdown. If ground visual references are not available or not sufficient, the flight crew may level off up to the missed approach point and then must start the missed approach procedure. From the FOR data, the flight crew set 600 ft as the minima. This is contrary to the published minima of 990 ft. Even if the flight crew had used the incorrect height as published in the JEPPESEN Chart at that time the minima should have been set to 645 ft or above. The choice of minima lower than the published minima considerably reduces the safety margins. Following the chart would lead the flight crew to fly on a parallel path 345 ft lower than the desired indicated altitude. The recordings show that the flight crew initiated a right turn according to the lateral missed approach trajectory without succeeding in reaching the vertical trajectory. Specifically, the flight crew didn't follow the vertical profile of missed approach as the missed approach altitude was set at 600 ft and the aircraft system went into altitude capture mode. When the flight crew realized that the altitude was too close to the ground, the PF over-reacted, which led to a high pitch attitude of 33°. The aircraft was mostly flying in the clouds during the last part of flight."

Aircraft reference details include registration RDPL-34233, MSN 1071, year of manufacture 2013.

Geospatial coordinates for this crash are approximately 15.1134°, 105.8151°.

Fatalities

Total

49

Crew

5

Passengers

44

Other

0

Crash Summary

A first approach procedure to runway 15 was aborted by the crew due to insufficient visibility. On the circuit to complete a second approach in bad weather conditions, the ATR72-600 crashed some 8 km short of runway and was completely submerged in the Mekong River. None of the 49 occupants (44 pax and 5 crew) survived, among them 7 French citizens and 6 Australians. Aircraft left Vientiane at 1445LT and should arrive in Pakse one hour later. Aircraft was built and delivered to Lao Airlines in March this year. First crash involving an ATR72-600 series. Up to date, worst accident in Laos. The Laotian Authorities released the following key sentences of analysis: "Under IMC conditions, with no reference to the ground, the SOPs lead to conducting an instrument approach. In Pakse the VOR DME approach procedure is in force. There is no radar service. The flight crew has to fly to the initial approach fix or the intermediate fix at an altitude above 4600ft, then start the descent to 2300ft until final approach fix. Finally the flight crew descends to the minima (990ft), if visual references with the ground are available and sufficient the flight crew may continue until touchdown. If ground visual references are not available or not sufficient, the flight crew may level off up to the missed approach point and then must start the missed approach procedure. From the FOR data, the flight crew set 600 ft as the minima. This is contrary to the published minima of 990 ft. Even if the flight crew had used the incorrect height as published in the JEPPESEN Chart at that time the minima should have been set to 645 ft or above. The choice of minima lower than the published minima considerably reduces the safety margins. Following the chart would lead the flight crew to fly on a parallel path 345 ft lower than the desired indicated altitude. The recordings show that the flight crew initiated a right turn according to the lateral missed approach trajectory without succeeding in reaching the vertical trajectory. Specifically, the flight crew didn't follow the vertical profile of missed approach as the missed approach altitude was set at 600 ft and the aircraft system went into altitude capture mode. When the flight crew realized that the altitude was too close to the ground, the PF over-reacted, which led to a high pitch attitude of 33°. The aircraft was mostly flying in the clouds during the last part of flight."

Cause: Human factor

Occupants & Outcome

Crew On Board

5

Passengers On Board

44

Estimated Survivors

0

Fatality Rate

100.0%

Known people on board: 49

Operational Details

Schedule / Flight

Vientiane - Pakse

Operator

Lao Airlines

Flight Type

Scheduled Revenue Flight

Flight Phase

Landing (descent or approach)

Crash Site

Lake, Sea, Ocean, River

Region / Country

Asia • Laos

Aircraft Details

Aircraft

ATR72-600

Registration

RDPL-34233

MSN

1071

Year of Manufacture

2013

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