Report on the Accident of MI-8MTV-1
Helicopter RA 27019 of Vertical-T, Russia (Operator) UNMIN (User)
at Bethan VDC Ward No. 9, Ramechhap on 03 March 2008

1. Synopsis
The MI-8MTV-1 helicopter with the call sign UN-301 and registration no. RA- 27019  operated by Vertical-T  for UNMIN, which was on the third leg of the day's flight took off from Dudhauli at 1002 UTC with 7 passengers and 175kgs. of cargo for Kathmandu. During the day there were overcast of clouds over most of the central and northern parts of the country.  After take-off it initially climbed up to 2700m (8900ft). Then upon seeing high clouds it made a descending turn to the left and then a steep climb was initiated to remain clear of terrain (The MOCA being 12,500ft) but deciding to continue in IMC (Instrument Meteorological Conditions).
The helicopter contacted Kathmandu Approach at 10:10 UTC and gave an ETA of 10:45 UTC and reported at 10:22 UTC as being 46 miles inbound. Mean while, Kathmandu Approach asked the helicopter to report at 25 miles. Thereafter there was no communication despite repeated calls from Kathmandu Approach at 10:35 UTC.
At about 32 minutes into the flight, UN-301 entered CB (cumulonimbus) cloud. The helicopter was thrown around in one of these clouds, lost control and both engines also shut down due to one of several reasons and as a result impacted terrain leading to total loss of aircraft, loss of lives of crew and passengers. Why and how both engines shut down could not be determined with certainty because there was no record of the crew's conversation in the flight deck due to the CVR spool not being set to the starting position before the first flight of the day.
The accident occurred at 10:33:43 UTC and the impact site is located at Bethan VDC, Ramechhap district of eastern Nepal. Its latitude and longitude are 27029' 08" N and 0850 49'50" E respectively and the altitude is 1389m (4555 feet).
The report of the crash was received at 1051 UTC which was confirmed later by Ramechhap Tower to Kathmandu Communication Centre. Local villagers reported the accident to Nepal Police and were engaged in removing dead bodies from the burning helicopter. A police team from Bethan Police Station was mobilized to the crash site.
The accident was notified to Ministry of Tourism and Civil Aviation, Government of Nepal, the States of Manufacturer, Design and Operator and International Civil Aviation Organization.

2. Damage to Aircraft
More than 80% of the helicopter was burnt. Main rotor and tail rotor blades were broken into pieces and scattered around the site. All other parts were found in a limited area without much scattering. Cockpit, central part of fuselage and some parts of tail boom were found totally burnt to ashes. Major parts like main gearbox, swash plate, hub, fan, instruments were also burnt completely. The remaining other parts were found in a damaged condition.

3. Causes
The commission has concluded that the probable cause of the accident was human error consisting of:

4. Safety Recommendations
4.1.    Interim Recommendation of the Commission
On 17th April 2008, the Commission issued Interim Recommendations in order to address some of the safety issues revealed as result of the investigation up to that time.
A letter was sent to Ministry of Culture, Tourism and Civil Aviation in this regard which subsequently sent a letter to Civil Aviation Authority of Nepal for necessary action.
4.2.    Safety Recommendations to Civil Aviation Authority of Russia     
4.2.1    CAA, Russia should take steps to prohibit the wrong practice of flight  crew of the helicopter carrying out IFR flight for VFR certified helicopters. 
4.2.2    When helicopters with Russia Registration are operated and based in another country, effective flight safety oversight should be carried out with a special program and done more frequently.  Some flight safety oversight functions and duties should be transferred to the local Civil Aviation Authority of Country of Operation through an agreement.
4.2.3    CAA, Russia should ensure establishment of proper offices for Technical Departments (Engineering, Quality Control, Operation, Store) at the operating base of the helicopter. 
4.2.4    CAA, Russia should ensure inclusion of oxygen use for high altitude flights in the SOP and issuance of internal memo by the operator for use of oxygen for high altitude flights.
4.2.5    CAA, Russia should ensure installation of serviceable FDR and CVR in helicopters fulfilling the latest requirement of ICAO Annexes and CAA, Russia.
4.2.6    CAA, Russia should establish a system in which flight data and cockpit voice data can be checked and compliance with safety regulations is ensured.
4.2.7    High altitude training, route check, pilot proficiency check, flight on new routes etc. conducted by operator should be strictly monitored by CAA, Russia.
4.2.8    CAA, Russia should ensure compliance of safety regulations of State of Operation as well.
4.3.    Recommendations to Vertical - T
4.3.1    Flying in IMC (Instrumental Metrological Condition) by helicopter certified for VFR flights only should be strictly prohibited. Operation Chief, Chief Pilot and Safety Director should monitor the flight performance and behavior of their pilots regularly. If any pilot is found conducting flight in IMC, it should be investigated internally. Such a case should be taken as "incident" and must be discouraged. The pilots should be encouraged to report in writing any event or violation of regulation and reasons thereto without fear of punitive actions from management.
4.3.2.   Company should frequently issue internal memo to all departments regarding flight operation,  engineering, quality control and management for the operating state as well as the works carried out on aircraft as per bulletins, prolongations, modification etc.
4.3.3    Pilots must get MET weather briefing for full day prior to conducting flights.
4.3.4    Pilots should be familiar with local weather. For a mountainous country like Nepal, the local weather condition changes rapidly during different seasons.
4.3.5    Company should have office for engineering, quality control, operation and store in the operating base e.g. Nepal, where they operate many helicopters for long periods. All documents, manuals, reference books, parts catalogs, service bulletins, airworthiness directives, internal memo, reports, license copies, airworthiness requirements, flight operations requirement, training records etc. should be kept properly.
4.3.6    Company should review the training course, PPC, route check, flight on new routes in Standard Operation Procedure Manual of the company for pilots flying in mountainous country like Nepal with a very short duration service period of 3 to 4 months only.
4.3.7    Internal safety audits of aircrafts and operating base should be carried out frequently. If there are some lapses found, the management must be notified without any hesitation and company should immediately rectify those lapses.
4.3.8    Chief Pilot or Instructor Pilot should be nominated to a base like Nepal for a longer period so that they could provide sufficient training to new pilots. New pilots should be sufficiently familiarized with the local terrain and local weather conditions. 
4.3.8    The operator should carry out checks of recorded flight data and cockpit voice data to ensure that company standard operating procedures are being followed.
4.3.9    The operator should install serviceable FDR and CVR in helicopters fulfilling the latest requirements of ICAO Annexes and CAA, Russia.
4.3.10  The flight crew should get clearance from ATC for any level change. They should pass on information of bad weather and any technical defect encountered during flight.
4.4.    Recommendations to UNMIN (User of Helicopter)     
It is found that UN is using different types of aircraft in different countries. Presently UN is using some MI-8MTV helicopters in Nepal. It is recommended that:
4.4.1    UN should ensure designation of responsible persons for Engineering, Quality Control, Chief Pilot, Store in-charge etc. at the operating base of the helicopter by the operator. 
4.4.2    UN should ensure satisfactory fulfillment of Flight Safety Oversight responsibilities of CAA, state of Registry and CAA, State of Operations. 
4.4.3    Proper internal Safety Audit should be conducted by the experts of UN Aviation Department of aircrafts, stores, documentation, maintenance process providing service by different operators for UN. If  they find any remarks, those should be informed to the operators for immediate actions.
4.4.4    UN should ensure pilots flying in Nepal have sufficient "High Altitude Clearance" with sufficient experiences of flight at high altitudes. The licenses of pilot should be checked for their experience and high altitude clearance. They must be given sufficient training for familiarization with Nepalese terrain and local weather conditions.
4.4.5    Effective safety oversight of the aircraft flight operation in Nepal be ensured by UNMIN also.
4.5     Recommendations to Civil Aviation Authority of Nepal
MI-8MTV helicopter RA-27019 was registered in Russia with civil registration. Helicopter was owned by Company Hawk United Transits Corporation from British Virgin Island and operated by Vertical-T, Russia Company. The helicopter was used by UN and was operated in Nepal since February 2007. Accordingly, it is recommended to Civil Aviation Authority of Nepal that:
4.5.1     The foreign registered aircraft operating in Nepal is made aware of safety regulations of Nepal. The mandatory requirements for type aircraft as per NCAR, FOR, AIP etc. be disseminated to the operator.
4.5.2    Safety recommendations, instructions, directives issued so far with regard to MI-8MTV/AMT operating in Nepal be strictly implemented.
4.5.3     Coordination be carried out with State of Registry to ensure effective safety oversight of the foreign registered aircraft operating in Nepal.
4.5.4     Full compliance with safety regulations and proper surveillance for the operation and maintenance of the aircraft in Nepal is ensured.
4.5.5     Aircraft details, maintenance details and the copy of license of pilots and engineers working in foreign registered aircraft operated in Nepal are checked. Incident and accident reporting of aircraft be made mandatory.
4.5.6     Review made of requirements of technical knowledge, experience. practical flying, P-I-C qualification, P-I-C clearance, recent experience and route/airport qualification etc. of flight crew of foreign registered aircraft operating in Nepal under the AOC of a foreign state so that the flight crew have sufficient knowledge, qualification, experience and clearance to operate in Nepal. 
4.5.7   Establishment of a system be ensured in which flight data recorder and cockpit voice recorder data be checked and compliance with safety regulations be ensured.