Accident ATR 72-212A (ATR 72-600) RDPL-34233,

ASN Wikibase Occurrence # 320662

Date:	Wednesday 16 October 2013
Time:	15:55
Type:	ATR 72-212A (ATR 72-600)
Owner/operator:	Lao Airlines
Registration:	RDPL-34233
MSN:	1071
Year of manufacture:	2013
Total airframe hrs:	758 hours
Engine model:	Pratt & Whitney Canada PW127M
Fatalities:	Fatalities: 49 / Occupants: 49
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	8 km NW of Pakse Airport (PKZ) - Laos
Phase:	Approach
Nature:	Passenger - Scheduled
Departure airport:	Vientiane-Wattay Airport (VTE/VLVT)
Destination airport:	Pakse Airport (PKZ/VLPS)
Investigating agency:	AAIC Laos
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
A Lao Airlines ATR-72 was damaged beyond repair in an accident near Pakse, Laos. All 44 passengers and five crew members were killed in the accident.
Flight QV301 originated in Vientiane, Laos at 14:45 and operated a domestic service to Pakse. Weather in the area was poor as a result of a passing typhoon.
The flight was cleared for a VOR-DME non-precision approach to runway 15. After passing the final approach fix, the procedure called for a descent to the minimum descent altitude of 990 feet. After this the approach may only be continued if ground visual references are available.
The crew however incorrectly set the altitude preselect (ALT SEL) mode to 600 feet. This was still below the (incorrectly) published height of 645 feet on their Jeppesen chart.
Since the ground was not visible at 600 feet, the crew disconnected the autopilot and aborted the approach with the intention to conduct a missed approach.
After the aborted approach, the Flight Director vertical mode switched to Go Around and immediately went into altitude capture mode because the altitude selected was 600 feet. The missed approach was followed by a right turn instead of a nominal climb as published in the VOR-DME approach chart. The airplane began losing altitude.
A series of EGPWS warnings sounded and the height reached the minimum value of 60 feet above ground level and the roll reached approximately 37° to the right.
When the flight crew realized that the altitude was too close to the ground, the captain over-reacted, which led to a high pitch attitude of 33°. The Flight Director command bars then disappeared from the screen because of the extreme aircraft position.
The airplane climbed to an altitude of 1750 feet until the airplane pitched down again. The Flight Director command bars then reappeared and centered during the descent, because the selected altitude was still 600 feet.
The descent was continued until the airplane impacted the Mekong River. The fuselage broke and sank in the river.

Causes of the Accident:
The probable cause of this accident were the sudden change of weather condition and the flight crew's failure to properly execute the published instrument approach, including the published missed approach procedure, which resulted in the aircraft impacting the terrain.
The following factors may have contributed to the accident:
- The flight crew's decision to continue the approach below the published minima
- The flight crew's selection of an altitude in the ALT SEL window below the minima, which led to misleading FD horizontal bar readings during the go-around
- Possible Somatogravic illusions suffered by the PF
- The automatic reappearance of the FD crossbars consistent with the operating logic of the aeroplane systems, but inappropriate for the go-around
- The inadequate monitoring of primary flight parameters during the go-around, which may have been worsened by the PM's attention all tunneling on the management of the aircraft flap configuration
- The flight crew's limited coordination that led to a mismatch of action plans between the PF and the PM during the final approach.

Accident investigation: