On 29 May 2022, Tara Air flight 9N-AET, a DHC-6 Twin Otter, crashed near Jomsom, Nepal, while operating a VFR flight from Pokhara to Jomsom. All 22 occupants (4 crew, 18 passengers) lost their lives. The aircraft impacted mountainous terrain in controlled flight (CFIT).
🌧️ Weather Conditions
The flight departed into deteriorating weather conditions with rain, low ceiling, and reduced visibility. The crew attempted to maintain VFR but inadvertently entered IMC conditions.
🔧 Key Investigation Findings
Captain expressed hesitation about weather but continued flight
TAWS (Terrain Awareness Warning System) was intentionally inhibited
First Officer had significantly less experience (520 vs 17,500 hours)
Poor Crew Resource Management (CRM) in the cockpit
Normalization of marginal VFR operations over time
External pressure (passenger/ground crew) to continue
⚠️ Key Human Factors Finding: The investigation identified plan continuation bias, authority gradient issues, and drift in safety margins as contributing factors. The accident report was "written years before the accident" through organizational decisions.
📚 Frameworks to Consider
As you answer the 10 questions, apply these human factors frameworks: Dirty Dozen, Swiss Cheese, Normalization of Deviance, Authority Gradient, Situational Awareness, Psychological Safety, Just Culture, Drift into Failure