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Invisible Peril: The crash of Palair Macedonian Airways flight 301


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The wreckage of Palair flight 301 lies in a area outdoors Skopje, Macedonia. (Rune Lind)

On the fifth of March 1993, a Fokker 100 jet flying for the nationwide airline of the newly unbiased republic of Macedonia misplaced management throughout takeoff from Skopje, rolling wildly back and forth earlier than cartwheeling right into a area and breaking up, killing 83 of the 97 individuals on board. Macedonian authorities wished to shut the case rapidly, drafting a last report simply two months after the accident. However a Dutch crew despatched to symbolize the plane’s proprietor and producer refused to simply accept this bare-bones inquiry, and stored investigating for an additional 12 months, revealing the science behind why the aircraft went down. The investigators uncovered disturbing proof of how small quantities of ice on the wings, interacting with heat and chilly gasoline mixtures contained in the gasoline tanks, may lead to a whole lack of roll management throughout takeoff — a terrifying emergency that the pilots didn’t have sufficient time to know. The crash led to modifications in the way in which Fokker pilots be taught in regards to the risks of icing, and to higher consciousness of the vulnerability of the plane kind to ice on the wings. However the modifications, as essential as they had been, didn’t forestall the identical kind of accident from occurring once more — not as soon as, however twice.

A Palair Macedonian Airways crew and aircraft, undated picture. (Historical past of Macedonia)

In 1991, as Yugoslavia started to crumble, the small, landlocked nation of Macedonia declared its independence as a sovereign nation. Largely avoiding the bloody conflicts which outlined the breakup of Yugoslavia, Macedonia (recognized since 2019 as North Macedonia) set in regards to the sluggish means of gaining worldwide recognition. By the spring of 1993 the method was virtually full, however the brand new nation was nonetheless a couple of month away from acceding to the United Nations. However, it had already taken one of many first steps towards presenting itself as a contemporary, unbiased nation: establishing a nationwide airline. Palair Macedonian Airways got here into being in late 1991 with a single Tupolev Tu-154, however by 1993 it was seeking to increase, and early that 12 months it added a Fokker F28 Fellowship and a bigger Fokker 100 leased from overseas corporations. Particularly, Palair acquired the Fokker 100 from a Dutch firm known as Plane Financing and Buying and selling, or AFT, which was collectively owned by Fokker Plane and engine producer Rolls Royce and specialised in leasing plane and crews to passenger airways.

PH-KXL, the plane concerned within the accident. (Torsten Maiwald)

The Fokker 100 arrived in Macedonia in January 1993, together with a complement of pilots from AFT, who would conduct line coaching for Palair’s pilots till they’d sufficient expertise to function the aircraft themselves. Flight crews had been thus often break up between one Dutch pilot and one Macedonian pilot. Upkeep was contracted out to Swissair, which carried out service each time the aircraft made its scheduled cease in Zürich, and likewise despatched a Flying Station Engineer, or FSE, who rode with the aircraft to all stops apart from Zürich in an effort to perform upkeep and different operational duties.

Late on the morning of the fifth of March, the Fokker 100 arrived in Skopje, the capital of Macedonia, after a routine flight from Frankfurt, Germany. The identical crew was alleged to fly the subsequent leg to Zürich, Switzerland, however the flight had been delayed and the crew knowledgeable the corporate that they wouldn’t be capable of conduct the second flight inside responsibility closing dates. AFT and Palair rapidly summoned a brand new crew to switch them, consisting of Captain Peter Bierdrager, who labored for AFT, and an unnamed Macedonian captain who was present process coaching to switch from the Boeing 737 to the Fokker 100.

Route of Palair flight 301. (Google + personal work)

When the crew arrived on the airplane round 11:30 a.m., the climate was poor with no indicators of enchancment. The temperature hovered round 0˚C and lightweight snow was falling, which instantly melted upon touching the bottom. The dew level — the temperature at which water vapor will condense out of the air — was -1˚C, very near the precise temperature, creating circumstances excellent for ice formation, particularly on chilly surfaces.

At Palair it was frequent apply to hold extra gasoline than was strictly crucial in an effort to keep away from increased gasoline costs at sure European airports, and when the aircraft landed in Skopje it nonetheless had a number of thousand kilograms of gasoline on board. In accordance with firm process, the outgoing crew had added nonetheless extra gasoline after touchdown till they reached the corporate customary of 6,800 kilograms. Then, upon studying of dangerous climate in Zürich, Captain Bierdrager added one other 900 kilograms simply to verify they’d sufficient for prolonged holding if circumstances prevented them from touchdown.

In the course of the flight from Frankfurt, the gasoline within the tanks was uncovered to very chilly temperatures at excessive altitudes, leading to what is called “cold-soaking.” Because the aircraft sat on the bottom, the gasoline within the wings remained a lot colder than the ambient air temperature, permitting the falling snow to freeze to the wing as a substitute of melting.

When extra gasoline was added to the tank, this gasoline got here from a gasoline truck the place the temperature was considerably increased than that of the surface air. This hotter gasoline entered by way of the collector tanks, situated close to the wings roots. Along with the collector tanks, every wing tank additionally consisted of three compartments, labeled from inboard to outboard, which had been linked to one another and to the collector tank solely by small flap doorways and holes in stringers. Consequently, the hotter gasoline combined totally into the collector tanks, however for probably the most half didn’t migrate to the opposite compartments, particularly compartment three. Consequently, a temperature gradient developed within the wings, the place the wing surfaces (heated by the brand new gasoline) had been hotter close to the wing roots and colder close to the wing ideas.

Round ten or fifteen minutes after refueling, the Flying Station Engineer carried out a walkaround test of the airplane to search for mechanical issues and ice. As was known as for in customary working procedures, he checked the highest of the wings for ice by standing on a baggage cart and working his fingers over the floor. He discovered solely moist, melting snow with none signal of ice. A number of floor handlers additionally checked and reported related findings. After the test, one of many floor handlers requested the FSE whether or not they would wish to de-ice the aircraft, grabbing a bunch of slush off one of many flaps to contextualize his query. However the FSE stated that the snow wasn’t sticking to the wings and would slide off throughout the takeoff roll, so no de-icing can be crucial. He then presumably went to the cockpit to inform the pilots about his resolution, which they apparently accepted uncritically.

The issue was that the FSE had checked for ice close to the wing root, the place the hotter gasoline was inflicting the snow to soften, and never close to the colder wing ideas, the place snow was sticking to the wing floor and forming ice. Unaware of the hazard, the pilots accomplished the pre-flight checks, began the engines, and taxied to the runway with out as soon as mentioning the climate circumstances.

With 92 passengers (together with the FSE) and 5 crew on board, Palair flight 301 to Zürich acquired takeoff clearance at 12:11 p.m. By this time the sunshine snowfall had turn into average to heavy, with visibility restricted to lower than 1,000 meters. However nonetheless the pilots, apparently unperturbed, didn’t talk about the climate.

With the Macedonian trainee captain sitting within the left seat and dealing with the controls, flight 301 sped off down the runway and lifted off usually some 30 seconds later. Within the tower, the controller watched the aircraft vanish into the snow.

As quickly because the aircraft began to climb, an uncommon vibration started. “Positi-i-i-ve,” Captain Bierdrager known as out as they began to climb, his utterance tinged half means via with sudden uncertainty.

What neither pilot knew was that the ice on the wings was severely affecting the efficiency of their airplane. By interrupting clean airflow over the wings, even a tiny layer of ice may end up in a major discount in carry. The diminished carry and elevated drag can even trigger the aircraft to stall at a a lot decrease angle of assault than regular. The angle of assault (the angle of the aircraft relative to the airflow) the place the Fokker 100 will stall is generally round 16.5 levels, however with ice on the wings, this was diminished to between 10 and 11 levels, barely beneath the angle of assault used throughout a routine takeoff. Consequently, when the trainee captain pulled again on his controls to climb, the airplane began to stall, inflicting violent buffeting because the airflow separated from the wings.

How ice on the wings impacts carry. (Dutch Security Board)

However the stall was solely half of the issue. Because of the means the gasoline was distributed, the ice had turn into concentrated close to the wing ideas, with much less ice and even no ice close to the wing roots. This was vital as a result of the ailerons, which management financial institution angle, had been additionally situated on the outboard a part of every wing.

Plane wings are designed to make sure that because the aircraft approaches a stall, the airflow separates first close to the wing roots earlier than progressing outward towards the wing ideas. As a result of the ailerons depend on clean airflow over the wings in an effort to function correctly, this helps make sure that it’s potential to manage the aircraft’s roll angle throughout a stall. However the ice on the wing ideas disrupted this sequence and brought about the airflow separation throughout the stall to progress outboard to inboard, reverse to the traditional path. Consequently, one of many first indicators of the stall was a sudden and surprising lack of roll management because the air stopped flowing easily over the ailerons.

Simply seconds after liftoff, concurrently Captain Bierdrager known as out “positive,” this manifested within the type of an uncommanded 11-degree roll to the correct, prompting the trainee captain to show left utilizing his management column. Surprisingly, he needed to apply almost full left aileron earlier than the aircraft returned to wings degree, permitting him to calm down his inputs.

However three seconds after that, all hell broke free: with none enter from the pilots, the aircraft abruptly rolled fifty levels to the left throughout the house of about one second. The trainee captain instinctively turned his management column all the way in which to the correct, however his inputs appeared to don’t have any impact.

“Ah shit!” Bierdrager exclaimed.

“What is it?” stated the trainee captain.

Two seconds after rolling exhausting to the left, the aircraft abruptly rolled during wings degree and right into a 63-degree financial institution to the correct. The trainee captain slammed his controls again to the left once more, however was unable to arrest the acute roll.

Bierdrager was now simply as confused as his copilot. The roll clearly wasn’t deliberate, so maybe it was the autopilot? He then known as out, “Oh, deselect!” earlier than reaching out to disconnect the autopilot. However the autopilot had by no means been turned on within the first place.

FDR knowledge from the accident flight exhibits how the aircraft swayed back and forth regardless of reverse inputs by the crew. Observe that the info from the final two seconds was misplaced attributable to injury brought about throughout the crash. (Dutch Security Board)

The stick shaker stall warning momentarily activated, but it surely was programmed primarily based on the stall traits of a clear wing, and solely got here to life properly after the airplane had already stalled. Whereas within the steep proper financial institution, the trainee captain pitched the nostril down, reducing the angle of assault and recovering sufficient roll management to return to a shallower, 15-degree financial institution. However now they had been descending at a price of two,000 toes per minute from a peak of simply 150 toes above the bottom.

“Nose up!” shouted the engineer from the cockpit leap seat. In a determined try to keep away from hitting the bottom, the trainee captain pulled up sharply, however this once more brought about the airflow to separate from the wing ideas, and so they as soon as once more misplaced management of the ailerons. The aircraft abruptly rolled 90 levels to the correct and plowed sideways right into a snow-covered area 380 meters past the top of the runway. The appropriate wing sliced a furrow throughout the bottom and thru the airport’s barbed wire perimeter fence earlier than the fuselage crashed to earth and broke aside, splitting into a number of items as hearth erupted from the riven gasoline tanks. Inside seconds, it was throughout, and the smoking stays of the jet got here to a halt beneath a curtain of falling snow.

The stays of the Fokker 100 had been strewn for a number of hundred meters throughout a area. (Rune Lind)

Nobody on the airport witnessed the crash, however a United Nations helicopter pilot strolling again to his workplace after parking on the ramp heard a loud growth coming from the top of the runway and rushed again to his helicopter to seek for the crashed aircraft. Lower than a minute later he arrived upon a scene of devastation. The aircraft had disintegrated, spewing seats and passengers everywhere in the area, whereas solely the tail part and the left facet of the cockpit remained intact. Spot fires burned all through the particles area. However behind the aircraft, some individuals had managed to outlive, together with one of many flight attendants. The UN pilot crammed seven survivors into his helicopter and rushed them to hospital, earlier than turning round and flying proper again to choose up extra. One other helicopter additionally arrived inside minutes, together with police and firefighters, and collectively the 2 helicopters ferried one other eight survivors to close by hospitals. However after that, rescuers may solely discover our bodies. A kind of taken to hospital additionally quickly died, leaving 83 individuals useless with solely 14 survivors.

The left facet of the cockpit was discovered considerably intact with a part of the fuselage wall nonetheless connected to it. (FAA)

The Macedonian Civil Aviation Authority rapidly arrange an investigation fee, which was to be run by Yugoslav investigators primarily based in Belgrade, as Macedonia had not but arrange its personal investigative company. In addition they invited investigators from the Dutch Security Board, who had been entitled to take part because the plane was manufactured and registered within the Netherlands.

The Dutch crew quickly took over a lot of the technical facet of the inquiry, which concerned complicated assessments carried out on particular simulators at Fokker Plane. However in Could 1993, properly earlier than any of the assessments had concluded, the Yugoslav and Macedonian investigators wrote up a last report which they then proceeded to take a seat on for a number of months till newspapers started reporting that the investigation had been accomplished. The Dutch Security Board was definitely not in settlement that the investigation was over, however in a gathering in September 1993 the Macedonians instructed the Dutch representatives that they need to both agree with the findings or add their feedback that very day. The Dutch Security Board rejected this outright, as a result of of their view the report was woefully incomplete, because it made no point out of the quite a few time-consuming experiments they’d been conducting close to gasoline temperatures, ice distribution, and lack of roll management, and it contained no dialogue of the human components concerned within the resolution to not de-ice. Moreover, worldwide guidelines gave the accredited representatives 60 days, not one, to make feedback on the report. Fortuitously, after the presumably explosive assembly, Macedonia agreed to offer the Dutch investigators the complete 60 days, after which they introduced an inventory of feedback longer than the ultimate report itself.

The tail part was the place all of the survivors had been seated. Nonetheless, the left engine penetrated the cabin throughout impression sequence and triggered a fireplace which burned over most of what was left of this space after they escaped. (Rune Lind)

Macedonia appeared to take offense on the implication that incorporating the Dutch feedback would contain an virtually complete rewriting of the report, and Dutch investigators described obvious stress on the Macedonians, presumably political in origin, to get the investigation over with and publish the findings. After extra negotiations, Macedonia agreed to publish a mutually acceptable possible trigger whereas the fee tried to resolve the disagreements over the main points. The Dutch Security Board finally ended up writing its personal last report primarily based across the skeleton of the report produced in Could 1993 and submitted this to Macedonia in 1994 — just for them to take a seat on it once more till 1996, once they knowledgeable the Dutch Security Board that they’d be submitting the unique 1993 report back to the Worldwide Civil Aviation Group, and that if the Netherlands wished to publish their very own report they need to accomplish that individually. No apparent cause was given for the two-year delay, which the Dutch Security Board stated may have been detrimental to aviation security.

One other view of the wreckage exhibits how half the cockpit was torn away. (Rune Lind)

For sure, the rather more thorough Dutch report has turn into the work of reference in regards to the crash of Palair flight 301, particularly for the reason that Macedonian report was by no means publicly launched. Its findings pointed to extra vital vulnerabilities in an plane kind that was already recognized to be at elevated threat of ice-related accidents.

The fundamental sequence of occasions started when an uneven temperature distribution throughout the gasoline within the wing tanks allowed ice to construct up on the outboard components of the wings however not on the inboard components. The Flying Station Engineer examined the inboard components of the wings, however he didn’t have a superb view of the wing ideas and couldn’t have seen the ice which was accumulating there. He in all probability checked the wing roots out of drive of behavior: up till the week of the accident, he had been dealing with Swissair Fokker 100s, which had particular ice detectors situated on this space. Palair’s Fokker 100 didn’t have any ice detectors, so there was no cause to test any specific a part of the wing vis-à-vis one other, however the engineer merely did what he had all the time carried out and examined the wing root.

United Nations personnel study the wreckage. (Rune Lind)

Apparently satisfied that the snow was melting and never sticking to the wings, the FSE instructed the bottom handlers that they wouldn’t must de-ice the aircraft, and presumably stated the identical factor to the pilots. Nonetheless, the pilots hadn’t adopted an organization process which known as for the cockpit voice recorder to be turned on earlier than beginning any checklists, so any potential document of this dialog was misplaced when the pilots and the FSE died within the crash.

A significant query that the investigators wanted to reply was why the pilots didn’t determine to de-ice anyway, on condition that circumstances had been excellent for ice formation. The temperature was round freezing with an analogous dew level amid falling snow; it could be exhausting to ask for climate extra conducive to ice. However the pilots could not have had good situational consciousness close to the climate. It didn’t begin snowing till shortly earlier than they arrived by automobile on the airport, and even then there have been just a few flakes which melted instantly. After that, they went straight inside to organize the aircraft for departure, a job which stored their focus contained in the cockpit moderately than outdoors on the climate. When the FSE reported that there was no must de-ice, this might have bolstered their outdated notion that the climate circumstances had been nothing to fret about. They’d have had little cause to query the judgment of the FSE, who was extremely regarded by all who labored with him, and represented Swissair, a revered provider. On the time there have been additionally no particular climate standards which might obligate a pilot to de-ice the aircraft, so the judgment of the certified engineer was thought-about ok. Following this, the pilots couldn’t have failed to note the rising snowfall as they taxied to the runway, however for the reason that snow nonetheless seemed to be melting when it touched the bottom, it won’t have occurred to them that it may however freeze onto the wings.

Even with ice on the wings, the aircraft was not doomed to crash on takeoff. However so long as the pilots remained unaware of the ice and its potential results, it would as properly have been. The detrimental results of the ice brought about the stall angle of assault to scale back beneath the angle of assault used throughout takeoff; in consequence, the aircraft began to stall virtually as quickly because the trainee captain pulled as much as climb. The stall got here unexpectedly as a result of the stall warnings had been programmed to activate at a degree calculated primarily based on the aircraft’s configuration and altitude, and couldn’t account for the truth that ice was considerably altering the jet’s aerodynamic traits.

The focus of ice on the wingtips allowed the stall to propagate from the wingtips towards the wing roots, inflicting airflow to separate from the ailerons early within the course of, a situation which the design of the wings would usually forestall. This resulted in a lack of roll management starting 4 seconds after takeoff, beginning with the 11-degree roll to the correct, then the 50-degree roll to the left. The pilots had no concept {that a} lack of roll management might be symptomatic of an ice-induced stall, as this phenomenon had by no means been noticed on a Fokker 100 earlier than. Captain Bierdrager’s try to disengage the autopilot (which was not really engaged) additionally means that he might need been trying to find a mechanical or computer-related trigger for the lack of management.

Aspect view of the cockpit, the place the impression with the bottom stripped away all the pieces to the correct of the captain’s seat. (Rune Lind)

Actually, unbeknownst to the pilots, the sudden rolling motions had been straight correlated with the aircraft’s angle of assault. Each time the angle of assault decreased beneath 10 levels, the trainee captain was in a position to recuperate to wings degree. (Actually, had he recognized what the issue was, he may have simply stored the pitch beneath this worth and climbed away with none hassle.) However every time he regained management, he proceeded to observe his flight director, an overlay on his perspective indicator, which was exhibiting him the nominal climb angle that he must be sustaining. He didn’t understand that the ice on the wings prevented him from really sustaining this angle with out stalling the airplane. Each time he pitched as much as attain this nominal climb angle, the angle of assault went above ten levels, the aircraft began to stall once more, and the uncommanded rolling would return. The terrified pilots didn’t have sufficient time to identify the connection. Solely 18 seconds handed between liftoff and impression, throughout which period the aircraft rolled barely proper, steeply left, sharply proper once more, returned to barely proper, then flipped utterly on its facet. The pilots understandably centered on attempting to degree the wings, unaware that the foundation trigger was one thing completely completely different.

One other view of the cockpit. The tail part may be seen within the background. (Rune Lind)

As a result of the bodily proof was ephemeral, the investigators couldn’t say precisely how a lot ice was on the wings on the time of the accident. However the excessive results of comparatively small quantities of ice on the Fokker 100 and its smaller sister craft, the Fokker F28 Fellowship, had been already well-known within the trade. The fundamental drawback was that closely swept wings with out forefront slats tended to lose extra carry attributable to smaller quantities of ice than different wing shapes. The Fokker F28 and Fokker 100 had been among the many most generally used airliners with this comparatively unusual design function, and their vulnerability had already led to quite a lot of accidents. The primary deadly icing accident involving the F28 occurred in Turkey in 1974, however a number of others had taken place since then. In 1989, Air Ontario flight 1363, an F28, crashed on takeoff from Dryden, Ontario after operational considerations compelled the crew to not de-ice, killing 24 of the 69 individuals on board. In 1992, USAir flight 405, one other Fokker F28, crashed on takeoff from New York’s LaGuardia airport beneath very related circumstances, killing 27 of the 51 passengers and crew. In each circumstances it was discovered that tiny quantities of ice invisible to the pilots had prevented the planes from turning into airborne. The 2 accidents led to an rising push within the trade to make sure that pilots or different certified personnel bodily contact the tops of the wings when deciding whether or not or not ice is current. The crashes additionally led to elevated use of anti-icing fluids along with present de-icing mixtures, and to higher emphasis on the risks of ice in Fokker’s documentation. However these measures failed to forestall the crash of Palair flight 301.

Little remained of the cabin close to the entrance of the aircraft. (Rune Lind)

Because of the accident in Macedonia, Dutch authorities issued an airworthiness directive requiring all Fokker F28 and Fokker 100 operators to include language of their operations manuals warning of the hazard of varied icing patterns brought on by gasoline distribution and the potential lack of roll management. The up to date documentation included a method for taking off with a decrease climb angle when the absence of ice can’t be assured — a way which might have prevented the crash of flight 301. Producers, together with Fokker, additionally began together with particular climate standards that might obligate a pilot to de-ice their aircraft, no matter whether or not ice was seen throughout the pre-flight inspection.

The cockpit is taken away from the scene on a UN flatbed truck. (Rune Lind)

Sadly, Palair flight 301 was not the final Fokker 100 to crash attributable to ice on the wings. On the twenty fifth of January 2007, Air France flight 7775, a Fokker 100, ready to take off from Paris Charles de Gaulle Worldwide Airport beneath circumstances similar to these in Skopje 14 years earlier. The temperature was as soon as once more 0˚C with a dew level of -1˚C in mild falling snow. A crewmember did a pre-flight walkaround test, however he couldn’t discover a step ladder which might permit him to entry the tops of the wings, so he solely checked the main and trailing edges, the place he discovered no ice. The pilots had been unaware that ice had the truth is shaped on high of the wings.

Throughout takeoff the aircraft began to stall and misplaced roll management; the jet banked 35 levels to the left, then 69 levels to the correct, then 59 levels to the left. The pilots pitched down in an try to land again on the runway, within the course of averting the stall and regaining roll management. The aircraft touched down shortly earlier than the top of the runway, then skidded off the top and throughout a street earlier than coming to relaxation in a area. All 54 passengers and crew survived, however a truck driver was killed when the aircraft’s wing struck his car because it was crossing the street. Aside from the end result, the incident was similar to Palair flight 301, besides that the crew violated all of the procedures put in place after that crash to forestall a recurrence. Within the wake of the accident in Paris, the European Aviation Security Company mandated on-ground wing forefront heaters on all Fokker 100s, though these nonetheless can’t take away ice from your entire wing.

The aftermath of the 2007 crash of Air France flight 7775. (BEA)

And but, in spite of everything of that, any such crash nonetheless stored occurring. On the twenty seventh of December 2019, Bek Air flight 2100, one other Fokker 100, crashed on takeoff from Almaty, Kazakhstan after the captain determined to not de-ice the aircraft regardless of the presence of freezing fog. The aircraft didn’t get greater than 20 toes off the bottom earlier than slewing off the facet of the runway and hitting a constructing, killing 12 of the 98 individuals on board. Though the investigation into the crash remains to be ongoing, preliminary findings confirmed that Bek Air, regardless of working in a chilly surroundings with a aircraft recognized for ice-related crashes, had not given its crews any winter operations coaching or supplied any coaching associated to the risks of ice. The victims of all of the earlier crashes will need to have been rolling of their graves. Fortuitously, Kazakh authorities completely grounded Bek Air attributable to these violations (and others, together with illegally eradicating knowledge plates from key parts, presumably to promote them on the black market, a discovering which raised questions on whether or not your entire airline was some type of organized crime entrance from the very starting).

The aftermath of the 2019 crash of Bek Air flight 2100. (AP)

In any case, with fewer and fewer Fokker 100s in service with every passing 12 months, it’s possible that this would be the final ice-related crash involving this plane kind. However then once more, many specialists in all probability would have stated the identical factor earlier than the Bek Air crash too. If there’s one factor each pilot ought to take away from this sordid story, it’s that ice on the wings just isn’t a joke.

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