• The Saurya Airlines CRJ 200 aircraft crashed at Tribhuvan International Airport while taking-off for Pokhara for repairs on July 24 of 2024.
• The investigation committee formed to probe the crash of Saurya Airlines’s 9N-AME aircraft has submitted its final report.
• Pilot Manish Shakya had miraculously survived the fatal plane crash that killed 18 occupants.
• During take-off, the V-speeds were V1 = 114 knots, VR = 118 knots and V2 = 125 knots. at 05:25:55 UTC

An investigation into the fatal crash of the Saurya Airlines CRJ 200 aircraft with registration 9N–AME has concluded that pilot error, not technical failure, was the primary cause of the accident that claimed 18 lives. 

Investigation Committee’s Chairperson and Civil Aviation Authority of Nepal (CAAN) Director General Ratish Chandra Lal Suman presented the report to Minister of Culture, Tourism and Civil Aviation Badri Prasad Pandey amid a programme organized at the latter’s office on Friday.

The crash occurred on July 24 of 2024, when the aircraft, on a ferry flight to Pokhara for C-check maintenance, went down near the runway shortly after takeoff from Tribhuvan International Airport. Pilot Manish Shakya survived, but all others aboard perished.

The aircraft was destroyed due to high velocity impact, and post impact fire as seen in Figure 4. The aircraft also collided with the container and shed of Air Dynasty Heli Services Pvt. Ltd.

The cockpit portion was stuck on the Air Dynasty container on the eastern side of the airport. Most of the fuselage structure and its components were damaged due to fire.

The impact of the right wing on the ground marked the start of the disintegration of the right wing and the subsequent accident.

The flight was approved as ferry flight, by Air Transport Division of the Civil Aviation Authority of Nepal on July 23, 2024, with an extension period of 72 hours.

The purpose of the ferry flight was to conduct base maintenance (C-check) of the aircraft, at Pokhara International Airport’s hanger. The aircraft had been grounded for 34 days prior to the event flight.

The Government of Nepal constituted a 5-member, Aircraft Accident Investigation Commission to find the most probable cause of the accident and suggest recommendations as to prevent the recurrence of similar accidents as per the provision of the Aircraft Accident Investigation Regulation, 2014 (2071 B.S.).

The commission carried out thorough investigation and extensive analysis, along with accident site visits and examinations, interviews with concerned personnels, study of different reports, records and documents and flight data analysis.

According to the report, the pilot raised the aircraft’s nose too steeply during takeoff, resulting in an excessive “pitch rate” that triggered a deep stall—a condition where airflow over the wings is disrupted, making further lift impossible. The aircraft then lost speed and altitude, eventually crashing.

Investigators found that the aircraft’s speed calculation was based on an incorrect and unauthorized speed card, which was not officially approved nor verified by the airline. The aircraft, weighing 18,500 kg, should have had a different V-speed (takeoff speed), but the faulty speed card led to miscalculation.

The contributory factors to the accident are:

• Incorrect speeds calculated based on erroneous speedcard. The interpolated speedcard of the operator for 18,500 kg TOW mentions incorrect V-speeds for take-off. This error in the speedcard went unnoticed since its development. There was no acceptance/approval of the speedcard booklet.
• Failure to identify and address multiple previous events of high pitch rate during take-off by the operator.
• The operator showed gross negligence in complying with the prevailing practices of ferry flight planning, preparation and execution. There is a lack of consistent definition of ferry flights.
• Gross negligence and non-compliances by the operator during the entire process of cargo and baggage handling (weighing, loading, distribution and latching), while violating the provisions of operational manual and ground handling manual. The load was not adequately secured with straps, tie-downs, or nets, while the flight preparation was rushed.

The aircraft met an accident during take-off at around 05:26 UTC (11:11 am local time), crashing within the premises of Tribhuvan International Airport. All occupants except the Pilot in Command lost their lives.

The ferry flight had not followed standard operating practices. The aircraft that had been grounded for 34 days before the flight, and had gained only 50 feet of altitude within five seconds of rotation before the right wing struck the ground.

Additionally, the investigation highlighted several violations of safety protocols by the airline.

The operator failed to follow proper cargo and baggage handling procedures. Maintenance tools and materials were loaded in the cabin without proper strapping or supervision.

Hazardous materials were found onboard, along with unmanifested personnel. No proper load distribution or weight verification was conducted. Non-crew members were aboard the aircraft unnecessarily.

The operator was also found to be using flawed speed cards across multiple flights without correction or reporting by flight crews. Pitch rates as high as 8.6 degrees per second were recorded, which are significantly abnormal.

The report criticized the airport authority for poor emergency preparedness. Crucial zones around the airport were not clearly designated, and construction materials were stored unsafely near the crash site.

On the day of the crash, the transfer of wreckage from the site to Saurya Airlines’ office was deemed potential tampering with evidence, reflecting serious negligence on the part of airport authorities.

There was also no resource analysis for tools or personnel, and standard protocols for issuing flight directives and briefing procedures were not followed.

The report paints a troubling picture of systemic failures at both the operator and regulatory levels, underscoring urgent needs for accountability, compliance with safety standards, and institutional reform to prevent similar tragedies in the future.

The commission issued three interim safety recommendations as immediate remedial measures. In this report, 41 safety recommendations are made for the advancement of safety.

• All operators shall immediately review their speed cards and RTOW charts.
• All operators shall comply with the requirements of the cargo and baggage handling. Baggage and cargo weighing, its distribution and latching should be ensured as stipulated in the operation manual and ground handling manual.
• Civil Aviation Authority of Nepal shall review and update the procedure and requirements for the permission of non-scheduled flights including all non-revenue and ferry flights.

Few other Safety recommendations by the Investigation commission are as follows:

• All operators of aircrafts in Nepal that have FDR/LDR installed shall immediately implement a FDM program and maintain a system of compliance with the findings of the program.
• Saurya Airlines shall establish and maintain a healthy and robust FDM program, staffed with capable human resources, as part of its Safety Management System. A competent FDM/FDA program would have noticed erratic judgements or shortcomings of the crew, such as rapid or unusually high pitch rates/angles during rotation for takeoff. A healthy and robust FDM program can identify risks and may identify erroneous FDR parameters proactively.
• The airline shall revise and implement SOPs to emphasize the requirement for achieving optimal rotation speeds during take-off. They shall include clear guidelines to address conditions where achieving such speeds may be challenging.
• Civil Aviation Authority of Nepal (CAAN) shall immediately establish a mandatory and robust flight data monitoring and analysis program applicable to all operators. CAAN shall also develop its own FDM/FDA capabilities. 2. As part of the renewal of C of A and ARC, CAAN shall mandate all the operators to submit the status of their flight data monitoring programs.
• The Tribhuvan International Airport (VNKT) shall conduct a comprehensive risk assessment to identify and classify critical zones for rescue operations, based on proximity to runways, passenger terminals, fuel storage areas, and other high-risk locations within the airport and its surrounding areas.
• Government of Nepal should establish a permanent investigation entity with sufficient financial, human and technical resources to competently meet the international obligation as per Annex 13 of the Chicago Convention.
• The aircraft manufacturer shall review as to why the right angle of attack of the aircraft tends to rise earlier than the left. This is significant in the fact that the right wing may be prone to early stall. 2. The stick pusher activated after around 6 seconds of stick shaker activation. The stick pusher activation requirements should be further investigated.