Himal Press 
KATHMANDU: The final report of the Aircraft Accident Investigation Commission has concluded that the fatal crash of a Saurya Airlines CRJ 200LR aircraft at Tribhuvan International Airport on July 24 last year was primarily caused by a deep stall during take-off, resulting from an abnormally rapid pitch rate at a lower-than-optimal rotation speed.
The aircraft bearing registration 9N-AME was on a scheduled ferry flight from Kathmandu to Pokhara to undergo base maintenance (C-check) after being grounded for 34 days. The accident occurred at 11:11 am, moments after take-off, when the aircraft crashed within the airport perimeter. All passengers onboard, except the pilot-in-command, died in the accident.
According to the commission’s findings, the key cause of the crash was a deep aerodynamic stall triggered by improper aircraft handling during rotation. The investigation pointed to erroneous take-off speed data calculated using a flawed speedcard that had never been formally approved or validated. The error had persisted undetected in the operator’s procedures since the speedcard’s creation, according to the report.
Speedcard refers to a document that provides pilots with critical airspeed information for various phases of flight, such as takeoff, climb and landing, based on the aircraft’s weight.
The report also highlighted several contributing factors. Saurya Airlines had failed to investigate or respond to several past incidents involving excessively high pitch rates during take-off. The airline demonstrated gross negligence in planning and executing the ferry flight, with unclear protocols and inconsistent application of procedures, it added.
Investigators also found serious violations in cargo and baggage handling practices. The load was neither weighed properly nor secured with tie-downs or nets, in clear breach of the airline’s operational and ground handling manuals. Flight preparations were rushed, and safety checks were bypassed.
The government had formed a five-member commission under former Director General of the Civil Aviation Authority of Nepal (CAAN) Ratish Chandra Lal Suman. Deepu Raj Jawarchan, Sanjay Adhikari, Dr Sudip Bhattarai and Mukesh Dangol were the other members of the commission.
The commission had earlier issued interim safety recommendations to prevent similar accidents in the future. It urged all operators to immediately review their speed cards and Runway Takeoff Weight (RTOW) charts and comply strictly with cargo and baggage handling protocols, including proper weighing, distribution, and secure latching as outlined in operational and ground handling manuals. Similarly, it advised CAAN to review and update its procedures and requirements for granting permission for non-scheduled flights, including non-revenue and ferry operations.
Likewise, it has advised Saurya Airlines to establish and maintain a healthy and robust flight data management (FDM) program staffed with
capable human resources, as part of its Safety Management System. “A competent FDM and Flight Data Analysis (FDA) program would have noticed erratic judgments or shortcomings of the crew, such as rapid or unusually high pitch rates/angles during rotation for takeoff,” it added.
