Saurya Airlines crash report exposes shocking system failures: CAAN, airline, and govt criticized for negligence

KATHMANDU: A final investigation report into the catastrophic crash of a Saurya Airlines aircraft on July 24, 2024, has revealed alarming failures at multiple levels—including gross negligence by Saurya Airlines, oversight lapses by the Civil Aviation Authority of Nepal (CAAN), and systemic weaknesses in Nepal’s aviation governance.

The accident of flight SAU-FER, a CRJ 200LR aircraft (9N-AME), claimed 18 lives and left the pilot in critical condition after the aircraft crashed during takeoff at Tribhuvan International Airport (TIA), Kathmandu.

The Aircraft Accident Investigation Commission (AAIC), formed under the Ministry of Culture, Tourism and Civil Aviation (MoCTCA), submitted its final report on July 14, 2025. The 62-page report lays bare the tragic sequence of events and critical safety oversights that culminated in one of Nepal’s deadliest domestic aviation accidents in recent years.

Most Probable Cause: Deep Stall from Rapid Pitch at Low Speed

According to the AAIC, the aircraft entered an unrecoverable deep stall during takeoff due to an abnormally high pitch rate at a speed significantly below the optimal rotation threshold. The plane banked sharply, rolled over 90 degrees, and crashed within seconds, bursting into flames.

Key Findings:
1. Faulty Speed Calculations and Unverified Documents
The flight was operating based on incorrect takeoff speeds (V-speeds) calculated from an erroneous speedcard developed by the airline.

Shockingly, this speedcard had never been approved or reviewed by either Saurya Airlines’ quality system or CAAN—a fundamental lapse in operational compliance.

2. Negligence in Load Management
Cargo and passenger baggage were haphazardly loaded throughout the cabin, with flammable materials like lubricants and contact cleaners stored unsecured.

No proper weight and balance verification was done, and gross violations of the airline’s own operations manual were uncovered.

Baggage was recovered not only at the crash site but also illegally removed to the airline’s corporate office—indicative of a collapse in post-crash protocol and airport security.

3. Ignored Warning Signs from Past Flights
Saurya Airlines failed to investigate multiple previous takeoffs that exhibited similarly dangerous high pitch rates in the same aircraft model.

Despite known risks, no flight data monitoring system was in place, and no remedial action was taken.

4. Misuse of Ferry Flight Classification
The accident flight was labeled a “ferry flight” for maintenance transfer, but this definition was loosely interpreted.

16 individuals were onboard, including non-required personnel and technicians, in what was essentially an unauthorized passenger flight disguised as a ferry flight.

Civil Aviation Authority of Nepal (CAAN): Oversight Failure
The report clearly implicates CAAN for its weak regulatory enforcement:

CAAN approved the ferry flight without verifying the load configuration or passenger count.

No enforcement action had ever been taken despite repeated safety violations by Saurya Airlines.

CAAN failed to detect the unapproved speedcard in use for years, despite its mandate to audit and certify operational manuals and technical documents.

Government and TIA: Infrastructure and Emergency Lapses
The Government of Nepal and Tribhuvan International Airport were equally criticized for systemic failures:

The runway safety area (runway strip) was found non-compliant with ICAO standards, narrowing rescue access and exacerbating the post-crash fire.

Firefighters arrived on time but failed to coordinate effectively. Only one of three vehicles actively engaged in firefighting, and basic firefighting techniques like sidelining and foam tendering were neglected.

Blind spots and obstructed emergency gates further delayed the rescue operation, leading to the death of potentially survivable victims.

“The survival of the pilot-in-command proves the crash was survivable—for more people—if rescue had been better coordinated,” the report said bluntly.

Aircraft and Crew Status: Fit to Fly—But System Failed Them
The aircraft, a 2003 Bombardier CRJ 200LR, had undergone short-term storage and a return-to-service check the same morning. Maintenance logs showed no critical faults.

The pilot in command had over 6,100 flight hours and was deemed medically and professionally fit. The first officer, though younger, was also qualified, but had a disrupted career due to layoffs and irregular flight hours—hinting at human factors possibly linked to systemic undertraining or financial pressure within the company.

Post-Crash Mishandling Raises Alarms
Perhaps most disturbing is the mishandling of evidence and security post-crash:

Some passenger baggage was removed without authorization and transported to Saurya Airlines’ office, bypassing all airport security protocols.

The report called this a “severe case failure of all entities involved during rescue and recovery”—including TIA security and CAAN supervision.

Safety Recommendations and Warnings
The AAIC issued 41 safety recommendations targeting:

Saurya Airlines: overhaul flight planning, staff training, load management, and documentation practices.

CAAN: implement stricter regulatory surveillance, audit oversight systems, and enforce penalties for non-compliance.

TIA and Government: urgently improve runway safety infrastructure, rescue planning, and emergency gate accessibility.

The Commission also called for:

Mandatory flight data monitoring systems for all airlines.

Standardization and strict enforcement of ferry flight definitions and approvals.

Audit of dangerous goods handling by all domestic carriers.