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On the 24th of July 2024, a regional jet plunged to the ground and exploded in flames seconds after takeoff from Kathmandu, Nepal, killing 18 people and leaving the captain as the sole survivor. The accident devastated the tiny airline, which not only lost one of just two operational aircraft, also nearly half its managerial staff, five of whom were on the plane. But none of them should have been there, because this wasn’t a passenger flight — in fact, it was ferry flight intended to relocate the aircraft, which had not flown in 34 days, to the city of Pokhara for maintenance. Carrying passengers on a ferry flight is unambiguously illegal. But that was just the tip of an iceberg of negligence — including several outlandish regulatory violations — that has been only partially revealed by the release of the investigation commission’s final report, one year after the crash.
Following the 2023 crash of Yeti Airlines flight 691, I wrote an article analyzing that accident in the broader context of Nepal’s poor safety record, which has made it one of the most dangerous places to fly. Now, the Saurya Airlines crash in Kathmandu has again highlighted the same issues that come up over and over in Nepalese accidents, and I don’t just mean the harsh terrain and bad weather — because this accident had nothing to do with environmental factors, and much more to do with the airline’s complete disregard for safety at every level. But it’s very difficult to determine the root cause of that disregard, in large part because Nepal lacks an independent accident investigation agency willing to pursue every lead. The following story of brazen negligence, incompetent operation, and glaring investigative omissions perfectly illustrates why that needs to change.
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Note: If you haven’t already, I recommend reading my aforementioned article on Yeti Airlines flight 691, either before or after reading this one. This article is partially written as a follow-up to that article. This article can be read as a standalone piece, but the previous article does provide helpful context.
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Nepal is a country blessed with extraordinary beauty, from the clouds of ice crystals blowing off the glaciated summits of the world’s highest mountains, down through precipitous gorges where sky-blue rivers tumble, to the terraces and temples of the foothills and the metropolitan fervor of the capital, Kathmandu. As beautiful as it may be, traversing that terrain by air can be hazardous for locals and tourists alike. But, if we want to adapt the proverb, it may be said that flying is the riskiest form of transport in Nepal, except for all of the others.
As of 2025, Nepal consistently ranks as one of the most dangerous countries in which to board an airplane, as measured by the number of fatal accidents divided by total commercial aircraft movements. Between 2010 and 2024, there were at least 12 fatal commercial airplane accidents in Nepal, most of which involved controlled flight into terrain while maneuvering near treacherous mountain airports in poor visibility. That’s more crashes than practically any other country suffered during the same period, including many countries with orders of magnitude more aircraft movements.
While geography contributed to most of these accidents, practically all of them were blamed at least in part on inadequate oversight by the Civil Aviation Authority of Nepal, or CAAN. In fact, according to a 2023 ICAO audit, the CAAN’s ability to oversee Nepal’s growing aviation industry is getting worse, not better. The agency is critically short-staffed and its leadership is more interested in swanky infrastructure projects than the day-to-day drudgery of running a safe system. The flight standards and flight operations monitoring departments are nowhere near the staffing levels required to provide even basic surveillance of most airlines, and major safety violations almost never result in enforcement action. For this reason, all Nepalese airlines have been blacklisted by the European Aviation Safety Agency for years.
This is the story of one of those airlines.
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In 2014, Nepal welcomed a tiny new air carrier called Saurya Airlines, which promised to become the country’s second airline to offer domestic services using jet aircraft. Cosmic Air, the first airline to try that, went bankrupt in 2008.
Saurya Airlines began operations with one Bombardier CRJ-200 twin rear engine regional jet, serving just two routes between Kathmandu and the cities of Biratnagar and Bhadrapur in the far southeastern part of the country. Although the airline’s founders had plans to grow their network, attempts to expand to five other cities ended in failure and the routes were terminated.
In 2016, a new law imposed a minimum fleet size of two aircraft for all Nepalese airlines engaged in scheduled passenger flights, presumably in order to encourage consolidation of tiny, unreliable airlines like Saurya. For a period of several months, Saurya Airlines was restricted to charter operations before it regained permission to fly scheduled flights in 2017 following the purchase of two additional CRJ-200s.
This reprieve didn’t last long. On July 7, 2018, Saurya Airlines suspended all flights due to financial difficulties, remaining grounded for over a month before resuming service on August 21. Three months later, the same thing happened again, and this time the grounding lasted even longer, from November 27, 2018 to March 7, 2019. Why the perpetually bankrupt airline was not grounded by the CAAN, or at least seized by its creditors, is unclear. In any case, it managed nine whole months of continuous operation this time, before being grounded on December 24 due to the nascent Covid-19 pandemic. Flights did not resume until October of 2020.
Following the pandemic, the airline somehow emerged intact. Now operating with two aircraft — the third went into storage in 2018 and never came back — the company managed to fly back and forth between Kathmandu and the southeastern lowlands without any major interruptions for more than three years. This unbroken streak convinced Saurya Airlines executives to publicly suggest that they might purchase ATR twin turboprops to expand their network, but this never took place. Instead, the company kept flying its two airworthy CRJs as often as it could, which was at least some of the time.
One of those aircraft, a 21-year-old CRJ-200 registered 9N-AME, came due for a certificate of airworthiness renewal inspection in March 2024. The inspection found the aircraft airworthy, with the caveat that an overhaul of the main landing gear would have to be completed by April 20. Saurya Airlines applied for and received an extension of that deadline to June 19, but that too expired with the work still not started. Consequently, on June 21 the aircraft was withdrawn from service and placed into short term storage until such time as the landing gear overhaul could be accomplished. The final report doesn’t say why this work took so long to get started, but given Saurya Airlines’ history, one wonders if that time might have been spent trying to scrape together enough cash to pay for it.
9N-AME ended up sitting at Kathmandu’s Tribhuvan International Airport for a total of 34 days, with short term storage checks every 7 days to keep it ready for flight. The landing gear overhaul was finally completed on July 22nd, but before the plane could return to service, it came due for a C-check — a regular heavy inspection performed approximately once every two years, or after a certain number of flight cycles. Apparently — the final report is light on details — Saurya Airlines used, rented, or contracted a C-check facility at the new Pokhara International Airport in Pokhara, Nepal’s second largest city. This airport and its sordid history should be familiar if you’ve read my Yeti Airlines article.
Following completion of the landing gear overhaul, Saurya Airlines requested and received CAAN approval to ferry the aircraft from Kathmandu to Pokhara for the C-check. Such a ferry flight is legally distinct from other flight types. Unlike a repositioning flight, in which the empty aircraft is moved to a new location for scheduling reasons, the purpose of a ferry flight is to move the aircraft for maintenance specifically. Ferry flights can be conducted with major mechanical failures on the aircraft, up to and including a failed engine (for some types). Such flights must carry only essential flight crew members, whereas there is no such restriction for repositioning flights.
It turns out that Saurya Airlines had no intention of complying with that regulation. In fact, besides the two pilots, a total of 17 other people made plans to travel on the ferry flight to Pokhara. Most of them were maintenance engineers, but the unauthorized passengers also included an off duty pilot, as well as Yagya Poudyal, Saurya Airlines’ Maintenance Manager; Ashwin Niroula, Continuing Airworthiness Manager; Dilip Verma, Chief of Quality Assurance; and Sagar Acharya, the Chief of Safety. Furthermore, even though the manifest listed all passengers as Saurya Airlines staff, two of them were not employees of the airline at all, but rather the wife and four-year-old child of one of the staff members.
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The final report on the accident doesn’t explain why all these people were traveling on the ferry flight, but since they were mostly in maintenance-related roles, I would assume that they were going to carry out the C-check, and the airline decided to place them on the ferry flight because it was cheaper than booking seats on a legitimate flight. Besides, there wasn’t anything mechanically wrong with the aircraft, so it was probably seen as a paperwork issue more than a safety issue. Still, as Chief of Safety, Acharya at least should have understood that paperwork, while a mere simulacrum of reality, does tend to reflect something constative. In fact, according to FAA statistics, ferry and repositioning flights are substantially more likely to be involved in an accident compared to scheduled flights, regardless of whether the airplane is being ferried with mechanical defects or not.
The fact that key personnel in charge of safety at Saurya Airlines saw no problem with such a blatant regulatory violation reflects as poorly on the CAAN as it does on their own judgment. Unhesitating willingness to violate rules doesn’t come from nowhere; rather, it develops when no one is held accountable for their actions. The actions of the airline’s management in this case suggest that they knew they would not be caught, or knew that if they were caught, nothing would happen.
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In addition to the 17 passengers, two pilots were selected for the flight. The first officer was 26-year-old Sushant Katuwal, a young airman with about 1,800 total flying hours, almost all of which were on the CRJ. He had obtained his pilot’s license in South Africa in 2019 and was hired straight out of flight school by Saurya Airlines, which sent him for CRJ ground training in Lithuania and simulator training in Germany. However, he failed his type rating simulator check, resulting in additional training that forced him to remain in Germany for an extra three months. Saurya Airlines later deducted the extra training expenses from his salary, and the company did not cover room and board, forcing him to take out a loan. He was still repaying the loan at the time of this flight, five years after the fact.
Katuwal’s finances were further strained when the airline furloughed him without pay during the Covid-19 pandemic. According to interviews with his friends, family, and colleagues, he was unhappy with the compensation and benefits that Saurya Airlines provided, and he was struggling financially. It also turned out that he had hidden the loan from his parents, which no doubt piled even more stress onto his shoulders. Considering all of these factors, there was almost no chance that Katuwal would turn down any flight assignment.
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The captain assigned to the ferry flight was 35-year-old Manish Shakya, who was also the airline’s Chief of Operations. He had 6,185 total hours, including almost 5,000 on the CRJ, over a 16-year career. He first obtained his pilot’s license in the Philippines in 2009, then returned to Nepal to fly the Beech 1900D for local carrier Guna Airlines. He joined Saurya Airlines shortly after its founding in 2015 and was sent to Lithuania and Germany to receive a CRJ type rating, just like First Officer Katuwal, except that he completed the training on the first try.
As the Chief of Operations, Shakya would have been aware of the decision-making behind carrying passengers on the ferry flight, and he might have even been involved in that decision-making. As a result, there was little chance that he would object to this violation either.
And so the plans for ill-advised flight went ahead, apparently without any objections from anyone.
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On the morning of July 24, a return to service check was completed, and airline personnel immediately began preparing 9N-AME for the flight to Pokhara. These preparations included the loading of a considerable quantity of cargo, which included but was not limited to maintenance equipment and consumables, toolboxes, wheel chocks, and food. The cargo was not loaded by the cargo handlers at Kathmandu, but rather by Saurya Airlines’ engineering staff, who possessed neither the appropriate licenses nor training to load an aircraft.
After filling the CRJ’s cargo compartments to the brim, these untrained personnel began loading additional cargo directly into the passenger cabin. The items were placed in the passenger seats with no restraint mechanism whatsoever. Even worse, this cargo included containers of flammable lubricants, cleaning solutions, hydraulic fluid, and engine oil. None of these hazardous materials were secured, nor was Saurya Airlines authorized to carry hazmat in the first place. Although the cargo loading blatantly violated three or four basic regulations, cockpit voice recorder evidence indicates that the pilots were aware of this arrangement and did not object.
The first pilot to arrive at the plane was First Officer Katuwal, sometime prior to 10:08 a.m. local time (UTC +5:45). The cockpit voice recorder was already running, and from that time it recorded Katuwal as he calculated the V-speeds for takeoff.
The V-speeds are the speeds that pilots use to time certain decisions and actions during the takeoff roll. Before every flight, the pilots calculate V1, the highest speed at which the takeoff can be rejected; VR, rotation speed; and V2, the takeoff safety speed, used in the event of an engine failure. Since these values are affected by the weight of the aircraft, the length of the runway, the temperature, the airport elevation, and other factors, the exact speed values vary from one flight to the next.
Although most major airlines use software programs to calculate the V-speeds, manual calculation was the historical norm, and still is in many places. For manual calculations, airlines provide pilots with a set of cards containing tables of figures, which are stored in the cockpit for easy reference. Pilots select the card corresponding to the projected takeoff weight and flap setting, which contains the base V-speeds, then add corrections for temperature and elevation by cross-referencing a corrections table. An example V-speed card from Saurya Airlines can be seen below.
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For this flight, the reported temperature was 26˚C with an airport elevation of 1,330 m (4,360 ft) and a planned takeoff flap setting of 20˚. The weight of the aircraft wasn’t precisely known because the passengers didn’t check in by the normal process and their baggage hadn’t been weighed. However, the dispatcher estimated that there were 600 kg of baggage on board, which in addition to the weight of the cargo, the fuel, the occupants, and the airframe resulted in a total calculated weight of 18,137 kg (39,985 lbs). Later, investigators algebraically derived the true weight of the aircraft using performance figures from the flight data recorder, which proved that the dispatcher’s estimate was fairly accurate. The real weight was assessed to have been about 18,300 kg (40,345 lbs) ±200 kg (441 lbs), a range that includes the dispatcher’s estimated weight. Since the V-speed cards were provided in 500 kg increments, and since pilots were expected to round up to the nearest 500 kg when calculating the V-speeds, any difference between the actual and calculated weights would not have changed the resulting V-speeds because the 18,500 kg card would have been used in all cases.
Using the aforementioned card, First Officer Katuwal calculated that V1 would be 114 knots; VR 118 kts; and V2 126 kts. These were the correct values for the current temperature and elevation using the 18,500 kg V-speed card. But he had no way of knowing that the card itself was wrong.
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The V-speed cards were created, presumably in 2014, by Saurya Airlines using the manufacturer’s data. At that time, the person who formatted the cards apparently copy-pasted the entire V-speed table from the 17,500 kg card onto the 18,500 kg card without changing anything. The final report doesn’t explain how this mistake escaped detection during approval of the card deck, nor does it explain why pilots didn’t detect the error. However, it seems likely that the 18,500 kg card was rarely used, since 9N-AME had a maximum takeoff weight of 24,400 kg. Most passenger flights are loaded fairly close to the maximum takeoff weight, or at least closer than 18,500 kg. At the same time, flights with the aircraft completely empty would weigh much less than 18,500 kg. So with 17 passengers in the 50-seat aircraft, plus cargo, the weight would have fallen into a middle area that would have been rarely encountered during normal operations. All of that having been said, it wasn’t the pilots’ responsibility to detect the discrepancy, and it should have been caught during routine paperwork inspections. Either these inspections were not being conducted or they were conducted in a disinterested manner.
After the accident, investigators calculated that the correct V-speeds would have been V1=117 kts, VR=122 kts, and V2=127 kts. These values were quite close to those calculated by the first officer, except for VR, which was four knots higher. This might not seem like a lot, but safety is eroded in increments.
The purpose of VR is to define a point at which the aircraft will respond to nose up pitch inputs by becoming airborne in a safe manner and with a reasonable margin for error.
If rotation is initiated very early, the nose will come up but the plane will stay on the ground until it has built up enough speed. That’s because airspeed is one of the components of the lift equation. Without enough of it, the airplane will not become airborne.
The lift equation has many components, but if we assume a constant aircraft configuration, weight, air density, and so on, then the two components most directly controlled by the pilot are airspeed and angle of attack. Angle of attack, often described as the angle of the lifting surfaces into the oncoming airflow, is also approximately equal to the difference between the pitch angle and the flight path angle. The higher the angle of attack (or AOA), the greater the lift coefficient, up until to the critical point, where airflow separates from the upper wing surface, a stall occurs, and the wing ceases to generate meaningful lift.
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Since all parameters other than these two are assumed to be constant during an exemplar takeoff, the amount of lift required to counteract the aircraft’s weight and become airborne is also a constant. Therefore, if the airspeed is lower, the required angle of attack must be correspondingly higher to compensate. In theory, below a certain airspeed, the AOA required to become airborne may even be above the critical AOA, resulting in an immediate stall if liftoff is attempted. However, many aircraft are geometrically limited, meaning that the tail will strike the ground at a certain pitch angle, effectively limiting the AOA to a value equal to that pitch angle (since the flight path angle is zero while on the ground). These aircraft will simply continue rolling until the airspeed is high enough to initiate liftoff at the constant geometrically limited AOA. That tangent aside, the point is that even rotating as little as four knots early means that the aircraft will need to achieve a higher AOA before it lifts off, and the difference between that AOA and the critical AOA will be less than if the rotation had been initiated at the correct speed.
It’s also worth noting that an aircraft on or near the ground will be influenced by “ground effect,” which tends to increase lift for a given AOA while also reducing the critical AOA. This can make it easier to stall non-geometrically-limited aircraft during rotation, and it can also result in a failure to climb after liftoff if the takeoff is very marginal (i.e. close to the minimum possible airspeed and maximum possible angle of attack).
Another factor that greatly affects the liftoff is the rate at which the pilot rotates. If the rotation rate is very slow, it will take longer to reach the required AOA, and the airplane will consume more of the runway. On the other hand, if the rotation rate is too fast, a stall could occur.
When the pilot pulls back on the controls, that input is transmitted to the elevators, which deflect in a nose up direction. Aerodynamic forces then pivot the aircraft about its center of lift, increasing the pitch angle. This increased pitch angle results in an increased AOA, which in turn increases lift, causing the flight path angle to rise. The airplane then lifts off and climbs away. But what’s important about this sequence is that AOA responds to control inputs before the flight path angle does. Therefore, if the AOA increases very rapidly, it could reach the critical point before the flight path has time to respond.
During a normal rotation, the pilot aims to achieve a pitch angle generally around 15 degrees (for jet transport aircraft at least). Of course, applying 15 degrees pitch up instantly would result in an AOA of 15 degrees as well, which would stall the aircraft. By contrast, pitching up slowly allows the flight path to respond before the AOA gets anywhere near the critical point. Once the flight path has responded positively, a higher pitch can be achieved without stalling, since AOA equals pitch angle minus flight path angle.
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Pilots of jet transport aircraft are usually taught to rotate at a rate of 2.5 to 3 degrees per second. Three degrees per second is the actual target, but rotating too fast is more dangerous than rotating too slowly, so the acceptable range is sometimes lowered to 2.5 to discourage over-rotating. According to Petter Hornfeldt (Mentour Pilot), with whom I discussed this case,* another common strategy to avoid over-rotation is to start rotating, then stop and gauge the response of the aircraft before continuing.
According to recorded flight data, Saurya Airlines’ CRJ-200 aircraft typically became airborne at an angle of attack between 6 and 8 degrees. The CRJ-200’s stall AOA under generic takeoff conditions, accounting for the influence of ground effect, is not stated in the final report, but the data suggests that it was about 10 degrees. That margin isn’t immense, and it’s below the CRJ’s geometric limit, which is why the flight operations manual strongly warned against rotating too quickly, due to the high stall risk.
*Note: For those who are unaware, since summer 2024 I have been working as a researcher and script writer for Mentour Pilot on YouTube. Check out his channel if you’re interested in seeing my work brought to life by a professional team of animators and graphic designers and edited and narrated by a professional pilot with more than 20 years of experience.
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After First Officer Katuwal calculated the V-speeds, Captain Shakya arrived at the aircraft at around 10:40. He asked Katuwal which checks had been performed, provided some general instructions, then started conversing with passengers about the new Pokhara Airport, the C-check, and topics unrelated to the flight. Notably, he did not cross-check Katuwal’s V-speed calculations, which is required. However, since he was also unaware of the incorrect V-speed card, it was unlikely that he would have detected the error.
After the last passengers boarded at 11:02, the crew closed the doors and began starting the engines. The left engine didn’t start on the first try, but it sputtered to life on the second attempt.
In the back, the passengers settled in next to the overflowing cargo. Although a flight with 17 passengers on the CRJ-200 normally requires a flight attendant, none was provided, and no safety briefing was conducted. It is unknown whether the passengers wore seat belts.
As the pilots taxied the aircraft up to the head of runway 02, they performed the before takeoff checks, but the control checks, intended to verify that full range of control surface movement, were only partially completed. Why the pilots chose to skip some checks before taking off in an airplane that was parked out in the open for 34 days is a mystery to me, but maybe that’s because I have a sense of self-preservation.
By the time 9N-AME lined up for takeoff, so many rules and regulations had been violated that the plane might well have arrived safely at its destination by breaking the laws of physics, too. But the thing that would tip this flight over the edge of disaster wasn’t the poorly loaded cargo, or the flammable liquids in the cabin, or the skipped control checks. No, it was something a little less glamorous but no less important: a lack of flight operations quality assurance.
After the accident, investigators downloaded flight data stretching back more than a year and a half from both 9N-AME and its sister ship 9N-ANM. This data showed that while most rotations were normal, a concerning number of rotations were performed with a 1-second rotation rate* greater than 4˚/s, and 14 takeoffs had a 1-second rotation rate greater than 5˚/s.
*Note: 1 second rotation rate means the average rate over the course of one second. The sampling interval for pitch was 4 times per second.
The two fastest rotations occurred on January 11, 2024 and March 19. 2024, and featured 1-second rotation rates of 5.8 and 5.5˚/s, respectively. Records indicated that in the latter event, Captain Manish Shakya was flying the plane.
The final report doesn’t explain why a chronic problem with excessive rotation rates developed at Saurya Airlines. It’s common for trainee pilots to over-rotate at first, but these rookie mistakes should be drilled out by the time the trainee walks out of a flight school with a type rating. Over-rotation should also have been something that instructors look out for during recurrent training, especially since the manual explicitly warned against it. Evidently these things did not happen. As for why, I only have an untested hypothesis. It is possible, but not provable, that in the absence of appropriate correction by instructors, Saurya Airlines pilots developed an overly aggressive rotation technique because the CRJ-200 is very easy to load with an excessively forward center of gravity, which will make it harder to bring the nose up on takeoff. Because of its very aft center of lift, it’s difficult to load a CRJ-200 with the CG too far aft, but it’s very easy to do the opposite. Anecdotally, CRJ pilots often have to move passengers and bags around to keep the center of gravity within the forward limit.
If Saurya Airlines pilots became accustomed to rotating sharply to compensate for a forward CG, they might end up rotating too aggressively when the CG is farther is aft, leading to an over-rotation. Furthermore, as the first Nepalese operator of the CRJ series, there might not have been a lot of institutional knowledge of these issues. But again, that’s merely my own hypothesis, not an investigative finding.
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At 05:25:25, First Officer Katuwal reported ready for departure, and the Tribhuvan tower controller cleared them for takeoff. With Captain Shakya at the controls, the pilots pushed the thrust levers forward and began the takeoff roll, accelerating away down Kathmandu’s 3,000-meter runway.
At 114 knots, Katuwal called out “V1,” followed by “rotate” at 118 knots. Shakya responded by initiating the rotation with a sharp nose-up input on his control column, one that would have required considerable strength. Because the aircraft was relatively light, with a reasonable center of gravity, this input was massively excessive. The resulting 1-second rotation rate peaked at 6.5˚/s, the highest ever recorded at Saurya Airlines.
Because Shakya was rotating at a lower than optimal speed, the AOA required to become airborne was higher than normal, and therefore the flight path would take longer to respond. Then, when he rotated at a rate of 6.5˚/s, the AOA rose so fast that it indeed approached the critical point before the flight path adequately responded. As a result, the stick shaker stall warning triggered just two seconds after liftoff at a height of 11 feet (3.3 m) above the runway. 9N-AME’s right wing had a chronically higher AOA due to some unidentified asymmetry, as a result of which the right side stick shaker activated one second before the left side, but this was of little importance. Either way, the only way to prevent a stall was to reduce the angle of attack.
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First Officer Katuwal reacted immediately to the rapid rotation and stick shaker, shouting, “Woah, woah woah, sir, sir, sir!” Unfortunately, his alarm didn’t translate into useful instructions, like “reduce pitch.” Even with rigorous upset training, few people have the clarity of mind to say anything useful in the first few seconds after such a surprising event, and these guys didn’t have that kind of time.
Pilots are trained to respond to a stick shaker on takeoff by applying maximum power and reducing the pitch to a shallow positive angle. Why that didn’t happen here is difficult to say. Perhaps the pilots had not drilled this scenario in the simulator recently, or perhaps events unfolded so rapidly that they were plunged into panicked confusion. In any case, Shakya continued to pitch up toward 15 degrees, while the angle of attack rose above 10 degrees, and the airplane began to stall. Beginning three seconds after liftoff, the right wing lost lift and dropped, sending the plane into a 25-degree right bank at very low altitude. Captain Shakya immediately threw the controls to the left to stop the roll, but he overcorrected, causing the plane to reach a dizzying 55-degree left bank before it began to roll back the other way. Throughout these few seconds, the stick shaker continued to rattle away, and the AOA hovered around 10 degrees.
Approaching 100 feet above the ground, the floor fell away beneath them, and the aircraft entered a fully developed stall. The right wing ceased to generate lift and the plane snapped over beyond the vertical, banking 94 degrees to the right. On the ground, people pointed, shouted, and ran. In the cockpit, the pilots seemed paralyzed.
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Because the CRJ is a T-tail aircraft, it is at risk of entering a so-called “deep stall,” in which the plume of disrupted air from the stalled wings envelops the elevators, leading to a loss of pitch control. In order to prevent this, the CRJ was required to have a “stick pusher,” which physically pushes the control columns forward to assist in the recovery before it’s too late. This device now activated, pushing the nose down below the horizon, but at such a low altitude, recovery was impossible. As the ground rose up beneath him, Captain Shakya desperately leveled the wings and pulled back with all his might, overriding the stick pusher in a panicked attempt to prevent a now inevitable crash.
Thirteen seconds after liftoff, the CRJ-200 crashed into the airport surface off the right side of runway 02, in a 30-degree right bank with 6 degrees of nose up pitch. The right wingtip gouged a furrow across a taxiway, then the wing exploded and the airplane cartwheeled, rolling inverted as it careened across the grass in a cloud of billowing flame. A split second later, the fuselage slammed into a shed, a helicopter, and a shipping container belonging to local helicopter company Air Dynasty. The impact sheared the cockpit away from the cabin, and the flight deck embedded itself into the shipping container. Locked together, the cockpit and the container plunged down an embankment into a ravine and came to a halt.
Meanwhile, the main fuselage and wings continued over the ravine, trailing fire and smoke, before plowing into a construction site 21 meters below the airport elevation. Powered by fuel from the ruptured tanks, the fire breached the badly damaged passenger cabin and swept through the interior, which was soaked in hydraulic fluid and oil from the improperly secured cargo. Although autopsy results suggested that blunt force trauma contributed to the deaths of all of the passengers, anyone who might have survived the initial impact certainly could not have escaped the fire, which overtook the cabin before rescuers could arrive.
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At the airport, practically everyone with a view of the runway witnessed the crash, prompting numerous ground personnel to run toward the crash site to search for survivors. The air traffic controllers also sounded the crash alarm, and fire trucks raced toward the scene, arriving in less than two minutes.
The first fire truck arrived to find that the aircraft had fallen down an embankment and was largely inaccessible. The fire crew were able to spray water onto the cockpit, which came to rest closer to the edge, but the cannons couldn’t reach far enough to suppress the huge conflagration consuming the cabin. Furthermore, the construction site was fenced off with limited gates, and the nearest gate down at the street level was blocked by construction materials, hindering access. And to make matters worse, the second fire truck to arrive at the scene did nothing to help; no foam or chemical suppressants were used; and no firefighters immediately attempted to descend the embankment to search for survivors. That task was left to untrained ground handlers, who arrived at the crushed cockpit to find Captain Manish Shakya struggling to extricate himself from the tangled wreckage. Miraculously, they managed to pull him free and assist him up the embankment to a waiting ambulance.
Unfortunately, while Shakya was rushed to the hospital with serious but non-life threatening injuries, First Officer Katuwal and an off duty pilot riding in the jump seat could not be saved before fire overran the cockpit. The final report states that impact forces for the cockpit occupants were theoretically survivable, but the two pilots who died on the flight deck suffered severe trauma prior to receiving burn injuries, and it remains unclear whether a more prompt rescue response could have saved them.
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In all, 18 people were killed in the crash, including Saurya Airlines’ Chief of Quality Assurance, Chief of Safety, Continuing Airworthiness Manager, and Maintenance Manager. Captain Manish Shakya, the airline’s Chief of Operations, was the only survivor.
In their final report, investigators criticized the Tribhuvan Airport fire rescue services for their disorganized response, which the report partially blamed on a failure to include the area of the crash site in tabletop or full-scale response exercises. However, both the response and the severity of the crash itself were also negatively affected by the presence of buildings and steep terrain in the impact zone. Under International Civil Aviation Organization (ICAO) rules, runways in the same class as Tribhuvan’s runway 02 should have a clear area extending for 140 meters either side of the runway centerline, but the Air Dynasty equipment struck by the airplane was only 120 meters from the centerline, and the down-sloping embankment was even closer. In the investigators’ opinion, if the required 140-meter clear area had been established, the damage to the airplane would have been less severe and more people might have survived.
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The causes of this accident were on the simple side compared to many I have covered. There were really only three direct causal factors: the incorrect rotation speed, the excessively fast rotation, and the flight crew’s failure to complete the stall avoidance maneuver. One factor that surprisingly had nothing to do with the crash was the cargo loading: despite speculation that improperly secured equipment shifted, leading to an excessively aft center of gravity, the flight data recorder refuted this. If the load had shifted, the pitch of the airplane should have responded to the elevator position in an abnormal manner, but it did not. The horizontal stabilizer, which has been a factor in previous takeoff stall accidents, was also found to have been set correctly.
Despite these findings, the final report still listed “gross negligence” during loading of the cargo as a contributing factor to the accident. I’m not entirely sure why they chose to do this, but its inclusion has some value insofar as it highlights the real root cause behind all other contributing factors, by which I mean the airline’s casual disregard for rules, regulations, and best practices.
In addition to flouting rules related to licensing of cargo loaders, carriage of hazmat, cargo restraints, and minimum crew on ferry flights, evidence indicates that the airline was skipping required training items, failing to instill basic competencies in its pilots, and ignoring basic quality assurance procedures.
Investigators found that the airline’s simulator training syllabus didn’t match the recorded duration of the training, suggesting that some items were skipped. Which items these were is unknown as the report didn’t examine this issue any further. These omissions could potentially explain why pilots were rotating incorrectly and why Captain Shakya failed to react appropriately to the stick shaker. However, the incorrect rotation techniques — and many other issues — could have been caught and corrected using simple quality assurance measures.
Flight operations quality assurance can be carried out in a number of ways, including but not limited to internal audits, flight data analysis, and collection of anonymous incident reports. At Saurya Airlines, none of those things were occurring. There were no internal audits, no event reporting system (anonymous or otherwise), and no flight data analysis program, even though the required equipment was already in place. The airline claimed to have a safety management system, or SMS, which uses data and reports to identify safety trends and develop corrections, but there were no data or reports to analyze, nor was there any evidence that they were trying to do so. The structure of the company also failed to hold high level staff accountable for safety, except, I assume, for Chief of Safety Sagar Acharya, who seemingly had no objection to boarding (and ultimately perishing aboard) the accident flight.
The actions of Saurya Airlines and its staff demonstrate that they did not expect to be held accountable for the safety of the service they provided. Furthermore, the deaths of so many of those same staff aboard a flight that should that should never have been allowed to take off suggests to me that they did not understand the risks they were taking. A culture of disregard for the rules had become so deeply established that Saurya’s management completely lost sight of what a safe airline ought to look like. We could call that “normalization of deviance.”
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The job of the Civil Aviation Authority is to prevent airlines from falling into this kind of intellectual purgatory. Inspections, audits, and ramp checks should reveal that procedures are not being followed, and sanctions should be applied. Unfortunately, this did not occur. The final report suggests that the CAAN simply does not have the staff to carry out these basic functions. The 2023 ICAO audit of Nepal’s aviation authorities also highlighted insufficient training for CAAN inspectors as a point of concern. Both of these problems need to be aggressively resolved if Nepal is to improve its dismal aviation safety record.
On the other hand, it should not be pretended that Nepal could conjure a world class aviation authority out of nowhere. Nepal is one of 44 states on the United Nations’ list of “least developed” countries, ranking 165th in nominal GDP per capita, although this statistic is improving. At the same time, its aviation sector is quite large for a country of relatively modest size and wealth, resulting in a mismatch between the government’s capability and the level of need. The CAAN — a subdivision of the Ministry of Culture and Tourism — is not equipped to handle the industry it is charged with overseeing, neither in terms of expertise nor funding. But at the same time, increasing funding for the CAAN is a low priority when a third of the country lives on less than US$3.20 per day, and the money that might be used to prevent a plane crash can be (and is being) used to prevent thousands of deaths via expenditures on things like basic sanitation infrastructure and maternity care instead. Under such circumstances, aviation safety might be seen as a bourgeois issue.
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Nevertheless, as the importance of tourism to the Nepalese economy increases, and as the country’s still largely rural population swiftly urbanizes, demand for safer transportation is growing and will continue to grow. And money is only half the battle, because the other half is attitude and awareness. That means reorienting the CAAN’s focus to promote a safety culture both among the airlines and within itself. Such a pivot will require not only visionary leadership, but also the nagging voice of a Nepalese NTSB. At present, Nepal does not have an independent accident investigation agency, and each crash is investigated by a specially appointed commission that lacks of the full range of capabilities afforded to a dedicated body. Formed under the Tourism Ministry’s umbrella, these commissions also lack independence and their objectivity is sometimes in question. Furthermore, the depth of accident investigations in Nepal is presently insufficient, as demonstrated by the number of times over the course of this article that I had to use the phrase, “the final report did not explain.” Most of the time, the real root causes of Nepal’s many aviation accidents must be discerned by reading between the lines. If safety is to improve, this kind of dancing around obvious truths must end, and only an independent, politically empowered investigation agency will be able to accomplish that.
If these steps are taken, then Nepal could achieve safety improvements without diverting money away from the country’s ongoing campaigns to reduce child mortality, improve literacy, install toilets, expand access to clean drinking water, and so on. These campaigns have seen substantial success over the last 20 years, and I have no doubt that a focused effort to improve aviation safety could produce similar results in that sector too. The current system is so underdeveloped that even a small amount of money could instigate real change. But giving that money to the CAAN’s current leadership would be pointless. The mindset at the top has to change first.
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One day after the accident, Saurya Airlines voluntarily suspended operations, for obvious reasons. Later, the CAAN revoked the airline’s operating certificate after concluding that the company was unable to carry out flights due to the loss of the aircraft and most of its maintenance staff. But in one last disheartening twist to the tale, as of April 2025 the airline is trying to get its certificate back. Reportedly, they have been hiring staff to replace those lost in the crash, though who those people are and with what money they were paid is unclear. As of this writing, Saurya Airlines’ website has not been updated, and the page listing its ten management-level staff members still includes five who were on the plane and four who died in the crash. There is also hardly any reason to believe that the company’s safety culture and practices have improved in any meaningful way. Nevertheless, the company chairman told local media in April that he believed the airline was close to restarting operations. To that I will say only two words: god forbid.
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Attention readers!
- Beginning next week, I will be changing my profile picture. Because my profile picture has been the same for many years, I’m giving a heads up in order to avoid confusion.
- This article did not take me a month to write. The reason it came out only now is because I’m working on two other articles simultaneously. One of them is [redacted] and the other one is Gazpromavia flight 9608, a Sukhoi Superjet that crashed in July 2024 due to improper installation of the angle of attack sensors leading to a fatal sequence of flight envelop protection activations. That promises to be a fascinating case, but I am also professionally translating the Russian-language report, which will take some time. Please check my Bluesky profile or this Reddit thread for updates. Thank you!
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Don’t forget to listen to Controlled Pod Into Terrain, my podcast (with slides!), where I discuss aerospace disasters with my cohosts Ariadne and J! Check out our channel here, and listen to our latest episode about a titanic battle between a BAC 1–11 and some wind. Alternatively, download audio-only versions via RSS.com, or look us up on Spotify!
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