KATHMANDU: The government has formally published the final investigative report concerning the Saurya Airlines CRJ-200 (registration 9N–AME) crash that occurred on July 24, 2024.

The report was handed over to Minister for Culture, Tourism and Civil Aviation Badri Prasad Pandey by the chair of the investigation commission, Ratish Chandralal Suman, during a formal event held at the ministry on Friday.

Accepting the report, Minister Pandey said the investigation was conducted without any assumptions or external pressure, and pledged that the ministry would fully implement the commission’s recommendations.

This explainer examines the Saurya Airlines crash, covering the incident itself, the formation of the investigation commission, its key findings, and the implications of the final report.

What unfolded on that tragic morning of July 24, 2024, when Saurya Airlines Flight 9N-AME plummeted to the ground moments after takeoff?

On the morning of July 24, 2024, a tragic aviation accident occurred at Tribhuvan International Airport (TIA) in Kathmandu, when a Saurya Airlines Bombardier CRJ 200 aircraft (registration 9N-AME) crashed shortly after takeoff.

The aircraft was on a ferry flight to Pokhara for scheduled maintenance, carrying 19 airline personnel, including pilots and engineers. Within seconds of liftoff from runway 02 at around 11:11 AM local time, the plane veered sharply right and crashed near runway 20, erupting in flames.

Eighteen people were killed, including co-pilot Sushant Katuwal, while pilot Manish Shakya was the sole survivor, sustaining multiple injuries.

Rescue teams, including firefighters, police, and army personnel, responded swiftly, extinguishing the fire and recovering the bodies, later sent for autopsy.

The crash prompted a temporary shutdown of TIA, disrupting domestic and international flights. The Civil Aviation Authority of Nepal (CAAN) launched an investigation, and a detailed probe was initiated by the Aircraft Accident Investigation Commission.

When did the government form the investigation committee on the Saurya Airlines crash, who led the committee, and who were its members?

The government-formed investigation committee submitted its report following the Saurya Airlines Bombardier CRJ-200 crash that occurred on July 24, 2024. The five-member commission was established immediately after the accident during an emergency Cabinet meeting to determine the causes of the crash.

It was led by Ratish Chandra Lal Suman, the former Director General of the Civil Aviation Authority of Nepal (CAAN).

The other members were Captain Dipu Jwarchan, Professors Kuldip Bhattarai and Sanjay Adhikari from Pulchowk Engineering Campus, and Mukesh Dangol, an Air Traffic Control Officer at CAAN.

The committee completed its investigation and submitted the report providing detailed findings on the circumstances and factors that led to the tragic accident, which claimed 18 lives.

What did the preliminary investigation identify as the main causes of the crash?

The Aircraft Accident Investigation Commission (AAIC) found several critical lapses. First, the aircraft’s weight and balance were improperly managed; the cargo was likely not secured as per guidelines, which may have shifted during takeoff.

Second, the takeoff speeds (V-speeds) entered and used by the crew did not match official reference speeds from the aircraft’s Quick Reference Handbook (QRH), raising the risk of aerodynamic instability.

Third, the pitch rate during takeoff reached an abnormal 8.6° per second, nearly triple the aircraft’s safe limit of 3°/s.

Additionally, the aircraft banked sharply left and right within seconds of liftoff, possibly due to incorrect trim settings or control inputs in response to load imbalance. No technical fault was initially observed in the engines.

The commission also flagged the lack of regulatory oversight in approving the ferry flight without verifying compliance with safety protocols.

What were the conditions of the aircraft and crew before the accident?

The aircraft had been grounded for 34 days prior to the crash and was scheduled for base maintenance in Pokhara. It underwent short-term storage procedures multiple times and had its return-to-service check completed on the morning of the accident.

While the aircraft had a valid airworthiness certificate, its maintenance records showed time extensions and short-term preparations rather than a long-term, thorough maintenance regime.

The pilot-in-command had over 6,000 hours of total flight time and nearly 5,000 on the CRJ-200, with valid licenses and recent rest.  The first officer was less experienced, with around 1,800 total flight hours.

There was also a supernumerary (S/N) engineer on board. Despite the apparent fitness of the crew and aircraft, crucial oversights in weight documentation, speed settings, and preflight planning may have compromised the safety of the flight.

How was the aircraft loaded, and did it contribute to the crash?

Yes, improper loading and load securing were central to the crash. The aircraft was carrying 19 individuals and 600 kg of baggage, with a total takeoff weight of 18,132 kg.

The center of gravity (CG) was reported at 20% MAC (Mean Aerodynamic Chord), and stabilizer trim was set to 6. However, the airline’s compliance with cargo loading protocols was insufficient.

Investigators found that cargo and baggage may not have been properly secured with straps or nets, as required by the airline’s own Ground Handling Manual. Shifting loads during takeoff can significantly impact balance and control, especially in a rear-heavy configuration.

The incorrect stabilizer setting or unbalanced CG may have contributed to the rapid pitch-up, causing a stall or loss of control. AAIC identified non-compliance with standard loading procedures as a key safety violation, emphasizing that such oversights are unacceptable even in ferry or non-revenue flights.

What role did regulatory oversight and flight permissions play in the incident?

The Civil Aviation Authority of Nepal (CAAN), which oversees flight operations and issues permissions, was found lacking in its oversight.

Saurya Airlines obtained ferry flight approval for this non-revenue flight from Kathmandu to Pokhara. However, investigators found that the flight permission process was inadequately followed.

The required documentation, including full compliance with CAAN’s 2015 Flight Permission Manual, was incomplete or missing.

Moreover, there was no verification that the aircraft met all safety, loading, and maintenance standards prior to approval.

This regulatory lapse enabled a flight to proceed without proper checks on critical safety elements like load distribution and updated speed charts.

The AAIC has recommended that CAAN urgently review and revise procedures for ferry and non-scheduled flights to ensure such incidents do not recur. Better coordination and enforcement of protocols could have prevented this tragedy.

What did the flight data and cockpit voice recorders reveal?

The Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) were successfully recovered and analyzed in Singapore, with oversight from Nepal’s AAIC and international observers from Canada, the USA, and FAA.

The data showed that the aircraft’s engines functioned normally during the event. However, a dangerously high pitch rate—peaking at 8.6° per second—was recorded during rotation, far exceeding safe limits.

The CVR recorded multiple stick shaker activations, indicating stall warnings. The aircraft also exhibited erratic roll movements: right, then left, and again right. Despite the pilot-in-command’s attempts to correct the aircraft’s attitude using control wheel inputs, the instability continued until impact.

The sequence of events unfolded in under 20 seconds after liftoff. These insights confirmed that while no engine fault occurred, human factors, improper speed settings, and loading issues likely created an unrecoverable aerodynamic situation soon after takeoff.

What safety recommendations have been issued so far?

The AAIC issued three interim safety recommendations. First, all airline operators in Nepal must immediately review their speed cards and Reduced Takeoff Weight (RTOW) charts to ensure accuracy and conformity with the aircraft manuals.

Second, strict compliance with cargo and baggage handling procedures is mandated—every piece of baggage or cargo must be weighed, correctly distributed, and securely fastened using nets or straps.

Third, the Civil Aviation Authority of Nepal must revise and improve its procedures for granting flight permissions, especially for non-scheduled and ferry flights. These recommendations aim to address the systemic lapses in technical operations, regulatory oversight, and ground handling.