Investigation Summary
The accident occurred during a ferry flight intended to relocate the aircraft for a 'C-check' maintenance procedure. Although ferry flights are typically restricted to essential crew, Saurya Airlines loaded the aircraft with 16 passengers, including the airline's safety, maintenance, and quality assurance managers. The cargo compartment was packed to capacity, and additional unsecured baggage and equipment were placed in the passenger cabin, violating ground handling manuals. During the pre-flight phase, the First Officer calculated V-speeds using an 'interpolated speedcard' that contained significant errors for the aircraft's weight, resulting in rotation speeds that were too low for the actual conditions. As the aircraft reached 120 knots, the captain initiated a rapid rotation, reaching an initial pitch angle of 13 degrees. This aggressive maneuver, combined with the low airspeed, triggered a stick shaker and ground proximity warning almost immediately after liftoff. As the aircraft entered a stall, the pitch reached 15 degrees while rolling 55 degrees to the left. The aircraft then suffered a violent roll to the right, reaching 94.6 degrees, before the right wing struck the ground approximately 6,100 feet from the runway threshold. The captain was the sole survivor, rescued from the cockpit section which separated from the burning fuselage.
Final Conclusions
The Aircraft Accident Investigation Commission (AAIC) of Nepal concluded in its final report that the primary cause was a deep stall during takeoff resulting from an abnormally rapid pitch rate commanded at a lower than optimal rotation speed. Contributing factors included the use of an erroneous speedcard that had gone unnoticed since its development, gross negligence in cargo weighing and securing, and the airline's failure to monitor and correct previous high-pitch rotation events. The commission also noted the illegal carriage of passengers on a ferry flight and a general lack of safety oversight within the operator.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Sole survivor; Chief of Operations for Saurya Airlines.
First Officer
Failed his first simulator test during training at Lufthansa Aviation Training in Germany.
Systems & Failure Modes
Stick Shaker / Stick Pusher
The CRJ-200 is equipped with a stall protection system that vibrates the control column (shaker) and pushes it forward (pusher) to prevent a stall; both activated during the short flight.
Speedcard
A reference document used by pilots to determine V-speeds based on weight; the operator's card for 18,500 kg contained incorrect values that were never caught during internal reviews.
GPWS
The Ground Proximity Warning System issued a 'Don't Sink' alert immediately after liftoff as the aircraft failed to maintain a positive climb rate.
Interesting Facts
- 01The flight was a ferry flight for a 'C-check' maintenance procedure, yet carried 16 passengers including airline management.
- 02The captain was the sole survivor of the 19 people on board.
- 03The V-speeds used by the crew were derived from an unapproved and erroneous speedcard.
- 04Cargo and baggage were not weighed or secured according to the airline's own manuals.
- 05The aircraft had not flown for 34 days prior to the accident flight.
- 06The right wing struck the ground first, and the wreckage spread over 1,000 feet.
Safety Actions & Advisories
Airline Suspension
Saurya Airlines suspended all flight operations immediately following the accident.
Regulatory Review
The investigation highlighted the need for an independent accident investigation agency in Nepal and stricter oversight of ferry flight operations by CAAN.
Known Controversies & Unanswered Questions
Illegal Carriage of Passengers
Reference ↗The flight was officially designated as a ferry flight for maintenance, which by regulation prohibits the carriage of passengers. Saurya Airlines nonetheless boarded 16 passengers, including a child and a spouse of a staff member, leading to accusations of gross regulatory violation.
Lack of Independent Investigation Agency
Reference ↗Critics, including aviation analyst Admiral Cloudberg, highlighted that Nepal lacks a permanent, independent accident investigation agency. The current system of ad-hoc commissions under the Ministry of Tourism and Civil Aviation is argued to be insufficient for addressing systemic safety failures within the Civil Aviation Authority of Nepal (CAAN).