The shortcomings of both regulator and operator were among the reasons for the Saurya Airlines plane crash during takeoff at Tribhuvan International Airport (TIA) on July 24, says the preliminary investigation report made public on Thursday (September 5).

The Bombardier CRJ 200 with a registration 9N-AME and operated by Saurya Airlines had crashed on the east side of the runway, shortly after taking off from runway 02 (Koteshwar side), killing 18 of the 19 onboard.

It was a ferry flight to Pokhara International Airport for conducting base
maintenance of the aircraft.

Captain Manish Ratna Shakya is the only survivor in the crash. 

A day ago, i.e. on July 23, the flight was approved by the Air Transport Division of the Civil Aviation Authority of Nepal (CAAN) with an extension period of 72 hours, says the report. CAAN acts as both regulator and service provider in terms of airport operations and air navigation services amongst others. 

The government had formed a five-member probe committee led by Ratish Chandra Lal Suman, former director general of CAAN. 

Other members included Deepu Jwarchan, Operation Director (Instructor Pilot) at Nepal Airlines; Sudip Bhattarai, head of the Mechanical and Aerospace Department at Pulchowk Campus; Sanjay Adhikari, aircraft maintenance engineer at Shree Airlines; and Mukesh Dangol, Air Traffic Control (ATC) Officer under the Ministry of Culture, Tourism and Civil Aviation.

Dangol served in the committee as a member secretary.

Read: Saurya Airlines Plane Crash brings into Light Nepal’s Poor Air Safety Record

The preliminary report submitted by the committee and made available by the the Ministry of Culture, Tourism and Civil Aviation on its website, says both CAAN and Saurya Airlines neglected their responsibilities, which was among the reasons for the crash.

While the operator, Saurya Airlines, failed to comply with the weight-related standard norm, the procedure for issuing the flight permission for ‘ferry’ flight was inadequate, according to the report.

“Inspection of the crash site, assessment of 9N-ANM, CRJ 200 aircraft and interviews with the ground personnel of Saurya Airlines Pvt. Ltd. revealed that the operator was not complying with the aircraft load weighing, loading and securing of load requirements stipulated in Chapter 7 of its Operations Manual - Part B,” reads the report.

Additionally, the report says the V-speeds mentioned in the operation flight plan of the crashed flight and that recorded in the Flight Data Recorder (FDR) were inconsistent with the Quick Reference Handbook (QRH).

The QRH contains instructions for pilots to follow during the abnormal and emergency conditions.

Moreover, according to the report, the interpolated speedcard of the operator for 18,500 kg takeoff weight (TOW) mentions incorrect V-speeds for takeoff.

V-speeds are the airspeeds defined for specific manoeuvres in specific
aircraft at specific configurations, according to the United States’ Federal Aviation Administration. 

Photo Credit: Preliminary report on the crash made public on September 5

Almost immediately after rotation, the aircraft underwent a right, left and right bank before the right wing impacted on the ground, according to the report.

Rotation refers to raising the nose of the aircraft during take off.

“After rotation for takeoff at 05:25:55 UTC, the aircraft attained a height of 50 feet above ground level (AGL) within 5±1 seconds,” reads the report. “The height from the radio altimeter and pressure altimeter…. indicates that the aircraft attained a height of slightly above 100 feet above ground level.”

But, the aircraft sank approximately 130 feet in 4 seconds, according to the probe report. After the first impact on the ground, the aircraft went on to collide with the container and shed of Air Dynasty Heli Services Pvt. Ltd. The cockpit portion got stuck on the container.

As a result of the blunt impact and disintegration of the aircraft, the most common cause of the death of persons onboard, according to the preliminary report, was blunt force trauma, followed by burn injury.

The first fire vehicle had arrived at the crash site at 1 minute 40 seconds after the impact, and started spraying water after 15 seconds of arrival, the report said.  While two other fire vehicles also arrived close to the crash site, they did not participate in the firefighting efforts simultaneously with the first vehicle. 

Most of the deceased were employees at Saurya Airlines. Of them, 17 were Nepalis and one was a Yemini national named Aref Reda.

The aircraft had been grounded for 34 days before the July 24 flight. However, the preservation and return to service maintenance checks were carried out, according to the report.

Read: Saurya Airlines Crash Causes Fear Among Residents Near Airport

Data from the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) were extracted and recovered in the facilities of the Transport Safety Investigation Bureau (TSIB), Singapore, under the supervision of the Aircraft Accident Investigation Commission (AAIC).

The preliminary analysis of FDR data did not show any abnormalities on engine parameters during the flight, report says. However, further analyses of all engine parameters are currently being performed.

The crash once again brought into surface Nepal’s poor air safety records.

Two weeks after the Saurya plane crash, an Air Dynasty Helicopter crashed in the Shivapuri area of Nuwakot district on August 7, killing five people on board.

Nepal has recorded more than 100 air crashes in its aviation history with more than 900 people having lost their lives in such incidents since 1955, according to CAAN.

Poor safety records have tarnished Nepal’s reputation in the international aviation sector.

The European Union which first banned Nepali airlines from operating flights  into the sky of the  EU member countries in 2013,  has continued the prohibition citing poor aviation safety record of Nepal.

Apart from Nepal’s difficult geography, many consider CAAN’s dual role–as a service provider and a regulator–as one of the major reasons affecting  aviation safety in the country.

The European Union as well as the International Civil Aviation Organisation (ICAO) have long been demanding the Government of Nepal to split the CAAN into a regulator and air service provider to enhance air safety. It is also one of the preconditions set by the EU to lift the suspension imposed on Nepali airliners.

Prime Minister KP Sharma Oli recently reiterated the government's commitment to improving air safety. More lawmakers have been saying they are in favour of splitting CAAN into a regulator and service provider.

However, the Civil Aviation Authority of Nepal Bill, and the Air Service Authority of Nepal Bill, which aim to do so, have been continuously ignored.

Three years after the Upper House endorsed the bills and more than eight months since the parliamentary International Relations and Tourism Committee directed the government to table them in the Lower House, the bills continue to gather dust.  

Meanwhile the preliminary report of the Saurya plane crash says the investigation will continue focusing on possible causes of unusual behaviour of the flight leading to the accident.

The further investigation will be centred on issues including weight and balance of the aircraft, aerodynamics and takeoff performance, operational and flight permission practices, human factors and safety management system among others.

The AAIC has also made some recommendations to ensure flight safety in the coming days.

While all the operators have been recommended to immediately review their speedcards and Runway Takeoff Weight (RTOW) charts and to comply with the requirements of the cargo and baggage handling, the CAAN has been asked to review and update the procedure and requirements for the permission of non-scheduled flights including all non-revenue and ferry flights.