The Ministry of Culture, Tourism and Civil Aviation has obtained the final investigation report on the fatal accident of a Saurya Airlines CRJ-200 aircraft (tail number 9N–AME) that crashed shortly after departure from Tribhuvan International Airport on 24 July 2024 claiming the lives of 18 people.

The report was formally presented to Minister Badri Prasad Pandey by Ratish Chandra Lal Suman, chairman of the government-appointed inquiry commission. Minister Pandey, at the handing-over ceremony, assured that the ministry would take action based on the report’s findings and confirmed that the inquiry was conducted independently and without the influence of any external party.

What, when and where?

On July 24 morning, a Saurya Airlines Bombardier CRJ-200, on a non-commercial ferry flight to Pokhara for routine maintenance, crashed seconds after lifting off from runway 02 of Tribhuvan International Airport. There were 19 people on board, including cockpit and engineering staff.

Shortly after takeoff at 11:11 am, the plane made a sudden rightward bank and plunged near runway 20, bursting into flames upon impact. Emergency responders—including airport firefighters, police, and the military—were deployed swiftly. The accident claimed 18 lives and temporarily shut down airport operations, delaying multiple domestic and international flights. Only the captain survived.

The incident prompted an immediate government response, and a five-member investigation commission was formed in an emergency Cabinet meeting. The team, which was headed by Ratish Chandra Lal Suman, former director general of the Civil Aviation Authority of Nepal (CAAN), also included Captain Dipu Jwarchan, engineering professors Kuldip Bhattarai and Sanjay Adhikari, and CAAN air traffic controller Mukesh Dangol.

Their finished report outlines the crash’s causes and provides recommendations for preventing such an incident from recurring.

What went wrong?

Preliminary reports suggest a number of operational failures. One of the most significant was incorrect weight distribution; bags were not properly stowed and may have shifted on takeoff. The crew also used takeoff speeds that did not match guide figures from the plane manual, resulting in unstable flight dynamics.

The report highlights that the pitch rate during takeoff was as high as 8.6° per second—nearly three times higher than that specified by the manufacturer—making the aircraft uncontrollable seconds after rotation. Furthermore, the ferry flight had been cleared without due supervision from CAAN, bypassing critical safety checks.

The aircraft had not been operated for over a month and was heading to Pokhara for base maintenance. Despite holding a valid airworthiness certificate and having undergone minimum return-to-service inspections, the report states that more thorough maintenance tasks had been deferred.

The captain, with over 6,000 hours of flight time—much of it on the CRJ-200—was accompanied by a far less experienced co-pilot. The technically competent crew, it is reported, failed to take into account critical parameters like proper trim settings, load balancing, and correct speed selection.

The aircraft was full of 19 individuals and approximately 600 kg of baggage, bringing its total takeoff weight to over 18 tons. The investigators found that proper load-securing measures, such as cargo nets and straps outlined in the airline’s Ground Handling Manual, were not followed.

It is estimated that the unsecured load created an aft center of gravity, which, in combination with an improper stabilizer setting, might have led to an uncontrollable nose-up pitch during climb-out—aerodynamically stalling.

The investigation also revealed procedural deficiencies at CAAN. The ferry flight was approved despite missing or incomplete documentation, contrary to the requirements of CAAN’s own 2015 Flight Permission Manual. The regulator was chastised by investigators for allowing a potentially non-compliant aircraft to fly without invoking appropriate safety checks.

The commission called for urgent overhaul of CAAN procedures for approving non-scheduled and ferry flights.

Both Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) were recovered and analyzed in Singapore with international help. Data revealed that both engines were functioning normally throughout the flight.

However, pitch rate data and audio transcripts revealed a series of stall warnings (stick shaker activations) seconds into the takeoff. The plane rolled uncontrollably as the pilot fought to regain control—first to the right, then left, and once again right—before the crash. It all took place in under 20 seconds, which reflected the rapidity with which events unfolded.

The investigation commission also issued a series of interim safety recommendations directed to airline operators and the CAAN. Among the significant directives was the revision and updating of takeoff speed charts and Reduced Takeoff Weight (RTOW) data with immediate effect so that they align with the aircraft manufacturer’s official manuals.

The commission demanded rigorous enforcement of baggage and cargo handling rules, with proper weight distribution and load securing using nets or straps to prevent load shifts during flight. It also called for the complete overhaul of CAAN’s flight authorization process, particularly ferry and chartered flights, to close oversight loopholes and improve compliance with established safety procedures.

In 2013 the European Union, citing safety issues, banned airlines licensed in Nepal from flying the European airspace.

Saurya Airlines will do “everything possible” to implement and adhere to the recommendations, operation manager Bivechan Khanal told Reuters. The crash highlighted the poor air safety record of landlocked Nepal, which depends greatly on air connectivity.