Nepal’s aviation history formally began 75 years ago in 1949 when a 4-seater lone powered vintage beach-Bonanza aircraft of Indian ambassador Mr. Sarjit Singh Mahathia landed at the then Gauchar Airport which was later renamed Tribhuvan Airport in 1955. In 1958 Royal Nepal Airlines began its service both internationally and domestically and during the same year, multiple airports were built across Nepal including; Pokhara Simara, Biratnagar, Bharatpur, and Bhairahawa. The inception of private airlines began in 1992 wherein the private sector like Necon Air commenced domestic operations from TIA with a Hawkey Siddeley HS 748.

Picture of the first time landing at Kathmandu Gauchar Airport (currently Tribhuvan International Airport) on 2005 Baishakh 11. The then-king Tribhuvan and Dilip Singh Majithia can be seen on the plane.

Source: CAAN

Despite the relatively brief history of aviation in Nepal compared to the world's 110-year history of commercial aircraft, Nepal currently hosts 55 airports including domestic, international, and hub airports. Additionally, it is home to 22 airline companies, including both rotor wing and fixed wing operations. Despite significant advancements, the airspace of Nepal continues to be labelled as the most hazardous globally. Much of this is largely due to a frequent number of accidents and questionable safety standards. From 1955 till 2024, Nepal has witnessed a total of 70 aeroplane crashes including both domestically and foreign-registered aeroplanes. While some of these crashes did report zero casualties,  there were 44 such accidents that had a significant number of deaths. The recent crashes including Yeti Airlines ATR 72 at Seti River gorge in Pokhara Valley in January 2023 and Saurya Airlines 9N-AME at Tribhuvan International Airport (TIA Airport) in July 2024 have again raised significant concerns about Nepal’s aviation safety standards and reignited debates on whether the country will ever see its flag bearers in European airspace again following the ban in 2013.

Nepal’s history of aeroplane accidents

Nepal’s first plane crash as per the annual report of the Civil Aviation Authority of Nepal (CAAN) occurred on 30 August 1955 where Flight VT-AZX of Kalinga Air crashed at Simara and resulted in 2 fatalities. The total of 10 accidents of foreign-registered aircraft in Nepal from 1955-2018 have claimed 373 lives. When we look at the history of aeroplane accidents in terms of Nepalese-registered aeroplanes, from 1960-2023, a total of 59 accidents have resulted in 473 deaths. The recent Saurya Airlines 9N-AME crash makes it 491 fatalities. 

If we look at the frequency of fatal aeroplane accidents in Nepal from 1955 onwards,  Figure 1 shows that the frequency of accidents and fatalities from Nepali-registered airlines has increased in alarming numbers after 1995. It is crucial to note that while Nepal initially joined the International Civil Aviation Organisation (ICAO) in 1960 the amount of aeroplane incidents was relatively low. Now this might be because of the fewer number of flights during this period. Subsequently, a series of accidents resulting in a total of 42 casualties occurred from 1962 to 1991 almost all from the then "Nepal Airlines". From 1992-2001, Nepal faced its worst decade in terms of airline disasters wherein 20 accidents claimed 395 lives. More than half of these casualties were caused by the Thai Airways A 310 crash at Gyanphedi which took 113 lives and Pakistan Airlines crash at Bhattedanda which claimed 167 lives in 1992. In the following years from 2011-2024, in 22 accidents there were a total of 258 lives lost out of which only 3 accidents were reported from foreign registered airlines including the US Bangala air crash which took 51 lives in 2018.

Figure 1: Fatalities in each accident of domestically-registered airlines from 1960 to 2024.

Source: Data compiled from CAAN’s annual report 2023.

In terms of Nepali-registered airlines, Nepal Airlines had the highest number of accidents followed by Yeti Airlines as seen in Figure 2. While some of the airlines such as Necon Air, Skyline Airways, Everest Air and Agni Air have already been closed owing to various underlying reasons, Yeti Airlines has nevertheless been still flying today. 

Figure 2: Total number of accidents from Nepali-registered Airlines from 1955 to July 2024.

Source: CAAN Annual Safety Report 2023

From 1955 to July 2024, owing to a large number of accidents as illustrated in Figure 2, Nepal Airlines had the highest number of fatalities, with 119 deaths, while Yeti Airlines came in second with a total of 108 lives lost as illustrated in Figure 3.

Figure 3: Accident Record with fatalities of Nepalese as well as foreign-registered aeroplanes from 1960-2024.

Source: Compiled from the annual database of CAAN

Particularly the Yeti Airlines 9N-ANC crash at the Seti River gorge in Pokhara in 2023 dubbed as the most severe global accident of the year claimed 72 lives and also was the worst aeroplane crash that the country witnessed since 1992. In that year, the Pakistan International Airlines flight AP-BCP crashed at Bhattedanda resulting in 167 deaths as visible in Figure 2.

Nepal has also witnessed a series of helicopter accidents, along with aeroplane accidents. The first of these occurred in December 1979 when the Allutte-III 9N-RAE helicopter crashed in Langtang leading to 6 deaths. Since then, there has been a total of 39 accidents resulting in 92 fatalities. Shree Airlines helicopter 9N-AHJ crash at Ghunsa, Taplejung on September 2006 was the major one which took 24 lives making it the deadliest helicopter crash in the country’s aviation history. Being mindful of a relatively bad history of aviation disasters, Nepal was banned from flying in the European Airspace since 2013 and all the carriers registered in Nepal were put on the EU air safety list.

As of July 2024, the total number of fatalities in aeroplane accidents including both domestically registered and international airlines is 864. If we add casualties from helicopter accidents, this number totals at 956. To put things into perspective, Bolivia which ranks at 17 in the list of world’s worst geographical regions for civil aviation has had 644 fatalities in 62 accidents. It’s crucial to highlight that, in the case of Nepal, the majority of these casualties have occurred in accidents involving airlines registered domestically.

Major reasons for airline crashes

Being mindful of the above numbers, CAAN in its annual report of 2023 identified seven significant risks, four risky phases of flight, and eight risky months in Nepal in terms of potential aviation accidents. The seven categories of significant risks are namely; Windshear or Thunderstorm (WSTRW), Controlled Flight into or Toward Terrain (CFIT), System/Component Failure or Malfunction (Non-Powerplant) (SCF-NP), Fuel Related (Fuel Related), Bird, Fire/Smoke (Non-Impact) (F-NI), and System/Component Failure or Malfunction (Powerplant) (SCF-PP).

Likewise, it identifies 4 risky phases of flight viz. en-route, approach, landing, and take-off and 8 risky seasons are January, March, May, April, June, August, October, and December. Amongst the key risks identified in the above list, SCF-NP and SCF-PP had the highest rate of occurrence per 1000 flying hours (FHs) in the last 5 years as provided in Figure 4. The SCF-NP was 0.95 whereas SCF-PP was 0.95.

Figure 4: Rate of occurrences of SCF-NP and SCF-PP per 1000 FHs in the last 5 years.

 

Source: Data compiled from CAAN’s annual report 2023.

This means that at majority of the time, an aircraft accident can likely be caused by SCF-NP or SCF-PP. While the severity of such occurrences does not necessarily result in an accident all the time, it nevertheless serves as a warning for the detection of an imminent accident. The number of similar occurrences reported in 2022 increased to 513 from 453 in 2021. These occurrences mostly occur in the en-route, approach, and landing phases of the flight.

Similarly, the National Aviation Safety Plan 2023-2025 (NASP) issued in line with the ICAO Global Aviation Safety Plan (GASP) and Asia Pacific Regional Aviation Safety Plan (AP RASP) highlighted the following 7 National high-risk categories under the Operational Safety Risks because of the number of fatalities and risk of fatalities associated with aircraft accidents. They are:

In addition to the above, the NASP underscored Nepal’s 4 common challenges namely

Furthermore, for 2023, the CAAN set up the Safety Performance Indicator (SPI) as an indicator based on the number of accidents that took place during that year. Concurrently, the Safety Performance Target (SPT) was set with the aim of reducing the number of accidents to zero. Unfortunately, this goal was not achieved either in 2023 or in 2024 due to the tragic Yeti Airlines 9N-ANC crash in Pokhara, which resulted in the loss of 72 lives and the Saurya Airlines crash at the TIA which claimed 18 lives.

To highlight one of many reasons for aircraft mishaps, the investigation commission’s report of the Yeti Airlines crash at Pokhara in 2023 can be taken as a reference where the report underscored contributing factors of the accident that put a question mark on CAAN’s fatigue management protocols amongst flight crew. The report revealed that the crew was stressed due to operating in a new airport with challenging terrain, leading to overlooked flight indications. Close terrain with a tight landing circuit coupled with a lack of necessary training for safe operation at the new airport led to the  Yeti 9N-ANC Accident. It did critically mention that human factors, including high workload and stress, resulted in propellers being mistakenly set to the feathered position resulting in the aircraft crash.

The above report critically mentions the terrain difficulties and raises questions on the competence of the pilot flying and pilot monitoring the aircraft while equally highlighting that CAAN failed to ensure the approval of appropriate visual flight paths, manage the impact of changes in the aviation system, and consider all safety-critical parameters during the aerodrome certification process.

ICAO’s Safety Audit Results

Contrary to the above areas for improvement and gaps within the implementation of international standards, the 2022 safety audit results from the ICAO’s Universal Safety Oversight Audit Programme (USOAP) indicated that Nepal had surpassed the global average in several categories. These categories pertain to the effective implementation of safety and aviation security oversight capacities, as depicted in Figure 4. With an overall Effective Implementation (EI) score of 70.10%, Nepal’s performance exceeds both the Asia Pacific average of 61.4% and the global average of 67.2%.

Figure 4: Safety audit results of Nepal under various categories compared to the global average.

Source: ICAO

However, out of 8 critical elements of the safety oversight system that the USOAP monitors, Nepal’s organization and accident investigation in aviation are below the world average. The country’s organization, or CIAA, in particular, got 45.46%, while the world average is 71.62%. The country’s accident investigation is at 21.69%, with the world average at 54.52%. This does therefore raise serious questions about CAAN’s functioning and Nepal’s efforts in terms of accident investigations. This is largely because of the government’s failure to establish a permanent investigation entity with sufficient financial, human, and technical resources to comply with its international obligations under Annex 13 of the Chicago Convention which has been concluded by the investigation commission’s report of Yeti Airlines crash at Pokhara in 2023 as well.

European Union Air Safety List: Ban on Nepali Airlines

As of July 2024, 20 airline companies registered in Nepal are banned from operating or are subject to operational restrictions within the Union. This ban comes from the EU regulation of 2005 “on the establishment of a Community list of air carriers subject to an operating ban within the Community and on informing air transport passengers of the identity of the operating air carrier”.  This ‘community list’  contains a list of aeroplane companies and operators that do not comply with the established obligations under the Chicago Convention and is updated every three months after necessary verification. This was not always the case as Nepal and the EU had an agreement on allowing certain aspects of air services between the two entities published in 2009.

Initial reasons behind the operational ban on airlines operating from Nepal to fly in EU’s airspace:

The “Commission Implementing Regulation (EU) No 1264/2013 of 3 December 2013 amending Regulation (EC) No 474/2006 establishing the Community list of air carriers which are subject to an operating ban within the Community Text with EEA relevance” mentions preliminary reasons for putting Nepal in the Community list of carriers:

1.  Inadequate Safety Standards: 

An ICAO audit in May 2009 found that Nepal's implementation of international safety standards was significantly below the world average. The audit revealed that the Civil Aviation Authority of Nepal (CAAN) was unable to effectively implement these standards in areas such as air operations, airworthiness, and accident investigation.

2.  High Accident Rate: 

Between August 2010 and September 2012, five fatal accidents involving Nepal-registered aircraft occurred, some of which involved Union citizens. Additionally, three more accidents occurred in 2013. This high accident rate indicated systemic safety deficiencies.

3. Significant Safety Concern (SSC): 

An ICAO Coordinated Validation Missions (ICVM) conducted in July 2013 found out SSC related to aircraft operations. Apparently, CAAN's initial Corrective Action Plan to address the deficiencies noted in the SSC was not completed within the stipulated time, leaving the SSC in place.

4. Insufficient Improvement and Weaknesses of the CAAN: 

Despite the efforts made by the CAAN, there was not enough evidence of clear and sustainable improvement. The Commission and the Air Safety Committee noted that while the CAAN was in a capacity-building phase, it lacked the necessary capabilities to fulfil its international obligations. The weaknesses of the CAAN led to a situation where it could not assure the safety of its carriers.

As a result of the aforementioned factors, the European Union Aviation  Safety Agency alongside member states concluded that all air carriers certified in Nepal did not meet the relevant safety standards and should therefore be subjected to an operating ban across EU airspace from December 2013. This ban is still in force owing to the recent updates on the list published on 31 May 2024. 

Fast forward to November 2022, the EU delegation initially planned to conduct an on-site assessment in Nepal for the status of the implementation of aviation safety standards as visible in Exhibit 1 below; 

Exhibit 1: Joint press release by EU and CAAN on 28 November 2022.

Source: CAAN

However, this on-site assessment was turned down via another joint press release from both CAAN and the EU on 20 Jan 2023 owing to the Yeti Airlines crash at Pokhara as maintained in Exhibit 2. 

Exhibit 2: Joint press release by EU and CAAN on 20 Jan 2023.

Source: CAAN

Finally, on September 2023, the European Union Aviation Safety Agency conducted an on-site assessment visit in Nepal from 11-15 September 2023 at CAAN and a separate sample assessment of two air carriers certified in Nepal namely; Shree Airlines and Nepal Airlines. The assessment concluded that:

1. Discrepancies between the approved organisational structure and the actual distribution of sections, departments, and personnel within CAAN.

2. Non-compliance with international safety standards in CAAN’s personnel licensing requirements and flight examiner systems, especially in helicopter operations. This necessitates urgent alignment with these standards and the establishment of clear criteria and surveillance mechanisms for Designated Check Pilots and examiners.

3. A gap in the effective monitoring and documentation of training for CAAN’s Personnel Licensing Inspector and Assistant Inspector roles.

4. Significant gaps in CAAN’s Flight Operations Division, particularly in overseeing fatigue related to duty period limitations and ensuring comprehensive compliance checks during the approval process. This indicates an urgent need for CAAN to implement robust fatigue management protocols and strengthen its technical evaluation and approval processes.

5. The assessment further identified discrepancies, such as non-compliance with Traffic Collision Avoidance System (‘TCAS’) requirements, fuel calculations, and oversight of flight time limitations, significantly impacting flight safety.

The assessment of the two sample airlines, Shree Airlines and Nepal Airlines, concluded the following:

Shree Airlines:

1. Operational and safety compliance issues extend to flight planning, crew fatigue management, and adherence to regulatory requirements in de-icing procedures, TCAS requirements, and the Minimum Equipment List for specific aircraft types.

2. Deficiencies were observed in managing the validity and quality of training certificates, coupled with unclear or incorrect instructor feedback, indicating a need for a more robust system to monitor and improve crew competencies and training efficacy.

Nepal Airlines:

1. The assessment highlighted deficiencies in its Safety Management System (SMS) and operational compliance, including inadequate hazard identification and management, repetitive findings in annual audits, and insufficiently detailed quality audit checklists.

2. Concerns were raised about the effectiveness of the Quality Assurance department, the lack of a comprehensive hazard log in the Continuing Airworthiness Management Organisation and Approved Maintenance Organisation, and shortcomings in manpower analysis.

3. Challenges were noted in maintaining operational oversight, with issues across various areas including training competencies, flight time limitations, document management, and compliance monitoring.

4. The observations suggest that Nepal Airlines requires a substantial overhaul of its systems and processes to achieve the necessary maturity in its SMS and ensure a robust understanding and management of its airworthiness approvals and operational oversight.

Thus, the aforementioned conclusions clearly show that there are myriad avenues to work on before Nepal formally gets its entry into the EU airspace. Regardless of these conclusions and suggestions which came out in September 2023, Nepal did face another tragic accident with the crash of Saurya Airlines flight 9N-AME.

Saurya Air Crash: Lessons and Suggestions

The recent accident involving an aircraft of Saurya Airline at TIA, where the flight was due for “c-type base maintenance” in Pokhara International Airport due to the absence of adequately equipped hangars at the TIA, indicates a lack of investment in essential infrastructure for operational safety by both the operators and relevant stakeholders in Nepali airline industry. This highlights the need for more attention to be paid to safety measures and infrastructure development in the aviation industry. While many are questioning the aircraft’s airworthiness, it still had 119 hours of flight time remaining with all necessary permissions in place, but needed to undergo maintenance for which it had to be transported to Pokhara International Airport. Notably, during a “ferry flight”, Saurya Airlines permitted 19 individuals onboard, a decision that has raised eyebrows as per the CAAN’s information officer. The officer also clarified that since this flight was neither “scheduled” nor a “cargo” flight, (implying that it wasn’t authorized to transport passengers) and said that CAAN had no reason or means to intervene as this falls squarely within the operator’s (Saurya Airline’s) responsibilities.

While the aforementioned remarks by the senior CAAN official do not entirely absolve him or CAAN from responsibility for the accident, there is a consensus among all parties that Nepal's aviation system requires a comprehensive overhaul. This includes changes in legislation, improvements in the functioning of the regulatory authority, investment in essential infrastructures, and the implementation of measures to guarantee that operators adhere to all safety standards.

Furthermore, the debates surrounding lapses in the security standards by CAAN and airline operators keep going on, another particular observation comes from the fact that ever since the present Director General Mr Pradip Adhikari assumed the office of CAAN on 3 February 2022 (Exhibit 3), there have been three significant aeroplane accidents involving Tara Air at Mustang, Yeti Air at Pokhara, and Saurya Air at TIA, resulting in the loss of 112 lives. Furthermore, two helicopter accidents involving Simrik Air in Sankhuwasabha and Manang Air in Solukhumbu have claimed an additional 7 lives. These incidents raise serious questions about his leadership and cast doubt on its effectiveness.

Exhibit 3: Announcement of appointment of Mr. Pradip Adhikari as the Director General of CAAN in February 2022.

Source: Twitter handle of Tourism Ministry

While not all of the accidents may be directly attributed to the shortcomings of CAAN, international norms often see leadership taking responsibility in the aftermath of such incidents, acknowledging acceptance of failure to comply with established rules, and demonstrating a foundering leadership. For instance, the chief of the Malaysian civil aviation authority stepped down following the disappearance of flight MH370, and the head of Sudan’s aviation authority resigned after a plane crash resulted in the loss of 32 lives. 

CAAN should also ensure that recommendations of the EU assessment and each investigation committee are properly implemented before long overdue. There have been no further updates yet on the primary recommendations from the investigation commission’s report of the Yeti Airlines crash at Pokhara in 2023 which stressed CAAN to install and further develop surveillance infrastructures alongside integrating the existing radar facility to enhance en-route surveillance capabilities at Pokhara International Airports and Gautam Buddha International Airports.

Importantly, the suggestion of the EU in terms of separating CAAN’s regulatory and service provider roles was duly addressed and the “Nepal Aviation Service Authority Bill 2076 B.S.” (NASA) was presented before the National Assembly on 24th February 2020 but as the tenure of the parliament ended on 17 October 2022, the bill never got an opportunity to crystallise into law. This bill would have given the Nepal Aviation Service Authority dedicated powers and responsibilities for overseeing the implementation of regulations issued by CAAN- a separate dedicated regulatory body. The establishment of NASA would ultimately aid Nepal’s dream of flying again in EU airspace with added financial benefits from trade and tourism. The increased connectivity could potentially boost the country’s economy by attracting more tourists, fostering international relations, and opening up new avenues for the export of local goods and services.

Moreover, the ultimate objective of minimising aeroplane accidents is not the responsibility of just one party. It’s also crucial for operators to adhere to international standards. They should make sure that the performance of their Captains, Co-Pilots, and crew during each flight is regularly evaluated. The airline operators should also guarantee that the operations director has been and will continue to, oversee the safe operational activities in accordance with the duties and responsibilities outlined in the operation manual approved by CAAN as highlighted by Yeti Airlines investigation commission’s findings. 

Finally, in today's aviation industry, every commercial aeroplane requires human intervention to fulfil its primary functions of transportation and commuting. This implies that even if efforts to mitigate risks through enhanced safety standards reach 100%, it's still impossible to guarantee that a plane won't meet with an accident at any given moment. For example, the 31 member states of the European Union Aviation Safety Agency (EASA) reported no fatal accidents from 2017-2021, yet experienced one in 2022, thankfully with no fatalities. This demonstrates that while effective implementation of established standards and reduction of Significant Safety Concerns (SSCs) may not completely eradicate the possibility of accidents, prioritizing these measures is nonetheless crucial for the state and relevant authorities to prevent tragic accidents like Saurya Airlines 9N-AME from repeating again.