It seems that both the airline company and the regulatory body were at fault in the accident of Soorya
What you should know
The investigative report on the plane crash of Solar Airlines last year inside Kathmandu Airport, which has facilities in the country, has revealed serious weaknesses in Nepali air safety. Although the report pointed to pilot error as the main cause of the accident, not bad weather, ship's engine or other technical problems, it showed various levels of negligence, inattention, and inaction.
In relation to the accident, Chairman of the Accident Investigation Commission, Ratish Chandra Lal Suman, had a brief conversation with him :
Is the pilot's error the only reason for the accident of Sourya's CRJ plane, or did the safety system of the airline fail? Why was the ship flown at a high 'pitch rate' up to 18 times in two years?
We found a record high 'pitch rate' of 18 times in two years during ship 'takeoff', that too in two CRJ aircraft of Solar. We came to know that by 'decoding' the data that was recorded in the flight data recorder (FDR) of that ship but was just downloaded without analysis. ICAO, the aviation regulatory body, has not mandated the FDR's 'data analysis' for ships weighing less than 27,000 kg. That is why the regulatory body of Nepal did not make it mandatory. ie not made binding. But there is no stopping today's airlines from going a step further than the regulatory body ICAO's standards. Like – Shree Airlines also flies CRJ aircraft. He not only 'downloads records' into his ships' FDRs, but also analyzes them. Analyzes the technical aspects that need to be improved.
Sourya bought the equipment and brought it. But because he does not have its 'program', 'software' and 'manual', it has not been put into operation. We have recommended mandatory implementation of data analysis. The regulatory body of Nepal has said that when renewing the certificate of ships weighing less than 27,000 kg but more than 5,700 kg Twin Otter, only record of 'data download' should be required. Such data should be analyzed only if any investigation is required. But ships below 19 seats do not have FDR. Cockpit 'voice recorder' is mandatory in them.
Why did only the paper process get priority in Surya Airlines, not security? Why was the error in 'speed card' never corrected for years?
Every airline company has skilled manpower to look after its 'Safety Management System' (SMS). Quality Manager, Safety Manager, Operations Director, Chief Pilot etc. They should be accountable to all authorities. They have a number of 'manuals' on aviation operations approved by the Authority. They must work honestly, otherwise the authority can remove them from the post. Unfortunately, almost all the 'postholders' of Sourya were killed in this accident. Only the captain was rescued alive. It was seen that the regulatory body also failed to 'audit' how the airline was operating.
Where did the Civil Aviation Authority go wrong in this? Weakness or institutional negligence? Neither 'speed card' check, nor 'pitch rate' analysis, what did the regulatory body do?
Both the airline company and the regulatory body were at fault in this accident. There are posts of 'inspectors' in the authority to check the ships, pilots, technicians and engineers of every airline company but not enough. The European Union has also said this. For example, the 'checklist' only says that FDR should be 'downloaded'. The examiner appointed by the authority only monitored what was on the 'checklist'. The regulatory body should reach beyond that. You can't always sit in the cockpit of all the planes at the airport and see how they are flown. However, sometimes checking, 'monitoring' is the job of 'inspector'. After Sourya's accident, the authority has dedicated an inspector at Kathmandu Airport. But the position is not kept. The authority does not have enough technical manpower. Even if there is, it seems that the capacity should be increased.
Why was the co-pilot silent in this accident? Is it due to fear or lack of training? Why could he not suggest serious and clear reforms?
In past incidents in Nepal, it has been seen that there is not a good combination when there are many senior and many junior pilots in the cockpit. Some accident studies have not considered this to be good, i.e. it is a 'gap'. There should be 'assertive communication' in the cockpit, i.e. if any error is happening or about to happen, the junior should speak positively. But there was no time to correct this incident. There was no room for 'correction' in just four seconds. Nor could he interfere with 'control'. However, the incident had gone out of control. Because a few decades ago, there was an accident in the plane of Nepal Airline Corporation due to a dispute related to the 'control' of two people.
Why are so many passengers kept on non-commercial flights? Was it a risk or negligence? There is no system to set limits on such flights?
ICAO, EU and other bodies have given different definitions for such a flight. It has become clear in this incident that there are more passengers than necessary.
When the ship takes off, the ship is stopped because people are coming again at the end. Because of own company's flight and staff, minor issues are ignored. The regulatory body of Nepal has not made a rule about how many passengers will be kept in the flight, 'test flight', 'positioning' flight. Even in the process of granting permission, it seems that sometimes the authority is delegated to the 'Air Ordnance' Division, sometimes to the Director General. Sourya's flight has been given permission by the department that issues regular flight permits for re-flights. He also did not follow the 'Operation Manual'. Nor has followed other flight related rules. A description is provided when asking for permission. A different description has been kept while flying. Consistency is not visible.
On the day of the accident, there was confusion in the rescue. A pile of construction materials obstructed the fire brigade at the accident site. Is this management negligence or not?
Kathmandu Airport has not yet been built according to ICAO standards. Its runway is said to be level up to 280 meters from the center line, but it doesn't look like this on the field. When inspecting the spot, the width of the 'runway strip' was only 150 meters. This is not enough. Emergency rescue drills are held at the airport every time, but due to lack of drills in difficult situations, it was difficult for the fire brigade to reach the place in the accident of Surya's ship. Construction materials were placed on the road. This is a serious matter. The 'fencing' inside and outside the airport should have roads where fire engines and ambulances can move easily.
Why is air safety reform being delayed? Laws, training, monitoring are all weak? Why is there no clear policy on non-commercial flights and technical document testing?
This time we have taken the help of American aviation experts. It is not that there is no improvement in the authority. But there is a shortage of manpower and efficiency. In the safety department of the regulatory body, even now, there is no skilled test pilot to monitor the pilot. Because there are better facilities outside. No one is attracted to being on the authority's salary. But improvements are being made.
Is the 18 times repeated mistake negligence or a complete failure of management?
We found 18 errors in two years. If we look at the 'data' before that, it can increase even more. This time, the Commission of Inquiry gave priority to the investigation of the humanitarian aspect. This topic is new in Nepal. At present, there is more weakness in the human aspect than in the technical aspect. To improve it, we have made various recommendations to Nepal government, authorities, operators and others. The report has been thorough.
