Nepal’s Crash Investigations: More Tabloid Drama Than Discovery

  • D. Nepal –

Every now and then, Nepal has to deal with an unfortunate aircraft crash, and then the government’s forced to put together a team to look into it and scribble out a detailed report. I say “forced” because thanks to Article 26 of the 1944 Chicago Convention, countries must have to investigate aircraft crashes – it’s mandatory. If it wasn’t for that treaty, I’m pretty sure the Nepali government wouldn’t even bother. I mean, let’s be real, nearly every report on aircraft crashes in Nepal is a big letdown. You could say it’s like a shortcut to disappointment, which you might call “jhaaro tarchan” in Nepali. And hey, it’s not just me griping about this – even ICAO, the folks who audit aviation safety worldwide, slapped Nepal with a measly 22 out of 100 for their accident investigation game.


While accident investigation stands as a pivotal element in averting future crashes, it’s glaringly clear that in Nepal, it’s treated more like a chore. Now, I’m about to present a few examples of what are supposed to be serious accident investigation reports.

Buckle up, because this read is gonna take a while. Let’s kick things off with some lighthearted gossip about someone having a crush or a fling in the cockpit. You know, these reports are meant to be all serious, filled with hard facts and technical stuff, without defaming anyone down. But guess what? This is Nepal, my friend, and we’ve got enough juicy drama even in accident reports.

9N-AJP, Sindhupalchowk

Crash Site Photo : Annapurna Post

Official Report

9N-AJP crashed during a disaster relief program for an INGO in 2015. It hit a neutral wire of a high tension transmission line owned by NEA and went down. Now, here’s the twist: the investigation decided that the pilot got distracted by a woman sitting up front because he was “young and unmarried” and listed it as one of the contributing factors for the crash.

But hold up, the chopper didn’t have a cockpit voice recorder to hear if they were having some not-so-professional chit-chat. And get this, they didn’t even bother talking to other co-workers or relevant passengers to check if this pilot was known for flirting while flying. Just because he’s young and not hitched, they assumed he was head over heels – not a great look when you’re reading a report that led to four deaths. And check this out: “passenger” gets a small letter, but “Distraction” gets an uppercase on the subsection title. Makes you think this important section maybe didn’t get peer-reviewed or even a second glance before making it a contributing factor to the crash.

9N-AEK, Lalitpur

Blogspot post by Prasain 

Even though the tourism ministry hasn’t officially posted any crash investigation report on their website, it seems we’ve got a news report from The Kathmandu Post’s journalist, Sangam Prasain, dated March 2, 2012. Since he’s a ‘business editor’ at a well-known media outlet, I’ll take his word.

Sangam Prasain profile

According to his report, the main reason for the Buddha Air Beechcraft crash was the pilot getting distracted, leading to a controlled flight into terrain – the usual deal. According to the news piece, one of the investigators mentioned that because the male captain didn’t exactly “command” the female co-pilot but more like “advised” her, there might be some space for a “personal relationship.” Seriously, are you guys even real? Interestingly, the same person seems to have mentioned that there’s no actual evidence of any personal relationship being on record. So, why even bring it up? You can’t make this up.

No emphasis on technical factors, only on human factors

Accident Investigation Manual

For Nepali authorities, an airplane crash is like a big joke. But, if you read the first line in the Foreword of MoTCA’s Aircraft Accident Investigation procedure manual, it says the whole point of investigating accidents is to find technical problems and tackle human issues so that future crashes can be avoided. But hey, why bother diving into complex and tricky technical stuff if you can just blame lame human factor, wrap it up, and call it a day? Let me show you an example:

9N-AMH, Lukla

Official Report 

So, here’s the deal: the crash happened because somehow the RH Power Lever yanked backward, which dropped the RPM on the right engine, making the plane go off-course to the right. But get this, the folks in charge of digging into what went down didn’t really bother looking into the technical nitty-gritty. Instead, they just pointed fingers at the co-pilot who had passed away, saying it was his last-minute call to grab the controls during takeoff that messed things up.

Here’s the lowdown from a report screenshot: they’re pointing the finger at an uneven power lever as the likely culprit for the crash. They’re also giving the co-pilot a slice of the blame pie. But get this, they didn’t round up enough proof to nail down exactly why that power lever suddenly went rogue. They totally skipped out on diving deep into their main hunch. And you know what’s wild? The head honcho pilot had actually talked with investigators about this plane or planes (?) having power lever issues before.

But hold up, they didn’t bother talking to other pilots to get their two cents on the matter. Plus, they never bothered ringing up the folks who manufactured the plane or chatting with the airline to dig into the service history of the power levers. And here’s the kicker – no sign they ever cracked open that faulty power lever to run any tests or failure analysis to figure out what went wrong from an engineering angle. All they got is this one head-scratching pic showing the power levers in asymmetric position, but they don’t even spill if it’s a real-deal snapshot from the actual crash or just some random illustration.

Alright, let’s throw in a few brownie points here – they did roll up their sleeves and check out some technical stuff about the accident. They took a peek at where the PEDAL and NOSE WHEEL CB switches were at, and they said everything seemed A-OK there. They also scratched the surface on the mystery of why there weren’t any CVR recordings on that doomed plane. They tried to put the blame on a botched CVR installation, but they didn’t have any slam-dunk evidence to back it up. In short, their attempt to break down the tech side of what happened with Summit Air (9N-AMH) was pretty lazy. They’re basically saying those power levers somehow moved on their own when no one was touching them, and let’s just point fingers at the dead co-pilot because, hey, he wasn’t exactly a pro at flying out of Lukla. Makes sense to you?

Crash investigators or medical experts?

When discussing the medical or psychological conditions of the crash victims, the report frequently falls short in citing reliable medical sources. Apart from referencing the IOM for post-mortem examinations, there’s a noticeable absence of credible medical sources when asserting claims about how someone’s medical/psychological condition might have contributed to the crash. Let’s take a couple examples here:

9N-AJH, Simikot


The report was quick to assume (“seemed”) about Post Traumatic Stress Disorder (PTSD), citing the pilot in command’s job changes after a previous serious accident in Simikot back in 2013. It’s worth noting that the deceased pilot had never been diagnosed with such a disorder before.

Interestingly, the report, authored by a commission comprising a few bureaucrats, a pilot, and an engineer, fails to mention whether they consulted any psychiatrists, mental health professionals, or medical authorities before bluntly asserting the pilot had a disorder. This seems quite off, especially considering the serious, technical nature of the report.

However, it’s worth mentioning that Dr. Rajeev Deo was referred to as an “aero medical expert” in the commission. Oddly, the report doesn’t provide his NMC number or specific qualifications apart from this title (which, to be honest, is a bit unclear). Checking out the provided link, it appears that Dr. Deo is listed as an oncologist, as per Hamro Doctor website

So, what is oncologist then ? Here is what dictionary have :

Regardless, they did make a recommendation for CAAN (Civil Aviation Authority of Nepal) to implement a process for checking post traumatic stress in pilots following significant incidents based on their “assumption.” So, it seems some positive outcome emerged from (mis)/diagnosing a deceased pilot.

In the same report, they explored the possibility of hypoxia (but seemingly didn’t consult a relevant medical expert). They mentioned some things that seem puzzling to me, a layman. Can a lack of oxygen really cause overconfidence and a sense of well-being? To make things clear, it would have been better if they had quoted a medical expert or forensics opinion before writing this:

Anyways, they ended up making “probable hypoxia” as a contributing factor for the crash, and closed their case. By the way, “probable” hypoxia was also the contributing factor in the Rabindra Adhikari helicopter crash. Oh and by the way, if you haven’t realized how lazy efforts are put into this reports, they aren’t better when VVIPs like minister Adhikari are involved in the crash either:

9N-AMI, Pathibhara


Alright, so in this report, where the six high level officials died in the crash, and they totally dished out their survival aspect. It might have been laughable if lives weren’t at stake. I mean, the civil aviation minister of the country passed away, and they didn’t even bother to figure out what his chances of surviving post-crash were because “the accident was fatal”. They didn’t even throw in a single line about how hard the impact force was, the fire after the crash, emergency exits, seat belts effectiveness or the geographical terrain. All they gave us was a simple “none of them made it,” without a hint of why. It gives you a peek into how much they were itching to wrap up the report and just move on.

Here is an example of 2010, Air India Express Flight 812 in Mangalore where they dedicated three total pages and four subsections to determine the survivability of the crash. Check section 1.15 Survival Aspect in this report.

Getting back to asserting medical claims without citing credible source, there is a very recent example of Tara Air crash whilst on approach to Jomsom as well. Take a look at this:

9N-AET, Jomsom


9N-AET was under the command of a 61-year-old pilot with a whopping 17,000 flight hours under his belt and a clean bill of health in terms of medical history. Unfortunately, the flight ended up crashing, seemingly due to a loss of situational awareness in bad weather.

As per the report, the co-pilot was relatively green in the field, which added a ton of stress to the 61-year-old captain. The investigation tried to link this extra stress on the older captain to a higher chance of pilot incapacitation. They attempted to prove this using a graph that honestly looked like it was hastily put together from a random google search, without giving any clear limits on the axes or providing a reliable source for where they found it.

So, I decided to do some detective work on those screenshots of graphs myself. Turns out, they snatched these from a powerpoint presentation, not even a published paper, by Dr. Anthony Evans titled “Upper Age Limits for Pilots.” (Source)

Seems like he put it together for the 2011 ICAO Summit in Mexico City. Those plots were made to help folks grasp the concept while the presenter talked through it. But, guess what the investigators did? They popped those plots into their technical report without giving proper credit, and then they tried to float the idea that the pilot’s age might have messed up his performance that day.

If you check out the same presentation by Dr. Evans, there’s a page that talks about how performance slowly goes downhill as reaction time, short-term memory, flexibility, vision, and hearing all gradually get worse. But get this, the investigators didn’t even bother interviewing with the pilot’s buddies or family to see if they noticed any of these symptoms. And they didn’t reach out to any medical experts for their opinion either, before trying to spin off this age-blaming theory as human factors of the crash in the report.

But you know what they missed out on investigating? The thing that could actually make the most sense in explaining why things went wrong due to human factors. So, here’s what happened: there was this someone, maybe a ground crew member or a passenger, who was really pushing the captain to take off for Jomsom that morning.

And guess what? The pilot wasn’t exactly gung-ho about firing up the engine and even delayed the takeoff after taxiing. Now, here’s the interesting part – it seems like this person’s voice got caught on the Cockpit Voice Recorder (CVR), which is like super solid evidence. But, guess what the investigation folks didn’t even bother with? Yep, they didn’t try to find out who this mystery person was. If this was some ground staff from the airline giving the pilot a hard time to fly in bad weather conditions, that’s a big deal, right? But nope, they didn’t even think of exploring that angle.

And that’s the scoop! These examples I shared are just the tip of the iceberg, but trust me, almost all of these accident investigation reports are like a big disappointment. Oh, and get this – check out the tourism ministry’s move: they’ve thrown up a draft of the final report on their official site, and guess what? Rajan and GN Lama are still supposed to sprinkle their wisdom on the findings of 2014 Last Resort Helicopter Incident.



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