Crash of a Cessna 402C in Papa Lealea

Date & Time: Jul 26, 2020
Type of aircraft:
Operator:
Registration:
VH-TSI
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Papa Lealea - Mareeba
MSN:
402C-0492
YOM:
1981
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Shortly after takeoff from Papa Lealea, enroute to Mareeba, Australia, the twin engine airplane lost height and crashed in an open field, bursting into flames. The pilot was not found in site and the aircraft was partially destroyed by fire. Later, the Royal Papua New Guinea Constabulary and the AFP found 28 bags containing what investigators believe is 500 kilograms of cocaine.

Crash of a PAC Cresco 08-600 near Carterton: 1 killed

Date & Time: Apr 24, 2020 at 0730 LT
Type of aircraft:
Operator:
Registration:
ZK-LTK
Flight Phase:
Survivors:
No
MSN:
30
YOM:
2002
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Crashed shortly after takeoff from a private field located about 20 km southeast of Carterton. The pilot, sole on board, was killed.

Crash of a Cessna 404 Titan in Lockhart River: 5 killed

Date & Time: Mar 11, 2020 at 0930 LT
Type of aircraft:
Operator:
Registration:
VH-OZO
Survivors:
No
Schedule:
Cairns – Lockhart River
MSN:
404-0653
YOM:
1980
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The twin engine aircraft departed Cairns on a charter flight to Lockhart River, carrying workers for the government. While descending to Lockhart River, the pilot encountered marginal weather conditions with rain falls and strong winds. A first approach to Lockhart River was abandoned and the pilot was forced to initiate a go-around. Few minutes later, while in a second attempt to land, the aircraft crashed on the Claudie Beach located about 4 km southeast of Lockhart River. All five occupants were killed.

Crash of a Lockheed EC-130Q Hercules near Peak View: 3 killed

Date & Time: Jan 23, 2020 at 1400 LT
Type of aircraft:
Operator:
Registration:
N134CG
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Richmond - Richmond
MSN:
4904
YOM:
1981
Flight number:
Tanker 134
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The airplane departed Richmond Airbase and was conducting fire control operations when contact was lost. Witnesses on the ground reported hearing a loud bang and saw a giant fireball around the time of the crash. ATSB said the fire retardant-laden aircraft, Tanker 134, was assisting with fire suppression efforts when the crash occurred near Peak View, northeast of Cooma. All three crew members were killed.

Crash of an Angel Aircraft Corporation Model 44 Angel in Mareeba: 2 killed

Date & Time: Dec 14, 2019 at 1115 LT
Registration:
VH-IAZ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Mareeba - Mareeba
MSN:
004
YOM:
2008
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
20000
Captain / Total hours on type:
300.00
Copilot / Total flying hours:
5029
Copilot / Total hours on type:
0
Aircraft flight hours:
1803
Circumstances:
On 14 December 2019, at 1046 Eastern Standard Time, an Angel Aircraft Corporation Model 44 aircraft, registered VH-IAZ, commenced taxiing at Mareeba Airport, Queensland. On board the aircraft were two pilots. The pilot in the left seat (‘the pilot’) owned the aircraft and was undertaking a flight review, which was being conducted by the Grade 1 flight instructor in the right seat (‘the instructor’). The planned flight was to operate in the local area, as a private flight and under visual flight rules. As the aircraft taxied towards the runway intersection, the pilot broadcast on the common traffic advisory frequency (CTAF) that VH-IAZ was taxiing for runway 28. The pilot made another broadcast when entering and backtracking the runway, then at 1058, broadcast that the aircraft had commenced the take-off roll. Witnesses who heard the aircraft during the take-off reported that it sounded like one of the engines was hesitating and misfiring. An aircraft maintainer who observed the aircraft take off, reported seeing black sooty smoke trailing from the right engine. The maintainer then watched the aircraft climb slowly and turn right towards the north. Another witness who heard the aircraft in flight soon afterwards, reported that it sounded normal for that aircraft, which had a distinctive sound because the engines’ exhaust gases pass through the propellers. Once airborne, the pilot broadcast that they were ‘making a low-level right-hand turn and then climbing up to not above 4,500 [feet] for the south-west training area.’ About 2 minutes later, the instructor broadcast that they were just to the west of the airfield in the training area at 2,500 ft and on climb to 4,000 ft, and communicated with a helicopter pilot operating in the area. After 8 minutes in the training area, the pilot broadcast that they were inbound to the aerodrome. At 1112, the aircraft’s final transmission was broadcast by the pilot, advising that they were joining the crosswind circuit leg for runway 28. Witnesses then saw the aircraft touch down on the runway and continue to take off again, consistent with a ‘touch-and-go’ manoeuvre, and heard one engine ‘splutter’ as the aircraft climbed to an estimated 100–150 ft above ground level. At about 1115, the aircraft was observed overhead a banana plantation beyond the end of the runway, banked to the right in a descending turn, before it suddenly rolled right. Witnesses observed the right wing drop to near vertical and the aircraft impacted terrain in a cornfield. Both pilots were fatally injured and the aircraft was destroyed.
Final Report:

Crash of a Britten-Norman BN-2A-20 Islander in West Portal: 1 killed

Date & Time: Dec 8, 2018 at 0828 LT
Type of aircraft:
Operator:
Registration:
VH-OBL
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Hobart – Bathurst Harbour
MSN:
2035
YOM:
1986
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
The pilot departed Hobart Airport at 0748LT on a positioning flight to Bathurst Harbour, southwest Tasmania. En route, she encountered poor weather conditions and limited visibility when the airplane struck the slope of a mountain located in the Southwest National Park, some 32 km northeast of the intended destination. The wreckage was found few hours later in West Portal, about 100 meters below the summit. The pilot, sole on board, was killed.

Crash of a Boeing 737-8BK off Weno Island: 1 killed

Date & Time: Sep 28, 2018 at 0924 LT
Type of aircraft:
Operator:
Registration:
P2-PXE
Survivors:
Yes
Schedule:
Kolonia – Chuuk – Port Moresby
MSN:
33024/1688
YOM:
2005
Flight number:
PX073
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
35
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
19780
Captain / Total hours on type:
2276.00
Copilot / Total flying hours:
4618
Copilot / Total hours on type:
368
Aircraft flight hours:
37160
Aircraft flight cycles:
14788
Circumstances:
On 28 September 2018, at 23:24:19 UTC2 (09:24 local time), a Boeing 737-8BK aircraft, registered P2-PXE (PXE), operated by Air Niugini Limited, was on a scheduled passenger flight number PX073, from Pohnpei to Chuuk, in the Federated States of Micronesia (FSM) when, during its final approach, the aircraft impacted the water of the Chuuk Lagoon, about 1,500 ft (460 m) short of the runway 04 threshold. The aircraft deflected across the water several times before it settled in the water and turned clockwise through 210 deg and drifted 460 ft (140 m) south east of the runway 04 extended centreline, with the nose of the aircraft pointing about 265°. The pilot in command (PIC) was the pilot flying, and the copilot was the support/monitoring pilot. An Aircraft Maintenance Engineer occupied the cockpit jump seat. The engineer videoed the final approach on his iPhone, which predominantly showed the cockpit instruments. Local boaters rescued 28 passengers and two cabin crew from the left over-wing exits. Two cabin crew, the two pilots and the engineer were rescued by local boaters from the forward door 1L. One life raft was launched from the left aft over-wing exit by cabin crew CC5 with the assistance of a passenger. The US Navy divers rescued six passengers and four cabin crew and the Load Master from the right aft over-wing exit. All injured passengers were evacuated from the left over-wing exits. One passenger was fatally injured, and local divers located his body in the aircraft three days after the accident. The Government of the Federated States of Micronesia commenced the investigation and on 14th February 2019 delegated the whole of the investigation to the PNG Accident Investigation Commission. The investigation determined that the flight crew’s level of compliance with Air Niugini Standard Operating Procedures Manual (SOPM) was not at a standard that would promote safe aircraft operations. The PIC intended to conduct an RNAV GPS approach to runway 04 at Chuuk International Airport and briefed the copilot accordingly. The descent and approach were initially conducted in Visual Meteorological Conditions (VMC), but from 546 ft (600 ft)4 the aircraft was flown in Instrument Meteorological Conditions (IMC). The flight crew did not adhere to Air Niugini SOPM and the approach and pre-landing checklists. The RNAV (GPS) Rwy 04 Approach chart procedure was not adequately briefed. The RNAV approach specified a flight path descent angle guide of 3º. The aircraft was flown at a high rate of descent and a steep variable flight path angle averaging 4.5º during the approach, with lateral over-controlling; the approach was unstabilised. The Flight Data Recorder (FDR) recorded a total of 17 Enhanced Ground Proximity Warning System (EGPWS) alerts, specifically eight “Sink Rate” and nine “Glideslope”. The recorded information from the Cockpit Voice Recorder (CVR) showed that a total of 14 EGPWS aural alerts sounded after passing the Minimum Descent Altitude (MDA), between 307 ft (364 ft) and the impact point. A “100 ft” advisory was annunciated, in accordance with design standards, overriding one of the “Glideslope” aural alert. The other aural alerts were seven “Glideslope” and six “Sink Rate”. The investigation observed that the flight crew disregarded the alerts, and did not acknowledge the “minimums” and 100 ft alerts; a symptom of fixation and channelised attention. The crew were fixated on cues associated with the landing and control inputs due to the extension of 40° flap. Both pilots were not situationally aware and did not recognise the developing significant unsafe condition during the approach after passing the Missed Approach Point (MAP) when the aircraft entered a storm cell and heavy rain. The weather radar on the PIC’s Navigation Display showed a large red area indicating a storm cell immediately after the MAP, between the MAP and the runway. The copilot as the support/monitoring pilot was ineffective and was oblivious to the rapidly unfolding unsafe situation. He did not recognise the significant unsafe condition and therefore did not realise the need to challenge the PIC and take control of the aircraft, as required by the Air Niugini SOPM. The Air Niugini SOPM instructs a non-flying pilot to take control of the aircraft from the flying pilot, and restore a safe flight condition, when an unsafe condition continues to be uncorrected. The records showed that the copilot had been checked in the Simulator for EGPWS Alert (Terrain) however there was no evidence of simulator check sessions covering the vital actions and responses required to retrieve a perceived or real situation that might compromise the safe operation of the aircraft. Specifically sustained unstabilised approach below 1,000 ft amsl in IMC. The PIC did not conduct the missed approach at the MAP despite the criteria required for visually continuing the approach not being met, including visually acquiring the runway or the PAPI. The PIC did not conduct a go around after passing the MAP and subsequently the MDA although:
• The aircraft had entered IMC;
• the approach was unstable;
• the glideslope indicator on the Primary Flight Display (PFD) was showing a rapid glideslope deviation from a half-dot low to 2-dots high within 9 seconds after passing the MDA;
• the rate of descent high (more than 1,000 ft/min) and increasing;
• there were EGPWS Sink Rate and Glideslope aural alerts; and
• the EGPWS visual PULL UP warning message was displayed on the PFD.
The report highlights that deviations from recommended practice and SOPs are a potential hazard, particularly during the approach and landing phase of flight, and increase the risk of approach and landing accidents. It also highlights that crew coordination is less than effective if crew members do not work together as an integrated team. Support crew members have a duty and responsibility to ensure that the safety of a flight is not compromised by non-compliance with SOPs, standard phraseology and recommended practices. The investigation found that the Civil Aviation Safety Authority of PNG (CASA PNG) policy and procedures of accepting manuals rather than approving manuals, while in accordance with the Civil Aviation Rules requirements, placed a burden of responsibility on CASA PNG as the State Regulator to ensure accuracy and that safety standards are met. In accepting the Air Niugini manuals, CASA PNG did not meet the high standard of evidence-based assessment required for safety assurance, resulting in numerous deficiencies and errors in the Air Niugini Operational, Technical, and Safety manuals as noted in this report and the associated Safety Recommendations. The report includes a number of recommendations made by the AIC, with the intention of enhancing the safety of flight (See Part 4 of this report). It is important to note that none of the safety deficiencies brought to the attention of Air Niugini caused the accident. However, in accordance with Annex 13 Standards, identified safety deficiencies and concerns must be raised with the persons or organisations best placed to take safety action. Unless safety action is taken to address the identified safety deficiencies, death or injury might result in a future accident. The AIC notes that Air Niugini Limited took prompt action to address all safety deficiencies identified by the AIC in the 12 Safety Recommendations issued to Air Niugini, in an average time of 23 days. The quickest safety action being taken by Air Niugini was in 6 days. The AIC has closed all 12 Safety Recommendations issued to Air Niugini Limited. One safety concern prompting an AIC Safety Recommendation was issued to Honeywell Aerospace and the US FAA. The safety deficiency/concern that prompted this Safety Recommendation may have been a contributing factor in this accident. The PNG AIC is in continued discussion with the US NTSB, Honeywell, Boeing and US FAA. This recommendation is the subject of ongoing research and the AIC Recommendation will remain ACTIVE pending the results of that research.
Probable cause:
The flight crew did not comply with Air Niugini Standard Operating Procedures Manual (SOPM) and the approach and pre-landing checklists. The RNAV (GPS) Rwy 04 Approach chart procedure was not adequately briefed. The aircraft’s flight path became unstable with lateral over-controlling commencing shortly after autopilot disconnect at 625 ft (677 ft). From 546 ft (600 ft) the aircraft was flown in Instrument Meteorological Conditions (IMC) and the rate of descent significantly exceeded 1,000 feet/min in Instrument Meteorological Conditions (IMC) from 420 ft (477 ft). The flight crew heard, but disregarded, 13 EGPWS aural alerts (Glideslope and Sink Rate), and flew a 4.5º average flight path (glideslope). The pilots lost situational awareness and their attention was channelised or fixated on completing the landing. The PIC did not execute the missed approach at the MAP despite: PAPI showing 3 whites just before entering IMC; the unstabilised approach; the glideslope indicator on the PFD showing a rapid glideslope deviation from half-dot low to 2-dots high within 9 seconds after passing the MDA; the excessive rate of descent; the EGPWS aural alerts: and the EGPWS visual PULL UP warning on the PFD. The copilot (support/monitoring pilot) was ineffective and was oblivious to the rapidly unfolding unsafe situation. It is likely that a continuous “WHOOP WHOOP PULL UP”70 hard aural warning, simultaneously with the visual display of PULL UP on the PFD (desirably a flashing visual display PULL UP on the PFD), could have been effective in alerting the crew of the imminent danger, prompting a pull up and execution of a missed approach, that may have prevented the accident.
Final Report:

Crash of a De Havilland DHC-2 Beaver off Cottage Point: 6 killed

Date & Time: Dec 31, 2017 at 1515 LT
Type of aircraft:
Operator:
Registration:
VH-NOO
Flight Phase:
Survivors:
No
MSN:
1535
YOM:
1963
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
The single engine seaplane was returning to the Rose Bay seaplane base at Sydney when it crashed in unknown circumstances into the Jerusalem Bay, about 30 km north of its destination. The airplane struck the water surface and sank rapidly off Cottage Point. All six occupants were killed.

Crash of a Britten-Norman BN-2A Islander in Saidor Gap: 1 killed

Date & Time: Dec 23, 2017
Type of aircraft:
Operator:
Registration:
P2-ISM
Flight Phase:
Survivors:
No
Site:
Schedule:
Lae – Derim
MSN:
227
YOM:
1970
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While cruising at an altitude of 9,500 feet in adverse weather conditions, the twin engine aircraft struck trees and crashed on the slope of a mountain located in the Saidor Gap, half way from Lae-Nadzab Airport to Derim. Immediately after the crash, the pilot was able to call for help and gave his position. Unfortunately, due to poor weather conditions and the difficulties to reach the crash site, it was not possible for the rescuers to intervene before December 26. Three days after the accident, as the weather conditions improved, the rescuers eventually reached the crash site but it was reported that the pilot died from his injuries.

Crash of a Cessna 441 Conquest II in Renmark: 3 killed

Date & Time: May 30, 2017 at 1630 LT
Type of aircraft:
Operator:
Registration:
VH-XMJ
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Renmark - Adelaide
MSN:
441-0113
YOM:
1980
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
14751
Captain / Total hours on type:
987.00
Copilot / Total flying hours:
5000
Copilot / Total hours on type:
1000
Aircraft flight hours:
13845
Circumstances:
On 30 May 2017, a Cessna 441 Conquest II (Cessna 441), registered VH-XMJ (XMJ) and operated by AE Charter, trading as Rossair, departed Adelaide Airport, South Australia for a return flight via Renmark Airport, South Australia. On board the aircraft were:
• an inductee pilot undergoing a proficiency check, flying from the front left control seat
• the chief pilot conducting the proficiency check, and under assessment for the company training and checking role for Cessna 441 aircraft, seated in the front right control seat
• a Civil Aviation Safety Authority flying operations inspector (FOI), observing and assessing the flight from the first passenger seat directly behind the left hand pilot seat.
Each pilot was qualified to operate the aircraft. There were two purposes for the flight. The primary purpose was for the FOI to observe the chief pilot conducting an operational proficiency check (OPC), for the purposes of issuing him with a check pilot approval on the company’s Cessna 441 aircraft. The second purpose was for the inductee pilot, who had worked for Rossair previously, to complete an OPC as part of his return to line operations for the company. The three pilots reportedly started their pre-flight briefing at around 1300 Central Standard Time. There were two parts of the briefing – the FOI’s briefing to the chief pilot, and the chief pilot’s briefing to the inductee pilot. As the FOI was not occupying a control seat, he was monitoring and assessing the performance of the chief pilot in the conduct of the OPC. There were two distinct exercises listed for the flight (see the section titled Check flight sequences). Flight exercise 1 detailed that the inductee pilot was to conduct an instrument departure from Adelaide Airport, holding pattern and single engine RNAV2 approach, go around and landing at Renmark Airport. Flight exercise 2 included a normal take-off from Renmark Airport, simulated engine failure after take-off, and a two engine instrument approach on return to Adelaide. The aircraft departed from Adelaide at 1524, climbed to an altitude about 17,000 ft above mean sea level, and was cleared by air traffic control (ATC) to track to waypoint RENWB, which was the commencement of the Renmark runway 073 RNAV-Z GNSS approach. The pilot of XMJ was then cleared to descend, and notified ATC that they intended to carry out airwork in the Renmark area. The pilot further advised that they would call ATC again on the completion of the airwork, or at the latest by 1615. No further transmissions from XMJ were recorded on the area frequency and the aircraft left surveillance coverage as it descended towards waypoint RENWB. The common traffic advisory frequency used for air-to-air communications in the vicinity of Renmark Airport recorded several further transmissions from XMJ as the crew conducted practice holding patterns, and a practice runway 07 RNAV GNSS approach. Voice analysis confirmed that the inductee pilot made the radio transmissions, as expected for the check flight. At the completion of the approach, the aircraft circled for the opposite runway and landed on runway 25, before backtracking and lining up for departure. That sequence varied from the planned exercise in that no single-engine go-around was conducted prior to landing at Renmark. At 1614, the common traffic advisory frequency recorded a transmission from the pilot of XMJ stating that they would shortly depart Renmark using runway 25 to conduct further airwork in the circuit area of the runway. A witness at the airport reported that, prior to the take-off roll, the aircraft was briefly held stationary in the lined-up position with the engines operating at significant power. The take-off roll was described as normal however, and the witness looked away before the aircraft became airborne. The aircraft maintained the runway heading until reaching a height of between 300-400 ft above the ground (see the section titled Recorded flight data). At that point the aircraft began veering to the right of the extended runway centreline (Figures 1 and 15). The aircraft continued to climb to about 600 ft above the ground (700 ft altitude), and held this height for about 30 seconds, followed by a descent to about 500 ft (Figures 2 and 13). The information ceased 5 seconds later, which was about 60 seconds after take-off. A distress beacon broadcast was received by the Joint Rescue Coordination Centre and passed on to ATC at 1625. Following an air and ground search the aircraft was located by a ground party at 1856 about 4 km west of Renmark Airport. All on board were fatally injured and the aircraft was destroyed.
Probable cause:
Findings:
From the evidence available, the following findings are made with respect to the collision with terrain involving Cessna 441, registered VH-XMJ, that occurred 4 km west of Renmark Airport,
South Australia on 30 May 2017. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing factors:
• Following a planned simulated engine failure after take-off, the aircraft did not achieve the expected single engine climb performance, or target airspeed, over the final 30 seconds of the flight.
• The exercise was not discontinued when the aircraft’s single engine performance and airspeed were not attained. That was probably because the degraded aircraft performance, or the
associated risk, were not recognised by the pilots occupying the control seats.
• It is likely that the method of simulating the engine failure and pilot control inputs, together or in isolation, led to reduced single engine aircraft performance and asymmetric loss of control.
• Not following the recommended procedure for simulating an engine failure in the Cessna 441 pilot’s operating handbook meant that there was insufficient height to recover following the loss of control.
Other factors that increased risk:
• The Rossair training and checking manual procedure for a simulated engine failure in a turboprop aircraft was inappropriate and, if followed, increased the risk of asymmetric control loss.
• The flying operations inspector was not in a control seat and did not share a communication systems with the crew. Consequently, he had reduced ability to actively monitor the flight and
communicate any identified performance degradation.
• The inductee pilot had limited recent experience in the Cessna 441, and the chief pilot had an extended time period between being training and being tested as a check pilot on this aircraft. While both pilots performed the same exercise during a practice flight the week before, it is probable that these two factors led to a degradation in the skills required to safely perform and monitor the simulated engine failure exercise.
• The chief pilot and other key operational managers within Rossair were experiencing high levels of workload and pressure during the months leading up to the accident.
• In the 5 years leading up to the accident, the Civil Aviation Safety Authority had conducted numerous regulatory service tasks for the air transport operator and had regular communication with the operator’s chief pilots and other personnel. However, it had not conducted a systemic or detailed audit during that period, and its focus on a largely informal and often undocumented approach to oversight increased the risk that organisational or systemic issues associated with the operator would not be effectively identified and addressed.
Other findings:
• A lack of recorded data from this aircraft reduced the available evidence about handling aspects and cockpit communications. This limited the extent to which potential factors contributing to the accident could be analysed.
Final Report: