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, he 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
Circumstances:
Shortly after takeoff from runway 25 at Renmark Airport, while in initial climb, the twin engine aircraft went out of control and crashed in a desert area located 4 km west of the airfield. The aircraft was destroyed and all three crew members were killed. They were performing a training mission (check flight) from Adelaide to Renmark and back.

Crash of a Beechcraft Super King Air B200 in Melbourne: 5 killed

Date & Time: Feb 21, 2017 at 0859 LT
Registration:
VH-ZCR
Flight Phase:
Survivors:
No
Site:
Schedule:
Melbourne - King Island
MSN:
BB-1544
YOM:
1996
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
Shortly after takeoff from Melbourne-Essendon Airport runway 17, while in initial climb, the pilot encountered technical problems and declared an emergency. The twin engine aircraft then banked left and crashed in flames onto a shopping mall located near the airport. The aircraft was destroyed upon impact and all five occupants have been killed. Apparently, an engine failed during initial climb, forcing the crew to return.

Crash of a Grumman G-73 Mallard in Perth: 2 killed

Date & Time: Jan 26, 2017
Type of aircraft:
Operator:
Registration:
VH-CQA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Serpentine - Serpentine
MSN:
J-35
YOM:
1948
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The aircraft left Serpentine Airfield at 1628LT with a pilot and his wife on board. They were performing a demo flight vertical to Perth and the Swan River to take part to the Australian Day celebrations. While cruising at an altitude of about 150 feet, the pilot attempted a turn to the left when the aircraft lost height and crashed in a near vertical attitude into the Swan River. The aircraft was destroyed upon impact and both occupants were killed.

Crash of a Pacific Aerospace Falcon 3000XL near Tiniroto: 2 killed

Date & Time: Dec 12, 2016 at 0900 LT
Operator:
Registration:
ZK-JPU
Flight Phase:
Survivors:
No
Site:
MSN:
117
YOM:
2004
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
While flying at low height northwest of Tiniroto, the single engine airplane hit power cables and crashed in a wooded area. Both occupants were killed. Power between Wairoa and Gisborne was cut. The aircraft was a PAC750XL model built in 2004, modified in 2011 and renamed Pacific Aerospace Falcon 3000XL.

Crash of a Britten-Norman BN-2T Islander in Kiunga: 12 killed

Date & Time: Apr 13, 2016 at 1420 LT
Type of aircraft:
Operator:
Registration:
P2-SBC
Survivors:
No
Schedule:
Oksapmin – Kiunga
MSN:
3010
YOM:
1983
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
12
Captain / Total flying hours:
4705
Captain / Total hours on type:
254.00
Circumstances:
The twin engine aircraft left Oksapmin at 1356LT for a short VFR flight to Kiunga. On final approach, the aircraft pitched up, almost vertically, banked right, stalled and crashed in a wooded area located 1,200 meters short of runway 07 threshold. Two passengers were seriously injured while ten other occupants were killed. Unfortunately, both survivors died from their injuries few hours later. At the time of the loss of control, it is reported that the right propeller was feathered. The below document is a preliminary report from the AIC of PNG.
Final Report:

Crash of a Cessna 208 Caravan I in Whitsunday Island

Date & Time: Jan 28, 2016 at 1530 LT
Type of aircraft:
Operator:
Registration:
VH-WTY
Survivors:
Yes
Schedule:
Hamilton Island - Whitsunday Island
MSN:
208-0522
YOM:
2010
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine float equipped aircraft left the harbor of Hamilton Island on a local flight to the neighboring island of Whitsunday with a pilot and 10 tourists on board. The approach to the Chance Bay was tricky with rough sea. Upon landing, the seaplane bounced several times and then continued over the beach. It eventually went into a wooded area, cut several trees and came to rest in a forest. Six occupants were injured while five others were unhurt. The aircraft was destroyed.