Crash of a Pacific Aerospace 750XL Falcon 3000 near Tiniroto: 2 killed

Date & Time: Dec 12, 2016 at 0857 LT
Operator:
Registration:
ZK-JPU
Flight Phase:
Flight Type:
Survivors:
No
Site:
MSN:
117
YOM:
2005
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
8518
Captain / Total hours on type:
3210.00
Aircraft flight hours:
8028
Circumstances:
At approximately 0500 hrs, 12 December 2016, the pilot of ZK-JPU, arrived at Gisborne Aerodrome. The pilot was accompanied by the operator’s recently employed (trainee) loader driver and already at the hangar was a senior loader driver. The pilot conducted the preflight checks of the aircraft for the day’s agricultural aircraft operations. Earlier that morning the Managing Director of the operator had called the pilot of ZK-JPU. The Managing Director requested that after finishing the first aerial topdressing task at Tauwharetoi Station and prior to the next planned task at Waimaha Station, the pilot complete a task at Pembroke Station. This was because the Managing Director was unwell and unable to undertake the Pembroke Station task as planned. The pilot of ZK-JPU agreed to the additional task. The original work plan for the day was for both loader drivers to attend the first task at Tauwharetoi Station, with the senior loader driver providing oversight for the trainee loader driver. The pilot and the senior loader driver were then to proceed to the second task of the day, while the trainee loader driver was scheduled to return to the aerodrome with the loader truck from the first task. The expectation was for the pilot to go straight from the Tauwharetoi Station task to the Pembroke Station task and then proceed to Waimaha Station. ZK-JPU departed Gisborne Aerodrome at approximately 0515 hrs with the pilot and both loader drivers on board. The aircraft was to operate from a nearby private airstrip where the loader truck was already located, as the task had been commenced the previous week. The aircraft landed at the airstrip at approximately 0530 hrs and the pilot assisted the senior loader driver to get the truck ready, double-checking the calibration of the weigh scales and fuel drain, before commencing the task at approximately 0600 hrs. On the day of the accident another pilot from the same operator, who was operating a similar Pacific Aerospace Ltd 750XL, ZK-XLA, was aerial topdressing an area of Bushy Knoll Station, operating off the Tongataha airstrip. Bushy Knoll Station is to the north of Tauwharetoi Station, alongside the route to the next two tasks scheduled for ZK-JPU at Pembroke and Waimaha Stations. The pilot of ZK-XLA commenced operating at approximately 0555 hrs and completed two to three loads before hearing the pilot of ZK-JPU over the radio at approximately 0615 hrs. The brief conversation that followed consisted of an exchange of greetings and description of locations and intentions. Both pilots then continued with their tasks without further direct communication. On completion of the first task the pilot of ZK-JPU landed at the private airstrip and instructed the senior loader driver to pack up the gear and head back to base. The senior loader driver refuelled the aircraft with 100 litres of fuel, packed up the gear and gave the trainee loader driver the radio which had been used to communicate with the pilot. After a 15 minute break the pilot of ZK-JPU was observed by the senior loader driver getting into the left seat of the aircraft and the trainee loader driver into the right seat. The senior loader driver observed ZK-JPU take off, and then departed the airstrip in the loader truck, to return to the aerodrome. At approximately 0850 the pilot of ZK-XLA received a radio call from the pilot of ZKJPU asking “are you breaking left or right?” followed by the pilot of ZK-JPU stating “I am to your left”. ZK-JPU was then observed by the pilot of ZK-XLA flying behind and to the left of ZK-XLA. The pilot of ZK-XLA advised the pilot of ZK-JPU that he was “sowing the boundary of Bushy Knoll Station […] finishing my run and […] turning right to head back to the airstrip”. Spanning the valley near the boundary of Bushy Knoll Station, near to where the pilot of ZK-XLA was operating were a set of 110 kV high voltage power lines (consisting of six wires termed ‘conductors’, supported by towers). These conductors comprised the two circuits supplying electricity to Gisborne and the East Coast region. The span traverses the valley approximately east-west and the height above terrain at the mid-span of the bottom two conductors (the lowest point of the span) was approximately 200 ft. At 0857 hrs the power supply to Gisborne and the East Coast was interrupted. Finishing the topdressing run, the pilot of ZK-XLA commenced a right climbing turn in order to return to the airstrip and sighted ZK-JPU over his right shoulder. At this point the pilot of ZK-XLA noted that something was trailing from the left wing of ZKJPU. Realising that the item trailing from ZK-JPU’s wing was a wire, the pilot of ZKXLA transmitted “you are trailing wire’’, however no response was received from ZK-JPU. The pilot of ZK-XLA witnessed ZK-JPU continue down the valley, slowly rolling to the left before impacting terrain, approximately 700 m further to the south. A postimpact fire ensued with the pilot of ZK-XLA observing “a lot of black smoke”. The pilot of ZK-XLA immediately commenced circling the accident site and attempted to call the operator via cellphone. Unable to make contact the pilot activated the emergency communications facility on the flight following equipment installed in the aircraft and reported the accident to Gisborne Tower. The accident occurred in daylight at 0857 hrs, approximately 24 NM W of Gisborne Aerodrome, at Latitude: S 38° 44' 30.85" Longitude: E 177° 28' 37.41".
Probable cause:
Conclusions
3.1 The aircraft struck six 110 kV high voltage power lines.
3.2 The pilot likely experienced inattentional blindness, in that the pilot’s attention was likely engaged on the other aircraft and thus the pilot failed to perceive the visual stimuli.
3.3 The pilot was appropriately rated and licensed to conduct the flight.
3.4 Research has shown that striking a wire that the pilot was aware of usually occurred because something changed, such as a last minute change of plan.
3.5 The pilot elected to change the plan at the last minute and detour during the positioning flight to an area where a pilot from the same operator was also conducting aerial topdressing.
3.6 The pilot did not conduct a hazard briefing for the area about to be flown and thus did not afford himself the most accurate and well informed mental model of the area the pilot elected to operate in.
3.7 Several human factors likely influenced the pilot’s decision-making and risk perception leading to the decision to change the original plan and deviate from the minimum heights as stipulated by CAR 91.311 and operators SOPs.
3.8 The safety investigation did not identify any mechanical defects which may have contributed to the accident.
3.9 The accident was not survivable.
Final Report:

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
Aircraft flight hours:
2407
Aircraft flight cycles:
2886
Circumstances:
On the afternoon of 13 April 2016, a Pilatus Britten Norman Turbine Islander (BN-2T) aircraft, registered P2-SBC, operated by Sunbird Aviation Ltd, departed from Tekin, West Sepik Province for Kiunga, Western Province, as a charter flight under the visual flight rules. On board were the pilot-in-command (PIC) and 11 passengers (eight adults and three children). The aircraft was also carrying vegetables. The pilot reported departing Oksapmin at 13:56. The pilot had flight planned, Kiunga to Oksapmin to Kiunga. However, the evidence revealed that without advising Air Traffic Services, the pilot flew from Oksapmin to Tekin. On departure from Tekin the pilot transmitted departure details to ATS, stating departure from Oksapmin. The recorded High Frequency radio transmissions were significantly affected by static and hash. The weather at Kiunga was reported to be fine. As the aircraft entered the Kiunga circuit area, the pilot cancelled SARWATCH with Air Traffic Services (ATS). The pilot did not report an emergency to indicate a safety concern. Witnesses reported that during its final approach, the aircraft suddenly pitched up almost to the vertical, the right wing dropped, and the aircraft rolled inverted and rapidly “fell to the ground”. It impacted the terrain about 1,200 metres west of the threshold of runway 07. The impact was vertical, with almost no forward motion. The aircraft was destroyed, and all occupants were fatally injured.
Probable cause:
The aircraft’s centre of gravity was significantly aft of the aft limit. When landing flap was set, full nose-down elevator and elevator trim was likely to have had no effect in lowering the nose of the aircraft. Unless the flaps had been retracted immediately, the nose-up pitch may also have resulted in tail plane stall, exacerbating the pitch up. The wings stalled, followed immediately by the right wing dropping. Recovery from the stall at such a low height was not considered possible.
Other factors:
Other factors is used for safety deficiencies or concerns that are identified during the course of the investigation, that while not causal to the accident, nevertheless should be addressed with the
aim of accident and serious incident prevention, and the safety of the travelling public.
a) Following the reweighing of SBC, the operator did not make adjustments to account for the shift of the moment arm as a result of the reweighing. Specifically, a reduction of allowable maximum weight in the baggage compartment.
b) The pilot, although signing the flight manifest on previous flights attesting that the aircraft was loaded within c of g limits, had not computed the c of g. No documentation was available to confirm that the pilot had computed the c of g for the accident flight, or any recent flights.
c) All of the High Frequency radio transmissions between Air Traffic Services and SBC were significantly affected by static interference and a lot of hash, making reception difficult, and many transmissions unclear and unreadable. This is a safety concern to be addressed to ensure that vital operational radio transmissions are not missed for the safety of aircraft operations, and the travelling public.
Final Report:

Crash of a Cessna 208 Caravan I in Whitsunday Island

Date & Time: Jan 28, 2016 at 1518 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
Captain / Total flying hours:
1350
Captain / Total hours on type:
230.00
Aircraft flight hours:
1510
Circumstances:
On 28 January 2016 the pilot of a Cessna Aircraft Company Caravan 208 amphibian aircraft, registered VH-WTY (WTY) was conducting a series of charter flights in the Whitsunday region of Queensland. The pilot was conducting his third flight of the day when the aircraft departed Hamilton Island Airport at about 1415 Eastern Standard Time with 10 passengers on board. The tour included a scenic flight over the Great Barrier Reef for about 50 minutes before heading to Chance Bay, on the south-east tip of Whitsunday Island, about 11 km north east of Hamilton Island Airport. Following a water landing at Chance Bay, the group was to spend 90 minutes at the beach before a short flight back to Hamilton Island. The tour was originally planned to include a landing at Whitehaven Beach, however wind conditions at the time required the water landing be altered to Chance Bay. Radar surveillance data showed WTY approach Whitsunday Island from the north and conduct an orbit about 2 km north of Whitehaven Beach at about 1510, before heading toward Whitehaven Beach. WTY flew over the southern end of Whitehaven Beach and the strip of land that separates it from Chance Bay. At about 1515, after crossing Chance Bay beach in a southerly direction, WTY descended below radar surveillance for the remainder of the flight. The pilot advised that he flew WTY over the western end of Chance Bay’s main beach in order to conduct a visual pre-landing check of the bay. The pilot noted the positions of various vessels moored in the bay to determine the best taxi path to the beach. During this fly-over, the pilot also noted the sea state and observed evidence of wind gusts on the water surface. The pilot then initiated a right downwind turn toward the landing area. The approach was from the south with the intent to land in the most suitable location within the designated landing area and then taxi to the beach. The pilot reported setting up for landing at about 50 ft above the water and then delayed the landing in order to fly through an observed wind gust. Passenger video footage indicated that, during the subsequent landing, WTY bounced three times on the surface of the water. After the second bounce, with WTY getting closer to the beach and terrain, the pilot increased engine power and initiated a go-around. The third bounce, which occurred almost immediately after the second, was the most pronounced and resulted in the aircraft rebounding about 30 to 50 ft above the water. While increasing power, the pilot perceived that the torque was indicating red, suggesting an over-torque for the selected propeller configuration. Noticing that the climb performance was less than expected with the flaps at 30˚, the pilot stopped increasing power and reduced the flap to 20˚. As the aircraft climbed straight ahead towards a saddle, climb performance was still below the pilot’s expectations and he assessed that WTY would not clear the terrain. In response, the pilot turned right to avoid the surrounding rising terrain. WTY clipped trees during this turn, before colliding with terrain and coming to rest in dense scrub about 150 m from the eastern end of the main beach, near the top of the ridge. The pilot promptly advised the passengers to exit and move away from the aircraft. Some of the 11 people on board suffered minor injuries but all were able to quickly leave the aircraft. There was no post-impact fire. The aircraft’s fixed emergency beacon self-activated during the collision with terrain and was detected by the Australian Maritime Safety Authority (AMSA), resulting in a search and rescue response being initiated by the Joint Rescue Coordination Centre (JRCC) Australia. The pilot reported also activating his personal locator beacon, however this was not detected by AMSA. In addition, the pilot used the company satellite phone to advise the operator of the occurrence and current status of all on board. At about the same time, several witnesses who were located in Chance Bay made their way to the aircraft before assisting everyone down to the beach. A tourist boat was utilized to transfer the pilot and passengers to Hamilton Island, arriving at about 1600. From there, one passenger was transferred by helicopter to Mackay for further treatment.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain involving amphibian Cessna Aircraft Company C208 Caravan aircraft, registered VH-WTY that occurred at Chance Bay, 11 km north-east of Hamilton Island airport, Queensland, on 28 January 2016. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing factors:
- The aircraft's initial touches with water were past the nominated decision point and beyond the northern boundary of the ALA, which reduced the safety margins available for a successful water landing or go-around.
- The pilot initiated a go-around without using all available power and the optimal speed, turned towards higher terrain and placed the aircraft in a down-wind situation, which ultimately resulted in the collision with terrain.
Other findings:
- The aircraft was equipped with lap-sash seatbelts, which have been demonstrated to reduce injury, and the use of emergency beacons and satellite phone facilitated a timely response to the accident.
Final Report:

Crash of a Cessna 550 Citation Bravo in Lismore

Date & Time: Sep 25, 2015 at 1300 LT
Type of aircraft:
Operator:
Registration:
VH-FGK
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lismore - Baryulgil
MSN:
550-0852
YOM:
1998
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
5937
Copilot / Total flying hours:
377
Aircraft flight hours:
2768
Circumstances:
On the morning of 25 September 2015, the captain and copilot of a Cessna 550 aircraft (Citation Bravo), registered VH-FGK, prepared to conduct a private flight from Lismore Airport to Baryulgil, about 40 NM south-west of Lismore, New South Wales. The aircraft had been parked at the northern end of the airport overnight, with engine covers and control locks on. After arriving at the airport, the flight crew conducted a pre-flight inspection, with no abnormalities identified. They then commenced the normal pre-start checks, which included the disengagement of the flight control locks. The crew elected to use runway 15 for take-off, and used the Cessna simplified take-off performance criteria (see Take-off performance simplified criteria) to determine the thrust settings and take-off reference speeds. The resultant reference speeds were 105 kt for the decision speed (V1) and 108 kt for the rotation speed (VR). At about 1300 Eastern Standard Time, the flight crew started the engines and performed the associated checks, with all indications normal. The crew reported that they completed the after start checks, and the captain then taxied the aircraft to the holding point for runway 15, less than 200 m from where the aircraft was parked. While stopped at the holding point, the crew completed the taxi and pre-take-off checks, the copilot broadcast the standard calls on the common traffic advisory frequency, and the captain communicated with air traffic control (ATC). The captain taxied the aircraft onto the runway, and turned left onto the runway centreline to commence the take-off run from the intersection. While rolling along the runway, the captain advanced the thrust levers to the approximate take-off setting. The captain then called ‘set thrust’, and the copilot set the thrust levers to the more precise position needed to achieve the planned engine thrust for the take-off. As the aircraft accelerated, the copilot called ‘80 knots’ and crosschecked the two airspeed indicators were in agreement and reading 80 kt. The copilot called ‘V1’ and the captain moved their hands from the thrust levers to the control column in accordance with the operator’s normal procedure. A few seconds later, the copilot called ‘rotate’ and the captain initiated a normal rotate action on the control column. The crew reported that the aircraft did not rotate and that they did not feel any indication that the aircraft would lift off. The copilot looked outside and did not detect any change in the aircraft’s attitude as would normally occur at that stage. The captain stated to the copilot that the aircraft would not rotate, and pulled back harder on the control column. The copilot looked across and saw the captain had pulled the control column firmly into their stomach. Although the aircraft’s speed was then about 112 kt, and above VR, the crew did not detect any movement of the attitude director indicator or the nose wheel lifting off the ground, so the captain rejected the take-off; applied full brakes, and set the thrust levers to idle and then into reverse thrust. The aircraft continued to the end of the sealed runway and onto the grass in the runway end safety area (RESA), coming to rest slightly left of the extended centreline, about 100 m beyond the end of the runway. The aircraft sustained substantial damage and the flight crew, who were the only occupants of the aircraft, were uninjured. The nose landing gear separated from the aircraft during the overrun, and there was significant structural damage to the fuselage and wings. The right wheel tyre had deflated due to an apparent wheel lockup and flat spot, which had progressed to a point that a large hole had been worn in the tyre.
Probable cause:
Contributing factors:
- There was probably residual braking pressure in the wheel brakes during the take-off run.
- The aircraft’s parking brake was probably applied while at the holding point and not disengaged before taxing onto the runway for take-off.
- The Citation aircraft did not have an annunciator light to show that the parking brake is engaged, and the manufacturer’s before take-off checklist did not include a check to ensure the parking brake is disengaged.
- The aircraft experienced a retarded acceleration during the take-off run, and did not rotate as normal when the appropriate rotate speed was reached, resulting in a critical rejected take-off
and a runway overrun.
Final Report:

Crash of a Rockwell 500U Shrike Commander in Badu Island

Date & Time: Mar 8, 2015 at 1230 LT
Operator:
Registration:
VH-WZV
Flight Phase:
Survivors:
Yes
Schedule:
Badu Island - Horn Island
MSN:
500-1656-11
YOM:
1966
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 8 March 2015, the pilot of an Aero Commander 500 aircraft, registered VH-WZV, prepared to conduct a charter flight from Badu Island to Horn Island, Queensland, with five passengers. The aircraft had been refuelled earlier that day at Horn Island, where the pilot conducted fuel drains with no contaminants found. He had operated the aircraft for about 2 hours prior to landing at Badu Island with no abnormal performance or indications. At about 1330 Eastern Standard Time (EST), the pilot started the engines and conducted the standard checks with all indications normal, obtained the relevant clearances from air traffic control, and taxied for a departure from runway 30. As the pilot lined the aircraft up on the runway centreline at the threshold, he performed a pre-take-off safety self-brief and conducted the pre-takeoff checks. He then applied full power, released the brakes and commenced the take-off run. All engine indications were normal during the taxi and commencement of the take-off run. When the airspeed had increased to about 80 kt, the pilot commenced rotation and the nose and main landing gear lifted off the runway. Just as the main landing gear lifted off, the pilot detected a significant loss of power from the left engine. The aircraft yawed to the left, which the pilot counteracted with right rudder. He heard the left engine noise decrease noticeably and the aircraft dropped back onto the runway. The pilot immediately rejected the take-off; reduced the power to idle, and used rudder and brakes to maintain the runway centreline. The pilot initially assessed that there was sufficient runway remaining to stop on but, due to the wet runway surface, the aircraft did not decelerate as quickly as expected and he anticipated that the aircraft would overrun the runway. As there was a steep slope and trees beyond the end of the runway, he steered the aircraft to the right towards more open and level ground. The aircraft departed the runway to the right, collided with a fence and a bush resulting in substantial damage. The pilot and passengers were not injured.
Final Report:

Crash of a Pacific Aerospace PAC 750XL in Taupo Lake

Date & Time: Jan 7, 2015 at 1216 LT
Operator:
Registration:
ZK-SDT
Flight Phase:
Survivors:
Yes
Schedule:
Taupo - Taupo
MSN:
122
YOM:
2005
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
12
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
588
Captain / Total hours on type:
14.00
Circumstances:
On 7 January 2015 a Pacific Aerospace Limited 750XL aeroplane was being used for tandem parachuting (or ‘skydiving’) operations at Taupō aerodrome. During the climb on the fourth flight of the day, the Pratt & Whitney Canada PT6A-34 engine failed suddenly. The 12 parachutists and the pilot baled out of the aeroplane and landed without serious injury. The aeroplane crashed into Lake Taupō and was destroyed.
Probable cause:
The following findings were identified:
- The first compressor turbine blade failed after a fatigue crack, which had begun at the trailing edge, propagated towards the leading edge. The blade finally fractured in tensile overload. The separated blade fragment caused other blades to fracture and the engine to stop.
- The fatigue crack in the trailing edge of the blade was likely initiated by the trailing edge radius having been below the specification for a new blade.
- The P&WC Repair Requirement Document 725009-SRR-001, at the time the blades were overhauled, had generic requirements for trailing edge thickness inspections but did not specify a minimum measurement for the trailing edge radius.
- The higher engine power settings used by the operator since August 2014 were within the flight manual limits. Therefore it was unlikely that the operator’s engine handling policy contributed to the engine failure.
- The operator had maintained the engine in accordance with an approved, alternative maintenance programme, but the registration of the engine into that programme had not been completed. The administrative oversight did not affect the reliability of the engine or contribute to the blade failure.
- It was likely that the maintenance provider had not followed fully the engine manufacturer’s recommended procedure for inspecting the compressor turbine blades. It could not be determined whether the crack might have been present, and potentially detectable, at the most recent borescope inspection.
- The operator had not equipped its pilots with flotation devices to cover the possibility of a ditching or an emergency bale-out over or near water.
- The pilot had demonstrated that he was competent and he had the required ratings. However, it was likely that the operator’s training of the pilot in emergency procedures was inadequate. This contributed to the pilot making a hasty exit from the aeroplane that jeopardized others.
Final Report:

Crash of a Fletcher FU-24-954 in Mount Linton

Date & Time: Nov 14, 2014 at 1300 LT
Type of aircraft:
Operator:
Registration:
ZK-EMN
Flight Phase:
Survivors:
Yes
MSN:
265
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot was engaged in an agricultural spraying mission. In unknown circumstances, the single engine aircraft impacted terrain and came to rest against a small hill in Mount Linton. The aircraft was damaged beyond repair and the pilot, sole aboard, was seriously injured.

Crash of a De Havilland DHC-6 Twin Otter 300 near Port Moresby: 4 killed

Date & Time: Sep 20, 2014 at 0935 LT
Operator:
Registration:
P2-KSF
Survivors:
Yes
Site:
Schedule:
Woitape - Port Moresby
MSN:
528
YOM:
1977
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
19290
Captain / Total hours on type:
5980.00
Copilot / Total flying hours:
432
Copilot / Total hours on type:
172
Aircraft flight hours:
34327
Aircraft flight cycles:
46302
Circumstances:
A DHC-6 Twin Otter aircraft was returning from Woitape, Central Province, to Jacksons Airport, Port Moresby on the morning of 20 September 2014 on a charter flight under the instrument flight rules (IFR). The weather at Woitape was reported to have been clear, but at Port Moresby the reported weather was low cloud and rain. Witnesses reported that the summit of Mt Lawes (1,700 ft above mean sea level (AMSL)) was in cloud all morning on the day of the accident. When the aircraft was 36 nm (67 km) from Port Moresby, air traffic control gave the flight crew a clearance to descend maintaining visual separation from terrain and to track to a left base position for runway 14 right (14R) at Jacksons Airport, Port Moresby. The clearance was accepted by the crew. When the aircraft was within 9.5 nm (17.5 km) of the airport, the pilot in command (PIC) contacted the control tower and said that they were “running into a bit of cloud” and that they “might as well pick up the ILS [instrument landing system] if it’s OK”. The flight crew could not have conducted an ILS approach from that position. They could have discontinued their visual approach and requested radar vectoring for an ILS approach. However, they did not do so. The Port Moresby Aerodrome Terminal Information Service (ATIS), current while the aircraft was approaching Port Moresby had been received by the flight crew. It required aircraft arriving at Port Moresby to conduct an ILS approach. The PIC’s last ILS proficiency check was almost 11 months before the accident flight. A 3-monthly currency on a particular instrument approach is required under PNG Civil Aviation Rule 61.807. It is likely the reason the PIC did not request a clearance to intercept the ILS from 30 nm (55.5 km) was that he did not meet the currency requirements and therefore was not authorized to fly an ILS approach. During the descent, although the PIC said to the copilot ‘we know where we are, keep it coming down’, it was evident from the recorded information that his assessment of their position was incorrect and that the descent should not have been continued. The PIC and copilot appeared to have lost situational awareness. The aircraft impacted terrain near the summit of Mt Lawes and was substantially damaged by impact forces. Both pilots and one passenger were fatally injured in the impact, and one passenger died on the day after the accident from injuries sustained during the accident. Of the five passengers who survived the accident, three were seriously injured and two received minor injuries. One of the fatally injured passengers was not wearing a seat belt.
Probable cause:
The following contributing factors were identified:
- The flight crew continued the descent in instrument meteorological conditions without confirming their position.
- The flight crew’s assessment of their position was incorrect and they had lost situational awareness
- The flight crew deprived themselves of the “Caution” and “Warning” alerts that would have sounded about 20 sec and about 10 sec respectively before the collision, by not deactivating the EGPWS Terrain Inhibit prior to departure from Woitape.
Final Report:

Crash of a Beechcraft 200C Super King Air in Nouméa

Date & Time: Sep 9, 2014 at 1150 LT
Operator:
Registration:
F-GRSO
Flight Type:
Survivors:
Yes
Schedule:
Lifou – Nouméa
MSN:
BL-11
YOM:
1980
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine airplane departed Lifou Airport on an ambulance flight to Nouméa-Magenta Airport, carrying two passengers and two pilots. On approach to Magenta Airport, the crew followed the checklist and lower the landing gears. As all three green light failed to came on the cockpit panel, the crew elected to lower the gears manually without success. The crew completed two low passes in front of the control tower and it was confirmed that the left main gear seems to be down but not locked. After a 45-minute flight to burn fuel, the crew completed the landing. Upon touchdown, both main landing gear collapsed while the nose gear remained extended. The aircraft slid for few dozen metres before coming to rest. All four occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The rupture of two teeth of the sprocket of the control cylinder of the left main landing gear caused the cylinder to be locked and thus caused the mechanical system to extend the landing gear. This blockage prevented the complete extension and locking of the landing gear. This rupture and other damage to the two main landing gear actuators was probably the result of improper installation of the toothed gear and / or improper adjustment of the assembly.
Final Report:

Crash of a PAC-750XTOL in Golgubip

Date & Time: Jul 19, 2014 at 1143 LT
Operator:
Registration:
P2-RNB
Survivors:
Yes
Schedule:
Kiunga – Golgubip
MSN:
190
YOM:
2013
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2930
Captain / Total hours on type:
1900.00
Aircraft flight hours:
143
Circumstances:
A Pacific Aerospace PAC P-750 XTOL single engine aircraft was chartered to transport store goods and six passengers from Kiunga to Golgubip. Although Golgubip is in mountainous terrain and the weather in the area is often poor, the pilot was tasked to fly there without ever having been to Golgubip before. The terrain to the north north east of Golgubip rises gradually behind the airstrip. Visual illusions which may affect the pilot’s perception of height and distance can be associated with airstrips situated in terrain of this kind. On arrival at Golgubip, the pilot orbited and positioned the aircraft for landing. During the final approach he decided to discontinue the approach and to initiate a go-around procedure. The aircraft impacted terrain approximately 500 metres northwest of the airstrip and was substantially damaged. The six passengers were unhurt while the pilot sustained serious injuries. The pilot was treated in Golgubip following the accident, and was airlifted the next day to Tabubil, where he was admitted to hospital. It was later reported that the GPWS alarm sounded on approach until the final impact.
Probable cause:
Loss of control on final approach, maybe following visual illusions.
Final Report: