code

Madang

Crash of an ATR42-300F in Madang

Date & Time: Oct 19, 2013 at 0900 LT
Type of aircraft:
Operator:
Registration:
P2-PXY
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Madang – Tabubil – Kuinga
MSN:
087
YOM:
1988
Location:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7100
Captain / Total hours on type:
3433.00
Copilot / Total flying hours:
3020
Copilot / Total hours on type:
2420
Circumstances:
Aircraft was performing a flight to Kuinga with an intermediate stop at Tabubil with a cargo consisting of 400 boxes of cigarettes for a total weight of 3,710 kilos. While accelerating on runway 25, just two seconds after Vr, captain decided to abort the takeoff procedure because the aircraft did not lift off. He started an emergency brake procedure but the aircraft was unable to stop within the remaining runway. It overrun, went through a fence and down an embankment before coming to rest in flames in the Meiro Creek. All three crew escaped themselves and were uninjured, except one slightly. Aircraft was partially destroyed by impact forces and post impact fire.

Crash of a De Havilland Dash-8-100 near Madang: 28 killed

Date & Time: Oct 13, 2011 at 1717 LT
Operator:
Registration:
P2-MCJ
Survivors:
Yes
Schedule:
Port Moresby - Lae - Madang
MSN:
125
YOM:
1988
Flight number:
CG1600
Location:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
28
Pax fatalities:
Other fatalities:
Total fatalities:
28
Captain / Total flying hours:
18200
Captain / Total hours on type:
500.00
Copilot / Total flying hours:
2725
Copilot / Total hours on type:
391
Aircraft flight hours:
38421
Aircraft flight cycles:
48093
Circumstances:
While approaching Madang, aircraft crashed in a jungle 33 km southeast of Airport. SAR arrived on scene few hours later and evacuated four people seriously injured while all 28 other occupants were killed. While descending to Madang, overspeed alarm sounded in the cockpit while both propellers oversped simultaneously and exceeded their maximum RPM limit by about 60%. Crew sent a mayday message and told ATC that both engines stopped. Shortly later, aircraft hit the ground in a relative flat position and was destroyed by impact forces and post crash fire. The four survivors were the captain, the copilot, a stewardess and a passenger.
Probable cause:
From the evidence available, the following findings are made with respect to the double propeller overspeed 35 km south south east of Madang on 13 October 2011 involving a Bombardier Inc. DHC-8-103 aircraft, registered P2-MCJ. They should not be read as apportioning blame or liability to any organisation or individual.
Contributing safety factors:
 The Pilot-in-Command moved the power levers rearwards below the flight idle gate shortly after the VMO overspeed warning sounded. This means that the release triggers were lifted during the throttle movement.
 The power levers were moved further behind the flight idle gate leading to ground beta operation in flight, loss of propeller speed control, double propeller overspeed, and loss of usable forward thrust, necessitating an off-field landing.
 A significant number of DHC-8-100, -200, and -300 series aircraft worldwide did not have a means of preventing movement of the power levers below the flight idle gate in flight, or a means to prevent such movement resulting in a loss of propeller speed control.
Other safety factors:
 Prior to the VMO overspeed warning, the Pilot-in-Command allowed the rate of descent to increase to 4,200 ft per minute and the airspeed to increase to VMO.
 The beta warning horn malfunctioned and did not sound immediately when one or both of the flight idle gate release triggers were lifted. When the beta warning horn did sound, it did so intermittently and only after the double propeller overspeed had commenced. The sound of the beta warning horn was masked by the noise of the propeller overspeeds.
 There was an uncommanded feathering of the right propeller after the overspeed commenced due to a malfunction within the propeller control beta backup system during the initial stages of the propeller overspeed.
 The right propeller control unit (PCU) fitted to MCJ was last overhauled at an approved overhaul facility which had a quality escape issue involving incorrect application of beta switch reassembly procedures, after a service bulletin modification. The quality escape led to an uncommanded feather incident in an aircraft in the United States due to a beta switch which stuck closed.
 Due to the quality escape, numerous PCU‟s were recalled by the overhaul facility for rectification. The right PCU fitted to MCJ was identified as one of the units that may have been affected by the quality escape and would have been subject to recall had it still been in service.
The FDR data indicated that the right PCU fitted to MCJ had an uncommanded feather, most likely due to a beta switch stuck in the closed position, induced by the propeller overspeed. It was not possible to confirm if the overhaul facility quality escape issue contributed to the beta switch sticking closed, because the PCU was destroyed by the post-impact fire.
 The landing gear and flaps remained retracted during the off-field landing. This led to a higher landing speed than could have been achieved if the gear and flaps had been extended, and increased the impact forces on the airframe and its occupants.
 No DHC-8 emergency procedures or checklists were used by the flight crew after the emergency began.
 The left propeller was not feathered by the flight crew after the engine failed.
 The investigation identified several occurrences where a DHC-8 pilot inadvertently moved one or both power levers behind the flight idle gate in flight, leading to a loss of propeller speed control. Collectively, those events indicated a systemic design issue with the integration of the propeller control system and the aircraft.
Other key findings:
 The flaps and landing gear were available for use after the propeller overspeeds and the engine damage had occurred.
 There was no regulatory requirement to fit the beta lockout system to any DHC-8 aircraft outside the USA at the time of the accident.
 The autopilot could not be used during the accident flight.
 The operator‟s checking and training system did not require the flight crew to have demonstrated the propeller overspeed emergency procedure in the simulator.
 After the accident, the aircraft manufacturer identified a problem in the beta warning horn system that may have led to failures not being identified during regular and periodic tests of the system.
Final Report:

Crash of a Britten-Norman BN-2A-26 Islander in Tep Tep: 8 killed

Date & Time: Dec 13, 2002
Type of aircraft:
Operator:
Registration:
P2-CBB
Flight Phase:
Survivors:
No
Site:
Schedule:
Tep Tep – Madang
MSN:
140
YOM:
1969
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Circumstances:
After takeoff from Tep Tep Airstrip, the twin engine aircraft collided with a cliff located in the Finisterre Mountain Range. The aircraft was destroyed and all eight occupants were killed. This was the inaugural flight from the newly constructed Tep Tep Airstrip.

Crash of a De Havilland DHC-6 Twin Otter 300 near Simbai

Date & Time: Nov 9, 1997 at 1000 LT
Operator:
Registration:
VH-HPY
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Koinambe - Simbai
MSN:
706
YOM:
1980
Location:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2206
Captain / Total hours on type:
576.00
Copilot / Total flying hours:
2460
Copilot / Total hours on type:
900
Aircraft flight hours:
18096
Circumstances:
The flight was one of a series being conducted by No. 173 Surveillance Squadron, 1st Aviation Regiment operating a de Havilland Canada DHC-6 (Twin Otter) aircraft as Exercise Highland Pursuit 2/97. The purpose of the exercise was to provide training for three No. 173 Squadron pilots in tropical mountainous operations in Papua New Guinea (PNG). All trainees were qualified on the aircraft type. The training pilot was the pilot in command. He had extensive experience in flying Twin Otter and other aircraft types in PNG as a civilian pilot and had also flown de Havilland Canada DHC-4 (Caribou) aircraft in PNG as a military pilot. Passengers were not carried on the flight. The plan for 9 November 1997 was to fly from Madang and return via a number of airstrips where landing and take-off exercises would be conducted. A flight plan was submitted to Madang Flight Service. At 0915 PNG time, the aircraft arrived at Koinambe where each trainee conducted landing and take-off practice. During this time, the training pilot occupied the right cockpit seat while the trainees, in turn, flew the aircraft from the left cockpit seat. The crew had flight-planned to track direct from Koinambe to Simbai. However, before departing Koinambe, they assessed that this would not be possible because of haze and cloud on track. The training pilot, who was still occupying the right control position, suggested that they could follow the Jimi River north-west from Koinambe and then one of its tributaries towards Simbai. This involved a right turn off the Jimi River about 37 km from Koinambe to follow the valley that passed about 2 km south of Dusin airstrip and then tracked south-east towards Simbai. The navigating pilot, in the left cockpit seat, suggested that, instead of following the tributary off the Jimi River as suggested by the training pilot, they should follow the valley which extended north-east off the Jimi River from a position about 17 km north-west of Koinambe. This was a shorter route than that suggested by the training pilot. The training pilot agreed that the route could be attempted. Neither during this discussion, nor at any earlier time, was there any reference to the elevation of the Bismarck Range. (The increase in ground elevation from the Jimi River to the Bismarck Range, a straight-line distance of about 17 km, is approximately 7,400 ft.) The crew was using an Operational Navigation Chart (ONC) 1:1,000,000-scale chart for in-flight navigation. After departing Koinambe, the crew began following the Jimi River, flying at about 1,000 ft above ground level (AGL). The training pilot had intended to remain in the right cockpit seat for the short flight to Simbai. However, to gain the maximum benefit from flying time during the exercise, he had adopted the practice of having trainees occupy both cockpit seats during the en-route sectors of the exercise. He would then monitor the progress of the flight from either between the cockpit seats or the aircraft cabin. In this instance, he vacated the right seat for a trainee who then became the flying pilot for the sector. The navigating pilot then made the required radio calls, one on VHF radio and the other (which was unsuccessful at the first attempt) on HF radio to Madang Flight Service to report the departure of the aircraft from Koinambe. A short time later, the navigating pilot became unsure of the aircraft's position. The flying pilot then conducted several left orbits while the navigating pilot obtained a Global Positioning System (GPS) fix and plotted the position on the ONC chart. He indicated on the chart, and received agreement from the training pilot, that he had identified the aircraft's position. The flying pilot then resumed tracking along the river. During this time the training pilot was in the cabin of the aircraft. He was wearing a headset which was equipped with an extension lead to enable him to communicate with the cockpit crew. He was frequently checking the aircraft's position through the cabin side windows. A short time later, the navigating pilot indicated what he believed to be the valley where the aircraft was to turn towards Simbai. The flying pilot turned the aircraft into this valley. He estimated that the aircraft was flying about 500 ft above the treetops at this time. The crew did not conduct a heading check to confirm that they were in the correct valley. When the aircraft was well into the valley, the training pilot heard over the intercom the flying and navigating pilots discussing the progress of the flight. He sensed some unease in their voices and moved forward from the aircraft cabin to a position between the cockpit seats. He immediately realised that the aircraft was at an excessive nose-high pitch angle and in a position from where it could not outclimb the terrain ahead or turn and fly out of the valley. The flying and navigating pilots ensured that the engine and propeller controls were set to full power and maximum RPM and selected 10 degrees flap. However, the training pilot assessed that impact with the trees was imminent. He ensured that the trainee seated in the cabin was strapped into his seat and then positioned himself on the floor aft of, and against, the cabin bulkhead. The stall warning activated at that time and, almost immediately, the aircraft crashed through the trees to the ground. When the crew had not reported to flight service by 1004, communication checks were initiated. An uncertainty phase was declared at 1023 when there was no contact with the crew. At 1045, this was upgraded to a distress phase after the pilot of a helicopter operating in the area reported that the aircraft was not on the ground at Simbai airstrip. The pilot of the helicopter was tasked with tracking from Simbai to Koinambe in an attempt to locate the aircraft. At 1127, the helicopter pilot reported receiving a strong emergency locator transmitter signal and, shortly after, located the accident site in a valley about 9 km south of Simbai.
Probable cause:
The following factors were identified:
1. There had been a significant loss of corporate knowledge, experience and risk appreciation within the Army concerning the operation of Twin Otter type aircraft in tropical mountainous areas.
2. No training needs analysis for the exercise had been conducted.
3. The tasking and briefing of the training pilot were incomplete.
4 The training pilot did not adequately assess the skill development needs of the trainees.
5. The supervision of the flight by the training pilot was inadequate.
6. The scale of chart used by the crew was not appropriate for the route they intended to fly.
Final Report:

Crash of a Britten-Norman BN-2A-21 Islander in Begesin: 2 killed

Date & Time: Dec 22, 1995
Type of aircraft:
Operator:
Registration:
P2-NAM
Survivors:
Yes
Schedule:
Madang - Bundi
MSN:
207
YOM:
1970
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
While approaching Bundi Airport on a flight from Madang, the pilot decided to divert to Begesin Airport for unknown reason. On final approach to Begesin Airstrip, he extended the approach and landed too far down the runway. Unable to stop within the remaining distance, the aircraft overran and crashed in a ravine. The pilot and a passenger were killed.

Crash of a Fokker F28 Fellowship 1000 in Madang

Date & Time: May 31, 1995 at 2210 LT
Type of aircraft:
Operator:
Registration:
P2-ANB
Survivors:
Yes
Schedule:
Port Moresby – Lae – Madang
MSN:
11049
YOM:
1972
Flight number:
PX128
Location:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
35
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Lae, the crew started the approach to Madang Airport runway 25. The visibility was limited by night and poor weather conditions. In heavy rain falls, the captain realized that all conditions were not met to land and decided to initiate a go-around. Following a short holding pattern, he started the approach to runway 07. The aircraft landed 300 metres past the runway threshold. On a wet runway surface, the aircraft was unable to stop within the remaining distance, overran and came to rest in a ravine. Due to torrential rain, all 39 occupants preferred to stay in the aircraft and were evacuated few dozen minutes later only. The aircraft was damaged beyond repair.
Probable cause:
The crew adopted a wrong approach configuration, causing the aircraft to land 300 metres past the runway threshold, reducing the landing distance available. The following contributing factors were reported:
- All conditions were not met for a safe landing,
- Wet runway surface,
- Poor braking action,
- Poor weather conditions,
- Limited visibility,
- Aquaplaning,
- Poor flight and approach planning.

Crash of a Britten-Norman BN-2A-21 Islander in Bank: 4 killed

Date & Time: Oct 13, 1993
Type of aircraft:
Operator:
Registration:
P2-HBE
Flight Phase:
Survivors:
No
Site:
Schedule:
Bank - Mount Hagen
MSN:
815
YOM:
1978
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
After takeoff from Bank Airstrip, while climbing in the Simbai Valley, the twin engine aircraft struck the slope of a mountain and crashed about 5,3 km from Bank Airfield. All four occupants were killed.
Probable cause:
The aircraft did not have sufficient power to complete a steep climb as expected by the crew. Apparently, the aircraft stalled while completing a last turn due to an insufficient speed. Poor judgment on part of the crew.

Crash of a Cessna 402A on Mt Otto

Date & Time: Aug 29, 1986
Type of aircraft:
Operator:
Registration:
P2-GKP
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Madang - Goroka
MSN:
402A-0121
YOM:
1969
Location:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot started the descent to Goroka in marginal weather conditions when the aircraft struck trees and crashed on the slope of Mt Otto located 15 km northeast of Goroka Airport. All three occupants were injured and the aircraft was destroyed.

Crash of a Britten-Norman BN-2A Trislander III in Annanberg: 4 killed

Date & Time: Nov 17, 1980
Type of aircraft:
Registration:
VH-BSG
Flight Phase:
Survivors:
Yes
MSN:
279
YOM:
1971
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
15
Pax fatalities:
Other fatalities:
Total fatalities:
4
Circumstances:
After liftoff from Annanberg Airfield, the three engine airplane encountered difficulties to gain height, stalled and crashed in the Ramu River. Four passengers were drowned while 12 other occupants were injured. The aircraft was destroyed.
Probable cause:
The aircraft was overloaded for such takeoff configuration, terrain and airfield.

Crash of a Cessna 402A near Annanberg

Date & Time: Jan 27, 1975
Type of aircraft:
Registration:
P2-SAB
Flight Phase:
MSN:
402A-0061
YOM:
1969
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Crashed in unknown circumstances in the Ramu River near Annanberg. Crew fate remains unknown.