Crash of a De Havilland DHC-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:
On the afternoon of 13 October 2011, an Airlines PNG Bombardier DHC-8-103, registered P2-MCJ (MCJ), was conducting a regular public transport flight from Nadzab, Morobe Province, to Madang, Madang Province under the Instrument Flight Rules (IFR). On board the aircraft were two flight crew, a flight attendant, and 29 passengers. Earlier in the afternoon, the same crew had flown MCJ from Port Moresby to Nadzab. The autopilot could not be used because the yaw damper was unserviceable so the aircraft had to be hand-flown by the pilots. At Nadzab, the aircraft was refuelled with sufficient fuel for the flight to Madang and a planned subsequent flight from Madang to Port Moresby. MCJ departed Nadzab at 1647 LMT with the Pilot-in-Command as the handling pilot. The aircraft climbed to 16,000 ft with an estimated arrival time at Madang of 1717. Once in the cruise, the flight crew diverted right of the flight planned track to avoid thunderstorms and cloud. The Pilot-in-Command reported that communications between Madang Tower and an aircraft in the vicinity of Madang indicated a storm was approaching the aerodrome. He recalled that he had intended to descend below the cloud in order to be able to see across the sea to Madang and had been concentrating on manoeuvring the aircraft to remain clear of thunderstorms and cloud, so he had been looking mainly outside the cockpit. Because of the storm in the vicinity of the airport, he said there had been „some urgency‟ to descend beneath the cloud base to position for a right base for runway 07 at Madang, the anticipated approach. On this route, the descent to Madang was steep (because of the need to remain above the Finisterre Ranges until close to Madang) and, although the aircraft was descending steeply, the propellers were at their cruise setting of 900 revolutions per minute (RPM). Neither pilot noticed the airspeed increasing towards the maximum operating speed (VMO); the Pilot-in-Command reported afterwards that he had been „distracted‟ by the weather. When the aircraft reached VMO as it passed through 10,500 ft, with a rate of descent between 3,500 and 4,200 ft per minute, and the propellers set at 900 RPM, the VMO overspeed warning sounded. The Pilot-in-command reported that he had been about to ask the First Officer to increase the propeller speed to 1,050 RPM to slow the aircraft when this occurred. He raised the nose of the aircraft in response to the warning and this reduced the rate of descent to about 2,000 ft per minute, however, the VMO overspeed warning continued. The First Officer recalled the Pilot-in-Command moved the power levers back „quite quickly‟. Shortly after the power levers had been moved back, both propellers oversped simultaneously, exceeding their maximum permitted speed of 1,200 RPM by over 60 % and seriously damaging the left hand engine and rendering both engines unusable. Villagers on the ground reported hearing a loud „bang‟ as the aircraft passed overhead. The noise in the cockpit was deafening, rendering communication between the pilots extremely difficult, and internal damage to the engines caused smoke to enter the cockpit and cabin through the bleed air and air conditioning systems. The emergency caught both pilots by surprise. There was confusion and shock on the flight deck, a situation compounded by the extremely loud noise from the overspeeding propellers. About four seconds after the double propeller overspeed began, the beta warning horn started to sound intermittently, although the pilots stated afterwards they did not hear it. The left propeller RPM reduced to 900 RPM (in the governing range) after about 10 seconds. It remained in the governing range for about 5 seconds before overspeeding again for about 15 seconds, then returned to the governing range. During this second overspeed of the left propeller, the left engine high speed compressor increased above 110 % NH, becoming severely damaged in the process. About 3 seconds after the left propeller began overspeeding for the second time, the right propeller went into uncommanded feather due to a propeller control unit (PCU) beta switch malfunction, while the right engine was still running at flight idle (75% NH). Nine seconds after the double propeller overspeed event began, the Pilot-in-command shouted to the First Officer „what have we done?‟ The First Officer replied there had been a double propeller overspeed. The Pilot-in-command then shouted a second and third time „what have we done?‟. The First Officer repeated that there was a double propeller overspeed and said that the right engine had shut down. The Pilot-in-Command shouted that he could not hear the First Officer, who – just as the left propeller began governing again and the overspeed noise subsided – repeated that the right engine had shut down and asked if the left engine was still working. The Pilot-in-command replied that it was not working. Both pilots then agreed that they had „nothing‟. At this point, about 40 seconds after the propeller overspeed event began, the left propeller was windmilling and the left engine was no longer producing any power because of the damage caused to it by the overspeed. The right engine was operating at flight idle, although the propeller could not be unfeathered and therefore could not produce any thrust. On the order of the Pilot-in-Command, the First Officer made a mayday call to Madang Tower and gave the aircraft's GPS position; he remained in a radio exchange with Madang Tower for 63 seconds. The flight crew did not conduct emergency checklists and procedures. Instead, their attention turned to where they were going to make a forced landing. The aircraft descended at a high rate of descent, with the windmilling left propeller creating extra drag. The asymmetry between the windmilling left propeller and the feathered right propeller made the aircraft difficult to control. The average rate of descent between the onset of the emergency and arrival at the crash site was 2,500 ft per minute and at one point exceeded 6,000 ft per minute, and the VMO overspeed warning sounded again. During his long radio exchange with Madang Tower, the First Officer had said that they would ditch the aircraft, although, after a brief discussion, the Pilot-in-command subsequently decided to make a forced landing in the mouth of the Guabe River. The First Officer asked the Pilot-in-command if he should shut both engines down and the Pilot-in-command replied that he should shut „everything‟ down. Approximately 800 feet above ground level and 72 seconds before impact, the left propeller was feathered and both engines were shut down. The Pilot-in-Command reported afterwards that he ultimately decided to land beside the river instead of in the river bed because the river bed contained large boulders. The area chosen beside the river bed also contained boulders beneath the vegetation, but they were not readily visible from the air. He recalled afterwards that he overshot the area he had originally been aiming for. The aircraft impacted terrain at 114 knots with the flaps and the landing gear retracted. The Flight Attendant, who was facing the rear of the aircraft, reported that the tail impacted first. During the impact sequence, the left wing and tail became detached. The wreckage came to rest 300 metres from the initial impact point and was consumed by a fuel-fed fire. The front of the aircraft fractured behind the cockpit and rotated through 180 degrees, so that it was inverted when it came to rest. Of the 32 occupants of the aircraft only the two pilots, the flight attendant, and one passenger survived by escaping from the wreckage before it was destroyed by fire.
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 Cessna 550 Citation II in Bwagaoia: 4 killed

Date & Time: Aug 31, 2010 at 1615 LT
Type of aircraft:
Registration:
P2-TAA
Survivors:
Yes
Schedule:
Port Moresby – Bwagaoia
MSN:
550-0145
YOM:
1980
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
14591
Copilot / Total flying hours:
872
Aircraft flight hours:
14268
Circumstances:
The aircraft was conducting a charter flight from Jackson’s International Airport, Port Moresby, National Capital District, Papua New Guinea (PNG), to Bwagaoia Aerodrome, Misima Island, Milne Bay Province, PNG (Misima). There were two pilots and three passengers on board for the flight. The approach and landing was undertaken during a heavy rain storm over Bwagaoia Aerodrome at the time, which resulted in standing water on the runway. This water, combined with the aircraft’s speed caused the aircraft to aquaplane. There was also a tailwind, which contributed the aircraft to landing further along the runway than normal. The pilot in command (PIC) initiated a baulked landing procedure. The aircraft was not able to gain flying speed by the end of the runway and did not climb. The aircraft descended into terrain 100 m beyond the end of the runway. The aircraft impacted terrain at the end of runway 26 at 1615:30 PNG local time and the aircraft was destroyed by a post-impact, fuel-fed fire. The copilot was the only survivor. Other persons who came to assist were unable to rescue the remaining occupants because of fire and explosions in the aircraft. The on-site evidence and reports from the surviving copilot indicated that the aircraft was serviceable and producing significant power at the time of impact. Further investigation found that the same aircraft and PIC were involved in a previous landing overrun at Misima Island in February 2009.
Probable cause:
Contributing safety factors:
• The operator’s processes for determining the aircraft’s required landing distance did not appropriately consider all of the relevant performance factors.
• The operator’s processes for learning and implementing change from the previous runway overrun incident were ineffective.
• The flight crew did not use effective crew resource management techniques to manage the approach and landing.
• The crew landed long on a runway that was too short, affected by a tailwind, had a degraded surface and was water contaminated.
• The crew did not carry out a go-around during the approach when the visibility was less than the minimum requirements for a visual approach.
• The baulked landing that was initiated too late to assure a safe takeoff.
Other safety factors:
• The aircraft aquaplaned during the landing roll, limiting its deceleration.
• The runway surface was described as gravel, but had degraded over time.
• The weather station anemometer was giving an incorrect wind indication.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Kokoda: 13 killed

Date & Time: Aug 11, 2009 at 1114 LT
Operator:
Registration:
P2-MCB
Survivors:
No
Site:
Schedule:
Port Moresby - Kokoda
MSN:
441
YOM:
1975
Flight number:
CG4684
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
11
Pax fatalities:
Other fatalities:
Total fatalities:
13
Captain / Total flying hours:
2270
Captain / Total hours on type:
1970.00
Copilot / Total flying hours:
2150
Copilot / Total hours on type:
1940
Aircraft flight hours:
46700
Circumstances:
On 11 August 2009, a de Havilland Canada DHC-6 Twin Otter aircraft, registered P2-MCB, with two pilots and 11 passengers, was being operated on a scheduled regular public transport service from Port Moresby to Kokoda Airstrip, Papua New Guinea (PNG). At about 1113, the aircraft impacted terrain on the eastern slope of the Kokoda Gap at about 5,780 ft above mean sea level in heavily-timbered jungle about 11 km south-east of Kokoda Airstrip. The aircraft was destroyed by impact forces. There were no survivors. Prior to the accident the crew were manoeuvring the aircraft within the Kokoda Gap, probably in an attempt to maintain visual flight in reported cloudy conditions. The investigation concluded that the accident was probably the result of controlled flight into terrain: that is, an otherwise airworthy aircraft was unintentionally flown into terrain, with little or no awareness by the crew of the impending collision.
Probable cause:
From the evidence available, the following findings are made with respect to the collision with terrain, 11 km south-east of Kokoda Airstrip, Papua New Guinea, involving a de Havilland Canada DHC-6-300 Twin Otter aircraft, registered P2-MCB, and should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing safety factors:
• Visual flight in the Kokoda Gap was made difficult by the extensive cloud coverage in the area.
• The crew attempted to continue the descent visually within the Kokoda Gap despite the weather conditions not being conducive to visual flight.
• It was probable that while manoeuvring at low level near the junction of the Kokoda Gap and Kokoda Valley, the aircraft entered instrument meteorological conditions.
• The aircraft collided with terrain in controlled flight.
Other safety factors:
• The copilot was assessed during normal proficiency checks for instrument approach procedures but was not qualified for flight in instrument meteorological conditions.
• The operator did not have a published emergency recovery procedure for application in the case of inadvertent flight into instrument meteorological conditions.
• The Civil Aviation Safety Authority Papua New Guinea surveillance of the operator did not identify the operations by the operator in contravention of Rule 91.112.
• The lack of a reliable mandatory occurrence reporting arrangement minimized the likelihood of an informed response to Papua New Guinea-specific safety risks.
• There was no qualified Director (or similar) of Aviation Medicine in Papua New Guinea (PNG).
• The lack of both flight data and cockpit voice recorders adversely affected a full understanding of the accident by the investigation.
Other key findings:
• The investigation was unable to discount the possible incapacitation of the copilot as a factor in the accident.
• Although not required by the aviation rules at the time of the accident, the adoption of threat and error management training for flight crews, and of the methodology by operators would provide a tool to identify and mitigate operational risk as follows:
– by flight crews, when flight planning and during flight; and
– by operators, when developing their operational procedures.
Final Report:

Crash of a De Havilland DHC-4A Caribou in Efogi

Date & Time: Sep 5, 2008
Type of aircraft:
Operator:
Registration:
A4-285
Flight Type:
Survivors:
Yes
MSN:
285
YOM:
1969
Location:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Damaged beyond repair following structural failure due to fatigue upon landing at Efogi, PNG. There were no injuries but the aircraft was damaged beyond repair and dismantled.

Crash of a Cessna 404 Titan II in Goroka

Date & Time: May 19, 2007
Type of aircraft:
Operator:
Registration:
P2-ALK
Survivors:
Yes
MSN:
404-0222
YOM:
1978
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight, the pilot started the approach to Goroka Airport in poor weather conditions. After landing on runway 17R, the aircraft was unable to stop within the remaining distance. It overran and came to rest few dozen metres further. All four occupants escaped uninjured while the aircraft was damaged beyond repair.

Crash of an Embraer EMB-110P1 Bandeirante near Kandrian: 2 killed

Date & Time: Mar 30, 2007 at 0523 LT
Operator:
Registration:
P2-ALU
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Port Moresby – Hoskins – Rabaul
MSN:
110-232
YOM:
1979
Flight number:
ND304
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
4653
Captain / Total hours on type:
1253.00
Copilot / Total flying hours:
4235
Copilot / Total hours on type:
610
Aircraft flight hours:
36962
Aircraft flight cycles:
43756
Circumstances:
The aircraft was refueled with 640 litres (L) of Jet-A1 (AVTUR) in preparation for an early morning departure to Hoskins, New Britain, on 30 March. On 30 March, the crew lodged a flight plan, which stated that the total fuel on board was 2,100 pounds (lbs) (1,208 L). The first sector of the planned route was from Port Moresby to Hoskins. The pilot-in-command (PIC) obtained an area forecast for the flight, which indicated that there were areas of rain and scattered cloud from 1500-5000 feet (ft), with deteriorating conditions forecast for the period between 0400-0800 hours (hrs); for their arrival at Hoskins. The forecast required 30 minutes holding fuel in addition to the flight and statutory fuel requirements. These conditions were normal for their destination at this time of the year.The aircraft departed Port Moresby at 0402, as flight number ND304 for Hoskins. It initially climbed to the planned Flight Level (FL) 140 (14,000 ft), which was 300 ft above the lowest safe altitude (LSA) on the initial RNC track between Port Moresby and Girua, an Instrument Flight Rules (IFR) reporting point on the north coast of the PNG mainland. The LSA for the sector between Girua and the en-route reporting point Maran was 3,300 ft, and the PIC had planned to cruise at 9,000 ft. The sector between Maran and Hoskins was planned at 9,000 ft, with a LSA of 8,300 ft. The purpose of the flight was to transport newspapers and general freight to Hoskins and Rabaul. Flight Information Area (FIA) communications with Nadzab Flight Service used High Frequency (HF) radio, and a Very High Frequency (127.1 MHz) repeater transceiver located near the township of Popondetta. This service was usually monitored by Nadzab Flight Service during their normal hours of operation, for aircraft operating on the Girua to Hoskins track. One of the functions of the Nadzab Flight Service Unit was to record all transmissions received via the Girua repeater site. The crew made a position report, intercepted by Port Moresby Flight Service, advising that they were overhead Maran at 0506, cruising at FL 110 (11,000 ft), and gave an estimated time of arrival (ETA) Hoskins at 0540. That was 2,000 ft higher than the planned level. The position report was received by Port Moresby Flight Service, because Nadzab Flight Service had not commenced operations. It subsequently commenced operations for the day at 0540. Because Nadzab was responsible for the airspace in which ALU was operating, Port Moresby Flight Service advised Nadzab of ALU’s position report, once Nadzab opened. The Maran position report was the last recorded radio contact with the aircraft. No transmission declaring the intention to descend below FL110 was heard from the crew of ALU. No MAYDAY transmission was reported by ATS or other aircrew. When the crew of ALU failed to report their arrival at Hoskins, a search was commenced of the Hoskins aerodrome. At 0650 a DISTRESFA Search and Rescue Phase (SAR) was declared indicating the degree of apprehension held for the safety of the aircraft and its occupants. Later that morning verbal reports were received from a coastal logging company in an area east of Kandrian, that an aircraft had crashed. The wreckage of ALU was found 27 km east of Kandrian, at an elevation of 780 ft above sea level. Both crew members had not survived the impact. The wreckage was located at position 06° 11′ 39.8′′ S, 149° 52′ 58.9′′ E, and was dispersed along a 500 m wreckage trail after colliding with numerous trees and impacting the terrain. The investigation estimated the time of the accident to be about 0523.
Probable cause:
The reason the crew were unable to maintain level flight above the en-route lowest safe altitude with one engine inoperative, and subsequently impacted terrain, could not be determined.
Final Report:

Crash of a De Havilland DHC-6 Twin Otter 300 in Bimin: 2 killed

Date & Time: Feb 22, 2005 at 1343 LT
Operator:
Registration:
P2-MFQ
Survivors:
Yes
Schedule:
Tabubil - Bimin
MSN:
174
YOM:
1968
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
On approach to Bimin-Wobagen Airport runway 30, the twin engine aircraft lost height and crashed in a wooded area. Both pilots (New Zealand citizens) were killed instantly and all 11 other occupants were injured, some seriously. They walk away to the village to find help and receive care. The aircraft has a single 11/29 grass/dirt runway located at an altitude of 1,767 metres and offer a 10° slope. Runway 29 is for landing only and runway 11 for takeoff only.

Crash of a De Havilland DHC-6 Twin Otter 300 near Ononge: 2 killed

Date & Time: Jul 29, 2004 at 1030 LT
Operator:
Registration:
P2-MBA
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
Schedule:
Port Moresby - Ononge
MSN:
353
YOM:
1973
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
While descending to Ononge, the crew encountered poor weather conditions and decided to divert to the Yongai Airfield located about 27 km northeast of Ononge. Few minutes later, while cruising at an altitude of 2,286 metres in clouds, the twin engine aircraft struck the slope of a mountain. Rescuers arrived on scene a day later. The loadmaster was seriously injured while both pilots were killed.
Probable cause:
Controlled flight into terrain.

Crash of a De Havilland DHC-6 Twin Otter in Sturt Island

Date & Time: Jan 5, 2004
Operator:
Registration:
P2-KSG
Flight Phase:
Survivors:
Yes
MSN:
509
YOM:
1976
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
During the takeoff roll from a grassy runway (780 metres long), the pilot noted standing water on the ground. He attempted to take off prematurely to avoid these puddles but the aircraft stalled and crash landed. All three occupants escaped uninjured while the aircraft was damaged beyond repair.

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.