code

Madang

Crash of an ATR42-320F in Madang

Date & Time: Oct 19, 2013 at 0915 LT
Type of aircraft:
Operator:
Registration:
P2-PXY
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Madang – Tabubil – Kiunga
MSN:
87
YOM:
1988
Flight number:
PX2900
Location:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7110
Captain / Total hours on type:
3433.00
Copilot / Total flying hours:
3020
Copilot / Total hours on type:
2420
Aircraft flight hours:
24375
Circumstances:
On 19 October 2013, an Avions de Transport Régional ATR42-320 freighter, registered P2-PXY (PXY) and operated by Air Niugini, was scheduled to fly from Madang to Tabubil, Western Province, as flight PX2900 carrying a load tobacco for a client company. There were three persons on board; the pilot in command (PIC), a copilot, and a PNG experienced DHC-8 captain whose function was to provide guidance during the approach into Tabubil. The PIC was the handling pilot and the copilot was the support monitoring pilot. The flight crew taxied to the threshold end of runway 25 intending to use the full length of the runway. The take-off roll was normal until the PIC tried to rotate at VR (speed for rotation, which the flight crew had calculated to be 102 knots). He subsequently reported that the controls felt very heavy in pitch and he could not pull the control column back in the normal manner. Flight data recorder (FDR) information indicated that approximately 2 sec later the PIC aborted the takeoff and selected full reverse thrust. He reported later that he had applied full braking. It was not possible to stop the aircraft before the end of the runway and it continued over the embankment at the end of the runway and the right wing struck the perimeter fence. The aircraft was substantially damaged during the accident by the impact, the post-impact fire and partial immersion in salt water. The right outboard wing section was completely burned, and the extensively damaged and burnt right engine fell off the wing into the water. Both propellers were torn from the engine shafts and destroyed by the impact forces.
Probable cause:
The following findings were identified:
- The investigation found that Air Niugini’s lack of robust loading procedures and supervision for the ATR 42/72 aircraft, and the inaccurate weights provided by the consignor/client company likely contributed to the overload.
- The mass and the centre of gravity of the aircraft were not within the prescribed limits.
- The aircraft total load exceeded the maximum permissible load and the load limit in the forward cargo zone ‘A’ exceeded the zone ‘A’ structural limit.
- There was no evidence of any defect or malfunction in the aircraft that could have contributed to the accident.
Final Report:

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 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.