Air Vanuatu Flight 241

Last updated
Air Vanuatu Flight 241
Accident
Date28 July 2018 (2018-07-28)
SummaryRunway excursion during emergency landing due to pilot error and loss of situational awareness. [1]
Site Bauerfield International Airport, Port Vila, Vanuatu
Total fatalities0
Total injuries13
Total survivors43
First aircraft
Air Vanuatu ATR72 (16555733838).jpg
YJ-AV71, the aircraft involved in the accident
Type ATR-72-500
Operator Air Vanuatu
Registration YJ-AV71
Flight origin Whitegrass Airport, Tanna Vanuatu
Destination Bauerfield International Airport, Port Vila, Vanuatu
Occupants43
Passengers39
Crew4
Fatalities0
Injuries13
Survivors43 (all)
Second aircraft
Unity Airlines Islander, Tanna, Vanuatu, June 2009 - Flickr - PhillipC.jpg
YJ-OO9, the aircraft involved in the accident
Type Britten-Norman Islander
OperatorUnity Airlines
RegistrationYJ-OO9
Occupants0
Third aircraft
TypeBritten-Norman Islander
OperatorAir Taxi
RegistrationYJ-AL2
Occupants0

On 28 July 2018, Air Vanuatu Flight 241, operated by ATR-72 registration YJ-AV71 suffered an in-flight engine fire while operating a domestic scheduled passenger flight from Whitegrass Airport, Tanna to Bauerfield International Airport, Port Vila, Vanuatu. On landing at Port Vila, a runway excursion occurred. The aircraft collided with two Britten-Norman Islanders, writing one off and severely damaging the other. 13 of the 43 people on board sustained minor injuries.

Contents

Aircraft & crew

The aircraft involved in the accident were:

The crew consisted of:

Flight

Flight 241 was a domestic scheduled passenger flight from Whitegrass Airport, Tanna to Bauerfield International Airport, Port Vila Vanuatu. On 28 July 2018, the ATR-72 operating the flight suffered an engine fire in the right engine, while over the island of Erromango. [3] Smoke and flames were witnessed by passengers, with smoke entering the aircraft's cabin. The engine was shut down and the aircraft continued to Port Vila. [2] The pilots experienced difficulty controlling the aircraft, with uncommanded roll occurring. [4]

On landing, the aircraft departed the runway and collided with two Britten-Norman Islander aircraft belonging to Air Taxi and Unity Airlines. The aircraft belonging to Air Taxi was severely damaged, with its vertical stabilizer ripped off. [2] It was damaged beyond repair. [5] The other plane, of Unity Airlines was also damaged beyond repair. Although nobody was injured in the collision, thirteen passengers were treated for smoke inhalation. [2]

All four crew and 39 passengers on board evacuated the aircraft without injury. The pilots of the ATR-72 reported that they had no brakes or nose wheel steering, which they gave as the reason for the runway excursion and subsequent collision. [4]

Investigation

The Civil Aviation Authority of Vanuatu asked Papua New Guinea's Accident Investigation Commission to investigate the accident. Canada's Transportation Safety Board is assisting the investigation. [4]

The preliminary report was relesed by Accident Investigation Commission on August 10, 2018, where some factors such as weather conditions, psychological factors or temporary inabilities of the pilots were discarded. The preliminary report revealed no signs of a fire occurring after the accident or before, even the engines were analysed. [4]

Survival factors were also analysed, where following the order from the pilot in command, the cabin crew conducted a flawless and orderly evacuation whereby the passengers escaped without injury. [4]

According to the preliminary report, the aircraft suffered substantial damage to the propellers and right landing gear, hitting the vertical stabilizer and rudder of the first Britten Norman Islander, damaging them, then the right landing gear of the ATR crushed the front fuselage of the another Islander destroying it, as in the first Islander the ATR hit the vertical stabilizer and the rudder this time without damaging them but tearing them from the fuselage. [4]

Causes

The Papua New Guinea Accident Investigation Commission released their final report on October 29, 2019, where it was established that although the engine failure was not the direct cause of the accident, the formation of smoke inside the cabin led the pilots to declare an emergency and begin immediate descent, this detection of smoke by the electronic smoke detector caused an ambiguous warning called ELEC SMK to be activated inside the cockpit, causing the pilot in command (PIC) to experience confirmation bias and subsequently divert the pilot's attention to the fault of the engine. [7]

This confirmation bias that was caused by the ambiguous "ELEC SMK" warning led to the co-pilot's selection and execution of the "Electrical Smoke" checklist. The co-pilot's lack of knowledge of the aircraft's systems and his introverted attitude increased the workload of the PIC and contributed to the excessive gradient of authority within the cabin which is the cause that heavily contributed to the deterioration of the Crew Resources Management. [7]

The oversight of a note within the "QRH SMOKE" checklist and the lack of information on the "QRH ELECTRICAL SMOKE" checklist have encouraged pilots to continue the checklist without making other considerations.

The shutdown of the ACW generators and the isolation of the DC BTC through the observance of the QRH "ELECTRICAL SMOKE" checklist by the pilots resulted in the loss of power of the hydraulic system pump and the illumination of the warning lights indicating faults, the crew was directed by QRH "ELECTRICAL SMOKE" to take actions regarding the QRH "ACW GEN 1+2 LOSS" checklist and to complete the "before landing" section instead of the normal QRH "Before Landing" checklist, this resulted in the crew becoming disinterested in checking the TLU setting. [7]

With the DC BTC isolated, the shutdown of engine number 2 caused a loss of power in all systems supplied by DC bus 2, this resulted in several faults, flaws and warnings, this activation of numerous faults and flaws messages is the result of the QRH "ELECTRICAL SMOKE" checklists and the second engine shutdown which significantly lead to cognitive saturation, reduced situational awareness and crew inattention. [7]

This lack of situational awareness led the pilots to select reverse thrust despite the ground control and braking system being unavailable at the time. Selecting reverse thrust caused the aircraft to turn right and ultimately exit the runway. the absence of hydraulic control, brakes and aerodynamic control made it impossible for the pilots to avoid the change of path, the runway excursion and the consequent impact with other aircraft. [7]

Aftermath

After the accident the Papua New Guinea Accident Investigation Commission released two safety reccomendations to Air Vanuatu, which focus on pilot and cabin crew training. Derick Nice of Air Vanuatu said that these recommendations have already been implemented and that Vanuatu Civil Aviation Authority has already enabled accordingly. Other three safety reccomendations are issued to the aircraft munufacturer which invite them to review the checklists for the pilots. Air Vanuatu agreed with the recommendations but also stated that their internal investigation found that the design of the ATR 72-500's warning system was also a contributing factor to the accident. the airline no longer uses this model of aircraft which was supposed to be replaced by the Airbus A220 but it is not known whether this happened. [8]

See also

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References

  1. Air Vanuatu crash report highlights lack of emergency training for pilots and crew
  2. 1 2 3 4 5 6 Hradecky, Simon. "Accident: Vanuatu AT72 at Port Vila on Jul 28th 2018, engine fire, runway excursion, collision with 2 other aircraft". Aviation Herald. Archived from the original on 29 August 2018. Retrieved 28 July 2018.
  3. 1 2 3 "Accident description". Aviation Safety Network. Retrieved 28 July 2018.
  4. 1 2 3 4 5 6 7 8 "PRELIMINARY REPORT AIC 18-1002 Air Vanuatu Operations Limited ATR 72-500 Loss of directional control during landing roll Bauerfield International Airport, Port Vila REPUBLIC OF VANUATU 28 July 2018" (PDF). Accident Investigation Commission. Archived from the original (PDF) on 11 August 2018. Retrieved 10 August 2018.
  5. 1 2 "YJ-OO9 hull loss description". Aviation Safety Network. Retrieved 4 August 2018.
  6. "YJ-AL2 Non hull-loss description". Aviation Safety Network. Retrieved 4 August 2018.
  7. 1 2 3 4 5 "FINAL REPORT AIC 18-1002 Air Vanuatu Operations Limited YJ-AV71 ATR 72-500 Loss of directional control during landing roll Bauerfield International Airport, Port Vila REPUBLIC OF VANUATU 28 July 2018" (PDF). Via: Aviation-Safety.Net. Retrieved 29 February 2024.
  8. Hakwa, Charles (2019-11-01). "Air Vanuatu responds to PNG Accident Investigation Report". Vanuatu Daily Post. Retrieved 2024-02-29.