Airlines PNG Flight 4684

Last updated

Airlines PNG Flight 4684
De Havilland Canada DHC-6-300 Twin Otter AN0848059.jpg
A De Havilland Canada DHC-6-300 Twin Otter, similar type of the crashed plane
Incident
Date11 August 2009 (2009-08-11)
Summary Controlled flight into terrain due to pilot error
Site Isurava, Papua New Guinea
8°53′S147°44′E / 8.883°S 147.733°E / -8.883; 147.733
Aircraft
Aircraft type Twin Otter
Operator Airlines PNG
Registration P2-MCB
Flight origin Jacksons International Airport, Port Moresby, Papua New Guinea
Destination Kokoda Airport, Oro Province, Papua New Guinea
Occupants13
Passengers11
Crew2
Fatalities13
Survivors0

Airlines PNG Flight 4684 (CG4682/TOK4684) was a scheduled domestic passenger flight operated by Papua New Guinean airliner Airlines PNG, flying from Jacksons International Airport in Papua New Guinea's capital Port Moresby to Kokoda Airport in Oro Province, Papua New Guinea. On 11 August 2009, the aircraft operating the flight, a de Havilland Canada Twin Otter, crashed into a forest in Kokoda Valley, a popular trekking site in Papua New Guinea, while carrying 13 people in bad weather. A search and rescue operation was conducted by authorities and found the wreckage of the crashed plane on the next day, 12 August 2009. The aircraft was severely damaged, and searchers found no signs of life. Papua New Guinean Search and Rescue Agency then announced that everyone on board was killed instantly in the crash. [1]

Contents

The Accident Investigation Commission (AIC) investigated the cause of the crash and released its final report, concluding that the plane crashed due to pilot error. The plane deviated from its original flight path and the visual reference in Kokoda Gap was obscured by clouds, causing the pilots to not be aware of their proximity with the ground. The AIC classified the accident as controlled flight into terrain. [2]

Flight

Kokoda Airstrip, the destination airport, pictured in 2008 Kokoda airstrip 2008.jpg
Kokoda Airstrip, the destination airport, pictured in 2008

The aircraft departed Jacksons International Airport at 10:50 am local time and reported to Jacksons Tower that they were climbing for 9,000 ft to Kokoda via the Kokoda Gap, with an estimated time of arrival at 11:20 am. At 11:11 am, while en route to Kokoda and on descent in Kokoda Gap, the crew of Flight 4684 conversed with the crew of an aircraft, registered P2-KST, which was departing from Kokoda. There was no indication that the crew of Flight 4684 had any problems with their aircraft. Inside the ATC recording, the crew was heard saying "Thank you very much, morning long you". This was the last communication of Flight 4684. [2] :4

Witnesses at Isurava village stated that they observed an aircraft fly low over the village at about the estimated time of the accident. Witnesses at the nearby Misima village stated that they heard an aircraft fly near their village but that they could not see the aircraft, as the area was covered by cloud. They reported that shortly after, there was a loud bang above their village and the sound of the aircraft stopped. Port Moresby ATC then lost contact with Flight 4684. [3] [2] :4

Port Moresby ATC then tried to contact Flight 4684, even requesting nearby aircraft in the area to contact the plane. However, there were no response from Flight 4684. They then asked to P2-MCD, an Airlines PNG plane departing from Efogi, if Flight 4684 had landed in Kokoda. The crews of P2-MCD then stated that P2-MCB did not land in Kokoda. Port Moresby ATC then declared Flight 4684 status to ALERFA (alert search and rescue phase), and then subsequently to DISTRESFA (distress search and rescue phase). [2] :4

Search and rescue team scoured the area where Flight 4684 had lost contact. But the search and rescue operation was hampered by bad weather, low visibility and rough terrain. On 12 August 2009, a search and rescue team Dornier plane detected an ELT signal in the search area. Later on, a search and rescue team found the wreckage of Flight 4684. The aircraft was totally destroyed. The search team did not detect any signs of life in the crash site, and announced that no one survived the crash. [4] [2] :30,5

Aircraft

The aircraft involved in the accident was a De Havilland Canada Twin Otter, registered in Papua New Guinea as P2-MCB. It had a serial number of PCE-PG0073. The aircraft was configured to carry 19 passengers and two crew, and had a maximum take-off weight of 5,670 kg. The aircraft was fitted with the required equipment for two-pilot IFR flight, but an autopilot system was not fitted in the aircraft. The aircraft had accumulated a total flying time of 46,700 hours. [2] :9–10

Passengers

The aircraft was carrying 11 passengers and 2 crew. The passengers included eight Australian tourists on their way to trek the Kokoda Track, two tour guides (one Australian and one Papua New Guinean) from No Roads Expeditions tour company, and a Japanese tourist. Seven of the nine Australian passengers on board came from Victoria, and two from Queensland. [5] Aboard the flight was part-time tour guide Matthew Leonard, who was the son of Western Australia police inspector Bill Leonard. [6] [7] [8]

NationalityPassengersCrewTotal
Australia909
Papua New Guinea123
Japan101
Total11213

The Captain was Jannie Moala from Papua New Guinea. She had accumulated 2,177 flying hours, of which 1,836 of them were on the Twin Otter. AIC found no evidence that she had been trained by Airlines PNG for Global Positioning System (GPS). However, training records that were provided by the operator showed that items identified within the operator's training syllabus that included the introduction to, and use of the GPS for en route navigation had been marked by the training captain as complete. No evidence as to the extent of that training, or level of understanding attained by Moala, was provided by the operator. The operator stated that at about the time of the accident, a GPS training package specific to the conduct of GPS non-precision approaches was being introduced. [2] :5–6 [9]

The co-pilot was First Officer Rodney Souka from Papua New Guinea. He had accumulated 2,150 flying hours, of which 1,940 were on the Twin Otter. AIC did not find any evidence that Souka had been trained by Airlines PNG for Global Positioning System (GPS) of the aircraft. [2] :7–8 [10]

Investigation

The accident was investigated by the Accident Investigation Commission (AIC), assisted by the Australian Transport Safety Bureau (ATSB). The AIC could only determine the cause of the crash without access to a CVR or FDR, as both flight recorders were not mandatory to be equipped on a Twin Otter. The lack of both flight data and cockpit voice recorders adversely affected a full understanding of the accident by the investigation. Alternatively, on board the aircraft was a small electronic GPS tracking and data telemetry device. Using the device's Non-Volatile memory, the ATSB was able to piece together portions of the flight path. [2] :18–19,48

High terrain in the surrounding area of Kokoda Valley. Early morning at Alola, Kokoda Track, Papua New Guinea.jpg
High terrain in the surrounding area of Kokoda Valley.

The weather in Kokoda Gap at the time was poor. Based on eyewitnesses accounts and photographic evidence retrieved by ATSB, Kokoda Gap was obscured by clouds at the time of the accident, making it difficult for the pilots to know if they were in close proximity with the ground. Given the surrounding mountainous terrain, the evident cloud in the Kokoda Gap, as in this instance, had the potential to severely limit the crew's escape options, increase their workload, and test their situational awareness. A reduction in situational awareness and the presence of mountainous terrain during an approach are known risk factors in instances of controlled flight into terrain (CFIT). [2] :13–16

Later investigation found that only one pilot had an IFR rating, while the other did not. The co-pilot, First Officer Rodney Souka, had been assessed for instrument approach procedures; however, he was not qualified for flight under the IFR. Although the crew had planned to fly under the IFR with visual procedures, the forecast cloud in the area ought to have alerted them that, under those procedures, visual flight in the Kokoda Gap could prove problematic. The visual descent into the Kokoda Gap required 5 km visibility, while at the time of the accident, the visibility was less than 5 km. [2] :40

The Australian ATSB then turned their attentions to Souka. They examined his postmortem and medical history. Investigators found that Souka had critical coronary artery heart disease, and the examining pathologist considered that Souka could have had a medical emergency at any time. Souka's relatives reported that they were not aware of any significant medical condition affecting him. If an emergency occurred in mid-air as the aircraft approached the cloud to the north of the Kokoda Gap would have instantly increased Moala's workload and distracted her from the primary task of flying the aircraft. Both those factors are known to increase the risk of CFIT. [2] :41

Investigators noted that Kokoda Airport was lacking with its navigation infrastructure. The lack of ground-based navigation aids at Kokoda Airport meant that the only potential navigation assistance for the crew during their approach to Kokoda was from the GPS, or via the ground-based non-directional beacon/distance measuring equipment (NDB/DME) located at Girua. [2] :41

The investigation concluded that the accident was probably a 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. [2] [ page needed ]

See also

Related Research Articles

de Havilland Canada DHC-6 Twin Otter Utility transport aircraft family by de Havilland Canada

The de Havilland Canada DHC-6 Twin Otter is a Canadian STOL utility aircraft developed by de Havilland Canada, which produced the aircraft from 1965 to 1988; Viking Air purchased the type certificate, then restarted production in 2008 before re-adopting the DHC name in 2022. The aircraft's fixed tricycle undercarriage, STOL capabilities, twin turboprop engines and high rate of climb have made it a successful commuter airliner, typically seating 18–20 passengers, as well as a cargo and medical evacuation aircraft. In addition, the Twin Otter has been popular with commercial skydiving operations, and is used by the United States Army Parachute Team and the 98th Flying Training Squadron of the United States Air Force.

Aeronautical Engineers Australia (AEA) is an Australian aeronautical engineering consultancy and aircraft technical service provider. It is the largest civil aircraft design organisation in the Asia Pacific region and is now headquartered in Adelaide.

<span class="mw-page-title-main">Mission Aviation Fellowship</span>

Mission Aviation Fellowship (MAF) is a Christian organization that provides aviation, communications, and learning technology services to more than 1,000 Christian and humanitarian agencies, as well as thousands of isolated missionaries and indigenous villagers in the world's most remote areas. There are three major operational centers – Nampa, Idaho, United States, Ashford, United Kingdom, and Cairns, Australia. These centres provide operational support to programs in the Americas, Africa and Asia Pacific regions. In 2010, MAF served in more than 55 countries, flying 201,710 passengers with a fleet of some 130 aircraft.

PNG Air is an airline based on the grounds of Jacksons International Airport, Port Moresby, Papua New Guinea. It operates scheduled domestic and international flights, as well as contract corporate charter work. Its main base is Jacksons International Airport.

<span class="mw-page-title-main">Kokoda Airport</span> Airport in Kokoda, Papua New Guinea

Kokoda Airport is an airport in Kokoda, Papua New Guinea. The airfield was a focal point of the intense battle along the famous Kokoda trail, during the second World War. It was taken and retaken several times by both Japanese and Australian troops, every time with heavy casualties.

Tabubil Airport is an international airport in Tabubil, Papua New Guinea. Asia Pacific Airlines operates out of Tabubil as its hub.

<span class="mw-page-title-main">West Coast Airlines Flight 956</span> 1966 aviation accident

West Coast Airlines Flight 956 was a scheduled commercial flight in the western United States which crashed on October 1, 1966, approximately 5.5 miles (9 km) south of Wemme, Oregon, southeast of Portland. Thirteen passengers and five crew members were aboard, but none survived. In its first week of service, the aircraft was destroyed by the impact and subsequent fire.

Isurava is a small town in Papua New Guinea, located in Oro Province, on the Kokoda Track. It is the site of the Battle of Isurava that occurred over the period 26 to 31 August 1942, as Australian forces were being pushed back toward Port Moresby by the advancing Japanese. The present site is to the north of the wartime village. It is the site of the Isurava Memorial, constructed in 2002 in remembrance of all those Australians and Papua New Guineans who fought and those who died on the Kokoda Track in 1942.

<span class="mw-page-title-main">Merpati Nusantara Airlines Flight 9760D</span> 2009 aviation accident

Merpati Nusantara Airlines Flight 9760D was a domestic commercial passenger 50-minutes flight, flying from Sentani Airport in Papua's Province Jayapura to Oksibil Airport in Oksibil, Indonesia operated by a de Havilland Canada DHC-6 Twin Otter 300. On Sunday, August 2, 2009, while carrying fifteen people over Papua, the aircraft went missing en route. Its wreckage was found a few miles from Oksibil two days later. All 12 passengers and 3 crew members were killed in the accident.

<span class="mw-page-title-main">Airlines PNG Flight 1600</span> 2011 aviation accident

On 13 October 2011, Airlines PNG Flight 1600, a Dash 8 regional aircraft on a domestic flight from Lae to Madang, Papua New Guinea, crash-landed in a forested area near the mouth of the Guabe River, after losing all engine power. Only four of the 32 people on board survived. It was the deadliest plane crash in the history of Papua New Guinea.

<span class="mw-page-title-main">Merpati Nusantara Airlines Flight 5601</span> 1992 aviation accident

Merpati Nusantara Airlines Flight 5601 (MNA5601/MZ5601) was a domestic scheduled passenger flight, that departed Achmad Yani International Airport, Semarang, Indonesia bound for Husein Sastranegara International Airport, Bandung, Indonesia. On 18 October 1992, the two-year-old CASA/IPTN CN-235-10 was on approach to Bandung when it crashed into the side of Mount Puntang, near Mount Papandayan, West Java, Indonesia at 1:30 pm in bad weather. The aircraft exploded on impact killing all twenty seven passengers and four crew on board.

The Papua New Guinea Accident Investigation Commission (PNGAIC) is an agency of the Government of Papua New Guinea (GoPNG) investigating aviation accidents and serious incidents. The office is located in Level 1, NAQIA Building, Morea-Tobo Road, 6 Mile, National Capital District.

<span class="mw-page-title-main">2012 Queensland DH.84 Dragon crash</span>

On 1 October 2012, Riama, a 1934 vintage de Havilland DH.84 Dragon passenger aircraft, crashed in Queensland, Australia, while flying from Monto to Caboolture. Radio contact was lost about an hour after the pilot reported to be in cloud with zero visibility. The wreckage was found in heavily wooded, hilly terrain two days later. The pilot and five passengers were killed in the accident.

<span class="mw-page-title-main">Nepal Airlines Flight 183</span> 2014 aviation accident in Nepal

Nepal Airlines Flight 183 was a scheduled domestic passenger flight operated by a DHC-6 Twin Otter that on 16 February 2014 crashed into a hill near Dhikura, Nepal.

<span class="mw-page-title-main">Trigana Air Flight 267</span> 2015 aviation accident

Trigana Air Flight 267 was a scheduled passenger flight from Sentani to Oksibil in the eastern Indonesian province of Papua. On 16 August 2015, the ATR 42 turboprop operating the service crashed on approach in the Bintang highlands region of Oksibil, killing all 49 passengers and 5 crew members.

<span class="mw-page-title-main">2016 Sunbird Aviation crash</span>

On 13 April 2016, a Britten-Norman BN-2T Turbine Islander operated by Sunbird Aviation crashed about 1,200 m short of runway 7 at Kiunga Airport in the Western Province of Papua New Guinea. The plane pitched up right before the crash, then dropped its right wing and fell almost vertically to the ground. Eleven passengers and the 31-year-old Australian pilot, Benjamin Picard, were killed. Nine people died on impact, with other three declared dead on arrival at Kiunga Hospital.

<span class="mw-page-title-main">Air Niugini Flight 73</span> 2018 aviation accident

Air Niugini Flight 73 was a scheduled service from Pohnpei, Federated States of Micronesia (FSM) to Port Moresby, Papua New Guinea, via Chuuk, FSM. On 28 September 2018, a Boeing 737, operated by Air Niugini, landed short of the runway at Chuuk International Airport in Weno (FSM) and came to rest in Chuuk Lagoon. Locals in small boats rescued most passengers and all crew members. One passenger was initially declared missing, and was later found dead by rescue divers. Forty-six people survived but six of them were injured.

<span class="mw-page-title-main">1994 South Pacific Airmotive DC-3 crash</span> Douglas DC-3 crash

The 1994 South Pacific Airmotive DC-3 crash took place on 24 April 1994, when a Douglas DC-3 airliner operated by South Pacific Airmotive, tail number VH-EDC, ditched into Botany Bay shortly after takeoff from Sydney Airport in Sydney, New South Wales, Australia. The cause of the crash was determined by the Bureau of Air Safety Investigation to have been a power loss in the aircraft's left engine caused by an inlet valve being stuck in the open position, compounded by inadequate action on the part of the pilots; Rod Lovell, the pilot in command of the flight, has disputed BASI's conclusions.

<span class="mw-page-title-main">Tara Air Flight 197</span> Passenger plane crash in Nepal

Tara Air Flight 197 was a scheduled domestic flight operated by Tara Air for parent company Yeti Airlines from Pokhara Airport to Jomsom Airport in Nepal. On 29 May 2022, the Twin Otter aircraft carrying 22 people departed at 09:55 NPT and lost contact with air traffic controllers about 12 minutes later at 10:07 (04:22). The wreckage was located 20 hours later on a mountainside. All 22 passengers and crew were killed, and all 22 bodies were recovered. This was Tara Air's second deadly accident on this route, after Flight 193 in 2016.

References

  1. "Kokoda plane slammed into cliff, no survivors, says PM". Sydney Morning Herald . 12 August 2009. Retrieved 12 August 2009.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 "Final accident investigation Report". Archived from the original on 10 November 2012. Retrieved 28 July 2011. CC-BY icon.svg This article contains quotations from this source, which is available under a Creative Commons Attribution 3.0 Australia licence.
  3. Wilson, Neil. "Tragedy was avoidable with bigger plane, says Kokoda expert". Herald Sun .
  4. Janine Hill and Kerryn Manifold. "No survivors in Kokoda crash". Sunshine Coast Daily .
  5. "Kokoda plane slammed into cliff, leaving no survivors". Sydney Morning Herald. 12 August 2009. Retrieved 15 June 2016.
  6. Carolyn, Patrick (1 September 2009). "Kokoda tour guide Matthew Leonard remembered after plane tragedy". Herald Sun. Retrieved 15 June 2016.[ dead link ]
  7. "Kokoda plane crash: Victorian, Queensland victims named". Sydney Morning Herald. 12 August 2009. Retrieved 15 June 2016.[ dead link ]
  8. "No survivors in PNG plane crash". Sydney Morning Herald. 11 August 2009. Retrieved 15 June 2016.
  9. Callinan, Rory (14 August 2009). "Australia Mourns Its Plane-Crash Victims". Time .
  10. Dowsley, Anthony; Buttler, Mark (11 August 2009). "Seven Victorians go missing as plane vanishes in Papua New Guinea". news.com.au. Retrieved 11 August 2009.