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The Papua New Guinea Accident Investigation Commission (AIC) has released its Final Report into the controlled flight into terrain that occurred near Kokoda, Papua New Guinea on 11 August 2009, involving a De Havilland DH-6 Twin Otter aircraft, registration P2-MCB. The AIC investigated this accident, together with support from the Papua New Guinea Department of Transport, in accordance with its obligations under Annex 13 to the Convention on International Civil Aviation. The AIC requested the Australian Transport Safety Bureau (ATSB) to assist their investigation by providing investigator support, information and technical advice and facilities support.

In accordance with paragraph 5.23 of Annex 13, the ATSB appointed an Accredited Representative and a number of advisors to the Accredited Representative (ATSB investigators) to assist the AIC during the on-site phase, in the technical examination of a number of recovered aircraft items and components, and as requested by the AIC during the remainder of the investigation.

The ATSB is reproducing the AIC report titled Controlled flight into terrain, 11 km south-east of Kokoda Airstrip, Papua New Guinea, 11 August 2009, P2-MCB, de Havilland Canada DHC-6-300 on its web site with the permission, and on behalf of the Commission. An abstract drawn from that report follows:

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.

The investigation identified a number of factors that led to increased safety risk. Those related to the crew of the aircraft, the weather conditions affecting the flight, crew training and the conduct of the flight. A number of the safety factors had the potential to adversely affect the safety of future aviation operations.

As a result of the investigation, the Accident Investigation Commission of PNG (AIC PNG) issued a safety recommendation in respect of the installation of cockpit voice recorders (CVR) in PNG aircraft with a seating capacity of 18 or more passengers. In response, the Civil Aviation Safety Authority of PNG (CASA PNG) intends legislating to require the installation of CVRs in turbine-powered aircraft with seating for more than nine passengers. As a result of the investigation, CASA PNG has also established a principal medical officer position and has advised of action to move responsibility for the administration of the PNG mandatory occurrence notification system to the AIC PNG. Extensive proactive safety action has been taken by the aircraft operator in response to the risk of inadvertent flight into cloud while employing visual flight procedures and in regard to operations into Kokoda Airstrip an effort to prevent a recurrence.

A full copy of the Papua New Guinea AIC report titled Controlled flight into terrain, 11 km south-east of Kokoda Airstrip, Papua New Guinea, 11 August 2009, P2-MCB, de Havilland Canada DHC-6-300 (File ref AS 09 1005) is available from the 'Download Final Report' link titled on the right, immediately above the 'Feedback' tab.

Any media enquiries in respect of the AIC report should be directed to:

Mr David Inau
CEO, Accident Investigation Commission
Telephone: +675 311 2406
Email: ceoaicpng@hotmail.com

Address:  
Accident Investigation Commission    
PO Box 1790, Boroko
National Capital District
Port Moresby, Papua New Guinea

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Download Preliminary Report
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Preliminary Report Released 18 September 2009

This accident is being investigated by the Papua New Guinea Accident Investigation Commission (AIC) in accordance with its obligations under Annex 13 to the Convention on International Civil Aviation. The AIC requested the Australian Transport Safety Bureau (ATSB) to assist their investigation by providing investigator support, information and technical advice and facilities support.

In accordance with paragraph 5.23 of Annex 13, the ATSB appointed an Accredited Representative and a number of advisors to the Accredited Representative (ATSB investigators) to assist the AIC during the on-site phase, in the technical examination of a number of recovered aircraft items and components, and as requested by the AIC during the remainder of the investigation. In addition, the ATSB supported the AIC in the development of its Preliminary Factual Report. An abstract drawn from that report follows:

At about 1055 local time on 11 August 2009, the pilot of a De Havilland DH-6 Twin Otter (Twin Otter) aircraft, registered P2-MCB, reported departure from Jacksons Aerodrome, Port Moresby on a charter flight to Kokoda, Papua New Guinea. On board the aircraft were two crew and 11 passengers. The weather in the area was forecast to include isolated showers and thunderstorms, with areas of rain. In addition, significant layers of cloud were forecast from 800 ft above ground level to 18,000 ft, with isolated embedded Cumulo Nimbus cloud within those layers.

The pilot's estimated time of arrival at Kokoda was 1120.

The flight service operator for the area made a number of attempts to contact the pilot by radio in order to advise of other traffic but without success. At 1135, another of the company's aircraft that was in the area advised flight service that the Twin Otter had not arrived at Kokoda.

At about 0810 on 12 August 2009, a search aircraft detected an emergency locator transmitter signal and, shortly after, visually identified aircraft wreckage on the eastern side of the Kokoda Gap, about 6 NM (11 km) south-east of Kokoda Aerodrome.

The aircraft had impacted steep, heavily-timbered terrain in a near-level attitude and was seriously damaged. The aircraft occupants were fatally injured.

The investigation is continuing and will include:

  • examination of the items that were recovered from the accident site
  • review of the relevant operational documentation
  • review of the aircraft's weight and balance
  • review of the forecast and actual weather conditions at the time of the occurrence
  • conduct of a number of interviews with relevant persons and organizations
  • review of the relevant risk controls and potential organisational influences that may have contributed to the development of the occurrence.

A full copy of the Papua New Guinea Accident Investigation Commission report titled Aircraft accident interim report involving DH-6. P2-MCB near Kokoda on the 11 August 2009 (File ref AS.09.1005) is available from the link on the right.

Any media enquiries in respect of the AIC report should be directed to:

Mr David Inau
CEO, Accident Investigation Commission
Telephone: +675 311 2406
Email: ceoaicpng@hotmail.com

Address:  
Accident Investigation Commission    
PO Box 1790, Boroko
National Capital District
Port Moresby, Papua New Guinea


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Safety issues

AE-2009-050-SI-01 - AE-2009-050-SI-04 - AE-2009-050-SI-03 - AE-2009-050-SI-02 -  

Emergency procedures for Visual flight in IMC

The operator did not have a published emergency recovery procedure for application in the case of inadvertent flight into instrument meteorological conditions.
Issue Number:AE-2009-050-SI-01
Who it affects:
Status:Adequately addressed


 

Flight recorders

The lack of both flight data and cockpit voice recorders adversely affected a full understanding of the accident by the investigation.
Issue Number:AE-2009-050-SI-04
Who it affects:


 

CASA medical director

There was no qualified Director (or similar) of Aviation Medicine in Papua New Guinea (PNG) that could enhance the administration of the PNG aviation medical regime.
Issue Number:AE-2009-050-SI-03
Who it affects:


 

Manditory occurance reporting

The lack of a reliable mandatory occurrence reporting arrangement minimised the likelihood of an informed response to Papua New Guinea specific safety risks.
Issue Number:AE-2009-050-SI-02
Who it affects:
Status:Adequately addressed

 

General details

Date: 11 Aug 2009 Investigation status: Completed 
Time: about 11:14 PGT Investigation type: Occurrence Investigation 
Location:11 km south east of Kokoda airstrip, Oro province of PNG   
State: International  
Release date: 31 Mar 2011 Occurrence category: Accident 
Report status: Final Highest injury level: Fatal 
 

Aircraft details

Aircraft manufacturer: de Havilland Canada 
Aircraft model: DHC-6 300 series 
Aircraft registration: P2-MCB 
Serial number: 441 
Type of operation: Charter 
Damage to aircraft: Serious 
Departure point:Port Moresby, Papua New Guinea
Departure time:1055 PGT
Destination:Kokoda, Papua New Guinea

Crew details

RoleClass of licenceHours on typeHours total
Pilot-in-CommandCommercial19702270
Co-Pilot/1st OfficerCommercial19402150
 

Injuries

 CrewPassengerGroundTotal
Fatal: 211013
Total:211013

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Last update 31 March 2011