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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

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




Released in accordance with section 25 of the Transport Safety Investigation Act 2003.

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