Air Niugini Flight 73 Crash: Final report released

"ttyymmnn" (ttyymmnn) 07/26/2019 at 10:36 • Filed to: wingspan, Planelopnik

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(US Navy)

The Papua New Guinea Accident Investigation Commission (AIC) released the !!!error: Indecipherable SUB-paragraph formatting!!! on Air Niugini Flight 73, a Boeing 738 that crashed into Chuuk Lagoon while attempting to land at Chuuk Int’l Airport in bad weather. The plane came to rest on the water, and passengers were rescued by local fisherman and US Navy divers. One passenger was killed. A flight engineer seated in the cockpit jumpseat filmed the final moments of the flight. The video has no sound, and stops shortly after impact.

Basically, once the crew disabled the autopilot, they had no idea what they were doing and ignored every single alarm that was alerting them to the botched approach. They didn’t realize their predicament until seconds before impact. Below is an animation created of the accident sequence constructed from the flight data, and an excerpt from the synopsis of the investigation.

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The investigation determined that the flight crew’s level of compliance with Air Niugini Standard Operating Procedures Manual (SOPM) was not at a standard that would promote safe aircraft operations.

The PIC intended to conduct an RNAV GPS approach to runway 04 at Chuuk International Airport and briefed the copilot accordingly. The descent and approach were initially conducted in Visual Meteorological Conditions (VMC), but from 546 ft (600 ft)   the aircraft was flown in Instrument Meteorological Conditions (IMC).

The flight crew did not adhere to Air Niugini SOPM and the approach and pre-landing checklists. The RNAV (GPS) Rwy 04 Approach chart procedure was not adequately briefed.

The RNAV approach specified a flight path descent angle guide of 3o. The aircraft was flown at a high rate of descent and a steep variable flight path angle averaging 4.5o during the approach, with lateral over-controlling; the approach was unstabilised.

The Flight Data Recorder (FDR) recorded a total of 17 Enhanced Ground Proximity Warning System (EGPWS) alerts, specifically eight “Sink Rate” and nine “Glideslope” . The recorded information from the Cockpit Voice Recorder (CVR) showed that a total of 14 EGPWS aural alerts sounded after passing the Minimum Descent Altitude (MDA), between 307 ft (364 ft) and the impact point. A “100 ft” advisory was annunciated, in accordance with design standards, overriding one of the “Glideslope” aural alert. The other aural alerts were seven “Glideslope” and six “Sink Rate” .

The investigation observed that the flight crew disregarded the alerts, and did not acknowledge the “minimums” and 100 ft alerts; a symptom of fixation and channelised attention. The crew were fixated on cues associated with the landing and control inputs due to the extension of 40° flap.

Both pilots were not situationally aware and did not recognise the developing significant unsafe condition during the approach after passing the Missed Approach Point (MAP) when the aircraft entered a storm cell and heavy rain. The weather radar on the PIC’s Navigation Display showed a large red area indicating a storm cell immediately after the MAP, between the MAP and the runway.

The copilot as the support/monitoring pilot was ineffective and was oblivious to the rapidly unfolding unsafe situation. He did not recognise the significant unsafe condition and therefore did not realise the need to challenge the PIC and take control of the aircraft, as required by the Air Niugini SOPM 6.

The Air Niugini SOPM instructs a non-flying pilot to take control of the aircraft from the flying pilot, and restore a safe flight condition, when an unsafe condition continues to be uncorrected.

The records showed that the copilot had been checked in the Simulator for EGPWS Alert (Terrain) however there was no evidence of simulator check sessions covering the vital actions and responses required to retrieve a perceived or real situation that might compromise the safe operation of the aircraft. Specifically sustained unstabilised approach below 1,000 ft amsl in IMC.

The PIC did not conduct the missed approach at the MAP despite the criteria required for visually continuing the approach not being met, including visually acquiring the runway or the PAPI.

The PIC did not conduct a go around after passing the MAP and subsequently the MDA although:

The aircraft had entered IMC;

the approach was unstable;

the glideslope indicator on the Primary Flight Display (PFD) was showing a rapid glideslope deviation from a half-dot low to 2-dots high within 9 seconds after passing the MDA;

the rate of descent high (more than 1,000 ft/min) and increasing;

there were EGPWS Sink Rate and Glideslope aural alerts; and

the EGPWS visual PULL UP warning message was displayed on the PFD .The report highlights that deviations from recommended practice and SOPs are a potential hazard, particularly during the approach and landing phase of flight, and increase the risk of approach and landing accidents. It also highlights that crew coordination is less than effective if crew members do not work together as an integrated team. Support crew members have a duty and responsibility to ensure that the safety of a flight is not compromised by non-compliance with SOPs , standard phraseology and recommended practices.

TheRealBicycleBuck > ttyymmnn 07/26/2019 at 10:55

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Controlled flight into ground (in this case, water).

Big mistake.

WilliamsSW > ttyymmnn 07/26/2019 at 10:55

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That’s... really bad.

These guys spend their time flying around the ITCZ, dealing with storms (and knowing when to go missed)  should be something they can do in their sleep.  

ttyymmnn > TheRealBicycleBuck 07/26/2019 at 10:58

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Possibly the biggest.

ttyymmnn > WilliamsSW 07/26/2019 at 10:59

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This seems to be  another example of guys who do fine when they monitor the automatic systems but suck at actually flying the plane.

vondon302 > ttyymmnn 07/26/2019 at 11:01

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I assume they drug tested these guys cause damn that's a f***up.

WilliamsSW > ttyymmnn 07/26/2019 at 11:03

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They weren’t actually doing a good job monitoring the automated systems either.

This all seems so brain dead - I wonder if fatigue was a factor?

user314 > ttyymmnn 07/26/2019 at 11:03

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Christ. Please tell me these two are now delivering pizzas or something else more in line with their demonstrated skills. 

ttyymmnn > vondon302 07/26/2019 at 11:04

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Probably, but I haven’t read the full report. Utter breakdown (or nonexistence) of CRM, complete lack of situational awareness. 

ttyymmnn > WilliamsSW 07/26/2019 at 11:12

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The report states:

>>>>>>

In that PIC’s report, it lists:

Sign off at Pohnpei at 11 pm

Sign on at Pohnpei at 07:50 am

The AIC notes that Section 4.10 of the Air Niugini Limited Flight Administration Manual (FAM) complies with the Flight and Duty Limitations of the PNG Civil Aviation Rules and requires pilots to be free of duty for 9 hours including the hours of 10 pm to 6 am. If that is not possible the duty-free period required is 10 hours. Therefore, the PIC did not meet the duty-free requirements of the CARs or the Air Niugini Limited F AM . The same duty requirements apply to the copilot and the cabin crew.

>>>>>>

However, the investigation did not cite fatigue as a factor, but did discuss other human factors that can lead to decreased vigilance such a absorption, fixation, channelized attention, fascination, and ‘tunnelling or channelizing.’

Ultimately , the report cites loss of SA but never uses the term “pilot error.”

ttyymmnn > user314 07/26/2019 at 11:13

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We can only hope.

facw > ttyymmnn 07/26/2019 at 11:15

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a Boeing 738 

Out of curiosity do you know how people refer to the 737 MAX 8?

WilliamsSW > ttyymmnn 07/26/2019 at 11:17

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While that might not technically meet the rest requirements, it doesn’t seem like a big deal - though that depends on what the pilot did between 11pm and 7:50 am.  If he had a 90 minute commute each way or insomnia or whatever he could have been fatigued.  

WilliamsSW > facw 07/26/2019 at 11:19

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Good question- 738 is a 737-800, not a Max, but idk what the code is for a Max 8.  Might be the same actually (73M is already taken by the Combi).

facw > ttyymmnn 07/26/2019 at 11:21

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So I’ve said before that we should have video of the cockpit (and probably a few other feeds) going into the black box, but I’d like to amend that to say that video should be uploaded post flight and randomly audited...

ttyymmnn > facw 07/26/2019 at 11:21

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I do not.  I have not heard a similar abbreviation as 738 for 737-800. Interestingly, RyanAir has removed the word MAX from the nose of their MAX 8s. And when I was on a SWA flight last month, I overheard the safety lecture for the people in the exit row. The FA said, “No, this is not a MAX.” That name is toxic now.

ttyymmnn > WilliamsSW 07/26/2019 at 11:22

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Right. And does that 9 hours mean “9 hours between the wheel stopping and the wheel turning,” or 9 hours of actual rest of f the airport? I’m guessing the former.

ttyymmnn > facw 07/26/2019 at 11:23

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I’m guessing that the pilot’s union will never agree to video.

ttyymmnn > WilliamsSW 07/26/2019 at 11:27

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Let’s make one of our own. I’ll go with 7382. Kind of clumsy, but it works. See my reply to facw. Ryanair is ditching the MAX name on their aircraft.

WilliamsSW > ttyymmnn 07/26/2019 at 11:31

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Ok I looked it up.  It’s B38M.  Max 9 is a B39M etc

Ash78, voting early and often > ttyymmnn 07/26/2019 at 11:33

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Granted, that storm came out of nowhere, but at the very least you can casually power up and voluntary go-around to give you time to reassess the situation.

They were acting way too casual about the whole thing. I’m just amazed that an uncontrolled, unflared crash into the water didn’t cause more death and injury (it’s one thing for Sully to gently settle a plane it into the Hudson on a clear day; another thing to fly — with power — directly into the ocean)

ttyymmnn > WilliamsSW 07/26/2019 at 11:34

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Thanks.

ttyymmnn > Ash78, voting early and often 07/26/2019 at 11:36

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The one guy who died was killed by blunt force trauma. So he may not have been wearing his seatbelt. Of course, the pax were never told to assume crash positions. They never knew what was happening.

WilliamsSW > ttyymmnn 07/26/2019 at 11:39

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I believe they all have to start with the manufacturer code, so the B is required and then they had 3 more digits to figure something out.

It’s funny when you go to the website and filter for Boeing there are 18 pages of results for everything from the PT-17 (ST75- it’s a Stearman) to the VC-25 (B 742, same as any other 747-200)

Ash78, voting early and often > ttyymmnn 07/26/2019 at 11:46

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Not even a “brace for impact” or -- as my late grandfather (flying since the early 50s) would have said -- every single pilot says “Oh Shit” right before they crash, without fail.

facw > ttyymmnn 07/26/2019 at 12:26

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That might work with the airlines, but the FAA and their international equivalents have considerably more ability to dictate.

jimz > ttyymmnn 07/26/2019 at 12:49

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hate to say it, but when the wipers went out of sync it almost seemed like the plane was flailing around yelling “WHAT THE HELL ARE YOU DOING?!?!”

Rusty Vandura - www.tinyurl.com/keepoppo > ttyymmnn 07/26/2019 at 13:51

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flightradar24 frequently lists ships as B738

Rusty Vandura - www.tinyurl.com/keepoppo > ttyymmnn 07/26/2019 at 13:51

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I believe they’ve had to ditch a pilot or two along the way as well.

ttyymmnn > Rusty Vandura - www.tinyurl.com/keepoppo 07/26/2019 at 14:24

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I think that is a standard international code. 

Rusty Vandura - www.tinyurl.com/keepoppo > ttyymmnn 07/26/2019 at 15:00

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Taken at face value, what you transcribe here is thoroughly damning.