Air Niugini Aircraft crash, Truk Lagoon

[lomapaseo]

And equally there are eyewitnesses who describe more than one impact. Here's one:



Arguing about which eyewitness to believe simply illustrates why we have flight recorders. :O

or mechanical pathologists :)

[longlegs]

https://www.abc.net.au/news/2018-10-25/aussie-hero-says-he-evacuated-passengers-crashed-niugini-plane/10424356Aussie 'hero' says he evacuated passengers from crashed plane after crew panicked7.30 (https://www.abc.net.au/7.30/)

By Michael Atkin (https://www.abc.net.au/news/michael-atkin/5778984) and Nadia Daly (https://www.abc.net.au/news/nadia-daly/6564026)

An Australian man who evacuated passengers from a sinking Boeing 737 after it crash-landed in Micronesia last month claims some of the Air Niugini crew panicked and left passengers to escape by themselves.

An Indonesian man died in the crash (https://www.abc.net.au/news/2018-10-02/passengers-body-found-after-air-niugini-plane-crash/10327378) despite Air Niugini initially announcing all 47 passengers and crew were safely evacuated.

It took a full day before the airline announced one passenger was missing and the body of Eko Cahyanto Singgih was later found by US Navy divers.

The cause of the crash is currently being investigated by the Federated States of Micronesia with support from the Papua New Guinea and USA governments, with a preliminary report expected by the end of the month.

Adam Milburn, a former Australian Navy clearance diver who lives in Micronesia, was on board flight PX 73 when it undershot the runway by 145 metres, landing in Chuuk Lagoon (https://www.abc.net.au/news/2018-09-28/flight-lands-in-a-lagoon-off-micronesia/10316434).

He has been described as "heroic" for getting passengers to safety.

He told 7.30 he was shocked when he realised the plane was in the water.

"I was like everyone, kind of floundering. 'How did we get here? What's happening? What are we doing right now in a plane that's floating on the water?'" he said.

Mr Milburn said that after the crash the crew yelled at passengers to remain seated.

"They were shouting, and I think I would have been in their situation as well. There was panic in their voices, you could hear the panic," he said.

He said he waited in his seat, but there were no further instructions so he grabbed his life jacket and helped others before heading to the exit.

"I remember I stepped out onto the wing and there was a gentleman there [another passenger] on his own, from memory, and he had the life raft but it hadn't been deployed," Mr Milburn said.

"He said, 'Can you find the inflation cord? I can't find the inflation cord.' So we were able to find the flap and inflate the life raft."

Mr Milburn said the pair then evacuated most of the 35 passengers who were on board, without crew assistance.

Local fishermen arrived with a flotilla of boats to help ferry the passengers to shore.

Mr Milburn said most passengers had head and neck injuries from hitting the front of their seat, and one was unconscious.

"The last two passengers that I remember were quite incapacitated, so then there was a challenge about trying to keep their head out of the water because by that stage there was probably water up to knees or waist," he said.

Mr Milburn said he did not see a cabin crew member do a headcount or check names against a flight manifest, but admits that does not mean it did not happen.

"I'm not sure of what the procedures should or shouldn't have been, but it was chaotic. It would have been really difficult to manage that," he said.

A group of sailors with the US Navy, who had been training nearby, were also key to the rescue, and Mr Milburn re-entered the sinking plane to help them search for survivors.

One Navy diver swam through the aircraft's interior to inspect it before they decided it was too dangerous and exited the plane.'Embarrassed to be called a hero'Mr Milburn said he had been replaying in his mind whether he could have done more to save the Indonesian man who died.

"If I'd just walked down there and got wet up to my shoulders and just felt around, perhaps I would have felt him and then you could have called for help, but hindsight is a great thing," he said.

"[His death] was hard to take. I was hoping beyond hope he was going to turn up somewhere.

"I literally touched everyone that came out the exit door on the left-hand wing, either assisted them into the life raft or physically carried them into the life raft, so no one was coming out and falling off the wing and drowning, I'm absolutely confident of that."

American journalist Bill Jaynes, editor of local paper the Kaselehlie Press, was on the flight and praised Mr Milburn for his actions.

"I know Adam and I know he would be the last person to call himself anything like a hero, [but] considering there was a plane in the water I would call it heroic," Jaynes said.

"Meanwhile flight attendants, in my section at any rate, were panicking and running up and down the aisles … and screaming for us to all calm down, which of course had the opposite effect.

"[Adam] was very calm throughout the whole situation. I can't recall if he actually took my hand as I stepped out of the plane or not. I just remember his demeanour.

"I remember him being very calm, which seemed to be a bit contagious, and other people kind of grabbed on to that."

Mr Milburn said he was "a bit embarrassed to be called a hero, because I don't think there was anything particularly heroic in what I did".

"I think one of the things that I came away from the crash with, just a real sense of optimism about humanity and human nature," he said.

Mr Milburn's wife Lauren was not on board but said she was concerned to hear his account of the evacuation.

"I still can't understand why it was my husband that was deploying the life raft and helping passengers into the life raft," she said.

"It does make you wonder what was going on in the aircraft."

Aviation consultant Neil Hansford said the accident raised serious questions.

"There is enough rafts and life jackets and everything else for it to have been handled without the intervention of the islanders, but thank God the islanders were there," he said.

"There was only 35 passengers."Investigation underwayThere are conflicting reports about weather conditions before the plane crashed. Air Niugini has said there was heavy rain, which caused poor visibility.

Investigators have access to information about the flight's final moments after the data recorder and cockpit voice recorder were recovered.

Mr Hansford believes that will be a central part of the crash investigation, including whether pilot error was a factor.

"He only dropped it into the lagoon 145 metres short of the runway, so he was too low for a very long time and I think what was probably playing on his mind is, he only had 6,000 feet of runway and maybe he was realising he didn't know the condition," he said.

The Milburn family have been strong supporters of Air Niugini but they have decided to stop flying with the airline for now.

Ms Milburn said they are looking for answers about what went wrong.

"We're very keen, just personally, to understand what happened, to make sense of what happened, but also then for us to be able to make decisions about flying and who we fly with and who we feel comfortable flying with," she said.

"We're optimistic and hopeful that we get some good learning and some good information out of the investigation."

Mr Milburn added that he would like to see Air Niugini work hard to improve safety.

"What I'd like to see is a clear demonstration of what steps they're going to take to ensure that doesn't happen again," he said.

It is the first fatal accident in the 45-year history of Air Niugini, which had previously had a good safety record.

Air Niugini did not respond to 7.30's questions.

But in a public statement on October 5, the deputy chairman of the Air Niugini board, Andrew Nui, thanked local islanders and the US Navy team who helped passengers and crew.

"Their courage and quick thinking helped save lives and our thanks and gratitude goes out to all of them," he said.

[b1lanc]

From Avherald,
On Oct 26th 2018 Papua New Guinea's Accident Investigation Board (PNGAIB), having been delegated the investigation by Micronesia, released their preliminary report (http://www.aic.gov.pg/pdf/PreRpts/TC&I%2018-1001%20%28AIC%2018-1004%20P2-PXE%29.pdf) stating the aircraft "impacted the water of Chuuk Lagoon about 1,500 ft (460 m) short of the runway 04 threshold, during its approach to runway 04 at Chuuk International Airport. As the aircraft settled in the water, it turned clockwise through 210 degrees and drifted 460 ft (140 m) south east of the runway 04 extended centreline, with the nose of the aircraft pointing about 265 deg."

[Hotel Tango]

Reading the Milburns' comments above all I can say is that if I stopped flying with every airline which has had an accident, I guess I wouldn't be doing much flying today! I appreciate that accidents can be attributed to poor training etc., but many more can be attributed to a multitude of other causes which can happen to any airline. One fatality in 45 years is pretty good going and it would certainly not put me off flying with Air Niugini today.

[Super VC-10]

Now confirmed, aircraft crashed short of the runway. Was approaching 04.

http://www.aic.gov.pg/pdf/PreRpts/TC&I%2018-1001%20%28AIC%2018-1004%20P2-PXE%29.pdf

[fox niner]

Stunning photo from the report:

https://cimg7.ibsrv.net/gimg/pprune.org-vbulletin/1415x896/04811263_14e4_4382_920d_b1dba44bb470_271bc969ca5723b821d767e 5526c1cec320eaa89.jpeg

[GordonR_Cape]

The report indicates that all of the seriously injured passangers (plus the one fatality) were located at the rear of the aircraft, and all were in window seats.

[DaveReidUK]

The report indicates that all of the seriously injured passangers (plus the one fatality) were located at the rear of the aircraft, and all were in window seats.

That's not altogether surprising - the tail would have hit the water first, given that the aircraft was on final approach, and all but 3 of the 35 pax were sitting in window seats.

[b1lanc]

That's not altogether surprising - the tail would have hit the water first, given that the aircraft was on final approach, and all but 3 of the 35 pax were sitting in window seats.

Interesting damage/injury differential between the 738 and Sully's A320.

[DaveReidUK]

Interesting damage/injury differential between the 738 and Sully's A320.

We won't know the extent of the damage until the aircraft is raised (surprising that it hasn't been by now).

The fact that there were only 4 serious injuries from 150 pax on the Hudson is likely to be down to the fact that the impact speed would have been lower than the 737 on final approach, and Sully's passengers were already bracing for the ditching.

[grizzled]

Interesting damage/injury differential between the 738 and Sully's A320.

Yes indeed, but remember one was a planned ditching, meaning Sully intended to ditch in the Hudson (albeit he had few viable options). Air Niugini was not intending to hit the water (we hope...). So the configurations (including gear down for Air Niugini, gear up for Sully) and speeds at impact would have been sufficiently different to account for damage and injuries.

[JPJP]

Interesting details in the Preliminary Report regarding the cockpit crew rest prior to duty. 10.3 hours off duty and reported sleep of 5.5 and 6.6 hours. Not ideal and barely legal.

Captain appears to have a respectable amount of time in the aircraft. All in the left seat. F.O. has decent total time, with very little in the 737.

[Cloudee]

Interesting that the CVR found its way out of its rack and out of a substantially undamaged fuselage and on to the sea floor. Where is it located in the aircraft? Is it designed to drop out?

“The SSFDR was located on its rack within the aircraft and was recovered by local divers.
The SSCVR was recovered from the seabed by US Navy divers about 440 feet (135 metres) back along the flight path from the 04 threshold, in the area ahead of the first point of water impact.”

[DaveReidUK]

Interesting that the CVR found its way out of its rack and out of a substantially undamaged fuselage and on to the sea floor.

Where is it located in the aircraft?https://cimg2.ibsrv.net/gimg/pprune.org-vbulletin/800x955/b738_cvr_0663efc6b15fcbc319557a562d40d260f21770f8.jpgIs it designed to drop out?

No.

[RatherBeFlying]

He was too careful in his descriptions, not what I would expect from a traumatic experience.Having been present at two fatal occurrences and having experienced a number of close calls, certain detailed memories never go away even though you might prefer otherwise.

[b1lanc]

Yes indeed, but remember one was a planned ditching, meaning Sully intended to ditch in the Hudson (albeit he had few viable options). Air Niugini was not intending to hit the water (we hope...). So the configurations (including gear down for Air Niugini, gear up for Sully) and speeds at impact would have been sufficiently different to account for damage and injuries.

Was it ever confirmed that the gear was down? Lots of unanswered questions - really don't know what configuration Air Niugini was in or where the crew thought they were (WestJet at St-Maarten comes to mind). Kind of interestng to read the PPPRuNe thread on Sully's attempts to flare though.

I'm a bit surprised that there hasn't been an attempt to raise it yet. JA2 was up in 55 hours (yes this is not SF but really, a month?).

[EDLB]

Doubt that they lift it at all. Remote location without heavy lift gear nearby. All parts of the plane are a total write off in sea water. I assume that they leave it as dive spot. What relevant additional information do you expect by lifting the plane, which you can not get by a nice clear warm water dive in the tropics?

[VolLibre]

Hope they do lift it. It is about 50 tons of alien materials that don't belong in that fragile ecosystem. We have enough trouble with illegal waste dumping around this region. Must be removed.

[SnowFella]

Was it ever confirmed that the gear was down?.

Going by the below bit in the prelim I'd hazard a guess the gear was down.

The initial examination of video taken by the divers showed that the main landing gear separated from the aircraft during the water impact. The rear fuselage behind the wing had fractured during the impact sequence.

[Mr Angry from Purley]

Interesting details in the Preliminary Report regarding the cockpit crew rest prior to duty. 10.3 hours off duty and reported sleep of 5.5 and 6.6 hours. Not ideal and barely legal.

Captain appears to have a respectable amount of time in the aircraft. All in the left seat. F.O. has decent total time, with very little in the 737.
JPJP Both crew members 40+ hours in last 30 days - what's next they were fatigued.....

[A Squared]

Hope they do lift it. It is about 50 tons of alien materials that don't belong in that fragile ecosystem. We have enough trouble with illegal waste dumping around this region. Must be removed.

True. Heaven forbid that the airplane contaminate the wreckage of the 10 Japanese warships and 30 merchant ships already at the bottom of the lagoon.

[Sailvi767]

Not to mention the hundreds of other airplanes.

[DaveReidUK]

What relevant additional information do you expect by lifting the plane, which you can not get by a nice clear warm water dive in the tropics?


The aircraft sank upright, and is resting on the floor of the lagoon, so the underside of the rear fuselage isn't readily accessible, even to a diver.

If for no other reason, raising it would answer this question:

Interesting that the CVR found its way out of its rack and out of a substantially undamaged fuselage and on to the sea floor.

That aside, I don't believe for a moment that it will be allowed to remain submerged indefinitely.

[lomapaseo]

The aircraft sank upright, and is resting on the floor of the lagoon, so the underside of the rear fuselage isn't readily accessible, even to a diver.

from a survivability standpoint, I sure would like to see a DFDR G-load trace against the damage to the underside

[HundredPercentPlease]

JPJP Both crew members 40+ hours in last 30 days - what's next they were fatigued.....

You sound like a scheduling officer!

For some people, operating an aircraft after just 5.5 hours sleep can cause suboptimal performance. Which pilots call "fatigue".

[Admiral346]

Reading the Milburns' comments above all I can say is that if I stopped flying with every airline which has had an accident, I guess I wouldn't be doing much flying today! I appreciate that accidents can be attributed to poor training etc., but many more can be attributed to a multitude of other causes which can happen to any airline. One fatality in 45 years is pretty good going and it would certainly not put me off flying with Air Niugini today.

The amount of fatalities over a certain time do not allow to conclude a certain risk.
It is important to factor in the number of flights done over that time. Big airlines with a thousand or more flights per day would have an accident every month at the same accident rate.

The Space Shuttle program had an accident rate of about 1%, that would mean about 10 crashes per day at the place I work at...

[Seaeagle109]

Here's the final report

http://www.aic.gov.pg/pdf/FinRpts/2019/AIC%2018-1004%20P2-PXE/P2-PXE%20AIC%2018-1004%20Final%20Report.pdf

[Maisk Rotum]

I hope these guys never fly again. That is the most appalling report I have ever read. Six Sink Rate, seven Glideslipe warnings and two Pull Up warnings and they ignored them and talked over them. "The crew had experienced these before and considered them nuisance alerts"- astonishing!! At 300 feet they were descending at 1530 fpm. They continued past the missed approach point and entered IMC. Just unbelievable. Same crew, previous day flew below the glide and got 28 Glideslope alerts and ignored them. Speechless.

[fdr]

Here's the final report

http://www.aic.gov.pg/pdf/FinRpts/2019/AIC%2018-1004%20P2-PXE/P2-PXE%20AIC%2018-1004%20Final%20Report.pdf


Well, we knew it would be disappointing reading.

OM policy presented in the report doesn't appear to include discussion on conditions required to descend below DA/MDA, however the Jepp review part of the OM notes actions for undertaking an MAP. As the same crew had studiously avoided response to a similar number of EGPWS/GPWS alerts on the prior flight into the same airport, that would appear to be an area of reinforcement training worth some effort by the company. Any discussion on criteria to continue an approach below DA(H)/MDA appears to be missing.

The images show that the VNAV and LNAV was properly displayed all the way to the water landing. FPV was not displayed in any PFD, but is available... The comments of P18 state that the pilot disconnected the AP when it commenced a pitch up for the GA... which doesn't gel with the function of the APFD of the displayed VNAV, and the altitude selected in the first cockpit image, however, what happened at that point is important to understand as to why the plane ended up out of sorts. The CVR transcript, and the DFDR would indicate what altitude was set on the MCP, and when it was set/reset to the MAP height. The change to VNAV mode that happened at the point that the AP was disconnected suggests that the aircraft did capture the MDA, and the images are of the MDA reset to the MAP alt. The importance of that is the fact it ensures that the aircraft would be destabilised by an ALT CAP at MDA, which sets up the wild ride thereafter. The "raw" data remains valid, the crew just end up throwing away a "stable" approach at relatively low level, disconnecting AP, losing FD, and going to manual thrust, which appears to have been reduced promptly.

The volume of recommendations looks great, but seems to have weight rather than relevance to recommendations on how to stop crew disregarding EGPWS/GPWS alerts and warnings, or continuing a descent to impact, well below MDA, without having a piece of concrete in front of them. The comments on the PAPI comes up before the visibility went bad due to the rain shower. Thereafter, having to turn on the windscreen wipers to get the seaweed off so that you can see the barnacles and oysters on the submerged rocks would make it unlikely that a PAPI was being followed.

At "100" is there any expectation that there should be a threshold clearly visible and a runway with all of the pretty markings and lights etc, somewhere near the window? If not needed at "100" when the MDA was some 20 seconds earlier, then at what point would the crew get a bit uncomfortable with the waves under their window.

Little in the recommendations appear to work on the underlying problem, continuing an approach below minima without seeing the runway, lights, PAPI etc.

GPWS is not installed just to increase the ZFW.

[safetypee]

Maisk Rotum, #277 ‘appalling report’
Alternatively a well considered, thorough report identifying significant issues within our industry.
If the ‘appalling’ interpretation relates to human performance, then why is this misappropriation any different (in principle) to any human performance, including reading, interpreting and commenting on a report.
We have yet another opportunity for learning, but what and how.

[Maisk Rotum]

Agreed. A factual and honest report. I think you know what the 'appalling' refers to.

[safetypee]

M R,
My less than overt point is that we often think that others know what is mean and understood. So as much as you might think (assume) that I will know something, might the crew have believed that many of the issues now identified with hindsight were acceptable to their way of thinking at that time.
The difficult task now is in unraveling why there should have been such a difference and what we can learn from this.

Opposed to declaring that the apparent failure to heed warnings and alerts is unbelievable (our way of thinking), we should reconsider that hearing is the first sense to degrade with increasing workload, together with the issues of fixation etc, as discussed the report (HF 2.3.1.), and that with many complacent historical items, all combined at an inopportune time.
Why should such contributions exist, and why was the combination so critical at that time. What might we do about these.

[Just a Grunt]

Reconstruction video, including some in-flight cockpit footage:

https://youtu.be/uIda0u5u9dE

[Sqwak7700]

I don’t understand. The report states that the crew did not have sufficient duty-free time. Off duty at 11pm, on duty at 750 am. So only 8:50 “off duty”, when they should have had 10:00. 1:10 short.

Yet under the human factors section, the “expert” states that fatigue was not a factor. Surely if you don’t achieve the required rest time under the regulations, fatigue is most certainly at least a factor? Otherwise, why bother having flight time limitations?

The report even outlines some symptoms of being distracted, which fit this crew’s actions pretty well, like task fixation and ignoring repeated GPWS alerts.

[gulliBell]

Aside from the blindingly obvious. Having watched the cockpit video the pilot seems to be continuously arm wrestling the controls in all directions, are all those vigorous and frequent control inputs really necessary to land a 737? Even if flying through a bit of a rain squall. Can't help but think he's working too hard on that, needlessly, and losing oversight of what's really important. I've seen a few helicopter pilots fly like that. Get them to take their hands off the controls and it will fly much better.

[lederhosen]

What happened is clear not least because of the video. Why it happened is less so. As an experienced captain on type I would venture a few comments. At first sight the crew were qualified and in terms of total flight time very experienced. However there was quite a marked cockpit gradient. What I mean by this is that the Australian co-pilot only had a few hundred hours on type while the local captain had 19,000 hours total time. This would not be the first time that a junior pilot was slow to speak up. Interestingly about 15,000 of the captain's hours appear to have been as co-pilot, which in a hiring interview would at least raise questions. Based on his performance on this and the previous flight we might reasonably speculate as to the reason why. The co-pilot did make the very reasonable suggestion that flaps 40 would be a good idea. With a potentially wet runway just over 1800 metres in length it is surprising that the captain was planning for anything else.

The 737 on a normal day is a very easy airplane to fly. With a short runway and a non precision approach in poor weather it needs another level of skill. The reconstruction shows very well the initial approach as just another day at the office. Bit of weather ahead, but the captain says they will break out in time, which is a pretty clear case of confirmation bias. If he had asked the co-pilot what he thought and whether they should hold for the weather to move away, he might well have got a different answer. Precisely because flying has become so routine there is a great tendency to continue. Doing something different is much less comfortable than just carrying on even with sink rate warnings etc. Alarmingly this is one of several very similar events I can think of with the 737. The Bali crash and the St Maarten Westjet event are two obvious examples. A particular issue is a high mda where you decide to continue and as per Boeing procedures click off the autopilot and autothrottle. At this point when you lose sight of the runway your actions should be clear, go-around. Flying a light aircraft you add power and in this case turn left towards the missed approach. In the Boeing you are in much less familiar territory and doing something many people very rarely do in real life, flying the aircraft without guidance or automatics.

There are of course many honourable exceptions to the rule. But as instructors know the weak pilots are the last ones to want to demonstrate their weaknesses and practice on line, even if the company allows it, which is of course another issue. There are a surprising number of large airlines who discourage switching off some or all of the automatics. The high cost of simulator time also means that these skills are often not the focus of valuable checking time. I would suggest that there would be a good market for a lower cost simulation alternative where manual flight could be regularly practised to achieve true competence on a regular basis.

[RickNRoll]

The high cost of simulator time also means that these skills are often not the focus of valuable checking time. I would suggest that there would be a good market for a lower cost simulation alternative where manual flight could be regularly practised to achieve true competence on a regular basis.

What would that do to the share price and Free Cash Flow?

[73qanda]

Did the Captain really keep his job as suggested here earlier?

[sheppey]

Air Niugini said it would continue investigating the crash, agreeing that it was a case of "human factors" and not pilot error that contributed to the crash."What we have to understand here is the pilots didn't purposely fly that plane into the water," Air Niugini's managing director Alan Milne told reporters, after the findings were handed down.He said both were experienced pilots, and something else "was a factor there that all came together to make that accident happen".

Well that's a huge relief. The crew are off the hook. At least we now know the pilots didn't deliberately fly the 737 into the water. The airline agreed it wasn't pilot error, either. That left Human Factors and something else was a factor. The dreaded something else. Time perhaps to resurrect Agatha Christie's detective, Hercule Poirot to solve the case of the missing factor? .

[Ewan Whosearmy]

The video from inside the cockpit:

https://www.youtube.com/watch?time_continue=45&v=QiAoRNOXBmM