Air Niugini crew ignored ‘pull up’ alerts

[Ref 30 July-5 August 2019 | Flight International P.10]

Occurrence Date/Time 28 September 2018
Aircraft Type Boeing 737-800 (P2-PXE)
Flight / Operator Air Niugini PX73
POB  35 passengers ;

12 crew members

Description The pilot in command (PIC) persisted with an unstable approach in contravention of the airline’s standard operating procedures (SOP);

The pilot in command (PIC) also reported that there was no visibility for the last 30s of the flight due to
encountering a small storm cell ;

The co-pilot was completely unaware of the hazardous situation unfolding and did not challenge the [pilot in command] and attempt to take control of the aircraft and execute a go-around, in accordance with company instructions ;

The pilots failed to respond to 16 aural alerts from
the enhanced ground proximity warning system (EGPWS)

 

Result The aircraft came down in Chuuk Lagoon around
460m (1,500ft) short of the runway 04 threshold, deflecting across the water several times and turning clockwise before coming to rest partially submerged
Contributory factors Captain lost situational awareness ;

Co-pilot did not challenge the Captain ;

Both pilots heed multiple warnings

Recommendation 12 recommendations to Air Niugini, mostly relating
to training around evacuations, safety placards and other deficiencies ;recommendation to Honeywell that the EGPWS be
upgraded to include a continuous “pull up” aural and primary flight display warning to replace the “sink rate” warning below 500ft radio altitude remains open
(a dissenting view from the US investigation agency: “NTSB staff disagree that an additional warning would have been effective in alerting the crew.”)

 


Read More –

Papua New Guinea’s Accident Investigation Commission (AIC) says that there were “many instances of non-compliancewith evacuation directives prohibiting baggage from being taken from the aircraft during evacuation.

Images reviewed by the commission found evidence that a loadmaster on board had his hands full with a backpack, clipboard and shoes when he left.

Also, there was one fatality, which a post-mortem examination concluded was due to injuries from the force of the impact.  The passenger who was not wearing a seat-belt at the point when the 737 struck the sea surface. This allowed his body to become a projectile resulting in massive head trauma injuries. The autopsy also determined that there was a lack of trauma around the waist and hips.

 

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