Crash: PNG DH8A near Madang on Oct 13th 2011, impacted terrain

An Airlines of PNG (Papua New Guinea) de Havilland Dash 8-100, registration P2-MCJ performing flight CG-1600 from Lae to Madang (Papue New Guinea) with 28 passengers and 4 crew, was lost from radar about 20km south of Madang around 17:00L (07:00Z). The aircraft was later located on land about 20km south of Madang, the aircraft was on fire.

There are unconfirmed reports of possibly 4 survivors, however, the fate of the occupants is unclear as of current.

Early Oct 14th Australia's Department of Foreign Affairs said no Australian was killed in the crash identifying one of the pilots survived. The Department continued that according to local authorities 4 people survived the crash, amongst them also the other pilot.

Papua New Guinea's Accident Investigation Commission (AIC) said, the airplane went down 20km south of Madang near the mouth of the Gogol River and caught fire, there are reports of survivors and fatalities. Rescue forces have reached the crash site, police has cordoned the site off, ambulances have reached the site, local hospitals are on stand by. A first investigator has reached Madang. The Australian Transportation Safety Board has been asked for assistance.

The airline stated there were 28 passengers and 4 crew on board. There appear to be a number of survivors while the remaining people are unaccounted for. Authorities have quarantained the aviation fuel at Lae Airport. PNG Airlines have grounded all their 12 Dash 8 aircraft until further notice.

No weather information is available for Madang (neither Metar nor local weather office data), however local residents reported a violent storm was in the vicinity at the time of the crash.

TAF Madang [AYMD]:
AYMD 130602Z 1308/1320 12008KT 9999 SHRA SCT016 SCT030 BKN140 Q1009 1011 1010 1008
AYMD 122301Z 1302/1314 12010KT 9999 SHRA SCT016 SCT030 BKN140 Q1010 1008 1009 1011

Crash: PNG DH8A near Madang on Oct 13th 2011, both propellers oversped

Papua New Guinea's Accident Investigation Commission (PNGAIC) have released their preliminary report via Australia's ATSB reporting, that the crew reported they were about 24nm before Madang descending through 13,000 feet MSL. About 3 minutes later the overspeed warning horn sounded shortly followed by both propellers overspeeding simultaneously and exceeding their maximum rpm limit by by about 60%. Witnesses on the ground reported hearing a loud bang at that time. The crew declared MAYDAY and reported both engines had stopped prompting Madang tower to immediately declare a distress SAR phase believing the aircraft would ditch in the ocean.

The aircraft however impacted terrain 33km south of Madang Airport, on sparsely timbered terrain on the north side of Buang River. The aircraft disintegrated due to impact with trees and ground, a intense fuel fed fire erupted. Villagers who had heard the initial bang and witnessed the aircraft descend proceeded to the crash site and help the four survivors out of the wreckage, that was engulfed in flames.

The four survivors were the captain (64, ATPL, 18,200 hours total, 500 hours on type) with serious injuries to his right leg, the first officer (40, ATPL, 2,750 hours total, 410 hours on type) with minor injuries, the flight attendant with minor injuries and a passenger with severe burns.

The wreckage trail was about 300 meters long, the traces indicating the aircraft contacted ground in a controlled state at a low rate of descent.

The aircraft had accumulated 38,421 hours in 48,093 flight cycles since its introduction to service in 1988.

ACCIDENTINVESTIGATION COMMISSION AIRCRAFT INVESTIGATION
ACCIDENT PRELIMINARY REPORT AIC31131010


Factual information
The information contained in this preliminary report is derived from initial investigation of
the occurrence. Readers are cautioned that there is the possibility that new evidence may
become available that alters the circumstances as depicted in the report.
History of the flight

On 13 October 2011, the flight crew of P2-MCJ (MCJ), an Airlines PNG DHC-8-103 aircraft,
lodged a Regular Public Transport (RPT) flight plan at Jackson’s International Aerodrome
Briefing Office for the scheduled CG1600 flight to Nazdab, Morobe Province and Madang,
Madang Province, Papua New Guinea (PNG) .

The aircraft departed Port Moresby and landed at Nazdab without recorded incident.
While the aircraft was on the ground Nazdab, it was refuelled in preparation for the flight to
Madang. The aircraft departed NADZAB at 1647 LM1 and tracked 284 degrees while
climbing to flight level 160 ; its estimated arrival time at Madang was 1717.


The 24-hour clock is used in this report to describe the local time of day, Local Mean Time (LMT), as particular events occurred. Local Mean Time was Coordinated Universal Time (UTC) + 10 hours.

The flight progressed normally and MCJ was transferred to Madang Air Traffic Control (ATC)
at 1710 with on descent into Madang. The descent profile on this sector was steep because
of the proximity of the Finisterre Ranges to Madang and the pilot-in-command (PIC), who
was the handling pilot, was hand-flying the aircraft because the autopilot was unserviceable.
He was manoeuvring the aircraft visually to avoid cloud and thunderstorms. At 1712, in
response to a request from Madang Tower, the flight crew stated the aircraft was 24 NM
from Madang, leaving 13,000 feet on descent.

Flight planned track from NADZAB to Madang and accident site location.
At approximately 1715, the aircraft’s overspeed warning horn sounded. Very shortly
afterwards, both propellers simultaneously oversped and exceeded their maximum permitted
revolutions per minute (rpm) by in excess of 60 percent. Witnesses on the ground reported
hearing a loud ‘bang’ as this occurred.

At 1717, the crew made a MAYDAY call to ATC and indicated that they were experiencing
an in-flight emergency and that both engines had stopped. Madang Tower declared a
DISTRESS SAR PHASE, believing the aircraft was about to ditch in the ocean.

The aircraft force-landed on sparsely timbered terrain on the northern side of the Buang
River, 33 km south east of Madang township. During the impact sequence, it was severely
damaged while colliding with trees and the ground, and an intense fuel-fed fire began.
Villagers who had heard and witnessed the aircraft in the final stages of its descent
proceeded to the crash site to find the fuselage severely disrupted and engulfed in flames.
They assisted the four survivors and took them to the nearest first-aid post.

The PIC sustained injuries to his right leg during the accident. The First Officer and the Flight
Attendant sustained minor injuries. One passenger survived with severe burns. Twenty-eight
passengers were fatally injured during the impact and subsequent fuel-fed fire.

The aircraft impacted sparsely wooded flat and rocky terrain, adjacent and parallel to a river
bed. The wreckage trail was approximately 300 m long, oriented on a magnetic bearing of
175 degrees. Evidence from the tree and ground witness marks indicated the aircraft struck
the terrain in a controlled state in a shallow angle of descent.

The outboard section of the left wing was located at the beginning of the wreckage trail,
followed by numerous other elements of the left wing structure and its components. The left
engine sustained a significant impact which separated it into two sections. The empennage
(tail section) separated from the fuselage and was found adjacent to the main fuselage
section. The remainder of the aircraft, which included the main fuselage, right wing, and right
engine were situated at the end of the wreckage trail.
Figure'3:'Aircraft'wreckage'overview
Thermal damage to aircraft parts and foliage indicated that a post-impact fuel-fed fire began
when the aircraft was about halfway along the wreckage trail. When the aircraft finally came
to rest, the fire intensified and totally consumed most of the aircraft.
On-site examination of the wreckage revealed that the aircraft was configured with the flaps
and landing gear in the fully retracted position. Both engines and propellers were examined

externally on-site. The left engine had separated from the left wing and had broken into two
sections. The left propeller hub was still attached to the reduction gearbox;
however, three of the four propeller blades had separated from the hub during the impact
sequence. The left propeller actuator was noted to be in the feathered position, indicated the propeller blade angles at the time of the accident.

The right engine was still attached to the right wing. It had sustained considerable thermal
damage in the post-impact fire. The reduction gearbox outer case had completely
disintegrated. The right propeller blades were noted to be in the fully feathered position

Both engines and propellers were removed from the accident site so that a detailed
disassembly and inspection could be conducted.

The PIC was 64 years old at the time of the accident. He had about 18,200 hours flying
experience, of which about 500 hours were on the DHC-8. He held a valid PNG Airline
Transport Pilot Licence (ATPL) number P21393, issued on 4 July 2011, without revocation
or suspension notices. He held a Class 1 aviation medical certificate, valid until 2 December
2011, and issued with the condition that he wear correcting lenses while flying.
First'Officer

The First Officer was 40 years old at the time of the accident. He had about 2750 hours
flying experience, of which about 410 hours were on the DHC-8. He held a valid PNG ATPL
number P21362, issued on 30 May 2011, without revocation or suspension notices. He held
a Class 1 aviation medical certificate, valid until 29 March 2012.
Flight'attendant

The Flight Attendant was 28 years old at the time of the accident. He held a valid PNG
Certificate number 601/2008 issued on 28 March 2008. He had approximately 2500 hours
flying experience, all of which with the aircraft operator.

The Bombardier DHC-8-103 is a high wing, twin turboprop, pressurised, retractable tricycle
undercarriage aircraft. MCJ was operated with a seating capacity of 36 passengers. Aircraft
information is summarised :-

Aircraft manufacturer Bombardier Inc.
Aircraft type DHC-8-103
Aircraft serial number 125
Aircraft Registration P2-MCJ
Aircraft hours /cycles before last flight 38,421.3 hours / 48,093
Aircraft year of manufacture 1988

Meteorological information

The area weather forecast covering the flight from NADZAB to Madang issued by the
Bureau of Meteorology for the period 0800 to 2200 LMT on 13 October 2011 indicated there
were generally south easterly winds with isolated cumulonimbus clouds between 1,600 and
45,000 feet, with areas of broken stratus between 800 and 3,000 feet with precipitation.
Middle-level cloud was forecast to be areas of scattered cumulus cloud between 1,500 and
15,000 feet, with tops up to 25,000 feet, and scattered stratocumulus cloud between 2,500
and 8,000 feet associated with areas of rain and drizzle. Upper-level cloud was forecast to
be altocumulus/altostratus, with embedded cumulonimbus.
The general forecast was for thunderstorms, rain, and thunderstorms in rain and drizzle with
visibility reduced to 8,000 metres in showers.

The Madang Aerodrome METAR issued at 1618 LMT by ATC indicated the wind was calm,
visibility was greater than 10 km, and there was smoke in the vicinity of the aerodrome.

The aircraft was fitted with a cockpit voice recorder (CVR) and a separate flight data
recorder (FDR). The CVR (P/N S-100-0080-00 & S/N 02501) and FDR (P/N S800-20000-00
& S/N 00973) were both solid-state units manufactured by L3 Communications. The CVR
and FDR were located in the aircraft’s tail section and had not sustained any damage from
the accident and post-impact fire. Both recorders were recovered from the accident site and
transported to Port Moresby under the control of the AIC.
From Port Moresby, accompanied by an ATSB officer, both recorders were transported to
the ATSB’s facilities in Canberra for examination and data download. They were received on
16 October 2011.

The CVR records the total audio environment in the cockpit area. This can include crew
conversation, radio transmissions, aural alarms and engine/propeller noises. The CVR that
was installed in MCJ retained the last 30 minutes of information, operating on an endlessloop principle.
The CVR was downloaded and examination of that download showed that the audio from
the accident flight had been successfully recorded. The 30-minute recording covered the
period commencing during the climb after takeoff at NADZAB until power was disrupted
during the forced landing.
The FDR system comprised the FDR, a Teledyne flight data acquisition unit (FDAU), aircraft
sensors and a triaxial accelerometer. The programming of the FDAU determined what
parameters were recorded. For MCJ, the recorded parameters included:
• pressure altitude
• indicated airspeed
• magnetic heading
• pitch attitude
• roll attitude
• control surface positions (aileron, elevator, spoiler, flap and pitch trim)
• accelerations (lateral, longitudinal and vertical)
• outside air temperature
• engine parameters (propeller RPM, torque, NH, and propeller feathered (i.e. solenoid valve opened or closed)
• autopilot engaged or disengaged
• yaw damper engaged or disengaged
• radio transmitters keyed or not keyed
• weight on wheels (i.e. airborne or on ground)

The data that was recovered from the FDR contained 53 hours of aircraft operation covering
the accident flight and 33 previous flights.
A preliminary CVR transcript, sound spectrum plot, FDR plots and data listings have been
supplied to the investigation team.

Analysis of the CVR and FDR data is ongoing and will include:
• detailed analysis of all the recorded parameters from the accident flight
• comparison with FDR data recorded during previous flights
• a sound spectrum (frequency) analysis of CVR audio particularly relating to
propeller/engine operation.

On-going investigation activities
The investigation is continuing and will include further examination and analysis of the:
• engine and propeller assemblies
• recorded information
• maintenance documentation and procedures


NH represents the rotational speed of the high pressure turbine.
• operations documentation and procedures
• components of the power lever quadrant.