Air Niugini Flight 73 (September 28, 2018)

Date: September 28, 2018
Passengers: 35
Crew: 12
Fatalities: 1
Cause: "The flight crew did not comply with Air Niugini Standard Operating Procedures Manual (SOPM) and the approach and pre-landing checklists. The RNAV (GPS) Rwy 04 Approach chart procedure was not adequately briefed...The flight crew heard, but disregarded, 13 EGPWS aural alerts (Glideslope and Sink Rate), and flew a 4.5º average flight path (glideslope). The pilots lost situational awareness and their attention was channelised or fixated on completing the landing. The PIC did not execute the missed approach at the MAP despite: PAPI showing 3 whites just before entering IMC; the unstabilised approach; the glideslope indicator on the PFD showing a rapid glideslope deviation from half-dot low to 2-dots high within 9 seconds after passing the MDA; the excessive rate of descent; the EGPWS aural alerts: and the EGPWS visual PULL UP warning on the PFD. The copilot (support/monitoring pilot) was ineffective and was oblivious to the rapidly unfolding unsafe situation. It is likely that a continuous “WHOOP WHOOP PULL UP”70 hard aural warning, simultaneously with the visual display of PULL UP on the PFD (desirably a flashing visual display PULL UP on the PFD), could have been effective in alerting the crew of the imminent danger, prompting a pull up and execution of a missed approach, that may have prevented the accident."


Legend:
CAM     Cockpit area microphone or sound source
RDO     Radio transmission from accident aircraft
EGPWS	Enhanced Ground Proximity Warning System
-1      Voice identified as captain
-2      Voice identified as co-pilot
-?      Voice unidentified
*       Unintelligible word
@       Non-pertinent word
#       Expletive
( )     Questionable insertion
(( ))   Editorial insertion
...     Pause
Times expressed in local time. No full transcript available, but pieced together from mentions in the report.


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0920:53		CAM-1	Okay, we on RNAV at oh four one and I'll go one thousand

0921:07		RDO-2	((stating they were established on 041 inbound via RNAV runway 04))

0921:27		CAM-1	((call for gears down and flaps 15))
			CAM-1	We just configure as we can ah

0922:33		CAM-2	That must be some storm, but it'll be out soon
			CAM-1	((call for landing checklist))
			CAM-2	((readout of landing gear, flaps, and lights and runway in sight))

0922:42		CAM-1	Ah we'll probably just go down to the PAPI's

0922:49		CAM-1	Alright flaps thirty, flaps forty

0922:54		CAM-1	Landing checks
			EGPWS	((1000ft call out))
			CAM-2	OK, stable
			CAM-1	((four seconds later)) Continue
			CAM-2	And visual, nine hundred cloud base

0923:41		CAM-1	I'm going back on profile

0923:43		CAM-1	((call for wipers to be switched on))

0924:46		CAM		((sound of alarm))

0923:49		CAM-1	Okay, landing

0923:52		CAM-2	Visual, one red...three whites

0923:53		EGPWS	Approaching minimums

0923:56		EGPWS	Minimums

0924:00		CAM-1	Okay I just wanna get on profile
			EGPWS	Sink rate. Sink rate

0924:03		CAM-2	Check
			EGPWS	Glideslope. Glideslope. Glideslope

0924:06		CAM-1	That's fine. I'll just go a little bit more
			EGPWS	Sink rate. Sink rate

0924:09		CAM-2	See the runway?
			EGPWS	Glideslope. Glideslope

0924:12		CAM-1	Monitor airspeed. Okay got it
			EGPWS	One hundred, glideslope

0924:13		EGPWS	Glideslope

0924:17		CAM-2	Too low! We're too low! We're too low! We're too low!
			EGPWS	Sink rate. Sink rate

0924:19		CAM		((sound of impact))
					((end of recording))


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https://www.youtube.com/watch?v=DnpdDMPulLc --- Actual video of crash from inside the cockpit.