Kabwum plane crash investigation highlights weaknesses in rescue coordination



The Chief Commissioner of the PNG Accident Investigation Commission, Mr Hubert Namani today released the Accident Investigation’s Final Report into the December 2017 fatal aircraft accident on the Sarawaget Ranges in the Morobe Province. Mr. Namani said that “on 23 December 2017, at 10:10am a Britten Norman BN-2A Islander aircraft, registered P2-ISM, owned and operated by North Coast Aviation, impacted a ridge, at about 9,500 ft, that runs down towards the Sapmanga Valley from the Sarawaget Ranges, Morobe Province.

“The pilot had elected to track from Derim Airstrip to Nadzab Airport, Morobe Province across the Sarawaget ranges. The aircraft impacted the ridge in a steep nose-down, right wing-low attitude about 150 m beyond the last GPS fix. It was destroyed by impact forces.” Rescuers arrived at the accident site on 27 December and reported that the pilot, the sole occupant, was deceased. They felled trees on the steep heavily timbered, densely vegetated slope about 20 metres from the wreckage and constructed a helipad. Mr Namani said “the pilot was expected to contact Nadzab ATC (Nadzab Tower) by 10:20am prior to entering Nadzab controlled airspace. However, because he had not established contact by 10:22am, the Nadzab Tower controller commenced radio communication checks, and subsequently declared a distress phase, which initiated search operations. The aircraft operator contacted the Nadzab Tower controller and reported that, according to their GPS tracker, the aircraft was stationary between Yalumet and the Saidor Gap, Morobe Province.”

In its Final report into the accident the AIC states “the on-site investigation determined that there was no evidence of any prior defect or malfunction in the aircraft that could have contributed to the accident. Propeller blade damage and bending was consistent with the engines producing significant power at impact.”

The investigation concluded that cloud build up along the pilot’s chosen route may have forced the pilot to manoeuvre closer to the ridge, in order to avoid flying into the cloud. The flight track for the last 30 to 60 seconds suggests that the pilot had deviated from his planned track to cross the ridge, possibly to avoid entering cloud. The aircraft impacted terrain while under the control of the pilot; Controlled Flight Into Terrain (CFIT).

Mr. Namani said “the investigation determined that PNG had no Rescue Coordination Centre established in accordance with ICAO Annex 12 to the Convention on International Civil Aviation. The AIC’s report revealed that prior to 9 July 2010, under Section 13, of the Civil Aviation Act 2000, the Civil Aviation Authority (CAA) that existed at that time was the agency responsible for ensuring the provision of search and rescue services. On 9 July 2010, the Civil Aviation (amendment) Act 2010 was passed in Parliament, in which Section 13 was repealed.

Despite PNG’s international obligations under ICAO Annex 12 Standards, there was no PNG legislated obligation on any organisation in PNG for the provision of search and rescue operations, or the establishment of a RCC, although PNGASL continued to provide some coordination services to the aviation industry through the activation of a RCC on a needs basis. 11/2018 31 July 2018 On 13 December 2016, the Civil Aviation (Amendment) Act 2016 was certified. Sections 8A and 8B included the requirement for the Minister to direct agencies for which he is responsible, and whose functions are consistent with search and rescue operations, to operate and maintain the search and rescue coordination centre. On 18 April 2018 the PNG Accident Investigation Commission issued Safety Recommendation AIC18- R03/17-1004 recommending that the Minister for Civil Aviation, in compliance with Sections 8A and 8B of the Civil Aviation Act 2000 (as amended in 2016), should ensure that a Rescue Coordination Centre is established, maintained, and operated, to co-ordinate and conduct aviation search and rescue operations in PNG.

This will also ensure compliance with ICAO Annex 12, thereby specifically complying with Section 8A(1)(b)(ii) of the Act. Under international investigation Standards set by the International Civil Aviation Organization, recipients of safety recommendations are expected to respond to the investigation authority proposing the recommendation within 90 days of it being issued. On 9 July 2018, the Hon. Alfred Manase, MP, Minister for Civil Aviation issued Minister’s Directive No. MD 2018/01 titled Search and Rescue. The Directive requires PNG Air Services Limited to operate and maintain the PNG Search and Rescue Coordination Centre (RCC). On 11 July 2018 the Minister directed PNGASL to establish and perform the functions of the RCC on behalf of the State in accordance with ICAO Annex 12.

It requires PNGASL to promulgate, without delay, operational Search and Rescue Policies and Procedures; ensure that the PNG RCC established under the Minister’s Directive is equipped and manned as a dedicated stand-alone unit that is independent of all other Air Traffic Services facilities in order that it cannot be rendered ineffective; and ensure that the RCC is staffed 24/7 by a dedicated team of trained and qualified personnel to coordinate and conduct aviation search and rescue operations in PNG.

On 27 July 2018, the Civil Aviation Safety Authority of PNG informed the AIC that a new Civil Aviation Rule Part 176, titled, “Search and Rescue Services Organization – Certification and Operations” will be released for Industry comments in August, as part of CASA’s NPRM Phase 5 rule making cycle and hopefully will be signed into law by the Minister of Civil Aviation by 8 Nov 2018.

Mr. Namani said “it is important for the aviation industry and the travelling public to know that the decisive safety actions taken by the Minister for Civil Aviation and the Civil Aviation Safety Authority of PNG have addressed the search and rescue safety concerns identified by the AIC”.

A copy of the AIC recommendation is available on the AIC website: http://www.aic.gov.pg

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