Estado: | Accident investigation report completed and information captured |
Fecha: | domingo 9 noviembre 1997 |
Tipo: |  de Havilland Canada DHC-6 Twin Otter 300 |
Operador: | Royal Australian Army |
Registración: | VH-HPY |
Numéro de série: | 706 |
Año de Construcción: | 1980 |
Horas Totales de la Célula: | 18208 |
Motores: | 2 Pratt & Whitney Canada PT6A-27 |
Tripulación: | Fatalidades: 0 / Ocupantes: 4 |
Pasajeros: | Fatalidades: 0 / Ocupantes: 0 |
Total: | Fatalidades: 0 / Ocupantes: 4 |
Daños en la Aeronave: | Considerable |
Consecuencias: | Repaired |
Ubicación: | 9 km (5.6 milles) SW of Simbai ( Papúa Nueva Guinea)
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Fase: | En ruta (ENR) |
Naturaleza: | Militar |
Aeropuerto de Salida: | Koinambe Airport (KMB), Papúa Nueva Guinea |
Aeropuerto de Llegada: | Simbai Airport, Papúa Nueva Guinea |
Descripción:On the third day of flying operations in Papua New Guinea, the crew of the Darwin-based Twin Otter were conducting a flight from Madang and return via a number of airstrips in the central highlands. When haze and cloud prevented them flying the flight-planned direct track between the Koinambe and Simbai airstrips, they decided to fly north-west via the Jimi River valley and one of its tributaries. Two of the trainees were occupying the cockpit seats, one as flying pilot and the other as navigating pilot using a 1:1,000,000-scale chart. When the crew turned the aircraft to follow a tributary off the Jimi River, the training pilot was in the aircraft cabin. A few minutes later, their discussion regarding the progress of the flight attracted the attention of the training pilot. By this time, however, the position of the aircraft in the valley, and its available performance, were such that an escape from the valley was not possible. The aircraft collided with trees before impacting steeply sloping ground.
Probable Cause:
SIGNIFICANT FACTORS:
1. There had been a significant loss of corporate knowledge, experience and risk appreciation within the Army concerning the operation of Twin Otter type aircraft in tropical mountainous areas.
2. No training needs analysis for the exercise had been conducted.
3. The tasking and briefing of the training pilot were incomplete.
4. The training pilot did not adequately assess the skill development needs of the trainees.
5. The supervision of the flight by the training pilot was inadequate.
6. The scale of chart used by the crew was not appropriate for the route they intended to fly.
Accident investigation:
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Investigating agency: | BASI  |
Status: | Investigation completed |
Duration: | 1 year and 9 months | Accident number: | BASI report 9703719 | Download report: | Final report
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Subsiguiente / acciones de seguridad
ATSB issued 5 Safety Recommendations
Issued: 20-JUL-1999 | To: 1st Aviation Regiment | R19980215 |
The Bureau of Air Safety Investigation recommends that 1st Aviation Regiment develop a procedure detailing the phases of aircraft operation during which the pilot in command must occupy a control seat. (Closed - Accepted) |
Issued: 20-JUL-1999 | To: | R19980219 |
The Bureau of Air Safety Investigation recommends that the Army include, as an on-going component of 1st Aviation Regiment Training Objectives, sufficient resources to maintain a core of expertise in tropical mountainous operations for each type of aircraft which may be required to operate in such conditions. (Closed - Accepted) |
Issued: 20-JUL-1999 | To: 1st Aviation Regiment | R19980220 |
The Bureau of Air Safety Investigation recommends that 1st Aviation Regiment review operational standards and procedures to ensure that maps and charts appropriate to the performance and type of aircraft involved, and the nature of the operation being conducted, are used for the planning and conduct of flying operations. (Closed - Accepted) |
Issued: 20-JUL-1999 | To: | R19980221 |
The Bureau of Air Safety Investigation recommends that the Army formalise the skill and experience requirements for tropical mountainous operations for each aircraft type and develop training programs to meet these requirements. (Closed - Accepted) |
Issued: 20-JUL-1999 | To: | R19990051 |
That the Army develop and promote a relevant aviation risk management culture at both operational and management levels. (Closed - Accepted) |
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Fotos
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Koinambe Airport to Simbai Airport as the crow flies is 24 km (15 miles).
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.