Investigation Summary
The approach to Chuuk International Airport was conducted during a period of rapidly deteriorating weather. As the aircraft descended through 548 feet, it entered a storm cell with heavy rain, significantly reducing visibility. Despite the loss of visual cues, the Captain (Pilot Flying) continued the descent, disconnecting the autopilot and attempting to manually regain the profile. The aircraft's flight path became severely unstable, reaching an average glideslope of 4.5 degrees, well above the standard 3 degrees. Between 307 feet and impact, the Enhanced Ground Proximity Warning System (EGPWS) triggered 14 separate alerts, including 'Sink Rate' and 'Glideslope' warnings, along with a red 'PULL UP' message on the Primary Flight Display. The crew disregarded these warnings, with the Captain stating he was trying to 'get on profile.' The First Officer failed to challenge the Captain's actions or take control until two seconds before impact, when he called out 'Too low!' The aircraft skipped across the water before settling and partially submerging. An engineer in the jump seat recorded the entire sequence on a smartphone, providing investigators with clear evidence of the cockpit environment and instrument readings during the final moments.
Final Conclusions
The Papua New Guinea Accident Investigation Commission (AIC) issued its final report on July 18, 2019. The investigation concluded that the crew failed to comply with Standard Operating Procedures (SOPs) and did not execute a missed approach despite the approach being unstabilized and the runway environment not being visible. The primary cause was the loss of situational awareness and fixation on landing, compounded by ineffective Crew Resource Management (CRM). The report also noted that the EGPWS configuration did not provide a continuous 'WHOOP WHOOP PULL UP' aural warning in this specific scenario, which might have prompted a more urgent response. Furthermore, the AIC criticized the Civil Aviation Safety Authority of Papua New Guinea for deficiencies in safety oversight and evidence-based assessment of the airline's operations.
Photographic Evidence (1)
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
52-year-old Papua New Guinean male.
First Officer
35-year-old Australian male.
Systems & Failure Modes
EGPWS
The Enhanced Ground Proximity Warning System provided 13 aural alerts and a visual 'PULL UP' warning, all of which were disregarded by the crew.
RNAV (GPS) Approach
The crew was conducting a non-precision GPS-based approach which required specific stabilization criteria that were not met.
Weather Radar
The Captain's navigation display showed a large red area indicating a severe storm cell between the missed approach point and the runway.
Interesting Facts
- 01The aircraft was a Boeing 737-800 leased from Loftleiðir Icelandic Airlines; it was originally delivered to Air India Express as VT-AXC.
- 02A ground engineer in the cockpit jump seat filmed the entire approach on an iPhone.
- 03The flight crew ignored 13 EGPWS aural alerts during the final descent.
- 04One passenger was found deceased inside the aircraft three days after the crash; he was not wearing a seatbelt.
- 05The aircraft had previously been involved in a runway excursion in India in 2005 while registered as VT-AXC.
- 06On May 12, 2018, the aircraft was struck by a Lynden Air Cargo L-100 (N403LC) while parked at Port Moresby, damaging its right winglet.
- 07Flight data revealed the same crew had ignored 28 'Glideslope' alerts on a previous flight sector.
Safety Actions & Advisories
EGPWS Logic Review
The investigation recommended that Honeywell and Boeing review EGPWS alert logic to ensure continuous 'PULL UP' aural warnings are provided during high-rate descents below MDA.
CRM Training Enhancement
Air Niugini was directed to improve Crew Resource Management training, specifically focusing on the requirement for the Pilot Monitoring to take control during unsafe conditions.