Investigation Summary
The accident flight was a non-scheduled charter operating under Visual Flight Rules (VFR). The pilot had planned a route from Kiunga to Oksapmin and back, but evidence revealed that he flew from Oksapmin to Tekin without advising Air Traffic Services (ATS). Upon departing Tekin at 13:56, the pilot reported to ATS that he was departing from Oksapmin; these transmissions were heavily garbled by static and 'hash'. As the aircraft entered the left-hand traffic pattern for Kiunga, the pilot configured the plane for landing by extending the flaps. This action normally causes a nose-up pitch, but because the aircraft's center of gravity (CG) was significantly behind the aft limit, the pitch-up was extreme and sudden. Despite the pilot applying full nose-down elevator trim, the aircraft entered a vertical attitude, rolled right, and stalled. The investigation revealed that the right engine was not producing power at impact; the propeller was feathered and the rudder trim was set to compensate for asymmetric thrust. While the exact cause of the engine failure was not proven, the right fuel tank was found empty, and evidence suggested the pilot had attempted to cross-feed fuel from the left tank. Furthermore, the operator's weight and balance records were found to be fundamentally flawed, failing to account for structural changes from previous repairs that had reduced the allowable baggage compartment load.
Final Conclusions
The Papua New Guinea Accident Investigation Commission (AIC) concluded the primary cause was the operation of the aircraft with an excessively aft center of gravity, which resulted in a loss of control during the landing configuration. Contributing factors included the failure of the right engine, the pilot's failure to accurately calculate the weight and balance, and the operator's use of an incorrect Weight and Balance Computation Sheet that did not reflect the aircraft's actual empty weight and balance following major repairs. The aircraft was deemed not airworthy at the time of the accident due to these discrepancies and an expired Emergency Locator Transmitter (ELT).
Photographic Evidence (1)
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Australian national Benjamin Andre Picard, aged 31.
Systems & Failure Modes
Elevator Trim Tab
Found in the full nose-down position, indicating the pilot's unsuccessful attempt to counteract the extreme pitch-up caused by the aft center of gravity.
Propeller Feathering System
The right propeller was successfully feathered, a procedure used to reduce drag after an engine failure.
Emergency Locator Transmitter (ELT)
The unit was expired and failed to function upon impact, though this did not delay the rescue as the crash was witnessed.
Interesting Facts
- 01The aircraft's center of gravity was found to be significantly beyond the aft limit.
- 02The right engine propeller was found in the feathered position, indicating a shutdown prior to impact.
- 03The right fuel tank was empty at the time of the crash.
- 04The Weight and Balance Computation Sheet used by the pilot was outdated and did not account for previous structural repairs.
- 05The Emergency Locator Transmitter (ELT) was past its mandatory replacement date and failed to activate.
- 06All 12 occupants died, including three children.
Safety Actions & Advisories
Radio Infrastructure Upgrade
The investigation recommended that the Air Traffic Service radio systems in the Kiunga area be upgraded to eliminate static and 'hash' interference that garbled pilot transmissions.
Weight and Balance Oversight
The report highlighted the necessity for operators to ensure Weight and Balance Computation Sheets are updated following any major repairs or modifications to the airframe.