FINAL REPORT AIC 16-1002 AIRCRAFT ACCIDENT INVESTIGATION REPORT Sunbird Aviation P2-SBC Pilatus Britten Norman BN-2T 1.2 Km west of Kiunga Aerodrome Western Province PAPUA NEW GUINEA 13 April 2016 The Papua New Guinea Accident Investigation Commission (AIC) was informed of an accident involving a Pilatus Britten Norman Turbine Islander BN-2T, on 13 April 2015. The accident occurred 1.2 km West of Kiunga Aerodrome, at 14:31 local time. An investigation was immediately commenced by the AIC and investigators deployed to Kiunga on 14 April 2016. This Final Report AIC 16-1002, dated 13 February 2017, was produced by the AIC, PO Box 1709, Boroko 111, NCD, Papua New Guinea, and is published on the AIC web site. www.aic.gov.pg The report is based upon the investigation carried out by the AIC, in accordance with Annex 13 to the Convention on International Civil Aviation, and the Papua New Guinea (PNG) Civil Aviation Act 2000 (as amended), and the AIC Policy and Procedures Manual. It contains factual information, analysis of that information, findings and contributing factors, other factors, recommendations, and safety actions. Readers are advised that in accordance with Annex 13 to the Convention on International Civil Aviation, it is not the purpose of an AIC aircraft accident investigation to apportion blame or liability. The sole objective of the investigation and the Final Report is the prevention of accidents and incidents. (Reference: ICAO Annex 13, Chapter 3, paragraph 3.1.) Consequently, AIC reports are confined to matters of safety significance and may be misleading if used for any other purpose. When the AIC makes recommendations as a result of its investigations or research, safety is its primary consideration. However, the AIC fully recognizes that the implementation of recommendations arising from its investigations will in some cases incur a cost to the industry. Readers should note that the information in AIC reports and recommendations is provided to promote aviation safety. In no case is it intended to imply blame or liability. Approved Mr. David Inau, ML Chief Executive Officer 13 February 2017 ii TABLE OF CONTENTS TABLE OF Contents ............................................................................................ iii FIGURES ................................................................................................................ vi TABLES ................................................................................................................viii APPENDICES ........................................................................................................ ix GLOSSARY OF ABBREVIATIONS .................................................................... x INTRODUCTION ................................................................................................... 1 1 FACTUAL INFORMATION ......................................................................... 3 1.1 History of the flight ............................................................................... 3 1.2 Injuries to persons ................................................................................. 5 1.3 Damage to aircraft ................................................................................. 5 1.4 Other damage ........................................................................................ 5 1.5 Personnel information ........................................................................... 6 1.5.1 Pilot in command ................................................................. 6 1.6 Aircraft information .............................................................................. 7 1.6.1 Aircraft data ......................................................................... 8 1.6.2 Airworthiness and maintenance .......................................... 8 1.6.3 Scheduled maintenance ....................................................... 9 1.6.4 Defects/Discrepancy ............................................................ 9 1.6.5 Engines ................................................................................ 9 1.6.6 Engine data ........................................................................ 10 1.6.7 Propeller ............................................................................ 10 1.6.8 Propeller data ..................................................................... 10 1.6.9 Weight and balance ........................................................... 11 1.6.10 Emergency Locator Transmitter (ELT) ............................. 12 1.6.11 Minimum Equipment List ................................................. 13 1.6.12 Fuel information ................................................................ 13 1.6.13 Airframe and engine control systems ................................ 13 1.6.14 Flight controls and flaps .................................................... 15 1.7 Meteorological information ................................................................. 19 1.8 Aids to navigation ............................................................................... 19 1.9 Communications .................................................................................. 19 iii 1.10 Aerodrome information ....................................................................... 19 1.11 Flight recorders ................................................................................... 20 1.12 Wreckage and impact information ...................................................... 20 1.12.1 Wreckage examination on the crash-site ........................... 20 1.12.2 Impact sequence and distribution of the wreckage ............ 20 1.12.3 Wreckage examination at Kiunga Aerodrome .................. 27 1.13 Medical and Pathological Information ................................................ 36 1.14 Fire ...................................................................................................... 36 1.15 Survival Aspects .................................................................................. 36 1.16 Tests and research ............................................................................... 36 1.16.1 Examination of engine-driven fuel pumps and fuel control units ....................................................................... 36 1.16.2 Examination of cockpit Instrument and warning lights ..... 37 1.17 Organisational and management information ..................................... 38 1.18 Additional information ........................................................................ 38 1.19 Useful or effective investigation techniques ......................................... 39 2.1 Introduction ......................................................................................... 40 2.2 Fuel ...................................................................................................... 40 2.2.1 Airframe ............................................................................ 40 2.2.3 Weight and Balance ........................................................... 42 2.2.4 Aircraft serviceability ........................................................ 42 2.2.5 Flight operation ................................................................. 42 3.1 Contributing factor .............................................................................. 45 3.1.1 Other factors ...................................................................... 45 4.1 Safety action ........................................ Error! Bookmark not defined. 4.2 Recommendations ............................................................................... 47 4.2.1 Recommendation number AIC 16-R12/16-1002 to PNG Air Services Ltd ................................................................. 47 4.2.2 Recommendation number AIC 16-R13/16-1002 to PNG Department of Health ........................................................ 48 5.1 Appendix 1: Weight and Balance ........................................................ 49 5.1.1 Load Data Sheet ................................................................ 49 5.1.2 Weight and Balance computation sheet used by the operator .............................................................................. 50 5.1.3 Manifest (No.004084) the accident flight .......................... 51 5.1.4 Weight and balance calculation estimate ........................... 52 5.1.5 Centre of Gravity envelope for SBC ................................. 53 5.2 Appendix 2: Fuel information ............................................................. 54 iv 5.2.1 Aviation Sales Release Receipt Tax Invoice (No. 0690639) ............................................................................ 54 5.2.2 Daily Flight Record (No.130393) ...................................... 55 5.3 Appendix 3: Elevator and Rudder trim ............................................... 56 5.3.1 Elevator trim controls ........................................................ 56 5.3.2 Rudder trim controls .......................................................... 57 5.4 Appendix 4: BN-2T Airframe fuel system .......................................... 58 5.4.1 BN-2T airframe fuel system diagram ................................ 58 5.4.2 BN-2T Fuel system schematic ........................................... 58 5.4.3 BN-2T Fuel cock system ................................................... 59 5.5 Appendix 5: Engine ConditionTrend Monitor .................................... 60 5.6 Appendix 6: P2-SBC Transcript and flight strips ...............................