Niugini AT42 at Madang on Oct 19th 2013, overran runway on rejected takeoff
Last Update: January 17, 2017 / 15:56:52 GMT/Zulu time
Incident Facts
Date of incident
Oct 19, 2013
Classification
Accident
Aircraft Registration
P2-PXY
Aircraft Type
ATR ATR-42
ICAO Type Designator
AT42
- The mass and the centre of gravity of the aircraft were not within the prescribed limits.
- The aircraft total load exceeded the maximum permissible load and the load limit in the forward cargo zone ‘A’ exceeded the zone ‘A’ structural limit.
- There was no evidence of any defect or malfunction in the aircraft that could have contributed to the accident.
- Anti-skid brake system inoperative, however that did not contribute to the accident.
- Braking performance analysis indicated that, in the conditions existing at the time of the accident, the aircraft could not have stopped on the runway available.
- The pilot in command’s decision to abort the takeoff was appropriate.
The conclusions read (without explaining the overload or actual cause of the accident):
Contributing factor
The investigation found that Air Niugini’s lack of robust loading procedures and supervision for the ATR 42/72 aircraft, and the inaccurate weights provided by the consignor/client company likely contributed to the overload.
Other factors
Other factors is used for safety deficiencies or concerns that are identified during the course of the investigation that while not causal to the accident, nevertheless should be addressed with the aim of accident and serious incident prevention.
- The Madang Airport fire-fighting tender vehicle did not have sufficient capacity to fight a more extensive aircraft fire involving an aircraft larger than the ATR 42.
- The Madang Airport did not meet the ICAO Annex 14 Standard with respect to the required aerodrome category 6, for rescue and fire-fighting services.
- The Madang Airport did not meet the ICAO Annex 14 Standard with respect to the runway end safety areas.
- The Madang Airport did not meet the ICAO Annex 14 Standards with respect to the required Airport Emergency Plan.
Interpreting the factual report as well as the findings of the report the causes of the accident probably should read: "The captain rejected takeoff when the aircraft did not respond to elevator inputs to rotate the aircraft for takeoff due to inappropriate load distribution and overload. Having accelerated beyond V1 the aircraft was unable to stop within the remaining runway resulting in the destruction of the aircraft."
The PNGAIC wrote in the factual part of the final report regarding the flight data recorder:
The FDR showed elevator deflection commanding a rotation had been initiated 29.5 sec after brakes release when the aircraft had travelled 870 m, but the aircraft did not respond.
A torque decrease consistent with power levers being retarded was observed on the FDR data 33.0 sec after brakes release when the aircraft had travelled 1,090 m. The command ‘stop’ was heard on the CVR 34.5 sec when the aircraft had travelled 1,175 m after brakes release. The aircraft travelled 160 m between the Vr call position and the position on the runway when the power levers were retarded. The investigation determined that P2-PXY left the sealed runway end at a speed of 35 kt.
The PNGAIC analysed:
The investigation determined that PXY left the sealed runway end at a speed of 35 kt. The investigation determined that at the deceleration rate as it left the sealed runway, it would have needed 278 m to stop, in the absence of frangible material in a RESA.
The aircraft anti-skid braking system on PXY was inoperative, however the investigation determined that it did not contribute to the accident.
While the evidence strongly suggests that PXY would not have been able to be stopped in the available length even if a RESA had been available, the lack of a RESA must be viewed as a greater safety hazard for the higher weight faster take-off speed jet aircraft such as the Fokker 100.
The PNGAIC analysed with regards to the operator:
The copilot stated that he drew a loading diagram for the operator’s ground handling staff showing the weight to be loaded in each of the aircraft’s six cargo compartments ‘A’ to ‘F’.
The Air Niugini Senior Cargo Officer was instructed by the pilot in command to put a maximum of 350 kg, 30 cartons, in the forward zone ‘A’. The investigation determined that 30 cartons actually weighed 395 kg.
The AIC obtained a copy of the ATR42/320 CARGO LOAD SHEET AND BALANCE CHART that was signed by the pilot in command, however the load of freight and the freight distribution in the zones within the aircraft did not accurately reflect the details on the signed ATR42/320 CARGO LOAD SHEET AND BALANCE CHART.
The investigation found that the lack of robust procedures and the inaccurate weights provided by the consignor/client company likely contributed to the overload.
The aircraft anti-skid braking system was in-operative, and the flight was permitted to operate without an operative anti-skid brake system, if operated in accordance with the Aircraft Flight Manual.
The investigation found that because the aircraft load was in excess of the maximum permissible weight, and the cargo zone ‘A’ weight exceeded the structural limit, the aircraft was not being operated in accordance with the Aircraft Flight Manual.
Six safety recommendations were released as result of the investigation.
Incident Facts
Date of incident
Oct 19, 2013
Classification
Accident
Aircraft Registration
P2-PXY
Aircraft Type
ATR ATR-42
ICAO Type Designator
AT42
This article is published under license from Avherald.com. © of text by Avherald.com.
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