Issued: 04-NOV-2018 | To: Air Niugini | AIC 18-R04/18-1004 |
The PNG Accident Investigation Commission recommends that Air Niugini Limited should ensure that the Safety on Board Card (passenger briefing cards) for the Boeing 737-700 and -800 fleet accurately show the exits to be used in a water ditching accident, and the accurate depiction of which exits have life rafts deployed. (CLOSED, RESPONSE ACCEPTED) |
Issued: 31-JAN-2019 | To: Honeywell Aerospace | AIC 19-R02/18-1004 |
The PNG Accident Investigation Commission recommends that Honeywell Aerospace should ensure that the Honeywell EGPWS MK V Computer should provide timely and continuous hard aural warning WHOOP WHOOP PULL UP, simultaneously with the Visual Display of PULL UP on the Primary Flight Display, which requires immediate action from the crew, when encountering an excessive Rate of Descent at very low Radio Altitude similar to that flown by the crew of P2-PXE |
Issued: 04-FEB-2019 | To: Air Niugini | AIC 19-R03/18-1004 |
The PNG Accident Investigation Commission recommends that Air Niugini Limited, as a matter of urgency:
(a) should ensure that all crew members are reminded of their obligation to comply with PNG Civil Aviation Rules, the Air Niugini Special Emergency Procedures (SEP), and the Air Niugini Corporate Emergency Response Manual, in particular Section 6.9.3; and
(b) should ensure all crew members are reminded of their obligation to ensure that passengers do not take any baggage from the aircraft (CLOSED, RESPONSE ACCEPTED) |
Issued: 04-FEB-2019 | To: Air Niugini | AIC 19-R04/18-1004 |
The PNG Accident Investigation Commission recommends that Air Niugini Limited, should review its policy and procedures in the Safety and Emergency Procedures Manual (SEPM) in relation to all aircraft in the Air Niugini fleet to ensure:
(a) a responsible and capable adult passenger is seated in the over wing exit row on all flights; and
(b) the passenger(s) seated in the over wing exit row are fully briefed on the tasks required to deploy the emergency exit and assist in passenger evacuation. (CLOSED, RESPONSE ACCEPTED) |
Issued: 04-FEB-2019 | To: Air Niugini | AIC 19-R05/18-1004 |
The PNG Accident Investigation Commission recommends that Air Niugini Limited, in order to mitigate the risk of a cabin crew member being unable to reach the over wing exit due to passenger congestion, should:
Review its policy and procedures in the Safety and Emergency Procedures Manual (SEPM)and the Airport Services manual (ASM) in relation to all aircraft in the Air Niugini fleet to ensure a cabin crew member is seated in the over wing exit row on all flights (CLOSED, RESPONSE ACCEPTED) |
Issued: 06-FEB-2019 | To: Air Niugini | AIC 19-R07/18-1004 |
The PNG Accident Investigation Commission recommends that Air Niugini Limited, should review the Air Niugini Safety and Emergency Procedures Manual Volume 6 (B737) Section 3.2.2 titled P2-PXC / P2-PXE location of Emergency Equipment to ensure the diagram clearly depicts the correct life raft stowage locations, and ensure all cabin crew are briefed on the correct location of the life rafts (CLOSED, RESPONSE ACCEPTED) |
Issued: 07-FEB-2019 | To: Air Niugini | AIC 19-R01/18-1004 |
The PNG Accident Investigation Commission recommends that Air Niugini Limited, should ensure that all flight crew comply with the Air Niugini Limited Standard Operating Procedures Manual (SOPM) and the Flight Crew Operating Manual (FCOM) with respect to operational procedures and primary flight crew duties, and do not use personal Electronic Flight Bag (EFB), and specifically do not use the Boeing OPT data during flight operations until approved by Air Niugini Limited. (CLOSED, RESPONSE ACCEPTED) |
Issued: 08-FEB-2019 | To: DCA Micronesia | AIC 19-R08/18-1004 |
The PNG Accident Investigation Commission recommends that the Federated States of Micronesia, Division of Civil Aviation, as a contracting State to the Convention on International Civil Aviation:
(a) should ensure that Chuuk International Airport meets ICAO Annex 14 Standards with respect to Airport Emergency Planning and specialist rescue services (equipment and personnel) for an emergency situation that might occur outside the airport perimeter in water; or
(b) should ensure that if the State is unable to comply with the Standards of Annex 14 as identified in (a) above, it will file the difference with ICAO between a States national regulations and practices and the related ICAO Annex 14 Standards and Recommended Practices, and publish the filed difference(s) through the Aeronautical Information Service. (CLOSED, RESPONSE ACCEPTED) |
Issued: 17-FEB-2019 | To: Air Niugini | AIC 19-R09/18-1004 |
The PNG Accident Investigation Commission recommends that Air Niugini Limited, should ensure that all flight crew are tested for competency in the vital actions and responses to be taken in the event of a GPWS or EGPWS warnings, and/or an unstabilised approach situation developing when below 1,000 feet amsl, and in instrument meteorological conditions. (CLOSED, RESPONSE ACCEPTED) |
Issued: 18-FEB-2019 | To: Air Niugini | AIC 19-R10/18-1004 |
The PNG Accident Investigation Commission recommends that Air Niugini Limited, should ensure that:
(a) Section 2.5.1.4 of the Standards Operating Procedures Manual is amended to use the operating verb shall for the instructions for compliance with the vital and essential safety of flight actions.
(b) All Air Niugini Limited Operational and Training manuals are reviewed and revised as necessary and appropriate to use the operating verb shall when appropriate to ensure the importance of taking essential safety action is recognised. (CLOSED, RESPONSE ACCEPTED) |
Issued: 20-FEB-2019 | To: Air Niugini | AIC 19-R11/18-1004 |
The PNG Accident Investigation Commission recommends that Air Niugini Limited should, as a matter of urgency, ensure that the relevant Air Niugini manuals, including the Quick Reference Handbook, Evacuation Checklist, are amended to provide instructions and emergency procedures for the manual operation of the emergency lighting switch in the cockpit, and the switch located on the Aft Attendants Panel, and that all pilots and Cabin Crew are instructed in their importance and use. (CLOSED, RESPONSE ACCEPTED) |
Issued: 25-FEB-2019 | To: Air Niugini | AIC 19-R12/18-1004 |
The PNG Accident Investigation Commission recommends that Air Niugini Limited should, as a matter of urgency, ensure that the Training Reference Manual and all relevant Air Niugini manuals related to emergency evacuation are amended to ensure descriptors on drawings are clear and unmistakeable, and that the Training Reference Manual and operational procedures clearly stress the requirement for life rafts to be deployed outside the aircraft before attempting inflation (CLOSED, RESPONSE ACCEPTED) |
Issued: 08-APR-2019 | To: CASA PNG | AIC 19-R13/18-1004 |
The PNG Accident Investigation Commission recommends that the Civil Aviation Safety Authority of PNG should draft Civil Aviation Rule(s) to require the fitment of image recorders in the cockpit of all CAR Part 125 and 135 aircraft, and promulgate through the April 2019 Notice of Proposed Rule Making (NPRM) process. (CLOSED RESPONSE NOT ACCEPTED) |
Issued: 10-APR-2019 | To: Air Niugini | AIC 19-R14/18-1004 |
The PNG Accident Investigation Commission recommends that Air Niugini Limited should review the Air Niugini Risk Assessment process and methodology to ensure they meet ICAO Annex 19 Standards,and where risk assessments have been made by Air Niugini Limited with respect to aircraft operations that those risk assessments are reviewed to ensure they meet ICAO Standards (CLOSED, RESPONSE ACCEPTED) |
Issued: 20-MAY-2019 | To: FAA | AIC 18-R17/18-1004 |
The PNG Accident Investigation Commission recommends that the Federal Aviation Administration should re-evaluate TSOs 151b and 151d and DO-367 related to EGPWS warnings and cautions, and ensure that the Honeywell EGPWS MK V Computer provides a timely warning in the form of acontinuous flashing visual display of PULL UP at the bottom of the Primary Flight Displays, as an absolute minimum standard. A flashing visual display PULL UP warning, accompanying an auralSINK RATE, would require immediate action from the flight crew when encountering an excessive Rate of Descent at very low Radio Altitude, similar to that flown by the crew of P2-PXE. |
Issued: 05-JUN-2019 | To: Jeppesen | AIC 19-R18/18-1004 |
The investigation found that the terminology used to indicate the Transition Level95 on the approach charts for Pohnpei and Chuuk was not consistent.On the Chuuk RNAV (GPS) Rwy 04 Chart, Jeppesen indicates the Transition Level as Trans: FL 055and on the Pohnpei RNAV (GPS) X Rwy 09 Chart as Trans: FL 55 although both are referring to the same thing Trans alt: 5,500.The PNG Accident Investigation Commission recommends that Jeppesen should ensure that standard terminology is used on both (Chuuk RNAV (GPS) Rwy 04 and Pohnpei RNAV (GPS) X Rwy 09) instrument approach charts. Jeppesen should also ensure that terminologies and the layout used on all Jeppesen Instrument approach charts are consistent and standardised |