What happened
On 28 September 2018, an Air Niugini Limited Boeing 737-8BK, registration P2-PXE, was conducting a scheduled passenger flight from Pohnpei to Chuuk, Federated States of Micronesia. While executing the final approach to land on runway 04 at Chuuk International Airport, the aircraft impacted the water of the Chuak Lagoon. The impact occurred approximately 1,500 feet before reaching the runway 04 threshold.
The investigation
The Papua New Guinea Accident Investigation Commission (AIC) conducted the investigation following a delegation of authority from the Federated States of Micronesia. The investigation involved the analysis of Flight Data and Cockpit Voice Recorder data at the AIC’s laboratory in Port Moresby. Technical assistance was provided by the US National Transportation Safety Board (NTSB), the Federal Aviation Administration, Boeing, and the Transportation Safety Board of Canada, which assisted with the readout of the damaged AFIRS system.
Investigators examined several critical factors, including the use of an unapproved Electronic Flight Bag (EFB), the flight crew's actions during the approach, and the performance of the Enhanced Ground Proximity Warning System (EGPWS). The investigation also reviewed the aircraft's maintenance history, crew duty and rest periods, and the operational risk assessments of the operator.
Findings
- The aircraft struck the water short of the runway threshold during the final approach.
- The flight crew utilized an unapproved Electronic Flight Bag (EFB) during the flight.
- The investigation noted that EGPWS glideslope alerts had been triggered during the previous flight sector from Chuuk to Pohnpei on 27 September 2018.
- The crew's actions and the use of non-standard electronic tools were identified as significant factors in the sequence of events leading to the impact.