What happened
On 9 February 2023, a PAC 750XL aircraft, registered P2-BJD, was attempting to depart Giramben Airstrip in Jiwaka Province, Papua New Guinea. The charter flight, operated by North Coast Aviation, was transporting cargo and three passengers toward Simbai Airstrip.
During the take-off roll, the aircraft's right wheel encountered a soft spot on the runway surface. This impact significantly reduced the aircraft's momentum and airspeed. Although the aircraft briefly became airborne, it descended back onto the runway after the pilot had already passed the designated committal point. The pilot elected to continue the take-off roll at full power in an attempt to regain necessary speed. However, the aircraft failed to clear the end of the runway, striking the perimeter fence's barbed wire with the main landing gear. The aircraft subsequently impacted the terrain approximately 103 meters from the runway end. The impact destroyed the aircraft, and while all four occupants survived, the pilot, one adult passenger, and an infant sustained serious injuries.
The investigation
The investigation examined the aircraft's maintenance history, the pilot's training records, and the ground handling procedures used during loading. Investigators reviewed the runway conditions at Giramben Airstrip and the operator's safety management systems. The inquiry also looked into the accuracy of the flight manifest and the pilot's adherence to standard operating procedures regarding weight and balance calculations.
Findings
- The aircraft was airworthy and properly maintained prior to the accident.
- The pilot had not completed the required route and aerodrome qualification for the specific airstrip.
- The aircraft's loading was not supervised by the pilot, and the manifest was completed by a ground handler who was not present during the actual loading process.
- There were discrepancies in the weight calculations, and the pilot failed to complete a required trim sheet.
- The pilot's decision to continue the take-off roll after passing the committal point was a critical factor in the accident.
- Wet surface conditions on the strip contributed to the loss of momentum during the initial roll.
- The operator's Quality Assurance and Safety Management Systems lacked effective oversight of operational processes and training requirements.