The Oct. 13, 2011 crash of a Bombardier DHC-8-100 about 22 miles southeast of Madang was the result of pilot error, according to the final report issued by the Papua New Guinea accident investigation commission. Twenty-eight of the 32 people aboard were killed when the aircraft crashed next to the Guabe River and caught fire.
The flight was descending at a steep rate (4,200 fpm) for arrival, with the power levers already pulled back. According to the report, the crew did not notice the aircraft’s speed increasing until the Vmo horn sounded at approximately 10,000 feet msl. The captain, who had 500 hours on type, mistakenly pulled the power levers back, but also up and over the reverse-thrust gate, causing both propellers to overspeed. This aircraft was not equipped with a Beta lockout mechanism. The left engine was badly damaged, while the right propeller feathered itself, causing a complete loss of power.
The crew failed to use any checklists during the emergency. As a result, they did not feather the left propeller, which continued to windmill, creating significant drag and control problems, as well as increasing the rate of descent. The crew also failed to slow the aircraft, further reducing the time available to manage the emergency. Neither landing gear nor flaps were used, which the report said could have reduced the severity of the impact. Beta lockout mechanisms are now required on all DHC-8s by June 2016.