On 28 September 2018, the Air Niugini aircraft crashed in a lagoon as it tried to land for an intermediate stop on its journey from Pohnpei to Port Moresby.
The flight had 35 passengers and 12 crew onboard.
Initially it was believed that all the passengers and crew aboard had survived. But when a second search of the half-submerged cabin was carried out three days later by Japanese divers, a body was discovered.
The report by the Papua New Guinea Accident Investigation Commission says that the plane landed 1,500 feet short of the runway threshold.
The captain and first officer ignored a total of 17 audible warnings that they were flying too low.
The report says: “The crew seemed to have disregarded and talked over all the caution annunciations. The crew had experienced those type of cautions on previous flights and perceived them as nuisance alerts with no resultant consequence.”
On their previous flight the day before, the two men had done exactly the same: “The flight crew did not take corrective action to bring the aircraft back onto the required flightpath.
“The flight crew disregarded and continuously talked over the aural alerts.”
As the plane approached Chuuk on the day of the crash, “Both pilots were not situationally aware and did not recognise the developing significant unsafe condition during the approach”.
The 52-year-old captain was from Papua New Guinea and had 20,000 hours of experience. He was at the controls and, according to the report, prepared for the landing at an “excessively high rate of descent and the aircraft increasingly being flown below the glideslope in an unstabilised manner”.
The Australian first officer, 35, failed to take control from the captain when it became apparent the plane was in danger. The co-pilot’s final words before impact were: “Too low! We’re too low! We’re too low! We’re too low!”
An engineer was also on the flight deck, and filmed the whole descent on his phone.
The passenger who perished, Eko Cahyanto Singgih, was not wearing his seat belt – “which allowed his body to become a projectile sustaining traumatic head and facial injuries,” the report concludes.
Immediately after the crash, there was confusion over what to do: “The cabin crew stated during their interviews that during the evacuation they shouted the word ‘evacuate’, but it appeared that some of the passengers did not understand what it meant.
"They then shouted the phrase ‘get out’ repeatedly which the passengers seemed to understand and followed.”
Several passengers took their cabin baggage with them, against instructions, and one member of cabin crew retrieved her handbag before exiting the aircraft.
A loadmaster employed by Air Niugini who was travelling on the flight “carried a backpack, a clipboard and shoes off the aircraft”.
Astonishingly, the US Navy divers who were helping with the rescue allowed a passenger to re-enter the aircraft and move forward to retrieve his shoes.
Some cabin crew acted with conspicuous courage to rescue passengers. One found a seriously injured passenger under water in the aisle and lifted him above water level, and with the assistance of another member of cabin crew hauled him to the over-wing exit. Another passenger was found still strapped in his seat, and was dragged to the same exit.
The report also says the Papua New Guinea Civil Aviation Safety Authority “did not meet the high standard of evidence-based assessment required for safety assurance, resulting in numerous deficiencies and errors”.
“Unless safety action is taken to address the identified safety deficiencies, death or injury might result in a future accident,” the report concludes.
The Foreign Office travel advice for Papua New Guinea says: “Since 2000 over 20 aircraft accidents have happened in Papua New Guinea.
"The worst recent crash was on 13 April 2016 when a Sunbird Aviation PNG Britten-Norman Islander aircraft crashed at Kinuga Airport, killing all 12 people onboard.”
The plane involved in the Chuuk accident, registration P2-PXE, was involved in a ground collision at Jacksons International Airport in 2017. It was owned by Icelandair.