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Airlines PNG Flight 4684

11 Aug 2009 · Isurava, Papua New Guinea

Twin Otter · Controlled flight into terrain due to pilot error

From Port Moresby Jacksons International Airport (POM) to Kokoda Airport (KKD)

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Event

Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
Event fatalities
13 · all aircraft and ground
Ground fatalities
Unknown
Occupants
13
Survivors
0
InjuriesFatal: death within 30 days. Serious: over 48 hours in hospital within a week, most broken bones, severe bleeding, nerve or organ damage, or serious burns. Minor: anything less. Glossary
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
Airline

Twin Otter

Aircraft type
Twin OTTER
Category
Airplane · from aircraft type
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
P2-MCB
Operator
Airlines PNG
Onboard fatalities
13
Route
From Port Moresby Jacksons International Airport (POM)To Kokoda Airport (KKD)

Cause areas

  • Personnel issues › Psychological
  • Environmental issues › Conditions/weather/phenomena
  • Personnel issues › Task performance

From the investigation findings the Wikipedia article reports, sorted into the NTSB's cause areas with AI assistance.

Approximate · Coordinates from the Wikipedia article; not checked against an investigation report.

From the Wikipedia article

Airlines PNG Flight 4684 (CG4682/TOK4684) was a scheduled domestic passenger flight operated by Papua New Guinean Airlines PNG, flying from Jacksons International Airport in Papua New Guinea's capital Port Moresby to Kokoda Airport in Oro Province, Papua New Guinea. On 11 August 2009, the aircraft operating the flight, a de Havilland Canada Twin Otter, the aircraft impacted terrain on the eastern slope of the Kokoda Gap at about 5780 ft above mean sea level in heavily-timbered jungle about 11 km south-east of Kokoda Airstrip. The aircraft was destroyed by impact forces. There were no survivors of the 13 people on board. A search and rescue operation was conducted by authorities who found the wreckage of the plane the next day, 12 August 2009. The aircraft was severely damaged, searchers found no signs of life. Papua New Guinean Search and Rescue Agency then announced that everyone on board had died.

The Accident Investigation Commission (AIC) investigated the cause of the crash and released its final report, concluding that the aircraft crashed due to pilot error. The plane deviated from its original flight path, visual references normally used in the Kokoda Gap were obscured by clouds, the pilots were not aware of their proximity to terrain. The AIC classified the accident as controlled flight into terrain.

Flight

The aircraft departed Jacksons International Airport at 10:50 am local time and reported to Jacksons Tower that they were climbing to 9,000 ft via the Kokoda Gap, with an estimated time of arrival at 11:20 am. At 11:11 am, while en route to Kokoda and on descent in the Kokoda Gap, the crew of Flight 4684 conversed with the crew of an aircraft, registered P2-KST, which was departing from Kokoda. There was no indication that the crew of Flight 4684 had any problems with their aircraft. On the ATC recording, the crew was heard saying "Thank you very much, morning long you". This was the last communication from Flight 4684.

Witnesses at Isurava village stated that they observed an aircraft fly low over the village at about the estimated time of the accident. Witnesses at the nearby Misima village stated that they heard an aircraft fly near their village but that they could not see the aircraft, as the area was covered by cloud. They stated that shortly after, there was a loud bang above the village and the sound of the aircraft stopped. Port Moresby ATC lost contact with Flight 4684.

Port Moresby ATC tried to contact Flight 4684, even requesting nearby aircraft in the area to contact the plane. However, there was no response from Flight 4684. ATC then asked other aircraft P2-MCD, an Airlines PNG plane departing from Efogi Airport, if Flight 4684 had landed in Kokoda. The crews of P2-MCD then stated that P2-MCB did not land in Kokoda. Port Moresby ATC then declared Flight 4684 status to ALERFA (alert search and rescue phase), and subsequently to DISTRESFA (distress search and rescue phase).

Search and rescue teams searched the area where Flight 4684 had lost contact, but the search and rescue operation was hampered by bad weather, low visibility and rough terrain. On 12 August 2009, a search and rescue Dornier aircraft detected an ELT signal in the search area. Later, a search and rescue team found the wreckage. The aircraft was totally destroyed. The search team did not find anyone alive at the crash site, and announced that no one survived the crash.

Investigation and cause

Investigation

The accident was investigated by the Accident Investigation Commission (AIC), assisted by the Australian Transport Safety Bureau (ATSB). The AIC could only determine the cause of the crash without access to a Cockpit Voice recorder or Flight Data Recorder, as neither recorder were required on a Twin Otter. The lack of both flight data and cockpit voice recorders adversely affected a full understanding of the accident investigation. Alternatively, on board the aircraft was a small electronic GPS tracking and data telemetry device. Using the device's Non-Volatile memory, the ATSB was able to piece together portions of the flight path.

The weather in Kokoda Gap at the time was poor. Based on eyewitnesses accounts and photographic evidence retrieved by ATSB, Kokoda Gap was obscured by clouds at the time of the accident, making it difficult for the pilots to know if they were in close to terrain. Given the surrounding mountainous terrain, the evident cloud in the Kokoda Gap, had the potential to severely limit the crew's escape options, increase their workload, and test their situational awareness. A reduction in situational awareness and the presence of mountainous terrain during an approach are known risk factors in instances of controlled flight into terrain (CFIT).

Later investigation found that only one pilot had an IFR rating, while the other did not. The co-pilot, First Officer Rodney Souka, had been assessed for instrument approach procedures; however, he was not qualified for flight under the IFR. Although the crew had planned the flight under Instrument flight rules, the forecast cloud in the area should have alerted the crew that under the actual conditions, visual flight in the Kokoda Gap would prove problematic. The visual descent into the Kokoda Gap required 5 km visibility, while at the time of the accident, the visibility was less than 5 km.

The Australian ATSB then turned their attentions to Souka. They examined his postmortem and medical history. Investigators found that Souka had critical coronary artery heart disease, and the examining pathologist considered that Souka could have had a medical emergency at any time. Souka's relatives reported that they were not aware of any significant medical condition affecting him. If an emergency occurred in mid-air as the aircraft approached the cloud to the north of the Kokoda Gap would have instantly increased Moala's workload and distracted her from the primary task of flying the aircraft. Both those factors are known to increase the risk of CFIT.

Investigators noted that Kokoda Airport was lacking in basic navigation infrastructure. The lack of ground-based navigation aids at Kokoda Airport meant that the only potential navigation assistance for the crew during their approach to Kokoda was from a GPS, or via the ground-based non-directional beacon/distance measuring equipment (NDB/DME) located at Girua Airport.

The investigation concluded that the accident was probably a controlled flight into terrain: that is, an otherwise airworthy aircraft was unintentionally flown into terrain, with little or no awareness by the crew of the impending collision.

Text from the Wikipedia article “Airlines PNG Flight 4684” (revision 1339318075, retrieved 2026-09-18) by its authors, under CC BY-SA 4.0. Extracted as plain text: references, tables, images and some sections are left out. Read the article

Sources

Wikipedia article: Airlines PNG Flight 4684
Article
Airlines PNG Flight 4684
Revision
1339318075 · 2026-02-19 · retrieved 2026-09-18
Wikidata
Q4016231
Licence
Text CC BY-SA 4.0, by the article's authors; Wikidata CC0; town positions GeoNames (CC BY 4.0)
Where each value comes from
Record
Wikipedia article "Airlines PNG Flight 4684" (page 23942628, revision 1339318075)
Date
Wikipedia infobox: date
Place and country
Wikipedia infobox: site
Map position
Wikipedia article coordinates
Aircraft, operator and route
Wikipedia infobox: aircraft type, registration, operator, origin and destination; route airports from the linked airport articles' Wikidata codes (OurAirports)
Operation
flight number in the article title
Fatalities
Wikipedia infobox: aircraft fatalities
Ground fatalities
not stated in the Wikipedia infobox
Summary
Wikipedia infobox: summary
Source notes (1)
  • Wikipedia · Facts from the Wikipedia article's infobox and coordinates, not checked against an investigation report. Independent review pending.