Pilot error was to blame for a fatal plane crash in Federated States of Micronesia last September.
The Air Niugini plane in the lagoon off Weno airport in Chuuk. Photo: AFP or licensors
The 737-800, from Papua New Guinea's national airline Air Niugini, crashed 460 metres short of the runway in Chuuk, killing one person.
The PNG Accident Investigation Commission today released the findings of its investigation.
The chief commissioner, Hubert Namani, said the two pilots were approaching the runway using instrument navigation, because of poor weather.
But he said they lost their situational awareness and said they missed several cues and warning alarms as they fell short of the runway, crashing into a lagoon.
The report said Air Niugini was quick to respond to the recommendations, which included fitting cameras into all cockpits.
Watch a video of the flight reconstruction here.
The recorded information from the CVR showed that a total of 13 EGPWS aural alerts (seven "Glideslope" and six "Sink Rate" and a "100 ft" advisory) sounded after passing the Minimum Descent Altitude, between 364 ft and the impact point.
Mr Namani said: "The investigation observed that the flight crew disregarded the EGPWS alerts and did not acknowledge the "minimums" and "100 ft" advisories or respond to the EGPWS aural alerts; a symptom of fixation and channelised attention."
"According to the Human Factors experts, inattention, or decreased vigilance has been a contributor to operational errors, incidents, and accidents worldwide. Decreased vigilance manifests itself in several ways, which can be referred to as hazardous states of awareness.
"Both pilots were fixated on cues associated with control inputs for the landing approach, and subsequently, were not situationally aware and did not recognise the developing significant unsafe condition of an increasingly unstable final approach," Mr Namani said.
