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The flight crew of an Air Niugini B737-800 jet carrying 47 passengers apparently ignored 13 loud automated alerts sounding in the cockpit during their landing approach, before they touched down in a lagoon instead of on the tarmac.

A passenger disappeared and was later found dead after the plane plunged into the sea just short of the runway while trying to land at the international airport on Weno, the main island of Chuuk state in Micronesia, last September.

Local fishermen arrived on the scene within minutes, in a flotilla of small motorboats. They began a rescue operation in conjunction with US Navy divers, which worked impressively.

The Papua New Guinea Accident Investigation Commission last week released the findings of its investigation into the crash.

The chief commissioner, Hubert Namani, said the two pilots were approaching the runway using instrument navigation, because of poor weather, Radio New Zealand (RNZ) reported.

They had “lost their situational awareness” and missed several cues, such as alarms sounding loudly, the report said.

The cockpit voice recorder shows that no fewer that 13 warnings, from the Enhanced Ground Proximity Warning System (EGPWS), sounded on the flight deck as the plane dropped below its Minimum Descent Altitude, between 364 feet (111 metres) and the impact point.

Namani said the crew’s failure to respond to these alerts was “a symptom of fixation and channelised attention”.

Passengers being rescued from the aircraft

“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,” Namani said.

Initial relief that everyone aboard had survived the bizarre crash later gave way to consternation when it turned out one of the passengers had disappeared.

Later reports said that the missing man survived and made off across the lagoon in a local dinghy.

Local authorities spent a weekend hunting for him, but then, on the following Monday, Air Niugini chief executive Tahawar Durrani said the man’s body had been found by divers in the lagoon.

Bill Jaynes, managing editor of a Micronesia-based newspaper, was on the plane when it hit the water.

“It’s just surreal. I thought we landed hard until I looked over and saw a hole in the side of the plane and water was coming in, and I thought, well, this is not, like, the way it’s supposed to happen,” he said in a video posted to Facebook.

Local boats coming to the rescue

Jaynes said the plane came in “very low” and at least one flight attendant panicked. Jaynes said people on the plane waded through seawater up to their waists as they floundered through an emergency exit – where the found fishing boats ready to pick them up.

The Papua New Guinea Accident Investigation Commission said Air Niugini had been quick to respond to its recommendations, which included fitting cameras into all cockpits.

Written by Peter Needham