One-Two-GO Airlines Flight 269

One-Two-GO Airlines Flight 269
Crash scene
Accident
Date September 16, 2007
Summary Crashed into the embankment on one side of the runway after a failed go-around on approach
Site Phuket International Airport
8°6′53.95″N 98°19′11.95″E / 8.1149861°N 98.3199861°E / 8.1149861; 98.3199861Coordinates: 8°6′53.95″N 98°19′11.95″E / 8.1149861°N 98.3199861°E / 8.1149861; 98.3199861
Aircraft type McDonnell Douglas MD-82
Operator One-Two-GO Airlines
IATA flight No. OG269
ICAO flight No. OTG269
Call sign THAI EXPRESS 269
Registration HS-OMG
Flight origin Don Mueang International Airport
Destination Phuket International Airport
Passengers 123
Crew 7
Fatalities 90
Injuries 40
Survivors 40

One-Two-GO Airlines Flight 269 (OG269), a McDonnell Douglas MD-82, crashed into an embankment beside runway 27 at Phuket International Airport (HKT) bursting into flames upon impact on 16 September 2007, about 15:41 ICT during an attempted go-around after an aborted landing, killing 89 of the 130 persons on board. (One survivor succumbed to burn injuries several days after the crash). OG269 was a scheduled domestic passenger flight from Bangkok to Phuket, Thailand.[1]

A two-year investigation by NTSB resulted in a report[1] largely incorporated into the crash report published by the Aircraft Accident Investigation Committee of the Ministry of Transport.[2] Both reports found that the captain and first officer had worked hours vastly in excess of the legal flight limits; that the first officer attempted to transfer control to the captain during the go-around; that neither pilot initiated a go-around and that the training and safety programs at the airline were deficient.

Corruption within One-Two-GO Airlines and the Thai Department of Civil Aviation was a factor for crash investigators. A television crew initially learned of fraudulent work rosters for the captain and first officer, obfuscating their illegal work schedule, had been provided to the crash investigators.[3] The lead Thai Department of Civil Aviation investigator reported that documents he had received from One-Two-GO were fiction. The National Transportation Safety Board report included the true work rosters, obtained by the family of a victim. The NTSB report documented possible check ride fraud among four other One-Two-GO pilots in the months following the crash.[4]:29 Legal filings[5] and press articles[6] reference an email among executives of One-Two-GO Airlines, including CEO Udom Tantiprasongchai.

More than three years after the crash, a British coroner[7] cited the "flagrant disregard for passenger safety" by the airline and said "the primary failure so far as I am concerned relates to the corporate culture which prevailed both One-Two-GO Airlines and Orient Thai Airlines prior to and following the air crash."

Between 2009 and 2010 One-Two-Go Airlines was prohibited from operating in European Union nations due to safety concerns.[8] At the time of the accident the airline was owned by Orient Thai Airlines and in July 2010, it fully re-branded as Orient Thai Airlines.

Crash

The aircraft involved in the accident in 1985, while still being operated by Trans World Airlines (TWA).

On the day of the crash, the McDonnell Douglas MD-82 [9] departed Bangkok's Don Mueang International Airport, Thailand at 14:31 en route to Phuket International Airport as flight number OG269.[2]:2 The flight crew consisted of Captain Arief Mulyadi, an Indonesian national and the Chief Pilot of One-Two-Go Airlines, and a former Indonesian Air Force pilot, and First Officer Montri Kamolrattanachai, a Thai national who had recently completed his flight training with One-Two-GO's ab initio program. The aircraft was carrying 123 passengers and seven crew members. OG269 was the fourth of six flights between Bangkok and Phuket that Arief and Montri were scheduled to fly that day.[2]

On approach to Phuket, Captain Arief made several radio communications errors including read-back/hear-back communications[2]:27 and misstating their flight number. First Officer Montri was the flying pilot.[2]:2

Another aircraft landed immediately prior to Flight 269 and experienced wind shear. That aircraft's captain contacted the tower and reported wind shear on final and cumulonimbus over the airport, a report audible to all incoming aircraft. Air Traffic Control requested Flight 269 acknowledge the weather information provided and re-state intentions. Captain Arief acknowledged the transmission and stated his intention to land.[2]:2

OG269 conducted an ILS approach just north of the centerline on runway 27. As the landing proceeded, ATC reported increasing winds at 240 degrees from 15–30 knots (28–56 km/h), then to 40 knots (74 km/h). Captain Arief acknowledged the reports. ATC requested intentions again. Captain Arief said, "Landing".[2]

As the aircraft descended to 115 feet (35 m) above threshold level (ATL), its airspeed dropped. Captain Arief repeatedly called for more power as First Officer Montri attempted the landing. The aircraft continued to descend and fell below 50 feet (15 m) ATL, causing the auto-throttle to reduce engine thrust to idle. One second later, First Officer Montri called "Go Around". This was acknowledged by the captain. The first officer then attempted to transfer control of the aircraft to Captain Arief. There was no verbal acknowledgement of this from Captain Arief.[2]

The pilots retracted the landing gear and set flaps for go-around. The aircraft pitch changed from 2 degrees to 12 degrees as the aircraft climbed, its engines still at idle. Airspeed fell and the aircraft climbed to a maximum altitude of 262 feet (80 m) ATL before beginning to descend. For 13 seconds the engines remained at idle. The aircraft pitch angle decreased to near zero and then the throttle was manually increased two seconds before impact with an embankment along the runway at 15:40. The aircraft was severely damaged by a post-crash fire.[2]:3

Recovery

Rescue efforts were hampered by a four foot (1.3 m) ditch beside and parallel to runway 27 running the length of the runway.[2]:32 Rescue vehicles were unable to cross this ditch, though they could have entered at either end of the runway. None did.[2]:17 One survivor complained that only a single ambulance arrived,[2]:16 and forced the healthy into the vehicle, leaving behind trapped and injured.

Additional fire and rescue from the town of Phuket arrived 30 minutes later.[2]:16 Their slower than normal response was due to the ATC radio call for help from town that an aircraft that had "slid" off the runway rather than declaring an emergency. Additionally, the airport failed to include "crash on airport" procedures in its air service manual as required by ICAO,[2]:16 so trained rescuers were never contacted. The only passengers who exited the aircraft alive did so of their own accord. These inadequate materials and delays may have had a negative impact on passengers who initially survived the crash. Some bodies were found days later in the mud beneath the aircraft.

A non-air conditioned airport hangar was used as a morgue until the identity of foreign victims was confirmed via either DNA or fingerprint. The bodies of foreign nationals were repatriated only after cremation or embalming, so autopsies were not possible.

Survivors and fatalities

Phuket International Airport

Of the 130 people on board, 85 passengers and five crew members died.[1][2]:3[10]

As of 09:17 local time (0217 UTC) on 18 September 2007, 21 of 57 bodies of foreign nationals had also been identified. The airline contacted the rest of the victims' families for evidence to aid in identification. Some victims suffered head injuries caused by dislodged baggage. Others were trapped and burned alive in the cabin. Many survivors sustained burns.[11]

Various embassies and ministries in Bangkok confirmed the following numbers:[12]

  • Australian embassy: 1 Australian killed and 1 survived
    (National Nine News reported at 15:00 on 18 September that Australian foreign minister Alexander Downer and his department felt confident that no more than two Australians died in the crash.)
  • British embassy: Eight Britons killed and at least two injured[13]
  • Canada: one killed and one injured[14][15]
  • French foreign ministry: Three French nationals killed, one injured, six missing
  • German officials: At least one German killed - a 29-year-old man, four injured
  • Ireland foreign ministry: One Irish national killed
  • Israel media: Eight Israelis killed, two injured[16]
  • Swedish foreign ministry: Two Swedes killed - a 19-year-old female and a 20-year-old male, and two survived with minor injuries
  • US embassy: Five American tourists killed[17]
  • Japan: one killed, two injured
  • Turkey: one killed, one injured

Investigation

According to Vutichai Singhamany, a safety director at Thailand's Department of Civil Aviation, the pilot had deployed the landing gear on approach to Phuket airport runway 27, but had retracted it when attempting a go-around. Singhamany added that the wheels had not touched the runway and that the accident had happened moments after the pilot raised the nose of the aircraft to abort the landing.[18][19]

At the time of the crash, speculation rested on the pilot's decision to land in poor weather conditions and on the airport's wind shear detection system, which was not operational that day. In the weeks after the crash, the lead crash investigator, Vuttichai Singhamany, continued to indicate wind shear as the likely cause.[19]

The U.S. NTSB takes an interest in commercial airline incidents involving U.S. manufactured aircraft, and they arrived on site within days. The NTSB inspected the aircraft, the crash scene, and interviewed survivors and witnesses. They took information obtained from the flight data recorder ("black box") to the United States for analysis. The flight data recorder immediately yielded significant facts about the flight,[1] including:

  • Wind shear was not a factor in the crash
  • First Officer Montri was the flying pilot
  • Captain Arief's radio communications with ATC were error prone
  • Many Crew Resource Management (CRM) issues occurred in the cockpit
  • There was no conversation between the pilots during the final 18 seconds of flight.
  • The go-around (TO/GA) button, used to configure the aircraft for go-around, had not been pushed
  • The throttle was pushed to take-off power only two seconds before impact.

Thai investigator Director-General Vuttichai announced that NTSB had notified his department saying that it was "unable to determine the cause of the accident" and "No punishment will be imposed on any agency or personnel after completion of the investigation because the accident was beyond control".[20]

Meanwhile, immediately after the crash, an unidentified pilot claiming to work at One-Two-GO or Orient Thai Airlines made a posting on a pilots' internet site detailing incompetence and corruption at the airline.[21] His claims quickly spread on the internet and came to the notice of Australian Channel 9. A Channel 9 crew, including Nick Farrow and Sarah Ferguson, came to Thailand to investigate. Their resulting program, broadcast in November 2007, detailed accusations of maintenance fraud and specifically by CEO Udom Tantiprasongchai, coercion and bribery of pilots to fly excessive hours.[3] The program contained an interview with lead Thai investigator Director-General Vuttichai as he reviewed the daily flight rosters for One-Two-GO given to him by reporter Ferguson, documenting Captain Arief and First Officer Montri's schedules showing that both pilots had flown beyond the legal limit for the week and for month of the crash. Director-General Vuttichai said he would demand an explanation for the fraud from One-Two-GO.[3]

The NTSB had not received flight roster information from the Thai investigators or from the airline.[1]

In late-February 2008, the victim's families, concerned about the impartiality and transparency of the crash investigation, created a website and on-line petition called InvestigateUdom.com calling for a proper investigation into the root causes of the crash.[22] The commercial aviation community responded with evidence, and the website soon became a repository of false statements and evidence of corruption within the airline, including

  • Approved One-Two-GO re-currency check-rides approved by a chief pilot who was out of the country for the month
  • The true daily work rosters August 2007 – 16 September for the One-Two-GO pilots showing an email from the One-Two-GO and Orient Thai's flight scheduler to COO Cho Tsing Tsang, and CEO Udom Tantiprasongchai detailing the roster fraud provided to crash investigators and suggesting log book alterations to cover up the illegal flight of OG269.

Family members provided this material to the NTSB. As requested by the Thai Government, the NTSB ghost-wrote the crash report for the Thai authorities who thanked the NTSB for their assistance.[1]

Conclusions

After completing the inspection of the aircraft, the NTSB found it to have functioned properly and to have remained fully controllable until impact.[1] The cause of the crash was found to be due to a combination of human performance and operational issues, including:

Human Performance:[1]

  • CRM issues, including attempted transfer of control of the aircraft at a critical moment
  • Failure of either pilot to apply power while attempting to regain altitude
  • Fatigue issues as both pilots had worked excessive hours for the week and the month

Operational:[1]

  • Lack of governance in the corporate culture at One-Two-GO airlines
  • Failure of One-Two-Go to complete pilot proficiency checks as required by law
  • Training on a simulator that did not include wind shear alerting and did not match the configuration of One-Two-GO's MD-82s.

The NTSB noted that, "although the weather deteriorated in the later stages of this flight, wind shear was not a factor in this accident” and “It is understood that during the accident sequence, the pilots were potentially distracted by the weather conditions; however, that distraction should not cause a loss of control of the airplane."[1]

The U.S. NTSB stated that the possible causes of this accident, consistent with available evidence, are that: The crew did not properly perform the go-around and failed to activate the TO/GA switch. Although the throttles remained available to the crew to advance power, they did not, nor did they monitor the throttles during the go-around. A transfer of controls, from the copilot to the pilot, occurred at a critical point in the go-around. The airplane's flight management system automatically retarded the throttles, since the approach slat/flap logic for landing was met. Lacking power application, the airplane slowed and descended until contact with the terrain.[23]

The Thai AAIC added that the flight crew did not follow the standard operating procedure of a stabilized approach, call outs, and emergency situations as specified in the airline's flight operation manual. Their co-ordination was insufficient, they had heavy workloads and accumulated stress, had insufficient rest, and were fatigued. The weather conditions changed suddenly prompting the go-around attempt.[24]

Aftermath

On 28 July 2008, Thai DCAT censured Orient Thai Airlines and One-Two-Go airlines over a number of issues,[25] including:

  • Failure to have safety and oversight programs to ensure pilots were properly trained and certified
  • Failure to have a system and oversight over a system to ensure pilots met and did not exceed duty time limitations
  • Committing offense and breaking the law by submitting deceptive check ride reports by MD-80 pilots

The Air Operator's Certificate of One-Two-GO Airlines was revoked, grounding the airline for 30 days.[25]

In April 2009, One-Two-GO Airlines was added to the EU blacklist.[22] It was removed shortly thereafter.[26] In September 2010, the One-Two-GO brand was dropped and the airline was merged with Orient Thai Airlines.[26]

October 2009, the NTSB crash report was published. Once the Thai crash report was complete, the British government began its inquest process into the deaths of the eight British citizens killed. The inquest, held 22–23 March 2011, was presided over by H.M. Coroner, S.P.G. Fisher. Coroner Fisher relied on a British aviation investigator, the NTSB, and Thai reports, and victim and family statements to make his conclusions.[7] Fisher twice contacted the airline to send a representative to the hearing. The airline replied that they would not take part in the proceedings.[7]

  • Modernine TV discussed One-Two-GO Airlines Flight 269 on TimeLine, 26 June 2017, in "Dead Landing".[27]

See also

References

  1. 1 2 3 4 5 6 7 8 9 10 National Transportation Safety Board (2009). "One-Two-Go Airlines Flight OG269, HS-OMG September 16, 2007, Phuket, Thailand" (PDF). NTSB/DCA07RA063: 1–2. Retrieved July 14, 2011.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Ministry of Transport, Thailand (2009). "One-Two-Go Airlines Company Limited McDonnell Douglas DC-9-82 (MD-82) HS-OMG" (PDF). Archived from the original (PDF) on February 2, 2014. Retrieved July 14, 2011.
  3. 1 2 3 Australian Channel 9 (2007). "Cut Price Safety". Archived from the original (mp4) on 2012-03-27. Retrieved July 14, 2011.
  4. ↑ National Transportation Safety Board (2009). "One-Two-Go Airlines Flight OG269, HS-OMG September 16, 2007, Phuket, Thailand; Appendix D" (PDF). NTSB/DCA07RA063. Retrieved July 14, 2011.
  5. ↑ "Deceased v. One-Two-GO Airlines, Orient Thai Airlines" (pdf). US District Court Southern District of Florida Miami Division 08-22558-CIV-MOORE/SIMONTON: 57. 2008. Retrieved July 14, 2011.
  6. ↑ Heidi Blake (22 March 2011). "Thai airline 'covered up failings behind crash which killed 90'". The Telegraph. Retrieved July 15, 2011.
  7. 1 2 3 SPG Fisher HM Coroner (2011). "HM Coroner's Summary into the 8 Inquests of an Air Accident that Occurred on the One-Two-GO Airlines" (pdf). Retrieved July 14, 2011.
  8. ↑ "." EU Bans Thai, Ukraine, Kazakhstan, Benin Airlines From EU.
  9. ↑ "JetPhotos.net Census info for HS-OMG". Retrieved 2007-09-17.
  10. ↑ "Investigators probe Phuket air disaster". Channel NewsAsia. 2007-09-17. Archived from the original on 2007-12-24. Retrieved 2007-09-17.
  11. ↑ "'People burning all around me', says Thai air crash survivor". Channel NewsAsia. 2007-09-17. Archived from the original on 2007-09-20. Retrieved 2007-09-17.
  12. ↑ "21 foreign victims of Phuket air crash identified: police". Channel NewsAsia. 2007-09-18. Archived from the original on 2007-12-30. Retrieved 2007-09-18.
  13. ↑ "Thai airport wind alert 'faulty'". BBC. 2007-09-18. Retrieved 2007-09-19.
  14. ↑ "Wind detection systems down during deadly Thai crash". Canadian Broadcasting Corporation. 2007-09-18. Retrieved 2007-09-23.
  15. ↑ "Vancouver woman confirmed dead in Thai plane crash". Canadian Broadcasting Corporation. 2007-09-23. Retrieved 2007-09-29.
  16. ↑ "Seventh Phuket crash victim identified". The Jerusalem Post. 2007-09-19. Retrieved 2007-09-20.
  17. ↑ "Survivors recount Thai jet crash". CNN. 2007-09-18. Retrieved 2007-09-27.
  18. ↑ "Thai crash officials probe system problem, foul weather". Channel NewsAsia. 2007-09-19. Archived from the original on 2007-10-05. Retrieved 2007-09-20.
  19. 1 2 "Thai plane dead may take weeks to identify: police". Channel NewsAsia. 2007-09-20. Archived from the original on 2007-10-03. Retrieved 2007-09-20.
  20. ↑ "A very telling letter..." pprune. 2007-09-18. Archived from the original on 2011-08-10. Retrieved 2011-07-23.
  21. ↑ "Matters of the Facts regarding Suspension of Air Operator Certificate of Orient Thai Airlines Co., Ltd. and One Two Go Airline Co., Ltd". Professional Pilots Rumour Network (PPRuNe). 2008-07-28. Retrieved 2011-07-23.
  22. 1 2 "Families Blame Lax Safety for Budget Airline Crash". The Sunday Times. 2008-07-20. Retrieved 2011-07-23.
  23. ↑ "Archived copy" (PDF). Archived from the original (PDF) on 2016-05-30. Retrieved 2016-05-15.
  24. ↑ https://aviation-safety.net/database/record.php?id=20070916-0
  25. 1 2 "Matters of the Facts regarding Suspension of Air Operator Certificate of Orient Thai Airlines Co., Ltd. and One Two Go Airline Co., Ltd" (PDF). Department of Civil Aviation News. 2008-07-28. Archived from the original (PDF) on 2011-07-13. Retrieved 2011-07-23.
  26. 1 2 "One-Two-GO flies into History". The Bangkok Post. 2010-09-15. Retrieved 2011-07-23.
  27. ↑ สํานักข่าวไทย TNAMCOT (26 June 2017). "ข่าวดังข้ามเวลา ตอน "Dead Landing รันเวย์มรณะ" [คลิปเต็มรายการ]". Modernine TV – via YouTube.
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Photos of HS-OMG before accident
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