One-Two-GO Airlines Flight 269
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|Date||September 16, 2007|
|Summary||Crashed into the embankment on one side of the runway after a failed go-around on approach|
Phuket International Airport|
|Aircraft type||McDonnell Douglas MD-82|
|Flight origin||Don Mueang International Airport|
|Destination||Phuket International Airport|
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 September 16, 2007, at 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.
A two-year investigation by NTSB resulted in a report  mainly incorporated into the crash report published by the Aircraft Accident Investigation Committee of the Ministry of Transport. 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. The lead Thai Department of Civil Aviation investigator reported 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.(p29) Legal filings and press articles reference an email among executives of One-Two-GO Airlines, including CEO Udom Tantiprasongchai.[needs update]
More than three years after the crash, a British coroner 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."
One-Two-Go Airlines is prohibited from operating in European Union nations due to safety concerns. 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.
On the day of the crash, the McDonnell Douglas MD-82  departed Bangkok’s Don Muang International Airport, Thailand at 14:31 local time en route to Phuket International Airport as flight number OG269.(p2) 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 7 crew members. OG269 was the fourth of six flights between Bangkok and Phuket that Arief and Montri were scheduled to fly that day.[page needed]
On approach to Phuket, captain Arief made several radio communications errors including read-back/hear-back communications(p27) and misstating their flight number.[not in citation given] First officer Montri was the flying pilot.(p2)
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.(p2)
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”.[page needed]
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.[page needed]
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 0 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.(p3)
Rescue efforts were hampered by a four-foot (1.3m) ditch beside and parallel to runway 27 running the length of the runway.:32 Rescue vehicles were unable to cross this ditch, though they could have entered at either end of the runway. None did.:17 One survivor complained that only a single ambulance arrived,:16 and forced the healthy into the vehicle, leaving behind trapped and injured.[not in citation given]
Additional fire and rescue from the town of Phuket arrived 30 minutes later.: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 situation.[not in citation given] Additionally, the Airport failed to include "Crash on Airport" procedures in its air service manual as required by ICAO,:16 so the highly skilled and trained rescuers within Thailand 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
Of the 130 people on board, 85 passengers and 5 crew members died.:3 As of 09:17 local time (0217 UTC) on September 18, 2007, 21 out of 57 bodies of foreign nationals had also been identified.[needs update] The airline contacted the rest of the victims' families for evidence to aid in identification. Some victims suffered head injuries caused by dislodged airline internals.[clarification needed] Others were trapped and burned alive in the cabin. Many survivors sustained burns.
Various embassies and ministries in Bangkok confirmed the following numbers:
- Australian embassy: 1 Australian killed and 1 survived
(National Nine News reported at 3 P.M. on 18 September that Australian foreign minister Alexander Downer and his department felt confident that no more than 2 Australians died in the crash.)
- British embassy: 8 Britons killed and at least 2 injured
- Canada: 1 killed and 1 injured
- French foreign ministry: 3 French nationals killed, 1 injured, and 6 missing
- German officials: At least 1 German killed - a 29-year-old man, 4 injured
- Ireland foreign ministry: 1 Irish national killed
- Israel media: 8 Israelis killed, 2 injured
- Swedish foreign ministry: 2 Swedes killed - a 19-year-old female and a 20-year-old male, and 2 survived with minor injuries
- US embassy: 5 American tourists killed
- Japan: 1 killed, 2 injured
- Turkey: 1 killed, 1 injured
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 while 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. It appears that the plane was caught in wind shear, causing it to sink abruptly. 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.
The US NTSB takes an interest in commercial airline incidents involving US manufactured aircraft, and they arrived on site within days. The NTSB inspected the aircraft, the crash scene, 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, 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 within 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 2 seconds before impact.
Yet 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”.[better source needed]
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.[better source needed] His claims quickly spread on the internet and came to the notice of an 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 the accusations of maintenance fraud and specifically by CEO Udom Tantiprasongchai, coercion and bribery of pilots to fly illegal hours leveled by a number of One-Two-GO.
Furthermore, 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 routes showing that both pilots had flown vastly 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.
But the NTSB did not receive information about the flight rosters from the Thai investigators or from the airline.
In late February 2008, the victim’s families, concerned about the impartiality and transparency crash investigation, created a website and on-line petition called InvestigateUdom.com calling for a proper investigation into the root causes of the crash. 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 – September 16 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.
After completing the inspection of the aircraft, the NTSB found it to have functioned properly and to have remained fully controllable until impact. The cause of the crash was found to be due to a combination of human performance and operational issues, including:
- 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 illegally excessive hours for the week and the month
- 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."
The US 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.
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.
July 28, 2008, Thai DCAT censured Orient Thai Airlines and One-Two-Go airlines over a number of issues, 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
In April 2009, One-Two-GO Airlines was added to the EU blacklist. It was removed shortly thereafter. In September 2010, the One-Two-GO brand was dropped and the airline was merged into Orient Thai Airlines.
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 8 British citizens killed. The inquest, held March 22–23, 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. Fisher twice contacted the airline to send a representative to the hearing. The airline replied that they would not take part in the proceedings.
In popular culture
- Modernine TV discussed One-Two-GO Airlines Flight 269 on TimeLine, 26 June 2017, in "Dead Landing".
|Wikinews has related news:|
- 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.
- 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.
- Australian Channel 9 (2007). "Cut Price Safety" (mp4). Retrieved July 14, 2011.
- National Transportation Safety Board (2009). "One-Two-Go Airlines Flight OG269, HS-OMG September 16, 2007, Phuket, Thailand" (PDF). NTSB/DCA07RA063: Appendix D. Retrieved July 14, 2011.
- "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.
- Heidi Blake (2011). "Thai airline 'covered up failings behind crash which killed 90'". The Telegraph. Retrieved July 15, 2011.
- 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. Cite error: Invalid
<ref>tag; name "Coroner Report" defined multiple times with different content (see the help page).
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- "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. Retrieved 2011-07-23.
- "One-Two-GO flies into History". The Bangkok Post. 2010-09-15. Retrieved 2011-07-23.
- สํานักข่าวไทย TNAMCOT (26 June 2017). "ข่าวดังข้ามเวลา ตอน "Dead Landing รันเวย์มรณะ" [คลิปเต็มรายการ]" – via YouTube.
|Photos of HS-OMG before accident|
- Aircraft Accident Investigation Committee, Ministry of Transport
- Final Report (Archive)
- "INTERIM REPORT ONE TWO GO AIRLINES COMPANY LIMITED MCDONNELL DOUGLAS DC-9-82 (MD-82) HS-OMG PHUKET INTERNATIONAL AIRPORT THAILAND 16 SEPTEMBER 2007." AAIC (Archive)
- "ผลการสอบสวนอบุ ตัเหต ิ กรณ ุ ี เครองบ ่ื นของบร ิ ษิ ทั วนั ทูโก แอรไลน จากํ ดั แบบ DC-9-82 (MD-82) เครองหมายส ่ื ญชาต ั และทะเบ ิ ยนี HS-OMG ประสบอบุ ตัเหต ิ ุณ ทาอากาศยานนานาชาต ภิเกู ต็ เมอว่ื นทั 16 ่ี กนยายน ั 2550." (Archive)
- "STATUS OF THE INQUIRY INTO THE ACCIDENT OF ONE TWO GO AIRLINES FLIGHT OG 269." (Archive) Royal Thai Embassy of Singapore
- HS-OMG on Aircraft Census Database