One-Two-GO Airlines Flight 269

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 documents check ride fraud among four other One-Two-GO pilots in the months following the crash. Legal filings and press articles reference an email among executives of One-Two-GO Airlines, including CEO Udom Tantiprasongchai.

More than three years after the crash, the 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.

The accident is the fourth-deadliest aviation incident in 2007, behind TAM Airlines Flight 3054, Kenya Airways Flight 507 and Adam Air Flight 574.

Crash

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. 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, 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.

On approach to Phuket, captain Arief made several radio communications errors including read-back/hear-back communications and misstating their flight number. First officer Montri was the flying pilot.

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.

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”.

As the aircraft descended to 115 feet (35 m) above 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) above 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 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.

Recovery

Passengers and crew of OG269 received little benefit from fire and rescue services. On the day of the crash, Phuket Airport did not meet the requirements of fire and rescue protection required by international standards. The foam and water in the trucks used three days earlier in a training exercise and had not been restocked. When an airport has a reduction in fire or rescue capacity, ATC is required to notify incoming traffic of the reduction, but no notification was made.

Hampering rescue efforts was a six-foot ditch beside and parallel to runway 27 running the length of the runway. Rescue vehicles were unable to cross this ditch, though they could have entered at either end of the runway. None did. Survivors complained that only a single ambulance arrived, 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. 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. Additionally, the Airport failed to include "Crash on Airport" procedures in its air service manual as required by ICAO, 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, 84 passengers and 5 crew members died. The body of the pilot, Arief Mulyadi, has been identified. As of 09:17 local time (0217 UTC) on September 18, 2007, 21 out 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 airline internals. 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

Three local hospitals treating the injured have released the following survivors according to their nationalities:

1 Australian, 1 Austrian, 8 British, 1 Canadian, 2 Dutch, 4 German, 3 Iranian, 3 Irish, 2 Israeli, 1 Italian, 2 Swedish and 14 Thai.

Survivor and investigator statements

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 whilst 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.

23-year-old Parinyawich Chusaeng, who survived the crash on flight 269, told Agence France Presse

"The plane just dropped really fast and then jerked back up. The right wing hit a tree and then the plane hit the ground. The people all around me were burning. Some on the floor and some standing, and they were on fire."

Chaisak Angsuwan, director general of the Air Transport Authority of Thailand said:

"The visibility was poor as the pilot attempted to land. He decided to make a go-around but the plane lost balance and crashed. It was torn into two parts."

A witness, William Harding, said:

"The inside (of the plane) was totally on fire and about five minutes of burning, there was a small explosion that blew off top of the plane."

Canadian survivor, Mildred Anne Furlong, said:

"We started to go for the landing and [the pilot] just about hit the runway, but couldn't make it, so he lifted back up. We started to circle. I thought he was going to circle back around and try again, and then we took a sharp right and we started going for the ground."

"We bounced once and then went straight into an embankment with trees and bushes."

"It was raining really hard. We saw a couple of people who were on fire. Just a handful of us made it out. I counted 17 or 20 who had made it out on their own.".

Investigation

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”.

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. 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.

Conclusions

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:

Human Performance:

• 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

Operational:

• 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."

Runway discrepancy

According to ICAO standards, the runway at an international airport must be at least 150 meters wide, clear of non-frangibles, with deviation permissible when there are physical barriers and the deviation is documented in the Aeronautical Information Publication used by pilots when landing at an airport. There is a discrepancy between the NTSB and Thai authorities relating to the width of runway 27. The NTSB measured the runway 27 to be 45 meters wide free of obstructions due to the location of the non-frangible embankment running along the runway. Thai DCAT claims that the runway is 75 meters wide free of obstructions. Thai DCAT do not plan to amend the AIP of Thailand.

Aftermath

July 28, 2008, after the internet publication of illegally excessive work hours and check fraud, 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

The Air Operator's Certificate of One-Two-GO Airlines was revoked, grounding the airline for 5 months.

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. Finding that the crash of OG269 fit neither a Manslaughter nor murder, Coroner Fisher provided a narrative verdict to the court. He said:

"There is no question in my mind that the catalog of systemic failures … contributed in no small part to the horrific consequences of the air crash on 16 September 2007."

"The evidence highlights systemic failures and a highly deficient safety culture at both [One-Two-Go Airlines and Orient Thai Airlines] airlines."

"[T]he Company falsified records in a clear attempt to mislead the Authorities who were investigating the circumstances surrounding this tragic air crash."

"[I]f I had powers to enforce the attendance of those two Chief Executive Officers [Udom Tantiprasongchai] I would have summonsed them to give evidence and account to you the families for the lack of safety culture that prevailed at One-Two-Go."

Fisher communicated his concerns for future travelers’ safety on Orient Thai and One-Two-Go Airlines via letters to the European Commission (EC) for Air Safety, the British Secretary for Transport and the Associate of British Travelers (ABT).