See Synopsis of the Crash and Criminality of One-Two-Go Flight OG269

Bonnies 2nd Attempt at a Translation. June 9, 2009.

Hyperlink on DCA website: Preliminary results of accident investigations. The case of an aircraft company One-Two -GO Airlines DC-9-82 (MD-82) a nationality and registration HS-OMG accident.   View as pdf  View as FRENCH pdf


The case of accident investigations
Aircraft of One-Two-GO Airlines Limited
A DC-9-82 (MD-82)
Nationality marks and registration HS-OMG
Accident
At Phuket International Airport
On 16 September 2550

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Event summary

On 16 September 2550 at approximately 14:30 am the company's aircraft One-Two-GO Airlines DC-9-82 (MD-82) a nationality and registration HS-OMG to fly the flight OG 269, a domestic flight with a regular flight crew. The aircraft and its passengers included 130 people flying from the Don Muang airport to Phuket International airport.

As to the Go Around at the Phuket International Airport: At 15:40:10 pm the aircraft hit a hill beside runway 27 to the north and caught fire. The aircraft was destroyed. 90 flight crew and passengers died, 26 people were seriously injured and 14 others were slightly injured.

Investigations were conducted by the Board of aircraft accident investigations for the Kingdom of Thailand to inform the International Civil Aviation Organization (ICAO) and the National Transportation Safety Board (NTSB) in the United States (state and public designers and manufacturers of aircraft engines). The United States
sent staff to participate in the investigation including the appointment of an accredited representative from NTSB officials from Federal Aviation Administration (FAA)[1] and an advisor from Boeing Commercial Airplanes Company Ltd. and its Pratt &. Whitney Co., Ltd division. In addition, the investigation committee coordinated with representatives from the dead and injured birth nations of the United Kingdom, Australia, Japan, France, Israel, Northern Ireland, Islamic Republic of Iran, Thailand, and Indonesia[2].

 

Time noted in the investigation report is local time.

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Cause


The commission investigating aircraft accidents in the Kingdom has determined the opinion that cause of the accident was:

1.      The pilot did not follow the Standard Operation Procedures (SOP) set by the Flight Operating Manual (FOM) for a stabilized approach, nor for an emergency call (Call Out Procedure), or for a new flight operation (Go Around Procedure) when the aircraft was in crisis.

2.      No one pressed the TO / GA switch which allows the aircraft to increase the speed and the
height of its flight. No one monitored (Monitoring) changes to the throttle during the crisis.

3.      Coordination in the cockpit (Crew Co-ordination) was ineffective. The workload of the pilots was too large.

4.      The weather changed rapidly in the vicinity of the airport.

5.      Pilots have accumulated stress (Accumulation of Stress) and fatigue (Fatigue). They had little rest which accentuated the fatigue.

6.      Control of the aircraft was moved from pilot to pilot during the crisis at the moment of the new (approach?).


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Recommendations for Safety

 

1.       Orient Thai Airlines Company Limited One-Two-GO Airlines Limited Action:

1.1.    CRM training for all staff. The imposition of comprehensive initial training (Initial) and annual review training (Recurrent) on ICAO Doc CIR217 Human Factors Digest is required, No. 2 - Flight Crew Training: Cockpit Resource Management (CRM) and Line-Oriented Flight Training (LOFT) (Circ 217), which received approval from the Department of Air Transport.

1.2.    Training pilots must successfully pass the pilot training course and practices in SOP. Strictly.

1.3.    Improve methods of Transfer of Control during the Crisis according to SOP.

1.4.    Verify the flight training as assigned by the Air Transport Department. Spot-check standards and particularly verify the pilot proficiency exam. (Pilot Proficiency Check).

1.5.    Use flight simulators as a training aid (Flight Simulator) to simulate the aircraft. Evaluate with the aircraft flying in different conditions.

1.6.    On flight schedules accumulate the Flight Time & Flight Duty. Periods Limitation for pilots and aircraft must be assured by the flight scheduler who must monitoring and provide advance notification when flying close to a time limit. Each pilot must verify their own flight hours.

1.7.    Establish a safety management system (Safety Management System: SMS) for quality assurance of flight operations to accidents and enhance security when operating a flight according to standards.

1.8.   To executives at all levels[5]: Build a supportive culture for the employees (Corporate Culture) with values and beliefs in practice. Create a culture that follows rules and regulations and reports unusual happenings and obstacles to improve performance and safety of aviation. The executive could provide training and incentives to employees.[6].


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2.       Airports of Thailand Company, Limited must as follows:

2.1.    Accelerate the work on the runway width (Runway Strip) is consistent with standards indicated in Annex 14 of ICAO. Improve flight assessments on instrument approach (Instrument Approach) to fit the existing Runway Strip. Establish a Safety Management System (SMS) to control the risk to safety standards.

2.2.    Firefighting and rescue (Rescue & Fire Fighting):

2.2.1. Add channel for fire rescue to cross the trench next to the water running on 27 of the Phuket International Airport to allow access to the accident area quickly. Provide training in the rescue area,
a barrier to fire and rescue.

2.2.2. The National Institute of Emergency Medicine, a government group which provides medical emergency management services for the airport and aircraft within their responsibility.

2.2.3. Full Scale Emergency Exercise (Full Scale Emergency Exercise) should be provided to all agencies and personnel. They have the responsibility to manage the actual event when it occurs so they must plan and effectively.

3.       Department of Air Transportation Action:

3.1.    Verify the safety for flight operations of One-Two-GO Airlines Ltd and Orient Thai Airlines, Ltd., are in effect. Issue regulations specifying guidelines complete CRM[5] training in full.

3.2.    Supervise and certify the safe operation of the Thai aircraft operators, who have responsibilities of raising their aviation to a higher standard. To be effective, increase monitoring and inspection measures.

3.3.    Ensure coordination with Aeronautical Radio of Thailand to determine the procedure for action when an aircraft crash occurs near the airport in the Manual of Air Traffic Services with full details as specified in Doc9137/AN898 Airport. Service Manual, Part 7 with that of Airport Emergency Planning, Chapter 4. Responsibility and Role of Each Type of Emergency.

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3.4.    Coordinate with the Meteorological Department of Thailand to improve LLWAS system maintenance, installed at different airports, so it can be quickly repaired in the case of failure. Consider installing LLWAS[6] at the entire airport for faster information when the wind shear occurs.

3.5.    Coordinate with the medical unit for a thorough review after an accident.

3.5.1. Air Force Institute of Aviation pathology.

3.5.1.1.              For a physical examination to breathing

3.5.1.2.              To collect material and autopsy samples for examination from the operating room with doctors from the Ministry of Health. And / or doctor from the Forensic laboratory National Police

3.5.2. Medical forensic laboratory National Police

3.5.2.1.              Collect samples and deliver them to the pathology laboratory, Institute of Air Force flight operations. (If prior to the accident).

3.5.2.2.              Collect material and autopsy samples for examination. ห้ of the year ฏิ Curtis Buckley, a ร่ the Campo, the เ, if the experience of the field, the professor, and a Business.
Air Force and / or doctors from the Ministry of Health.

3.5.3. Ministry of Public Health Medicine.

3.5.3.1.              Collect material samples to laboratories for checking the pathology delivery to Institute of Air Force flight operations.(If prior to the accident).

3.5.3.2.              Conduct autopsy and collected material samples สำ for inspection. ห้ of the year ฏิ Curtis Buckley, a ร่ the Campo, the เ, if the experience of the field, the professor, and a Business. Air Force and / or medical forensic laboratory, or national police office.

 

 

 

 

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[1] This is the 2nd time Ive heard senior Thai government officials misunderstanding the relationship between FAA & NTSB.

[2] No mention of the US. This is probably accurate; weve received no governmental support or information once my brothers body was returned.

[3]Udom, they wrote a special action just for you. Dont forget, you are responsible for ALL the actions by the airline, past, present and future.

[5] Gee, thats worrisome considering the incentives Orient Thai has given in the past.

[5] Crew (or Cockpit) Resource Management

[6] Low Level Windshear Alert System

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This campaign brought to you in memory of the passengers of Flight OG 269.
Please direct inquires to Bonnie at InvestigateUdom.com.