House of Cards: The crash of One-Two-GO flight 269
On the 16th of September 2007, a McDonnell Douglas MD-82 flying for Thai budget airline One-Two-GO crashed while attempting to land on the resort island of Phuket. As the plane approached the runway in the midst of a powerful thunderstorm, wind shear forced the pilots to abandon the approach, but during the attempt to climb out, the plane lost altitude and smashed into an embankment alongside the runway, tearing the airplane apart and killing 90 of the 130 passengers and crew. At first, wind shear seemed to be the most likely cause of the crash, which took the lives of tourists and crewmembers from at least 13 countries. But it soon became apparent that the sequence of events was actually rooted in the way the pilots executed the go-around. Their tragic errors during the maneuver led investigators to a series of disturbing revelations about One-Two-GO and its parent company Orient Thai — including that airline officials had been lying to the investigation committee in an attempt to throw them off track.
One-Two-GO was a wholly owned low-cost subsidiary of Orient Thai Airlines, complementing the parent company’s mostly international routes with domestic service to tourist destinations within Thailand. With frequent daily flights from Bangkok to Chiang Rai and the famed resort island of Phuket, the airline became a top choice for budget-minded travelers from abroad, especially from Europe. As Thailand’s first budget airline, it had relatively little competition, and for a year the airline prospered. But just over 12 months after its founding in 2003, disaster struck: on Boxing Day 2004, the devastating Indian Ocean Tsunami slammed into beaches in countries across the region, killing at least 230,000 people and destroying much of Thailand’s coastal tourist infrastructure. Tourism to the region plummeted, and both Orient Thai and One-Two-GO fell on hard times. By 2007, tourism had only just begun to return to pre-tsunami levels, and the financial hardship had yet to be alleviated.
It was on the 16th of September 2007 that 123 passengers and 7 crew boarded One-Two-GO flight 269 for a regular flight from Bangkok to Phuket. In command of the McDonnell Douglas MD-82 that afternoon was Captain Arief Mulyadi, an experienced Indonesian pilot with over 16,000 flight hours. Joining him in the cockpit was First Officer Montri Kamolrattanachai, a Thai national who had been trained from scratch through Orient Thai’s in-house training program, and had since accumulated a little over 1,400 flight hours.
The weather conditions over Phuket that day were quite stormy, with reports of lightning, rain, and shifting winds. By the time flight 269 began its descent toward the airport, other airplanes had already reported significant airspeed fluctuations on approach. Despite the difficult conditions, however, First Officer Kamolrattanachai was at the controls rather than the much more experienced Captain Mulyadi, who was working the radios.
As flight 269 descended into Phuket, Kamolrattanachai had a lot on his plate. The approach to Phuket’s runway 27 was complicated by a 1.4-degree offset to ensure terrain clearance — meaning that the instrument landing system would guide them in on a heading not quite aligned with the runway, and they would need to manually line up after making visual contact with the runway environment. In order to get ready for this turn and to more easily combat shifting winds, Kamolrattanachai disconnected the autopilot at 1,500 feet. But the weather conditions were rapidly deteriorating. At 3:37 p.m., as flight 269 was descending through 1,400 feet, the tower controller reported a wind reading of 240 degrees at 15 knots (28 km/h) and cleared them to land. But just one minute later, the tower reported that the wind speed had doubled to 30 knots, as a powerful thunderstorm rolled over the airport. Heavy rain began to fall and visibility plummeted, prompting the controller to ask, “Say your intentions now?”
“Landing,” Captain Mulyadi curtly replied, passing on his first officer’s decision.
Wind shear — sudden changes in wind speed and direction — began to cause major fluctuations in their airspeed. Nevertheless, the runway was in sight, so they pressed onward. At 3:39, the tower called them again to inform that wind over the runway had increased to a blistering 40 knots.
Moments later, as they passed through 200 feet, the plane’s rate of descent increased to over 1,800 feet per minute, more than twice the normal rate on landing, possibly due to a downdraft associated with the thunderstorm. The plane began to fall below the glide slope.
“Power,” said Captain Mulyadi. “Below.”
“Correcting,” said First Officer Kamolrattanachai, reaching over and pushing the throttle levers to a higher power setting. This failed to correct the descent.
“Power,” Mulyadi said again, “Power, power, power!”
“ONE HUNDRED,” the ground proximity warning system announced, calling out their height above the ground.
“More, more more,” said Mulyadi.
“FORTY,” said the GPWS. “SINK RATE! SINK RATE!”
Recognizing that they were seconds away from slamming hard into the runway, First Officer Kamolrattanachai announced, “Go around!”
“Okay, go around!” said Captain Mulyadi. Kamolrattanachai pushed the throttle levers to go-around power, and the plane began to climb back away from the runway.
It was in these few critical seconds that First Officer Kamolrattanachai made a fatal error. Up until this point, the MD-82’s autothrottle had been engaged in what is known as Speed mode, in which it automatically adjusts engine power to maintain a target speed set by the pilots for the descent. However, if the plane is configured for landing with the flaps extended and the landing gear down, and the height of the plane drops below 50 feet, the autothrottle enters Retard mode (stress is on the SECOND syllable), in which it decreases engine power to idle in preparation for touchdown. When flight 269 descended below 50 feet above ground level in the moments before First Officer Kamolrattanachai called for a go-around, the autothrottle entered Retard mode and began reducing thrust, which Kamolrattanachai promptly overrode using the throttle levers. The problem was that moving the throttles does not cancel Retard mode, and if the pilot were to let go of the levers, the autothrottle would simply resume what it was doing before — that is, reducing thrust to idle. This is why the correct way to initiate a go-around is to use the go-around switches, a pair of buttons located on the throttle levers, which when pressed place the autothrottle in go-around mode, causing it to accelerate to takeoff/go-around (or TOGA) power. Alternatively, the pilot can turn off the autothrottle entirely by pressing the autothrottle disconnect buttons on the sides of the throttle levers, allowing power to be added manually. In short, it should have been trivial to take the autothrottle out of Retard mode. But in the heat of the moment, First Officer Kamolrattanachai simply forgot to do either of these things.
By pushing the throttles to TOGA power without pressing the go-around switches, Kamolrattanachai failed to cancel Retard mode. Just a couple seconds after calling for the go-around, he took his hand off the throttle levers, and the autothrottle began reducing thrust back to idle again.
At that moment, still unaware of what the autothrottle was doing, Kamolrattanachai made a surprise decision to relinquish control of the airplane. “Flaps fifteen, your control,” he said to Captain Mulyadi.
Mulyadi could not have expected that he would be called upon to fly the plane while in the middle of executing a go-around, but he dutifully took over control, holding onto the yoke to guide the plane up and away from the airport. “Set my heading,” he said, instructing Kamolrattanachai to enter a target heading to fly back to the beginning of the approach. “Landing gear?”
“Gear is up,” said Kamolrattanachai. A warning began to call out, “LANDING GEAR, LANDING GEAR,” as the aircraft’s systems still believed they were trying to land.
By now engine power had reduced all the way to idle, and they began to lose speed. Their altitude peaked at 300 feet and the plane started to descend.
“DON’T SINK,” the ground proximity warning system called out, warning of a loss of altitude during climb.
At first, neither pilot seemed to react to the warning. Caught like deer in the headlights, they did nothing to save themselves as their plane plunged toward the ground.
“DON’T SINK!” the GPWS called out again. “SINK RATE! PULL UP!”
Upon hearing “pull up,” Captain Mulyadi jammed the throttles to TOGA power and pulled back to climb, but it was far too late. Two seconds later, flight 269 struck the ground just to the right of runway 27. The MD-82 careened across a ditch and plowed into an earthen embankment, which sent it sliding sideways down the runway margin. The front of the plane peeled open like a banana then rolled underneath the fuselage, shedding massive chunks of debris behind the aircraft as it slid to a stop. The ruptured fuel tanks immediately ignited, and a wall of fire clawed its way upward through the driving rain, filling the cabin with a pall of pitch-black smoke.
Inside the plane, the majority of the passengers had survived the impact, including both pilots. But the severe damage to the airplane caused the emergency lighting to fail, and passengers were forced to grope their way toward the exits amid pitch darkness, choking smoke, and scorching fire. Most of those who managed to escape did so through the left overwing exit, while those who were unable to get out in time collapsed from toxic gases or perished in the flames. Fire trucks rushing to respond to the disaster found that there was a deep ditch in between the runway and the airplane that prevented them from getting close to the seat of the fire, and they were forced to spray water over the ditch and onto the plane from a considerable distance. Meanwhile, those who escaped the plane found that only one ambulance with a single medical crew had responded to the crash, which was woefully insufficient to deal with the dozens of injured passengers streaming from the shattered fuselage.
By the time fire crews had extracted everyone from the airplane, 90 people were dead, including Captain Mulyadi and First Officer Kamolrattanachai, who — like many of their passengers — survived the impact only to die in the fire. Among the dead were citizens of 13 countries, including dozens of Thais, eight Israelis, eight Britons, and five Americans. Forty people survived, over half of whom suffered serious injuries — some of them significantly exacerbated by the delay in medical care caused by the lack of ambulances. It would soon be discovered that the poor emergency response to the crash stemmed from the fact that Phuket Airport had not created an emergency plan for what to do in the event of an accident. In the absence of a coordinated plan that all involved parties could practice — something which was required by regulations — word was slow to get out, and when it did, various agencies and organizations all attempted to assist in an uncoordinated manner that prolonged the rescue operation.
Meanwhile, Thailand’s Aircraft Accident Investigation Committee (AAIC), with the assistance of the US National Transportation Safety Board and Boeing, set about finding the cause of the crash. Initially, the high number of reports of wind shear by planes that landed just before flight 269 suggested that a sudden downdraft such as a microburst could have been the reason why it lost altitude during the go-around. But a more detailed analysis of the weather and the flight data showed that the sequence of events was completely contained within the cockpit. During the approach, something — probably wind shear — forced the plane below the glide path to the runway, prompting the first officer to call for a go-around. But neither pilot ever pressed the TOGA switches, causing the autothrottle to remain in Retard mode, where it attempted to reduce thrust to idle in preparation for touchdown. Neither pilot noticed that the autothrottle had reduced engine thrust until after the plane began to lose altitude, by which point it was too late to prevent the crash.
The central area of inquiry therefore became the pilots themselves. What were their histories? Were they fatigued? How had they been trained? The AAIC had to acquire this information from One-Two-GO itself, and it was at this point that things started to get messy. Investigators wanted to look at the pilots’ recent schedules to determine whether they had been overworked, so One-Two-GO provided them with documents listing all the flights completed by Captain Arief Mulyadi and First Officer Montri Kamolrattanachai during the three months before the crash. Everything seemed to be in compliance with duty time regulations, seemingly ruling out fatigue as a cause of the accident. But one month after the crash, an Australian television station conducting research for a feature piece on the accident uncovered a bombshell: the documents given to the AAIC were fake. Real documents acquired by Channel 9 showed that both pilots had regularly been violating duty time limits throughout the last several months, including as recently as two days before the crash. Thai investigators were astounded: not only was One-Two-GO violating the rules on a regular basis, the airline had also tried to pull wool over the eyes of the AAIC.
An analysis of the documents provided to investigators by Channel 9 showed that both pilots’ minimum rest period was violated on September 14th, and that the First Officer had exceeded his duty time limit (8 hours within every 24 hour period) on that same day. In the seven days before the crash, the First Officer had flown more than the maximum of 30 hours per seven-day period, which had also occurred in two other periods in the summer of 2007, including one in which he went over the limit by a full 8 hours. Kamolrattanachai had also exceeded the 30-day limit of 110 flight hours in two of the last three 30-day periods. And in addition to the incident on September 14th, his minimum rest period was also violated on six other occasions. An exposé by Channel 9 interviewed several former One-Two-GO pilots who explained that this pattern of violations was encouraged on the highest level through a backhanded scheme where pilots would be given cash bonuses upon completing flights past their duty time limits. And this wasn’t the only area where the airline put illegal pressure on pilots. Former pilots at Orient Thai and One-Two-GO also told Channel 9 that the airline had no money to fix mechanical problems, and if a pilot refused to fly a broken airplane, management would simply find a less scrupulous pilot who would agree to do it. One former pilot even accused the chairman of Orient Thai and One-Two-GO, Udom Tantiprasongchai, of personally calling him on his mobile phone and pressuring him to fly an airplane that was not airworthy. In an interview with Channel 9, Tantiprasongchai calmly denied every one of the aforementioned allegations. France later put out an international warrant for Tantiprasongchai’s arrest, but he was never detained, and he was convicted in absentia to four years in prison.
But the problems didn’t end with the maintenance and management: the quality of the pilots themselves was reportedly quite poor. Experienced pilots from other parts of the world, many of whom turned to One-Two-GO for employment after being laid off during the post-9/11 aviation downturn, had few positive things to say about those newer pilots who were trained internally by the airline. The AAIC found that the training was indeed of very poor quality. Captain Mulyadi hadn’t received training in crew resource management (CRM) — the most critical tool to prevent pilot error — since 2001, and First Officer Kamolrattanachai hadn’t received any CRM training at all. Other training violations discovered by the AAIC included the use of simulators which weren’t equipped with wind shear alerting systems or ground proximity warning systems; numerous skipped items during proficiency checks; incomplete training on control handovers; and the complete absence of any sort of training for flight dispatchers. These deficiencies had led to a number of close calls, including a 2004 incident in which an Orient Thai jumbo jet came within 200 meters of striking the Tokyo Tower after the pilots strayed off course while on approach to Haneda Airport.
Still, that was not all: even in an environment where many pilots had been brought up through this lackluster training system, multiple former pilots reported that Captain Arief Mulyadi was especially frustrating to work with. It was an open secret at One-Two-GO that Mulyadi tended to completely freeze up when faced with difficult approaches or adverse weather. One former first officer said to Channel 9, in heavily stilted English, “Two pilots at the time did advise me before I started to fly with Captain Arief. It was very short, he just say: ‘well you are going to fly alone.’” Another former pilot said that he once flew with Mulyadi into Kabul on a charter flight to pick up Afghan president Hamid Karzai, and during the difficult approach into Kabul, Mulyadi froze up and was unable to make any decisions or control the airplane in any way. For the return flight with Karzai on board, Mulyadi was relieved of command.
After reviewing the evidence, both the AAIC and Channel 9 came to agree that One-Two-GO and its parent company Orient Thai had created a culture in which safety was willfully disregarded. The AAIC refrained from forceful language, but noted that the company was full of employees from numerous countries who spoke different languages and had different concepts of safety, and “no effort” had been made to foster a unified approach to regulatory compliance. Channel 9 simply let those who had seen the airline from the inside speak their mind. “They’re one of the lowest standards of an airline within Asia. I would make the comparison to aviation in Africa,” said one former pilot. “I wouldn’t fly it if you paid me to,” said another. The consensus seemed to be that things became markedly worse after the 2004 tsunami, when financial problems caused the airline’s management to start finding creative ways to reduce expenses.
An advocacy group for the survivors and the families of the victims, called “Investigate Udom,” went even farther, digging up yet more documents that have yet to be corroborated. Among their more shocking findings: that a captain who was recorded as having been on leave for a month to participate in the Hajj was nevertheless listed as the instructor on four other pilots’ checkrides during the time he was supposedly in Mecca. Did these checkrides actually occur? If the documents are real, it would seem that they didn’t.
With all of this additional information, it was possible to explain why the pilots of flight 269 failed to properly execute the go-around. They had been overworked without enough rest for months and were not at the top of their game. First Officer Kamolrattanachai, despite having fewer hours than a first officer in the United States would have on day one of the job, ended up flying the approach despite the bad weather and other aggravating circumstances, something which former One-Two-GO pilots felt was irresponsible. Possibly, Captain Mulyadi did not want to fly the approach because he was incapable of handling adverse circumstances.
During the flight, very few words were exchanged between the pilots. Until the go-around, the only intra-cockpit conversations registered on the cockpit voice recorder were some occasional altitude and speed callouts, some bare-bones checklist items, and a few one- or two-word interjections about the conduct of the flight. This is probably because Mulyadi was Indonesian while Kamolrattanachai was Thai, and their only common language was English, which neither of them appears to have spoken particularly well. Therefore not only was Mulyadi prone to freezing while flying difficult approaches, the level of communication in the cockpit was below even the bare minimum — Kamolrattanachai really was on his own.
As he struggled to bring the plane in against a 40-knot headwind, rain, and wind shear on an offset ILS approach, First Officer Kamolrattanachai’s stress levels would have been significantly elevated. Add onto that his chronic fatigue combined with that mid-afternoon lull in the body’s circadian rhythm and it didn’t take much to send the whole house of cards crashing down. Tired, stressed, and operating above his experience level, Kamolrattanachai’s inner lizard brain said “push the throttles forward to go fast,” and forgot all about the TOGA switches and the autothrottle modes.
It was at this moment that he finally decided that he had reached the limit of his abilities and could take it no longer. He handed over control to Captain Mulyadi at the worst possible time: in the middle of a complex maneuver, with virtually no warning. Mulyadi, who was also fatigued, would have had just seconds to intuit what the airplane was doing. This task apparently required the use of both hands. At the same time, Kamolrattanachai, having given up control, also stopped guarding the throttles. Before either pilot could figure out what was going on, the autothrottle rolled the engines back to idle, the plane lost speed, and they fell out of the sky.
As a result of the findings of the investigation, the European Union banned Orient Thai from operating into its airports. After the publication of the official report in 2008, the government of Thailand grounded both Orient Thai and One-Two-GO for 56 days while they implemented structural changes. The AAIC report itself, however, was a disappointment. Many of the subtleties behind the pilots’ actions could only be assumed by the reader, and were never explicitly stated. Most of the egregious violations discovered by Channel 9 never made it into the report. And much of what did end up in the report seemed to be based off a summary submitted by the US NTSB representative, to the point that Aviation Consulting Group president Robert Baron described the report as having been “ghost-written” by the NTSB. In fact, Thai officials seemed to be aware of much more that was wrong behind the scenes than they let on in the official report. In a legal statement justifying the grounding of the airlines, Thai authorities cited a number of additional revelations, including One-Two-GO’s complete lack of a quality assurance program; its lack of actual managerial staff (everything was done by Orient Thai employees as a sort of full-time side gig); Orient Thai’s failure to stop violating duty time limits despite being ordered to do so; and the fact that One-Two-GO’s MD-80-series training program had not been certified by the Department of Civil Aviation (DCA), along with the airline’s deliberate deception of the AAIC, which the DCA described as a criminal offense. Following the grounding, both airlines resumed flights under close supervision by the DCA, but the safety problems ultimately led to the demise of the company. In 2010 the One-Two-GO brand was subsumed into Orient Thai, only for Orient Thai to have its Chinese operations suspended by the Civil Aviation Administration of China due to violations. Orient Thai was suspended again by Thailand in 2017, then briefly resumed service before ceasing operations permanently the following year.
The crash of One-Two-GO flight 269 could be described as a wakeup call for Thailand’s aviation authorities. Prior to this accident, Thailand had experienced a major crash every few years, usually involving flag carrier Thai Airways International, and Thailand was often lumped together with other Southeast Asian countries like Indonesia as part of a broader regional trend of poor aviation safety. Just two months before the crash, the FAA had privately informed the Thai DCA that Thailand’s level of safety oversight was “seriously deficient.” But the DCA’s sharp response to the crash of flight 269 was a major departure from previous cases, and represented a genuine change — especially remarkable given that the chairman of Orient Thai was closely connected to the King of Thailand. Now, almost 14 years later, there has yet to be another major accident in Thailand or involving a Thai carrier. No longer do aviation experts have any reason to mention Thailand in the same breath as Indonesia, which continues to suffer a major crash approximately every two years. But more could have been done: despite the pleas of the crash survivors and the relatives of those who died, Udom Tantiprasangchai, friend of the former Thai king and leader of what many feel was a criminal enterprise, passed away in January 2021 without ever being brought to justice.
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