Deadly Airline Culture! The Story of One-Two-Go Airlines Flight 269
at what point do you decide to abort an approach and what would cause you to do that the pilots of this md-82 is soon going to be faced with that very question and their answer will have terrible consequences Quantico Airlines was a low-cost airline based in Don Wang airport in Bangkok Thailand the airline was owned and managed by another airline called Orient Thai Airlines and both of these companies shared training departments and operations center and because of that they also shared company culture which will be really crucial to this story Montego Airlines operated a fleet of five McDonald Douglas md-82 aircraft who flew almost exclusively domestically within Thailand mainly from Bangkok to Chiang Rai and Phuket the pilots working for the airline came from many different backgrounds and nationalities and when it started its operation back in 2003 the global aviation industry was still reeling after the impact of the 911 terrorist attacks which meant that pilot jobs were few and hard to come by this led a lot of pilots from all corners of the world to sign up with this new Thai airline but pretty soon complaints about the safety culture inside the airline started to be heard according to news report from the time the company didn't take technical issues very seriously and would try and pressure their pilots to fly on aircraft that they weren't comfortable with after the horrible Boxing Day tsunami in 2004 it reportedly got even worse when the financial situation for want to go Airlines became more strained because of the decrease in tourism in Thailand the pilot pay on the md-80 fleet was considered low by industry standards which led to some of the more experienced Pilots leaving and the overall pilot experience level to start to drop but the most serious allegations from the time was that the airline top management regarded the pilot and cabin crew flight time limitations as something that they should be a bit flexible with now flight time limitations are written in stone in the entire Aviation world and Pilots willfully exceed the maximum time limitations can actually lose their licenses these regulations are incredibly important in order to safeguarding has fatigue and are not in any way flexible but Pilots employ that want to go Airlines at the time told stories about how management would give cash payments to pilots who would be willing to exceed their maximum flight time limitations or reduce their mandated rest times things like that would likely have set the state for a really LAX attitude towards these important rules and they save the culture inside of an airline is likely the most important factor in maintaining the overall safety and it's affected by all facets of attitudes expressed inside of the company I'm sure that you've all seen examples of this in your own lives the ah it's okay to skip that I saw X doing this last week and the company didn't mind mentality this can never ever be allowed to happen but all evidence shows that precisely that was going on inside a want to go Airlines before this accident happened on the 16th of September 2007 a flight crew of seven reported for duty of Don Wang International Airport in Bangkok they were scheduled to fly six sectors between Bangkok and Phuket with each flight planned to last about 1 hour and 20 minutes that would make the total planned flight time of day exactly eight hours which was the maximum allowed according to their operations manual both Pilots had received adequate rest during the previous night but they had been working hard in the month before the flight something that will become important later on the captain of the flight was a 57 year old Indonesian National he was very experienced with over 16 700 hours of Total time and 4 330 of those flown on the md-82 before he started his civilian flying career he had worked for the Indonesian Air Force his training record was okay but he had a reputation among his colleagues of not operating well on the stress and the last CRM course that he had done was in 2001 a full six years earlier together with him in the cockpit was a 30 year old Thai first officer he started his flying career only a couple of years earlier and was there for considerably less experienced his total flying time was just under 1 500 hours with the vast majority being flown on the md-80 fleet now September is traditionally the coldest and wettest month in Thailand since it's just at the end of The Summer monsoon season this means that the weather can change quickly between recently sunny and warm to the development of huge thunderstorms with heavy rain and Gusty winds this was exactly the type of weather that the pilots saw when they were going through their pre-flight preparation and because of that they plan to upload plenty of extra fuel for each of the legs that would give them plenty of holding time or options for diversions if they would end up needing it because of a storm being parked over the destination airport for example the winds were forecasted to be Westerly at Phuket airport so the 1.4 degrees offset ILS approach for armor 2 7 was planned to be in use now an ILS approach is normally perfectly aligned with the center line but if there are for example obstacles close to the approach the localizer beam can be directed slightly offset to make sure that the approach has sufficient obstacle clearance margins this would mean that the autopilot would need to be disconnected a bit earlier than normal to allow the aircraft to be maneuvered onto the center line prior to Landing now normally that's not an issue but in times of bad weather it can add a layer of complexity and workload for the pilot flying in any case the pilots proceeded to breathe their five chemical crew members and then they all walk together out to the aircraft the captain verified the technical status of the aircraft which was fine there was no known issues with it there's no real information about the first two flights between Bangkok and Phuket that the crew flew on that day they seem to have gone on without any major issues and on the third flight the first officer was going to be Pilot Flying the time was now around 1400 in the afternoon and it's typically during the late afternoon that the strongest thunderstorms moves in over Phuket Island because of that the crew uplifted close to 10 tons of fuel more than twice the fuel burn that they would need on that one hour and 20 minute flight over towards Phuket the crew boarded the 123 passengers consisting of largely holiday makers from several different countries who are eager to go and explore the Fantastic beaches nightlife and islands in the archipelago outside Phuket and kravi now I know how they must have felt because that part of Thailand around kirabi and R9 is actually one of my favorite places in the whole world so I've flown as a passenger in that area several times the the natural beauties truly astounding when the boarding was completed want to go Airlines flight 269 requested pushback and start and at time 14 30 the aircraft took off normally and started climbing Southwest towards Phuket the climb up was perfectly uneventful and the aircraft was eventually clear to climb to their cruising altitude of 32 000 feet to join up with Airway golf 458 which would bring them towards the destination now during the flight the captain was acting as pilot monitoring and was therefore in charge of the radios the cockpit voice recorder shows that he made multiple radio related mistakes like confusing the call sign and missing some air traffic control instructions this could be a sign of fatigue but given the fact that this was the third flight on the same route that day it might also just be a case of mixing up cold signs from earlier flights now a flight that is one hour and 20 minutes long is a fairly short flight it takes around 30 minutes to climb and then another 30 minutes to descend so it's very likely that the crews started preparing for the approach and gathered weather information pretty soon after they reached their cruising level and when they did that they would have seen that the weather in Phuket has started to take a turn for the worse there was a special weather report issued for Phuket meaning that the weather had changed dramatically between the two schedule observations prompting a new observation to be made the new weather report stated that the wind was coming from 270 degrees with nine knots there was visibility of four kilometers in heavy rain scattered clouds at 1500 feet broken clouds at 11 000 feet the temperature was 26 degrees with a dew point of 24 degrees and a pressure setting of 1006 hectarescal now this weather probably didn't look that bad to the pilots because the wind was pretty light I was blowing straight down the runway and even though there was Heavy Rain reported as long as there was no thunderstorms in the area and the runway wasn't flooded this would have been perfectly doable however given that these Pilots were very familiar with the weather in the area it's also likely that they knew that this type of weather with heavy rain could mean a quickly deteriorating situation with possibly much worse visibility and heavy winds later on in any case the first officer stayed on this pilots flying and started preparing and briefing for the approach there doesn't seem to have been any discussions about the possible change of controls over to the captain which would probably have been a good idea because of the weather that I was around Instead at approximately time 15 10 local time the pilots started their initial descent down towards the airport but before I explained the full accident sequence here comes a short message from my sponsor whether you're interested in learning about cutting-edge science or exploring the mysteries about ancient civilizations today's sponsor curiosity stream will have something for you it's the best platform for 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this QR code and use the promo code Mentor pilot to save 25 percent they have loads of Aviation and science content that I just know that you guys are going to love so support me by supporting my sponsor and click on this link or scan up here thank you curiosity stream now let's continue the story as the aircraft was descending down towards Phuket the crew requested diversion vectors around bad weather on a few occasions so there's no questions about the presence of active thunderstorms in the area the captain continued to make some radio mistakes during The Descent and at times it seemed like he had problems hearing what the first officer was saying but apart from that the cockpit atmosphere seemed relaxed and good at time 1522 the area air traffic controller cleared the aircraft to fly direct towards the Phuket VR Beacon which was situated on the Airfield at that point they were also cleared to Descent of flight level 130 and only two minutes later they were handed over to the Phuket approach controller when they joined this new frequency they were told to descend to 8 000 feet proceed direct to watch an ornament Point called unfill and be ready for the ILS approach run with 2-7 which is exactly what they had previously briefed on this frequency there was also another flight from a company called Orient Thai Airlines which was a few miles ahead of them and it seemed like this aircraft had mischarged their distance a little bit because at time 1525 they asked the controller if they could do a 360 left turn to lose some altitude now this is a maneuver that we use sometimes when we judged up we don't have enough track miles available to enable us to both descend and decelerate as much as we need the issue with this type of maneuver is that it complicates things a little bit for a traffic control because it will take around two minutes to make a full 360 turn and that will of course mean that the traffic behind will be getting closer so the pilots of Flight 269 were now told to slow down to their minimum clean speed meaning the slower speed that they could fly without having to configure the aircraft with flaps flight 269 was now about 15 miles away from the airport descending to 4600 feet and the first officer decided to start configuring the aircraft a bit early possibly to slow it down further in order to increase the distance to the preceding aircraft the slats were extended and at this point the aircraft was still flown using autopilot and outer throttle the preceding aircraft had now completed the 360 turn and was following the ILS localizer down to watch the airport but apparently the approach controller still wasn't quite happy with the separation because he now asked Flight 269 to turn on to heading 160 degrees for a slight delaying Vector the problem was that as the pilots turned onto that heading they could see some really bad weather on their weather radar in front of them so the first officer now asked the captain if he could request to use heading 1 8 0 degrees instead to avoid that weather this heading was now approved and it serves to show that the CRM and the situational awareness was working well at this stage but this will soon change the aircraft that was flying ahead of them was now handed over to the Phuket tower frequency and the pilots of Flight 269 was now expecting to get vectors to intercept the ILS localizer but instead of getting clear to do that the controller instructed them to fly through the localizer in order to further extend the distance to the preceding aircraft the pilots accepted that but the problem was that on the other side of the localizer the pilots could see another large thunderstorms which they didn't want to get close to so they asked for further write search which prompted the controller to finally clear them for the ILS now as you can see here there was already a lot of bad weather around the aircraft and unfortunately the weather of the airport didn't look any better maybe this was the reason why the crew now missed completing their approach checklist because some stress and possibly also some fatigue had started to creep in eventually the aircraft established itself on the ILS approach and when they had done so they were also handed over to the Phuket Tower controller for the landing clearance on that new frequency the preceding aircraft had just landed and as they were vacating the runway the pilots transmitted what's called a pyrep or a pilot report they said that there was now a thunderstorm over the airport and that they had experienced a wind shear with again and loss of airspeed of around 15 knots during the last 5 miles of the approach now a wind shear is basically what it sounds like it's a phenomenon when the wind changes either direction or intensity very quickly causing the aircraft AirSpeed to change with it an aircraft measures its speed not in relation to the ground but in relation to the amount of air flowing over its wings so if the wind changes suddenly it will cause a sudden increase or decrease in the indicated AirSpeed which can be quite dangerous especially during takeoff and Landing when the margins to aerodynamic stalls are much smaller wind shears are typically associated with large storm clouds and it's actually one of the reasons why we avoid flying close to these type of clouds in the first place so the aircraft that had just landed in front of them reported a share of around 15 knots which is a significant Shear but can still be dealt with providing that the pilots are ready for it and that they add some margin to their fly speed it is important to point out here that there is a difference between reporting a wind share in our pyrep and actually receiving a wind shear from the ground proximity warning system Pilots can sometimes report speed fluctuations as wind shear in order to advise traffic behind them about the possible issue but it might still have been possible to fly that approach in a stabilized way if a ground proximity warning system wind shear warning is issued or if the aircraft's handling Falls outside some specific parameters a wind shear Escape maneuver must be flown but that had not happened to the preceding aircraft thank you the tower controller acknowledged the report and then called up flight 269 to verify that they had also heard the information and the captain responded that they had now here it's worth taking a moment and look at the situation a bit closer flight 269 was established on Final and the weather ahead was clearly not good it was raining heavily on the airport the previously aircraft had reported a thunderstorm over the runway and heavy speed fluctuations on approach during these type of circumstances it would probably have been prudent to discuss abandoning the approach and wait for the storm to pass remember they were carrying extra fuel precisely for that reason and if they didn't want to wait they could also have considered the possibility of handing over the controls from the first officer to the captain to let him fly the approach but there were no discussions about this in the cockpit instead the pilots continued to configure the aircraft the first officer asked for the gear to be extended and once that was done for the flaps to be extended to 40 degrees for the landing now some of you might ask shouldn't there be some kind of warning system on the airport warning Pilots if an active wind share is in progress over the runway and yes those systems do exist and they are referred to as low level wind shear alert systems or llwas one of these systems had recently been installed at Phuket airport but on this day three of the six sensors that the system used were not functional because and this is crazy they were driven by solar power and given the Cloudy weather during the preceding few days they had no power now if you ask me it's probably not a great idea to have bad weather warning equipment depending on good weather but maybe that's just me in any case it didn't really matter in this story because the pilots had received a warning Anyway by the previous aircraft as the aircraft descended through about 1500 feet the first officer disconnected the autopilot in order to hand fly the aircraft but curiously he didn't disconnect the outer throttle which was still engaged in speed mode meaning that the outer throttle would try to maintain the speed selected by the pilots it is very rare to leave the outer throttle active when you're hand flying especially during strong winds as the outer throttle is typically much slower to react and move the thrust levers than the pilots are sudden unexpected changes in thrust driven by the outer throttle can also cause handling difficulties so disengaging it is definitely the norm but that didn't happen instead the first officer now started to battle the winds in order to try to line the aircraft with the runway like I mentioned earlier the localized that Runway 27 was a bit offset meaning that the aircraft was now Slightly North of the center line and the first officer needed to sort that out almost immediately after he had disconnected the aircraft started to oscillate in pitch and the first officer was struggling to keep the aircraft stabilized in the increasingly Gusty winds the tower controller now came in and cleared the aircraft to land Runway 27 and he also gave the pilot the surface wind of two seven zero degrees 15 knots and warned them that the runway was wet the captain read back the landing clearance and the set the fly speed to 140 knots before he started running through the landing checklist at time 1538 and 28 seconds the tower controller came back in and advised the crew of strong winds now coming from two four zero degrees at 30 knots that's double the wind that they had just a few seconds ago the captain acknowledged this and after he had done that the tower controller immediately came back asking the crew for their intentions now for the controller to ask for the Pilot's intention is a little bit unusual and it's likely an indication that the controller was a bit worried about the developing situation with a rapidly changing wind and the previously reported wind shear the final decision though to continue the approach always lies with the flight crew one the captain responded Landing after having first looked at the first officer to confirm this but just to be sure the captain now asks the tower controller to repeat the wind information and the controller came back with an even stronger wind of 240 degrees at now 40 knots just after that the aircraft descended through 500 feet and now started to encounter the rapidly Changing Winds which the other aircraft had reported the airspeed initially increased slightly which caused the steel active outer throttle to reduce the engine back to 1.3 engine pressure rate to your epr which is close to idle trust as this happens the aircraft increased its decent rate to close to 1 800 feet per minute which is way higher than the stabilized approach criteria below a thousand feet which tends to be a maximum of a thousand feet per minute both these decent rate and the idle truss condition should have triggered a go around but the crew continued to now unstabilized approach and things were about to get even worse as the aircraft descended through 115 feet the strong Gusto headwind which had caused the speed increased earlier now disappeared as quickly as it had come this caused the speed to quickly drop down to watch 126 knots well below the calculated approach speed when the captain saw this he called out power you're below speed power and the first officer responded by manually pushing both thrust levers forward to an epr of 2.0 which is basically Max go around thrust he also pitched up slightly in order to reduce that descent rate remember this is all happening very fast and now very close to the ground this increase in thrust likely combined with another gust of wind increased the speed to 166 knots as the aircraft passed through 50 feet basically over the runway threshold the ground proximity warning system now suddenly called out a think rate think rate warning this was the last straw for the first officer who now wisely decided to go around he called out go around flaps 15 and then pitch the aircraft up to about 12 degrees altitude before he without warning handed over the controls to the captain with the words your controls this happened at a very critical stage of the flight and very close to the runway it was not a suitable point to hand over the controls and the captain who had agreed to the go-around decision would likely have been really surprised by this he had just selected flaps 15 as the first officer had asked for and now he took over the controls likely with both of his hands on the control wheel and he called set my heading and landing gear to which the first office responded the gear is up as he had just selected it up thank you the aircraft has started to climb away but during this very rushed and Confused situation two critical things had happened remember how I said that the outer throttle was still engaged well there is a function of the outer throttle which was programmed to help the aircraft during a landing when engaged if the aircraft was configured in landing configuration and it wasn't in go around mode the outer throttle would start retarding the trust back to idle when it descended through 50 feet off the ground because the aircraft had briefly descended through 50 feet before the Goron was initiated the mode was now active and the trust reduced from 2.0 epr back to about 1.1 and
stayed there for the next 13 seconds and the second critical thing well when the first officer initiated the go around likely startled by the sudden sink rate warning he had already pushed the trust levels fully forward as part of his earlier speed correction and then during the rushed initiation of the Goron he forgot to push the Palm toga button if he would pushed us the outer throttle would not have engaged in the mode instead it would have selected and kept go around trust but since that was missed and the system had gotten low enough for the mode to activate this was now the reality if the first officer would have kept control of the aircraft he would have probably noticed that the trust was coming back but since he handed over the controls to the captain he instead started to focus on retracting the gear and the captain who had been handed the aircraft in the middle of a recently executed go around likely kept both of his hands on the control wheel thinking that the toga Button had already been pushed if any of the pilots would have scanned their flight mode enunciator they would have seen that the outer throttle was in but at this point things were happening very quickly the first indication that something was wrong came as the speed remained quite low around 122 knots even though the captain started pitching forward to accelerate the aircraft reached a maximum altitude of 262 feet before it started descending back down again and since the gear have been selected up the ground proximity warning system warning landing gear could be heard twice followed by a and pull up warning this must have alerted the captain to what was going on because the trust levels were now suddenly pushed forward and the engine started accelerating back towards go around thrust but it was too late the last thing that could be heard on the cockpit voice recorder was a wind shear warning before one second later the aircraft crashed into the grass on the Northern side of Runway two seven the front of the aircraft sustained massive impact damage and the right wing was torn clear off as it impacted an embankment spilling the remainder of the extra fuel that the aircraft had been carrying out under the aircraft where it ignited and caused a major fire when the aircraft finally came to a stop some passengers managed to escape through a left side overwing exit but 85 passengers and five crew members including both Pilots perished in the ensuing fire the fire and rescue operations started immediately but was hampered by a large ditch between the runway and the wreckage there were two entry points of the ditch at both Runway ends but these were not used there was also some considerable confusion when it came to the coordination of the rescue work especially to involve rescue forces from the nearby City because it was later found that the airport didn't have a developed crash on Airport emergency plan available once the rescue operation was concluded the investigation started and both the flight data recorder and the cockpit voice recorder were found and in good condition with the help of those it was relatively quickly established that the failure of the pilots to execute a go around when the approach became unstabilized was the first major error the then failure of the first officer to push the toga button was the reason that the outer throttle had gone into mode so the aircraft had functioned exactly as it was designed the first officer's decision to then hand over the controls at such a critical phase of flight and the captain's failure to notice that the trust levers were an idol further aggravated the situation and ultimately led to the accident but it was when the investigation started to try and understand why the pilots took the decision to start the approach fully knowing that the bad weather of the airport was there and to continue the approach even though it was clearly unstabilized that some really shocking information started to emerge it was found that both the captain and the first officer had exceeded the maximum Duty time during the month before the flight possibly leading to fatigue issues and accumulated stress they had also received less than their minimum rest on a few occasions and this was found to be a relatively common thing throughout the one to go Airline operation as well as with their mother company orientai Airways and if that wasn't enough the airline allegedly first provided investigators with falsified records of the Pilot's flight time the pilot training at the airline was found to not have been up to International standards with simulators who didn't properly work and checking syllabi which wasn't followed there was no set procedure for when and how a Handover of controls were supposed to be done nor had the crew gone through any recurrent CRM courses even though that this was mandated to be done at least every 12 months by their own manuals all of this also shown a bad light on the Thai Aviation authorities who had regularly audited both of these Airlines without finding any of these growth short comments the safety recommendations included changes at Phuket airport including widening of the open safety area on the side of the runway which was not wide enough improvements on Rescue planning and coordination as well as more permanent sources of power for the wind shear alerting system when it came to the airline the investigation was very harsh as there was numerous signs of willful neglect and incredible shortcomings which all needed to be sorted for the airline to be allowed to continue to operate these shortcomings led to the airline being put on The Blacklist in the European Union and even though they would never have flown in the EU anyway this was a clear sign for anyone out there that this was not a safe airline to fly with now I really recommend everyone out there to have a look at this Blacklist before you book any flight with a smaller company in a country that you're not familiar with I will link to the list in the video description here and I will also put it on my website mentorpilot.com where by the way you can also find some cool Aviation news from all over the world want to go Airlines were folded into its parent company in 2010 and the whole operation ceased in 2018 so they're thankfully not around anymore but before we finish I have one last really important message to share after this accident happened several ex-want2go Pilots came out in the Press giving witness about the unsafe practices that they had witnessed inside of the airline several of them also said in these interviews that they were just waiting for an accident to happen now that's just not good enough if you're a professional pilot or anyone really it's your duty to report any unsafe practices that you see first to the airline through established channels and finally to the proper Authority if you don't feel confident doing so in person or through your employer there are Anonymous reporting service available everywhere including the confidential human factors reporting program or sharep the FAA hotline and ertha's confidential safety reporting I will link to all of them in this video and also on my website now check out this video next which I think you're really gonna like or this playlist support my work by giving a super thanks joining my wonderful Patron crew by the link below or buying some cool merch have an absolutely fantastic day and I'll see you next time bye
2023-02-14 03:19
