PPRuNe Forums - View Single Post - NTSB report on Orient Thai/One-Two-Go OG269 released to families
Old 10th Dec 2009, 17:02
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InvestigateUdom
 
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NTSB report on Orient Thai/One-Two-Go OG269 released to families

The entire NTSB public docket on the OG269 crash, , September 16, 2009, including the NTSB crash report, supporting material and Thailand's request for technical assistance.

The report would humorous, if it weren't so tragic. The report clearly states no technical failures and
"windshear was not a factor in this accident."
It indicates a lack of honesty on the part of the Thai DCA investigators (no record of a NOTAM on LLWAS outage... don't worry, we believe you), references the excessive flight hours and continued illegal flight after the crash, and provides detailed instructions for the Thai DCA investigators to document the training, oversight, and human performance failures at Orient Thai/One-Two-Go.

A sampling:
5.Document that One-Two-Go Airlines and Boeing procedures called for
the flying pilot to push the TO/GA button, advance the power, and call
for max power during a missed approach/go-around. Document that
the TO/GA button was not pushed and that this allowed the throttles to
retard to idle during the missed approach/go-around.

6. From the FDR information, document that the throttles retarded to idle
and remained at idle thrust for approximately 14 seconds. Document
that the throttles retarded to idle because the pilots failed to push the
TO/GA button during the missed approach/go-around.

7. From FDR and CVR information, determine and document why the
pilots failed to monitor the engine power setting and allowed the engine
power to remain at idle power for about 14 seconds during a critical
point in the missed approach/go-around.

8. Determine and document whether One-Two-Go Airlines training and
guidance provides sufficient information to pilots concerning the effects
of a failure to push the TO/GA button during a missed approach/goaround.

9. Determine and document whether One-Two-Go Airlines training
provides sufficient guidance to pilots concerning the need to apply,
monitor, and maintain sufficient power during a missed approach/goaround.

10. Document that weather conditions were not the cause of this accident,
but may have been a contributing factor
See the report and material at: www.InvestigateUdom.com
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