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    incident

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    © All Rights Reserved
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    15 views160 pages

    1980

    Uploaded by

    lynnlynn23
    incident

    Copyright:

    © All Rights Reserved
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    of 160
    AIRCRAFT ACCIDENT INVESTIGATION.COMMITTEE, MINISTRY OF TRANSPORT, THAILAND AIRCRAFT ACCIDENT FINAL REPORT. ONE TWO GO AIRLINES COMPANY LIMITED MCDONNELL DOUGLAS DC-9-82 (MD-82) HS-OMG PHUKET INTERNATIONAL AIRPORT THAILAND 16 SEPTEMBER 2007 ‘The investigation process of the Aireraft Accident Investigation Committee of ‘Thailand follows the procedures in ICAO Annex 13 Aircraft Accident and Incident Investigation which the objective of the investigation of an accident or Incident shall be the prevention of accidents and incidents, Iti not the purpose ofthis activity to apportion blame or abil CONTENTS SYNOPSIS 1. FACTUAL INFORMATION 1 History ofthe Flight 1.2 _Injuriesto Persons 13 Damageto Aircraft 14 Other Damage 1.5. Personne! Information 15.1 Pilot in Command 1.52 The Co-Pilot 1.6 Altera formation 164 Aisplane 162 Left Engine 1.63 Right Engine LT Meteorologieal Information 18 Aids to Navigation 1.9 Communications 1.10. Aerodrome Information LI Flight Recorders 1.12 Wreckage and Impact Information 1.13. Medical and Pathological Information Ld Fire 14 115. Survival Aspects 1.16 Test and Research 1.17 Organizational and Management Information 118 Additional Information 1.19 Useful or Effective Investigation Techniques 1.20. Crew Resource Management (CRM) 1.21 Department of Civil Aviston’s Regulatory Supervision over One ‘Two Go Airis Company Limited and Orient Thai Aitnes Company Limited 1.22 Flight Cew Training 2. ANALYSIS. 1s 0 a 2 a 23 24 25 3. CONCLUSIONS 31 Finding: 32. Probable Causes 4, SAFETY RECOMMENDATIONS 5, SAFETY IMPROVEMENT APPENDICES Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix? Appendix 8 Appendix 9 Appendix 10 Appendix 11 Appendix 12 Appendix 13, Appendix Appendix 15 Appendix 16 Append 17 Appendix 18 Appendix 19 Appendix 20, Appendix 21 Appendix 22 Append 23 AIP announcement on Runway Physical Characteristics Information from Digital Fight Data Recorder (DFDR) ‘Transcript ffom Cockpit Voice Recorder ‘Accident Site Layout [NTSB report: Introduction and Summary [NTSB report: Detail of the Investigation NTSB report: Operational and Human Performance Appendix A Honeywell EGPWS Report Appendix B Honeywell Windshear Report Appendix C Human Performance Questions Appendix D Operational Documents Provided tothe NTSB Flight Standards Bureau Promulgation: Pilot Training Program FCTM of One Two Go Ailines: CRM. FOM of One Two Go Aitlines: Flight Time Limitation FOM of Orient Thai Airlines: Flight Time Limitation Rule and Practice Guidelines on Flight Time and Flight ity Period Limitations, Flight Safety Division, Department of Aviation Department of Civil Aviation Announcement on Flight Time and light Duty Perio Limitations Go Around Procedure ‘Transfer of Contol Procedure Stabilized Approsch Control Flight Time records ofthe Pilot nd Co-pilot US Summary Comments onthe Draft Final Report AAIC Reply to US Comments onthe Draft Final Report PAGE, Ea 37 38 2 6 ae 65 66 o 3 Bea 1 10s 107 6 n7 19 rt ra BI 37 138 13 148, 1st SYNOPSIS (On 16 September 2007, at approximately 14:30 hours, an airplane MD-82 of One Two Go Airlines Company Limited (One Two Go), nationality and registration mark HS-OMG, departed fom Don Mueang International Airport to Phuket Intemational Airport on a domestic ight OG 269 with 130 crew members and passengers on board At 15:40:10 hours, during conducting go-eround at Phuket, Intemational Airport, the airplane veered off and hit an embankment located in the [North of Runway 27, broke up in flames, and was completely destroyed. Asa result, 90 crew members and passengers died, 26 were seriously injured and 14 suffered minor njuies. ‘The Aireraft Accident Investigation Committee of Thailand (AIC) conducted an investigation and notified the International Civil Aviation Organization (GCAO) and the National Transportation Safety Board (NTSB) of the United States ‘of America as the State of airplane and engine Design and Manufacture. In addition, ‘he United States sent aceredited representatives ffom NTSB and Federal Aviation ‘Administation (FAA), as well 38 advisors from Bocing Commercial Airplanes Company Limited and Pratt & Whitney Company Limited to participate in the investigation, Morcover, the AAIC notficd the representatives of the United Kingdom, Commonwealth of Austalia, Japan, France Republic, Site of Israel, Norther Ireland, Islamic Republic of Iean, Federal Republic of Germany, and Republic of Indonesia asthe Statos having sufleed fatalities or serious injures to theirs citizens. LOCAL TIME IS USED IN THIS REPORT 1. FACTUAL INFORMATION LA History of the Flight (On 16 September 2007 at approximately 14:30 hous, One Two Go Aitlines’ McDonnell: Douglas MD-82 airplane with Nationality and Registration Mark HS-OMG, departed on «scheduled passenger flight number 06269 from Don Muang Intemational Aisport for Phuket Intemational Airport with 123 passengers and 7 crew members on board, The Plotn-Command (PIC) sated on the let was a Pilot not Flying (PNEYPilot Monitoring and the Co-pilt seated on the right was Pilot Flying (PF), The flight was en route on airways G48 at light Levet (FL) 320 (62,000 feet) and the estimated time of aval at Phuket Tateratonal Aiport was 15:50 hours, ‘At 15:36:21, during the time that Might OG269 was approsching the Phuket Intemational Aisport, the Orient Thai Aitines fight OX2071, while vacating fiom Runway 27 after landed atthe Phoket Intemational Airport, eportd the Ar ‘Traffic Controller (ATC) of the weather condition prior to landing that Cumulonimbus (CB) was over the airport area and there was windshear a 5 nautical miles before reaching the Instrument Landing System (ILS) station, resulted in sirspeed gain and loss of 15 knots. The ATC asked flight 06269 whether they acknowledged the weather conditions reported by fight OX2071, because both flights were on the same aerodrome rio ffequency (118.1 MH), The PIC of flight (04259 acknowledged the information and extended the landing gears for landing, ‘At 1533731, the ATC informed flight 06269 of surfice winds from 240 degres at 15 knots and gave clearance to land on Runway 27 with wet runway precaution At 15:38:27, the ATC informed fight 06269 of surface winds from 240 degres at 30 knots and asked the Might 0269 to state its intention of landing, ‘The fight OG 269 affirmed. ‘At 15:29:00, the Night 06269 requested for information of surface ‘wind condition. The ATC informed a surface wind condition of 240 degrees at 40 ‘ots and the ight OG 269 acknowledged. At that instant, dhe Radio Altitude Aural Call Out system automatically called out 500 fet” and the PIC called out thatthe slrepeed was at 136 knots ‘At 15:39:23, the PIC ordered for more engine power and reminded ‘the Co-Pilot thatthe azplane was descending below the ILS glide path, The Co-plot affirmed the conection. The PIC then ordered to increase engine power tree moce times. During that time, the airplane was atthe altitude of 100 feet. At 15:39:45, the Radio Altitude Aural Call-Out system automatically called out ‘40 feet” and the Enhanced Ground Proximity Wamning System (EGPWS) called out ‘sink rate sink ate’ ‘At 15:39:49, the Co-Pilot called out fora go-around and the PIC said “Okay, Go Around” ‘At 15.39.50, the Co-Pilot called for “laps 15° and transferred the airplane control to the PIC. Then, the PIC told the Co-Pilot to set the autopilot airplane heading and to retract the landing gear ‘At 15:40:1, the airplane veered off and bit an embankment located in the North of Runway 27 and broke upin lames 1.2 Injuries to Persons Tajuries | Crew Passengers ‘Other | Totad Fuad 5 B 5 30 Seow z mi - % ‘MinorNoae | 1a : i# [Total 7 1 ~ 0 1.3 Damage to Aireraft ‘The airplane was destroyed, 14 Other Damage Approximately 60 meters ofthe fence enclosing the embankment at Phuket International Airport was damaged. 1.8. Personnel Information 15. Pilot in Command Age: Nationality: Pilot License: Rating: Medical Certificate: 57 years old Indonesian Airline Transport Pilot License No. 4094 was fssued by Directorate General of Civil Aviston (DGCA) of Indonesia on 21 Temuary 1994, Ie was last extended on 23 Apel 2007 and valid until 31 October 2007, |A Rendering Certfate NO, 031 of the Personnel License was isued by Department of Civil Aviation (DCA) of Thailand on 1 November 2006, It was last extended on 27 Jane 2007 and valid wat 31 October 2007. ‘According tothe License No, 4094 F100 F0 - 737-200, MD 80's According to the Rendering Cerificate NO, 031 PIC for MD 80's (MD 82/83) Medical Certificate Class 1 was issued by DGCA of Indonesia on 15 June 2007 and valid until 31 December 2007 Medical Limitations: Holder shall wear lenses that correct for stant vision and possess glasses that correct for near vision Flying Experience ‘Total Bight ime 16,752:00 hours Flight ime on DC-9-82 (MD-82) 4.33000 hours Flight ime on DC-9.82 (MD-82) for the last 90 days 241:87 hours Flight time on DC-9-82 (MD-82) forthe last 30 days 10605 hours ‘Flight time on DC-9-82 (MD-82) for the last 7 days 30:39 hours Flight Time and Flight Daty Period. (1) Flight time on DC-9-82 (MD-82) forthe last 24 hours: Flight Time 5:08 hours light Duty Period 8.08 ours (2) Rest Period Before Duty on 16 September 2007 13:07 hous (@) Accumulated flight time from 10 September 2007 to 30:39 hours the flight before the accident flight which exceeded the limutation stated inthe Fight Operations Manual (FOM) of Orient Thai Aitines: the accurnlated fight time stall not exceed 30 hours within any 7 consecutive dys (4) Flight duty period on 13 September 2007, 9:10 hours Rest Period before 14 September 2007 which was less 8:25 hours than the timitation stated inthe FOM of Orient Thai Airlines: the rest period is atleast 10 hours, ‘Training Record ‘The PIC attended the Crow Resource Management (CRM) training ‘course on 12-16 February 2001, at Merpati Training Center, Jakarta, Indonesia. However, no record of any recurrent taining in CRM thereafter wa found, Pilot Proficieney Check ‘The PIC passed the last Pilot Proficiency Check on 21 April 2007, at Lion Training Center, Jakarta, Indonesia. 1552 The Co-Pilot Age: 20 yours 8 Nationality Thai Commercial Pilot License No, B-3082 issued by DCA of Thailand on 18 December 2005. It was valid until 17 October 2007, Pilot Licen Rating: Single & Multi engine-land Instrument Rating Co-pilot for MD-82 Medical Certificate: Class 1 issued by Institute of Aviation Medicine Directorate of Medical Services, Royal Thai Air Force (RTAF), on 24 October 2006. twas valid until 10 November 2007. Medical Limitations: None Flying Experience otal ight ime 1,465:00 hours Flight ime on DC-9.82 (MD-82) 1.24000 hours Flight ime on DC-9-82 (MD-82) forthe last 30 days 12027 hours Flight ime on DC-9.82 (MD.$2) forthe last 7 days 32:49 hours light Time and Flight Duty Period (1) Fight ime on DC-9-82 (MD-82) forthe fast 24 hours Flight Time 437 hous Flight Duty Period 725hours (2)Rest Period Before Duty on 16 September 2007 190hous (@) Accumulated fight time on 14 September 2007 which 9:29 hours exceeded the limitation stated in the FOM of Orient ‘Thai Airlines for domestic route: the accumulated Aight time shall not exceed 8 hours within any 24 consecutive hours, (4) The accumulated Might time exceeded the imitation stated in the FOM of Orient Thai Aitlines: the ‘accumulated flight time shall not exceed 30 hours ‘within any 7 consecutive days. The Co-Pilot had flight ‘ime as follows: Accumulatod fight time from 10 September 2007 to the accident light Accumulated flight ime from 20 t0 26 August 2007 + Accumulated flight ie ftom 2to 8 July 2007 (5) The accumulated flight time exceeded the limitation stated in the FOM of Orient Thai Aitlines: the accumulated flight time shall not exceed 110 hours within any 30 consecutive days + Accumulated flight time ftom 18 August 2007 10 the sccident light Accumulated Aight time fiom 19 June 2007 to 18 July 2007 (©The Co-Pilot had rest period less than the limitation stated in the FOM of Orient Thai Aisines: for the fight duty period exceeding 12:00 hours but not ‘exceeding 14:00 hours, the minimum rest period shall be 14 hours before the nex ight, a follows «Flight duty period on 14 September 2007 + Rest period before the next ight (1) The Co-Pilot had rest period less than the limitation stated in the FOM of Orient Thai Aisines: for the flight duty period exceeding 14:00 hours but not exceeding 16.00 hours, the minimum rest period shall ‘be 16 hours befor the next ight, as follows: Flight duty period on 8 July 2007 Rest period before the next ight + light duty period on 7 July 2007 Rest period before the next ight 3249 hous 31:09 hours 3801 hours 12027 hours 117 hours 1252 hours 11:3 hours 14:10 hous 9:45 hours 1410 hours 9:58 hours Flight duty period on 6 July 2007 1438 hours + Rest period before the next fight 9:20 hours ‘Training Record No record of CRM taining was found. Pilot Proficiency Check ‘The Co-Pilot passed the lst Plot Proficiency Check on 21 March 2007, at Altoon Boeing, Kunming, People's Republic of China 1.6 Aireraft Information 1.64 Airplane ‘Type ‘Manufacturer Company: Date of Manufacture: Owner: [Nationality and Date of Registration: ‘Time Since N Last C-Cheek: De9.82 (MD-82) McDonnell Douglas 1983 Grandmax Group Company Limited, British Virgin Island, wo leased the Aispane to Orient Thai Company Limited, which later sublease the Aisplane to One Two Go Company Limited HS-OMG 49183 21 March 2007 65,965:10 hous; 35,498 eyeles September 2008; Time Since New 63,333:00 hours at ‘American Airline Company Limited. Time Since Last C-Check: —2,632:10 hours Last Al-Check: 8 May 2007; Time Since Now 65,028:70 hours, Last A2-Cheek: 30 June 2007; ‘Time Since New 65,436:60 hours. Last A3-Chesk: 31 August 2007; ‘Time Since New 65,851:40 hours, 162 Left Engine Engine Type: srep-217 Manufacturer: Pratt & Whitey, United States of America Serial No.: ‘9n10 Time: ce New: 53,3170 hours; 28,729 eyles 1.63 Right Engine Engine Type: srsp.2174 ‘Manufacturer: Pratt & Whitney, ‘United States of America Serial No.: T1368 ‘Time Since New: 38,718:70 hous; 2,983 cycles Note: ‘Time Since New was calculated uni the last fight before the accident Sight ‘om 16 September 2007, 1.7 Meteorological Information LIT Special Weather Reports (SPECD provided by the meteorological station at Phuket Intemational Airport to ATC on 16 September 2007 were as follows: LI7.LA At approximately 15:3, the surface wind direction of 270, degrees at 9 nots with visibility of 4 kilometers in heavy rain, scattered cloud layer at 1,500 feet, broken cloud at 11,000 feet and 30,000 fee, surface air temperature =10- was 26 degrees Celsius ((C) and dew point temperature was 24 °C. Atmospheric pressure above mean sea level was 1,006 hectopascals (APs) 1.17.1.2 At approximately 15:45, the surface wind direction of 270, degrees at 28 knots with visibility of $00 meters in heavy rain, scattered cloud layer at 1,500 feet, broken cloud at 11,000 feet and 30,000 fet; surface air temperatre was 25°C and dew point temperature was 22°C. Atmosphere pressure above mean sea level was 1,006 hPa 1.17.2. Surface wind information provided by ATC at Phuket Intemational Ainpor tothe accident fight crew as follows: L172. At approximately 15:37, the surfce wind was from 240 degrees at 15 knots, 1.1722 At approximately 15:38, the surface wind was from 240 egress at 30 knots. 11723 At approximately 15:39, the surfce wind was from 240 degrees at 40 knots, 1.8 Aids to Navigation ‘The navigation aids at Phuket Intemational Airport functioned normally during the time of accident 1.9 Communications ‘The communications between the ATC at Phuket international Aisport and the flight crew were norma 1.10 Aerodrome Information 1.10.1 Phuket Intemational Airport is located a iatitude 8 degrees 6 minutes '38 seconds North and longitude 98 degrees 18 minutes 45 seconds East, The runway (0927 i 45 meters wide, 3,000 meters long with an asphaltic concrete surface. The aerodrome elevation is 25 meters above mean se level. The aerodrome has an one embankment ong with Runway 27 0 the Nort, with a distance of 90 meters from the sunway centerline, Another embankment is located to the South of Runway 27 where the at traffic contol tower is located. 1102 The Low Level Windshear Alert System (LLWAS) is installed at Phuket International Aiport by the Meteorological Department as a supplemental ‘equipment to measure and report the current wind speed and diretion to the air trafic control tower and also as the primary means of detecting windshear and/or microburst at the surfice and alof. However, this installation was not oficilly ssnounced in the Aeronautical Information Publication (AIP). The LLWAS had six remote anemometers sensors stations located strategically throughout the airport property. Three of which filed to function during the time of accident. The absence of data from the three was therefore significant enough to decrease the performances of LLWAS algorithms and aletwaming issuance. 1103 Runway Seip ‘Phuket Intemational Airport is categorized as Aerodrome Reference Code 4 E, ICAO Standard and Recommendation of Annex 14 states thatthe with of runway strips, classified as precision approgch runway, shall extend laterally to & distance of atleast 150 meters on each side ofthe centerline ofthe along the entire runway. However, Phuket Intemational Airport has the geographical contains on ‘he locaton of embankments a the side of the runway; therefore limits the width of| runway strip to only 75 meters on each side ofthe center fine, This limitation is declared in Aeronautical Information Publication (AIP) Thailand, (Detailed in Appendix 1) 1.11 Flight Recorders LLL Digital Flight Data Recorder (DFDR) and Cockpit Voice Recorder (CVR) were brought forth by the AAIC to be read out at the NTSB, US.A. The paticipants in the reading out comprise the representatives from NTSB, FAA, Bocing Company, Prat & Whitney, and the AIC, LIL2 DFDR, manufietured by L3 Communications Fairchild Company, art number 2100-4042-00 and serial number 1196, installed inthe aft section of the airplane, was suecessflly readout (Detaled in Appendix 2) ne 1.113 CVR, manufactured by L3 Communications Fairchild Company, part number 2100-1020-00 and serial number 000199420, installed in the aft section near the DFDR, was read out and transcribed, (Detaled in Appendix 3), 1.11.4 Data obtained fom the DFDR and CVR indicated that: L141 During the operation ofthe accident flight, the Hight crew incorrectly communicated (read-back and hea-back) several times, i. ineoret call sign identification and incorrect response to the ATC. 11142 Data obtained ftom the DFDR and CVR during. the descending and go around indicated that: ~The flight crew conducted the ILS approach with the sieplane aligned just to the north ofthe Runway 27 centerline = Between 15:39:41 and 15:39:43, as the airplane was descending through 115 feet above threshold level (ATL), the airspeed dropped fom 140 KCAS to 126 KCAS. (Detaled in Appendic 2, Plot 1). At 15:39:43, the PIC called for power (Detailed in Appendix 3, page 12-21), and the engine pressure ratio (EPR) subsequently increased toward “go around thrust’. The EPR for both engines increased from about 1.16 to 2.0 in approximately three seconds and remained about 2.0 fr the following 2 seconds, until about 15:39:48, ~ Between 15:39:40 and 15:39:47, the pitch angle increased ffom 0 degrees to 5 degrees, and then decreased to about 2 degrees at 15:39:48; reaching an altitude of 48 feet ATL before starting to climb. (Detailed in Appendix 2, Plot). = Between 15:39:43 and 15:39:48, the airepesd increased dhring this time, fom 126 KCAS to 165 KCAS at 15:39:48, (Detaled in Appendix 2, Plot 1). At 15:39:47, the row received a “sink rate” waming from the EGPWS, (Detaled in Appendix 3, Page 12-21). + At 15:39:48, as the airplane descended below $0 feet ATL, the autothrotle system initiated an automatic eduction of al engine thrust ‘The engine EPR decreased fom 2.0 (‘go around thrust’ o about 1.14 (idle thrust’) at 153953, This reduction of power occured ats rte consistent with an sutothrotle ‘command, (Detailed in Appendix 2 Pot 1). + At 153949, the Co-Pilot called for a goatound (Detailed in Appendix 3, Page 12-21), and the pitch ofthe airplane increased from out 2 degrees to about 12 degrees at 15:39:54, asthe aiplane climbed. The trust oe ‘continued to decrease towards ts “dle" postion, while the airspeed decresed from 165 KCAS to about 122 KCAS at 15:39:57. (Detailed in Appendix 2, Pot 1. ~ AL 15:39:50, the Co-Pilot transfered airplane contol to the PIC (Detailed in Appendix 3, Page 12-22), 8 the thrust was reaching idle EPR. - The EPR remained at the ‘idle’ level for about 13 seconds (from 15:39:53 to 15:40:06), a6 the airplane continued to climb to a maximum altitude of 262 feet ATL at 15:40:01, and then stated descend again, Dring this time, the landing gear was retracted, and the flaps were set to 15 degrees (Detailed in Appendix 2, Pot 7); however, the take off/go-around (TOIGA) switeh was never activated, (Note: the autopilot was “off” during the approach, and the ‘autotrotle was “on” and selected tothe “speed” made.) ~ Beeween 15:39:57 and 15:40:08, the pitch angle Aecreased fiom 12 degrees to 0 degrees, while the sitspeed remained relatively constant at around 122 KCAS, with about H- 4 knot excursions about this average (Detailed in Appendix 2, Plot 1). + Between 15:40:06 and’ 15:40:07, two ‘don't sink’ warnings from EGPWS sounded in the cockpit, as the airplane was descending through approximately 175 feet ATL. ~ At 15:40:08, a ‘Sink Rate’ warning ffom EGPWS, followed by a ‘pull up’ warning sounded in the cockpit. (Detifed in Appendix 3, Page 12-23). During these wamings, the pitch began to increase from 0 degrees to approximately 5 degrees over the next socond. The EPR began to increase again, reaching ‘go around tht’ at 15:40:09. + At 15:40:10, a sound similar to windshear alert from the ‘Windshear Alerting and Guidance System and then the sound of impact were beard (Detailed in Appendix 3, Page 12-23), + AL1S:40G11, th recording ended, ae 1.12 Wreekage and Impact Information The sitplane wreckage was at latinde 8 degrees 6 minates 51.2 seconds north and longitude 98 degrees 19 minutes 10.4 seconds east; afer the sigplane hit the embankment and went up in flames. The aixplane completely broke into 3 pars. The nose section was heading to 010 degros, while the fuselage section ‘was heading to approximately 300 degree and the tail section beginning from the engine was aligned parallel with Runway 27. The nose section collapsed and twisted, ‘The right wing hit the embankment and was tom fiom the fuselage, causing the fuel Teak. The left wing came to rest across the ditch along the runway. The posterash fire bumed from the nose section to the mid of fuselage section. (Detailed in Appendix 4) 1.13 Medical and Pathological Information ‘The external examination of the body ofthe Might erew by the Royal Thai Police areas follows 1.151 Pilotin-Command ‘The examination by the Instiute of Forensic Medicine, Police General Hospital, presumes that the cause of death is ffom the severe bums iowever, there is no information on laboratory tests indicating any use of substances ‘hat could potentially effect the flight operation. 1152 CoPilot The examination by the Institute of Forensic Medicine, Police General Hospital, presumes that the cause of death is from the lak of Oxygen. However, there is no information on labortory tests indicating any se of substances that could potentially effect the Hight operation, 1.14 Fire After the airplane hit the embankment and then the ground, the post- rash fires burt ffom the nose section ofthe plane, with no indication of pre-impact re, “15 LAS Survival Aspects 1.15.1 Witness statements regarding the reseve and fie fighting at Phuket Intemational Airport areas follows: 115.11 Statements from the rescue and fire Sighting staff ‘The reseue and fire fighting staff said, “At approximately 15:40 hours, the fire fighting staff received an emergeney call from the ATC reporting thatthe airplane of One Two Go Airlines Flight OG 269, MD-82 serie, depared from Don Mueang International Airport and was scheduled to land at Runway 27, veered off the runway along with the fence in Mai Khao district. There were 130 passengers and crew on board. The airplane was refueled with 22,000 ‘pounds fom Don Mueang Intemational Aiport. ‘The rescue and fire fighting staf, with 3 fre mucks (the ‘tucks no, 1, 2 and 4), reached the acident site witha 2 minutes. The staff managed to control the fire. The fire station called another 18 sta who were at rest to assist the team, with another fire truck (the tuck no, 3) and water rescue truck 0 extinguish the fire and rescue passengers. The assisting staff reached the accident site a approximately 15:46 hours and controlled the fire success.” ire Truck Charscteristes Truck No. | Capacity of Water (Lite) | Discharge Rate of Foam Solution CLiterMinate) 7 38 Tam, z 3B aR 3 ae a a Tiss TE At approximately 16:01 hours, fre tucks no, 1, 2, and 4 retumed to the fire station o refill wate, while the truck no, 3 stayed a the accident site, spraying water to cool down the hea around the Fuselage rea, At approximately 45 minutes after the commencement of rescuing and fire fighting , the supporting staff fiom Phuket Municipality, Thep Krasatd Municipality, Choeng Tale “Municipality, Medical serves fiom many hospital, reseue foundations of Phuket eee and nearby provinces, andthe Narenthon Center (curently, the Emergency Medical Institute of Thailand), assisted the reseue staf 1.15.12. Statements fom the Survivors ‘The survivors escaped ffom the sisplane through an exit oor over the left wing, sid off the aleplane, and ran to the runway, The first fie lnuck reached the accident site within approximately 3-5 minutes. The ditch barricaded between the fire truck and the airplane was the obstacle for the spraying ‘waterffoam to reach th airplane. At that time, there was one ambulance present to help casualties. 1.15.13. Statement from staff of Orient Thai Aicnes Co, Lid ‘The mechinic of Orient Thai Aiplines stated that “at approximately 15:45 hours, there was heavy min, strong wind and the maximam visibility of 5 meters. The Load Master staff of Thai Airways Intemational Public Company Limited informed the mechanie thatthe aiplane flight OG 269 veered off fiom the Taxi Way and therefore, the mechanic drove a ear to the acident site When he arrived atthe acident ste, there was one fie track spraying waterifoam and two stand-by fire tock” 115.14 Statement from Tower Contoler and Watch Supervisor ‘The Tower Contoler andthe Watch Supervisor ofthe Aero ‘Thai Company Limited who were on duty during the accident, concurrently stated ‘hat when the airplane was over Threshold, it cauld not land, Then, the airplane nose ‘was up and maintained its height for a moment. After that, the airplane yawed tothe right, then started to continuously descend, and finally collided withthe ground at ‘Marker no. 6 near the ditch, located to the north of runway. Then, it exploded and ‘was on flame with smoke covering the secdent site, At approximately 15:41 hours, the Tower Contoler informed the rescue and fire fighting station via the hot line. Then, the Watch Supervisor onlered the Ground Controller to contact the rescue and fire fighting station immediately via the sport radio: Channel F2, to inform the occured cident at the North of runway, near the ditch area, and ordered the Approach Control to hold all airplanes in its contol sir space: Nok Airlines, flight 7625, Separted from Had Yai Intemational Aiport. Approximately 2-3 minutes after the 7 hot line was used, the rescue and fir fighting staff reached the accident site and the ‘Watch Supervisor ordered the Approach Control to inform flight 7625 to retum to Hat Yai ternational Aiport 1152. Rescue Difficulties 11521 There is the ditch, 3.Smeter in width and 13-moter in depth, located to the North and paralleled with Runway 27 ofthe airport, The airport ‘has entrances for rescue and fire fighting at both ends of the runways. However, those entrances were not usd inthis ecient. 1.1522 After the accident, taf from different foundations asisted the reseve and moved casualties from the accident site. However, some foundations never attended Phuket Intemational Airport's Emergency Plan Exercise; leading to inefficiency in coordinating with the reseue and fire fighting teams and incomplete performing in curing the catualties eg. unsuitable protection equipment used and incorect method of transporting the casualties, which may lead to more serious injures 11523 The Aeronautical Radio of Thailand Company Limited (Acro Thay as not included ‘Crash on Airport’ procedures in Manual of Aix Tealie Services for the Phuket Intemational Airport, 2s to be consistent with the Aiport Emergency Plan: Airplane Accident on Aitpor. 11524 The Narenthom Center, a division in the General Deparment, Ministry of Public Healt, has duty on emergency medical support and transfer injured casualties to hospitals. However, the Airport Emergency Plan of Phuket Intemational Aiport dd not include the Narenthron Center in the contact ist; ‘thus, the Narenthorn Center didnot attend the emergency training, resulting to the lack of experience in coordination with the rescue ad fit fighting team. 1.16 Test and Research 116.1 The non-volatile memory ofthe systems, the Windshear Alerting and Guidance System, the EGPWS, the Autothrottle, and the Digital Fight Guidance ‘System (DPGS) were sent to examine atthe NTSB, Washington D.C, US.A, as the State of Design and Manufacture, whether the systems were functioning nortlly as designed during the acident. The data downloaded from these systems along with ‘he data from the DFDR were used for the investigation. Results indicted that 1.16.11 During the accident, the Windshear Alerting and Guidance System, the BGPWS, the Autothrotle, and the DFGS functioned as regularly as designed. 1.16.12, The sizplane was equipped with « Honeywell ‘Legacy’ ‘reactive windshear warning sytem. An assessment ofthe DFDR dita indicates that the only windshear warning issued during the scident oceured at about 15:40:09 epproximately 1 second before the end of DFDR dats). The legacy windshear _waming system performed its function as designe. 1.16.13 The EGPWS, Mark V EGPWS part number 965-0976-003- 216-216 and serial number 18254, produced by Honeywell, was sent to Redmond, Washington, Hobeywell flit for examination. Te intial examination ofthe unit ‘was conducted with he presence of a representative from the NTSB and FAA, The data indested that four aleris were recorded over an approximate 43-second span, ‘The frst alert (Sink Rate) was recorded at 20 sconds ofthe data. The second alert, (Sink Rate) was recorded at 39 seconds of the data. The third alert (Sink Rate) was recorded at 42 seconds of the data, The fourth alert (Pull Up) was recorded at 43 seconds ofthe data, Aer the lst alert, the data recording ended, presumably the time the airplane had impacted. Figure 2 EGPWS Aleris -19- 1161.4 The autothrtte system is controlled by the DFGS. The assessment of the DFDR data indicated that throughout the final approach phase, the sutothottle system was engaged and functioning. tts modes fuctuated between the speed mode (SPD SEL), Clamp Mode, and the Low Limit Mode (Low Lim) until the RETD mode was activated at 15:39:47. When the speed mode funetion of the sutothrottle system is operating, the autothrttle system seeks fo maintain the Reference Airspeed/Mach thatthe flight erew selected in the SPD/MACH window. Since the DFDR data did not receive confirmed Airspeed/Mach parameter, the specific selected Reference Airspeed/Mach was unidentified. ‘At 15:39:41, the data indiated that during the decent at shout 150 feet (RA), the left and right engines were commanded to accelerate. The EPR for both engines increased ftom about 1.16 to shout 2.0 in approximately 3 seconds and remained above 2.0 for almost 3 seconds. According to the Boeing Company, the MD-82 autotrottle system has the capability of commanding the autothrotle levers ata maximum rate of about 8 degrees per second. At 8 degrees per second, it would take the trots approximately 5.5 seconds to go from idle to take off position. According to the Bocing Company, the engines are capable of accelerating foster than the autothrotle system can command. Therefore, the ‘manufacturer concludes thatthe 3.second engine acceleration rat is consistent with manual operation ofthe thotle levers. This would have overridden the autothrotles ‘but the auoshottles would remain engaged At about 15:39:47, withthe aixplane in the SPD mode at shout 50 feet (RA), the sitplane HS-OMG experienced an automatic eduction of all engine trust fom about 2.0 EPR to about 1.1 EPR due tothe Retard (RETD) Mode function of the autothotle system, automatically activating, Both engine's EPR remtined at about 1 for approximately 13 seconds, allowing the airspeed to drop below 120 knots. According to the Boting Company, the RETD mode is ‘automatically ectivated a a function of radio altitude and landing fap configuration ‘when the auothrti is nat in the FPR GIA mode, With the approach satifiap logic ppliod to the autothrotle system, the las positioned to at least 20 degrees, and the radio altitude less than or equal to 50 feet, the Retard Mode of operation is automatically established. The DFDR data indicates the RETD mode activating when the flaps ae positioned at 40 degrees and the airplane descend below the SO-feet utothotte retard altitude. Once activated, the FMA displays “RETD” and both throttle levers are driven to the aft stop at arate dependant upon the radio altitude ‘The autothrotle retard mode is independent of the autopilot or fight dizector- ‘operating mode. 1.162 The NTSB submitted the accident investigation report to the AIC on 1 July 2008, consistent with avaiable evidence as follows: 1.1621 The summary of the accident sequences and the possible causes) of the accident: The investigation relied on evidence atthe site, the CVR, the DFDR, and the component of elated system examination (Detailed in Appendix 9. 1.1622 The details of the investigation, consisting of the on-scene ‘examination, meteorological conditions, emergency response, and system ‘xaminaton. (Detzled in Appendix 6). 11623 The operational and human performance (Detailed in Appendix 7) 1.1624 Appendix A Honeywell EGPWS Report (Detaled in Appendix 8) 1.1625 Appendix B Honeywell Windshear Report (Detaled in Appendix 9) 1,162.6 Appendix C Human Performance Questions (Detailed in ‘Appendix 10) 1.162.7 Appendix D Operational Documents Provided tothe NTSB (Detailed in Appendix 11) 1.163 The AIC conducted a flight test by using the fight simulator of MD- 80 at Lion Air, Jakarta, Indonesia. The Sight simulator simalated a go around in the ‘same condition as recorded inthe DFDR of the acident fight. It indicates that, et 40 feet, the autothrotle system is activated tothe retid (RETD) mode and th co-pilot id not activate the TOVGA switch, when he Wanted to inereage engines powe for the go-around. Whereas, he pushed the throttle levers forward, then released his dhand, resulting thatthe autothrotle system automatically retarded the throttles levers for decreasing engines power in the Speed Mode Control. oa 1.17 Organizational and Management Information LITA One-Two-Go Airlines Company Limited LITLL. The Air Operating License (AOL) was issued tothe carer ‘on 18 January 2006 and valid until 17 January 2011. The Air Operator Certificate (AOC) No.15/2549 was issued to the cartier on 15 September 2006 and valid until 17 January 2011 1.17.12 The headquarters is located at 138/70 17th PL, Suite 1, Jewellry Center Building, Nares Road, Si Phraya, Bangrak, Bangkok. 1.17.13. The Company wet lease five MD-82 airplanes, one MD-83 seplane, and two MD-87 airplanes from Orient Thai Airines Company Limited 117.14 The Company has 148 light atendants and 10 dispatches 1.17.2. Orient Tai Ainines Company Limited 1,172.1 The AOL was issued tothe carrer on 25 October 2002 and valid until 17 January 2011. The AOC No. 04/2545 was issued to the carrer on 29 October 2006 and valid until 17 January 2011 1.1722 The headquarters is located on 138/70 17th Fl, Suite 1, Jewellry Center Building, Nares Road, Si Phraya, Bangrak, Bangkok 1.1723 The Company operates three Bosing 747-100 Series, ive Boeing 747-200 Series, three Boeing, 747-300 Series, five MD-82 airplanes, one (MD.83 airplane, and two MD-87 airplanes. 1.1724 The Company has 95 flight erew, 284 flight atendants, 2 Slight crew scheduling officers, and 3 dispatchers. L173 The FOM of One-Two-Go Airlines and Orient Thai Aitines are approved by the DCA and prescribe the procedures on go around, stabilized approach, EGPWS, and light time & flight duty period limitation, However, the ‘CRM training and transfer of contol between flight crew procedures were left incomplete L174 The flight simulator for Plot Proficiency Check did not install the Windshear Alerting and Guidance System and EGPWS. LITS The flight crew scheduling officers of One-Two-Go Airlines are ‘managed by the fight management center of Orient Thai Aline, lessor ofthe wet eased airplane. <2. 1.176 The audit result of One Two Go Airlines and Orient Thai ities, by {he Th DCA ater the acident, found that = The training and proficiency checks of all light crew of Orient Thai Aitines didnot comply with the Crew Teasing Manual (CIM), Revision 1, effective on 22 January 2004, Volume Vi, Seton 6.500, Anicle B, which was approved by the DCA, saying that there were no tainings of Ground Tring, Bnergency ‘Training, Qualification, and Special Operations Training (when applicable). ~ Orient Thai Aitlines has the Aight me and Aight duty period sscorded system, However, tb stem were not overseen resulting inthe exceating Aight ties and shortage of rest times of the pilot as prescribed by fight ine and Aight dy period itatonin the FOM, approved bythe DCA. ~ There were no evidences indicating that 3 dispatchers of Orient ‘Thai Aitlines and 10 dispatchers of One Two Go Airines were trained as required in the Fight Operations Ofcer Manual (FOOM), Dispatcher QualiScaion, Arle Basic Indoctinaton and Arle 2 Emergency Training 117.7 Comporate Culture “The One Two Go Airlines Company Limited and Orient Thai Aitines Company Limited comprise staff varying in many basics such as nationals, languages, values, belief, and slipions, especially in the fight operation division where ight crew come fiom many foreign counties, The management levels id not seriously encourage personne! to have wigue corporate culture in having values and ‘elit t carefilly perform tee jobs, in accordance with laws and regulation and ia no support the personel taining which may come of use for niproving task ffcieney and increasing sey perfomance 1.18 Additional Information None 1.19 Useful or Effective Investigation Techniques None ea. 1.20 Crew Resource Management (CRM) 1.20.1 The DCA has announced the Flight Standards Bureau concerning the Pilot Training Program, on 2nd July 2007, prescribed in article 1.2.7 of the Crew Resource Management training. However, there were no guidelines and details of the CRM training forthe operator. (Detailed in Appendix 12) 1.202. The Flight Crew Training Manual (FCTM) of One Two Go Aisles Company Limited requires that Might crewmember should complete the major gy oem ne kellie mom ied = le ced apeiron APPENDIX 2 vet reset ‘SETI cnenw Fcewite a eran iy He He ull eg : us ‘ig SIE ey era a 46- APPENDIX 3 ‘Transcript from Cockpit Voice Recorder “nse of 1.9 CommunitinsFA210-1020 sb stat cock oie ‘renter insted on One Two-So Anes SotglicDomell Doulas 02 (i-oty whch cose dng ning t Pak, Mallard LEGEND 20 fasotweasenton goto ‘oe adamant Pt spac (cen maaan Se TTY 3 ected tenga eaten Em -50- STEEN eirnmssmss nn meena day sees =p ewan w¥9 Ses a 55 ‘etomeoninnte er Snes mane oh osu omen annie sy. eeninen +38 6. national Airport /Aerodrone Gr: 66. APPENDIX 5 NTSB report: Introduction and Summary One-Two-Go Airlines Flight 06269, HS-OMG September 16, 2007, Phuket, Thailand A. INTRODUCTION: ‘This paper relates to the September 16, 2007, accident of One-Two-Go_ Aitines fight ©6269, Thailand registration HS-OMG, a Boeing-McDonnell Douglas MD-82 that crashed during an attempted go-around at the Phuket International Aiport (HKT), Phuket, Thailand. The fight departed the Don ‘Muang Aiport (DMG), Bankok, Thailand on a regularly scheduled passenger fight destined for (HKT). There were 123 passengers and 7 crewmembers on the fight, of which 89 persons were fatally injured. Among the ftaties were both plots and 3 ofthe 5 cabin crewmembers, As the State of Design and Manufacture of MD-82 aitplanes, a U.S. Accredited Representative and advisers’ participated in the Arcraft Accident Investigation Committee of Thailand (AIG) investigation. To evaluate the role ofthe alrplane and ts systems in this accent, the. Investigate team relied on evidence at the ste, the cockpit voice recarder (CVR), fight data recorder (FOR), and component systems testing. 5. SUMMARY: (On September 18, 2007, at 1541 focal tne, One-Two-Go (OTG) Altines. fight 06269, Thatand registration HS-OMG, a MéDonnel-Dougias MO-82, ‘crashed during an atlempted go-around at the Phuket International Aiport (HT), Phuket, Thailand. ‘The fight from DMG was conducted uneventfully and as the fight arived Inthe PT area, the fight ctew conducted the ILS RWY 27 approach to the ‘port, with the fst officer as the tying pilot. After the fight crew reported to Air ‘raffle Control (ATC) that they were ‘established fon the] iocaizer* the crew that preceded the accident fight tothe aiport (HK), reported weather information that they encountered during thelr approach. This information included an Airspeed gain and loss of 15 knots during the final portion ofthe approach and Noted a "CB over the airport” The fight crew of OTG269 acknowledged the transmission and they were cleared to land at 1597, with @ wind report of 240 degrees at 15 knots. One minute later, the controller Issued another wind report, *OTG269, strong wind 240 degrees 30 knots." The plot of OT 6269 acknowledged the report, and shorty afer, Inqulred again about the wind ov te US, co Repose bal rie an han Tapio ay ‘Br Fal Aion Anton Bong Canmar ginea Paaeey eu essyoel <6 ‘condition. The tower responded "240 degrées 40 knots,” and the pot ‘acknowledged the report. Information obtained from the CVR and FOR indicated thatthe fight crew ‘conducted the ILS approach vith the airplane aligned just tothe noth ofthe runway 27 certerine Betveen 0839:41 and 0899:49, as the airplane was descending through 115 feot above threshold evel (ATL), the auspeed dropped ftom 140 KCAS 12 125 KCAS. At 0839:43 the captain called for power, andthe engine pressure ratio (EPR) subsequently increased toward ‘go around thrust’ The EPR for both engines increased fom about 1.16 020 approximately tree seconds and remained about 2.0 forthe folowing 2 seconds’, untl about 0898:48. Between (0839:40 and 0638:0838-47, the pitch angle increased from 0 degrees to S degrees, and then decreased to about 2 degrees at 0839:48. Despite the increase of thrust and pitch, the airplane continued to descend Lunt about 0899:48, reaching an alttude of 48 fect ATL. before starting to climb However, the airspeed increased during this time, from 128 KCAS at 83849 to 166 KCAS at 0899:48. At 0839.47, the crew received a “sink rate” warning, and 9 0898:48, as the airplane descended below 50 feet ATL, the autothote ‘system inated an automatic reduction of ll engine thrust. The engine EPR decreased from 2.0 (go around thrust’) at 0839;48 to about 1.14 (idle trust) at 0830.53, ‘At 089349, the first ofcer called for go-around, and the plteh of the airplane inctessed ftom about 2 degrees to about 12 degrees at 0839'54, as the airplane climbed. The thrust continued to deerease towards ts ‘le’ poston, wile the airspeed decreased ftom 165 KCAS to about 122 KGAS af 0530 57, ‘At 089950, the frst officer transferred aircraft contralto the caplain as the thrust was reaching idle EPR, “The EPR remained atthe ‘le’ love for about 13 seconds (rom 0838:53, to 0840:06), a the alplane continued to cmb toa maximum alttude of 262 foet ‘ATL at 0840-01, and then started descend again, Durng this time, the lending {gear was retracted, andthe Raps were set to 15 degrees; however, he {akeotigo-around (TO/GA) switen was never pressed, ‘he ATL aus re ado couse enze ait fil lvton tthe ray ee * Acai Bee th as coer er at ats sytem woul teed (ecu fuer ms pope) There thinnest yea soma {ewe of te to va ‘Sfosraacin of powe cred ta atc wih nasa command ‘The autopet was" rg the approacy, ante aut¥te nas" ad ete the ‘speed made ee Between 0899.57 and 0540208, the pitch angle decreased trom 12 degrees to about 0 degrees, while the airspeed remained retatvely constant at around 122 KGAS, with about ¢ 4 knot excursions about this average. ‘At 0840:06, a “don sink” warning sounded in the cockpit, as the airplane was descending through approximately 175 feet ATL. The EPR began to, Increase again, reaching ‘go around thrust at 0840-08; however, the altude and pitch continued te decrease, ‘At. 0640.09, a “sink rate" warning, folowed by a “pull up" warning sounded inthe cockpit During these wamings, the pitch began to increase from 0 degrees. The pitch increased to approximately § degrees over the next second, Luni the sound of impact was heard at 0840:11, and the recording ended. ‘This paper provides the US. investigative team's position on the possible ‘cause(s) ofthis accident, consistent wih avalable evidence as follows! ‘+ The EGPWS, Windshear and Autothrotte systems functioned as designed, ‘+ Failure to activate the TOIGA switch during the go-around rested in the airplane's fight management system automateally retarding the throties, since the approach slataplagic for landing was appliee™ + Lacking power application, the airplane slowed and descended until contact with the terran, ‘+The crew lid nol property perform the go-around maneuver or ‘monitor the thrattles during the go-around, ‘+ Regardless of autopilot or autotrotle use, the thrties remained available to the crew to advance power, during the entire accident ‘sequence, ‘+ Atransterofcontos, fom the coptot fo the plot, occured ata citical point inthe go-around, ‘+The FDR data was consistent with the engines producing power as requested by the autthrtte system andlor fight ere up to the beginning ofthe accldent sequence, and the on-scene physical evidence was consistent with both engines rotting during the accident sequence, ‘Although the weather deteriorated in the later stages ofthis fight, \Windshear was not a factor inthis accident, APPENDIX 6 NTSB report: Details of the Investigation © DETARS OF TE MVESTONTION, 10m Scene Extn ‘Tho aiplane and assoted weckago was removed tom the accent site and aento an cutéoor ara one aor prior the ava oft US. ‘Team. As heavy equipment was used to cla the scents, bah the ‘used orton eco FLIGHT OPERATIONS MANUAL -120- THALL ‘Minion reat period lg duty pi ‘Minima opr ‘Notexceed aout ‘hows Exceeding # hoursbutnotexccesng 10 hours hows — 0 no Tahoe - ies a tae hoses oa : n 20nours ie. 20 2° 2eroure ane ee ee Sahowe ‘Minima et prod ble NOTE: Dy rnin at wane ting Same DUTY TIMELIMITATIONS FOR DISPATCHERS. A. The Company wil provide enough gpatcero care proper operational conto tench ie , The Company wil schalul Displchersin manner that permite th individ to trsome trough maa ited ace ae conins ange ‘outeto be xad ele tht inl Spates orsaes igh watch apa ‘ss tore . Esceptin exesofemergcrey orekcumstanes beyond he Company’scom 1. "Thecorpany will aetachedule Dispatchers former than IOconscetive hours ota 2, WaDepicheris sd for more th Or of ty in sy 24 comective our ind wil bo schedue oratlcat Shouse ator before the not 0hoursof dy 13. Entrar lb scheduled to bof day for 24 hourat easton in any Sonsconveay ped . AaQa Duty Disthe vil remsinon dy un eieved by acter glifed Dis. faichessucssall era for whic bors epoeitichave ded al have (Etreioscdoutatuhich ine the Disp ay be taken oy. sn APPENDIX 16 Rule and Practice Guidelines on Flight Time and Flight Duty Period Limitations Flight Safety Division, Department of Aviation By virtue of the Civil Aviation Board Rule No. 4, Section Sand the Standards sot forth in the Intemational Civil Aviation Organization Annex 6 Part 1, Chapter 9, Article 9.6 conceming Flight Time and Flight Duty Period Limitations, the Flight Standards Bureau, Department of Civil Aviation, hereby issues the Fight Time and Flight Duty Period Limitations of Crew Member, as follows: 1. Definitions 1L1 “crew member” means a person assigned by an operator to duty on an aircraft during Aight time 1.2 “flight crew memibec” means a licensed crew member charged with duties essential tothe operation ofan area during fight time. 1.3 “cabin attendant” means a crew member who performs, inthe interest of safety of passengers, duties asigned by the operator or the pilotin-command of the sizcrafl but who shall not set a aight erew member. 14 “flight time” means the total time from the moment an aircraft first ‘moves under its own power forthe purpose of taking off until the moment it comes to rest atthe end ofthe ight 1.5 “fight duty period” means the total time from the moment & crew ‘member commences duty, immediatly subsequent to a rest period and prior to making & Aight ora series of fights, tothe moment the fight crew member is relieved ofall duties, ‘having completed such light or series of flights, and shall include: 1.51 The time spent by crew member in training and/or test of professional fitness on the ground andor onthe synthetic training equipment as well as on other activities scheduled by the operator in relation to his speci function. 1.52 The time spent by crew member in being tansported by air for the operator's convenience, in order fo take up duties assigned to them orto return from such dus, <1. 1.53 The duty period, whether it includes one or several consecutive legs of flight shall be considered to commence atleast one hour before tho first take off ‘and terminate at least hal'an hour after the last ending. 1.6 “technical landing” means the out scheduled landing, in case of ‘emergency situation or which endangers the safety ofthe aircraft or persons. 1.7 “test period” means any period on the ground during which a crew member i relieved of ll duties by the operto. 2. Flight time and fight duty period Uimitation, ew Copan Fight | Day] TCanding[ Tiga | Colada] Caledar ‘Tine | Tine | Frequency | Conseatve | Mout | Yer Tica reopie | witin2+ | Domessc | thm. | ite, | stenting | 20m. on — | conseative | Rowe foray icons | Hos siren 110m, | 10008 | tcontes teremaonal | 0b | 15888 | pes aot FBC int Route faerte | 6mm, [7 Teepe Foo Piar+ TEC PIoT technical | oR sten | ant, | nding) 2.2 Capi 1 Co-Pilot +1 FECCoPot "Flight ime and Hight duly prio limitation table <3. 3, Minimum rest period light day peiod | Minar period] ‘Not exceed § hours _ ‘8 hours Exceeding 8 hous but not exceeding 10 hours 1 nours "10 . ne 12hows “2 . “ hours “4 . 6 * I6toars 6 . 8 18hoars “8 . » 20 house "0 . ne 26 hours 2 : “ 32 ows ‘Wisin et period able Announced as ofthe 7th March BE. 2539 (1996) (Signed) Viehai Pratoepprecha (Mr. Viehai Prateepprecha) Director of Fight Standard Bureau 2124 APPENDIX 17 Department of Civil Aviation Announcement ‘on Flight Time and Flight Duty Period Limitations By virtue of the holder of Air Operator Certificate, operating schedule and rnon-schedule, domestic and intematonal ight to comply withthe Civil Aviation Board Rule No, 4, Section 5 and the Standards set forth in the Intemational Civil Aviation Organization Annex 6 Part 1, Chapter 9, Article 9.6 conceming Fligh Time and Flight Duty Period Limitations, the Department of Civil Aviation, hereby issues the Flight Time snd Flight Duty Period Limitations of Crew Member, as follows 1. Definitions 1.1 “crew member” means a person assigned by an operator to duty on an aircraft during Aight time, namely, fight crew member, Hight engineer, and cabin crew member 1.2 “Right crew member” means a licensed crew member charged with duties essential tothe operation ofan irra during light time. 1.3 “eabin crew member” means a crew member who performs, inthe interest of safety of passengers, duties assigned by the operator or the pilot-in-command of ‘that fight, but who shall not act asa fight crew member 14 “light time or block time” means the total time from the moment an sircrft fst moves fiom the parking bay to destination airport forthe purpose of taking off ntl the moment it comes to rest at th end ofthe Bight. 1.5 “light duty period (FDPY" means the total time from the moment a ‘tew memiber commences duty, immediately subsequent toa rest period and duty prior to ‘making a flight until the moment the Hight crew member is relieved ofall duties having completed such flight ora series of fights, and shall inchude: 1.541 The time spent by crew member in test of profesional fitness and traning onthe synthetic training equipment 1.5.2 The time spent by erew member in being transported by air in ‘order to take up duties assigned to them oro return from such duties, = 1s 1.5.3 The duty period, whether it includes one or several consecutive legs of flight shall be considered to commence at least one hour hefore the first take off and terminate atleast haf an hour after the last landing. 1.6 “duty period” means a consecutive period which stat when a crew member commences duty or being a passenger as required by a holder ofthe Air Operaor CCenifeate, including period of commences Aight operations, positioning, ground operations, and airport standby, whereas stand by at home or hotel are not counted as duty period. 1.7 “test period” means the time from the moment a crew member is free fiom duty assigned by a holder ofthe Air Operator Certificate, Inthe flight operations, rst period starts at 30 minutes afer an on-block (check-in) perid, Inthe positioning, a rest period stars after on-block. In both flight operations and positioning, a rest period ends 1 hour before the next scheduled departure time or the latest notice of estimate time of departure 1.8 “standby” means 2 defined period of time during which a crew member is required by the holder of Air Operator Certificate to be avilable to receive an assignment for duty. 1.9 “positioning” means the transferring of crew member from place to place, atthe behest of the bolder of Air Operator Certificate to commence as assigned, excluding traveling time from the rest place toa designated reporting plave. 1.10 “local night” means a period between 10.00 pm. and 6,00 am. locel time 1.11 “augmented crew” means an augmented crew which more than the ‘minimum number of flight crew members required for operations in which an augmented crew can commence duty instead ofthe Might crew member of that fight. 1.12 “origin” means a location located in the same country in which a cxew member stay over 120 consecutive hours, 1.13 “est fility" means 1.13.1 Adequate rest facility as follows: 1.13.11 One business class reclining seat blocked off for one resting crew, preferably separated and sereened from the galleys andthe passenger, or when a business cass seat is not sufficiently available, shall use, =126- 1.13.12 One economy class reclining seat, preferably separated and sereened fom ihe galleys and the passenger. 1.132 Suitable et failiy a follow: 1.13211 A bed or a bunk separated and screned from the cockpit, galleys and he passenger, 1.13.22 A recining seat, preferably separated and sereened fom the galleys andthe passenger, of 1.13.23 Any applicable horizontal rest facility as such, 1.14 “student plot” means a person who curently under conto, directs, and adeninister of an instructor pilot 1.15 “instructor pilot” means a person who instructs a student pilot in & private pilot taining course, a commercial pilot training course, an instrument rating ‘using course, anda multi-engine taining course 2 Flight Time and Flight Duty Period Limitation of Crew Member 2.1 Within 24 consecutive hours, the flight duty period of erew member shall not exceed as follows; 2.1.1 The flight duty period for airplane with single pilot operation shall be as follow; i ‘Fight Day Paid (PDP) for single plot operations Seco Localtime of departure | Upto | 5 6 7] formore 06100-0759 a 7 ‘00-145 ies eta [oso Soe leet 1500-2159 | 9as [30 | a B00 0559 aaa a 3 3 -127- (Gn a case of an instructor pilot, the flight duty period shall not exceed & ‘hours and a student pilot shall not exceed $ hous) 2.1.2 The fight duty period for airplane with two pilots or two pilots and one flight engineer shal be a follow; ‘light Duty Period (FDP) for multi plot and fight engineer operations Sectors Localtime T7273 )*] Ss) e] 77 8 of departure or more 600-0759 |_| 1259 | aS | as [Thad | Sas | 9] va00 1459 _[ 14 TRAS | 1230 Tas | has | 104s | 930] 9 1500-2159 | 13 | was | ThB0 | Toms | TOP os | oT D009 (I TIS] 930) 9 fo | 9 Poo 2.13 The flight duty period for helicopter operations shall be as fallow; Tielicopter Operations Single Pilot Two Pilot | Local ime Block Time PP Bock Time DP of departure 6000859 3 7 9 0700 15:39 330 8 7 10 1400-2159 7 2 630 . m0-0559 [+ 63 330 8 (ns ease of an insnactor pilot, the Tight duty period shall not exceed 8 hours and a student pilot shall ot exceed § hours) -128- 2.2 The local night operation which fight time exceeds three hours shall have atleast one augmented crow. 23 If the Might duty period is in or partially in 00:00 ~ 05:59 am. of| local time at origin and the Aight time in each series of fight less than thre hours, the flight mein 2.1.1, 21.2 and 21.3 shal be reduced to ale 24 Within seven consecutive days, the flight duty period of a crew rember shall not exceed 55 hours, the flight duty period of an instructor pilot shall not exceed 40 hours, and the fight duty period ofa student pilot shall not exceed 30 hous. 25 Within 28 consecutive days, the flight duty pesiod ofa crew member shall not exceed 160 hours, with fight time not exceeding 110 hours. The fight duty period of an instractor pilot shall not exceed 120 houre, with flight time not exceeding 90 hours and the flight duty period of student pilot shall not exceed 90 hours, with flight ‘ime not exceeding 70 hous 26 Within 12 consecutive months, a crew member shall not have flight ‘ime exceeding 1,000 hours and an instructor pilot shall not have light time exceeding 900 hours 2.7 In each light, the calculation of Right time limited in Section 2.5, and 26 fora flight crew member shall be s follows; 80 percent of flight ime when the flight has one augmented crew, ~75 perceat of flight ime when the fight has two augmented crew. 70 pereat of fight ime when the flight has three augmented crew. ‘The caleulation of flight time fora cabin crew member shall be calelated a8 follows; 80 percent of fight ime for ight having flight time exceeding 8 +75 percent of fight time for fight having ight ime exceeding hours. +70 perceat of fight time for fight having flight time exceeding zhu. -129- 3. Rest Period of a Crew Member ‘When a crew members relieved of al duties; 3.1 If the flight duty period does not exceed 8 hours, a crew member shall havea rest period at least 8 hours. 3.2 If the fight duty period exceeded § hours, but not exceeded 12 hous, a crew member shall have completed a rest period of 12 hours, and a rest period shall exceed 4 hours itis in or partially in 00:00 -06:00 asm, before back to commence duty. 33 Ifthe ight duty period exceeded 12 hours, but not exceeding 16 ‘hours, screw member shall have a rest period of 24 hours before back to commence duty 3.4 Ifthe flight duty period exceeded 16 hours, but not exceeding 20 ‘ours, a crew member shall havea rest period of 48 hours before back to commence du. 3.5 If the performing of Aight duty followed 2.2 andior 23, without considering the time of fight duty period, a crew member shall have a rest petiod of 24 ‘hours before back t commence duty 4. The maximum flight duty period could be extended when, 4.1 An augmented crew shall have a qualification and license at an ‘equivalent level of augmentation flight operations, by indicating in a flight operation ‘manual ofthe holder of Air Operator Cerificate, 42 An sireraft with 2-man crew, alight crew memiber could extend the maximum light duty period, as indicate in 2.1.2, 8 follow: 42.1 A Oiht with 1 augmented crew, the extended maximum Aight duty period is 14 hours, withthe provision of an adequate rest facility or 16 hours with a provision of suitable rest facility 422 An aircraft with 2 augmented crew, the extended ‘maximum Might duty period is 16 hours withthe provision of an adequate ret facility, or 20 hours wih a provision ofa suitable rest cil 443 An sirraft wih 3-man crew and 1 augmented crew, the extended ‘maximum flight duty period is equivalent to as indicated in 4.2.1, except an airraft in which a fight engineer could operate asa Cruse pilot, the extended maximum flight duty period i equivalent to as indicated in 4.22 -130- 4.4 Cabin Crew Member. ‘Wax. hours of FDPs afer Extention Hours of Res for With Adequate ‘With Suitable ach Cabin Crew Member | Rest Faility Rest Factty W051 No extension No exeion T0009 Upio 105 Upto Teo TH) OHSS piste Upw Te eNO Upioiso Wp TH0 Announced as ofthe 26th May B.E. 2550 (2007) (Signed) Chaisale Angsuwan (Mr. Chaisak Angsuwan) Director-General ofthe Department of Civil Aviation “11 APPENDIX 18 Go Around Procedure mp-80 FUGHT CREW OPERATING MANUAL, FUcHT DOECTOR APPROACH dein mai. marly stn totes, an TOGA ben aed ol tas scr scree mde ceva fon 82 (is soc ai} {Gievcn kam noon ge tan el Sn poh maser Serger 196 TH dr TK OD” 132 mpb-80 FLIGHT CREW OPERATING MANUAL (20 AROUNO FROM FLIGHT OIRECTOR APPROACH (Cane) sterol cing tu egos HOG Sle rab nnn let HOG sl co engage hag sel med Vert an ale (Pair set Yor osm bc sso wl area haan = Spina HOS ‘Nui FAS wi py EPRGA) "700 SELTGO RNS Forstertngenls, ALF Sennen PUR omit pul ol on ALT seta arm FOS lr ined apposch att ati ‘rim way A eta pe cont het ae eqs asda fo et acon. ch ede ‘hegeeto ven oP Put CL mx ton EPA ino tswlb epaed a EPA LM read at {pn tte bugon EP gos iits azoretsaly poten ssots edo tagan Om EPA GRIDER SPOMUACH Rane ee ee 8 Fouate SFOMACH aot ict dso sped epparsin SFOMACH rato, ATS net tevemeninasieinrnnmrenanncrnimitnmms — PPTON 133. ‘Marek 15,2007 Crew Oper fis loro a % uw} REED « rates “134. * Sika iors faa mo. Mrghat te aecect of ge Sh ce ata Aue pve 9 Spe wt 10 amg seater cote eft tate Sea en OO ere oe ge se HS 28 sr tar spe ate cet + tm mre ce Se tog “+S tl ppc sad en SSE. + Ses apne ae ae ot iaetaact concern ae fs Io" h ans see ‘eps vet aetna HER acon FO ov fp ce op te gear, Fb i en me ea ‘heartbeats pth introns tem De Npearear comer -138- [NORMAL PROCEDURES rey cement i rom eee seman atin ial peach tie tc act loa eas amined ne rena spect nace ec OLIN ae nbn ate oe ed fpe o 6dapeto povk F00 Steamer nt tds ee wane Sone mantener {Ee emo en marta has 81 npg wt Gy mae Fp / St ‘okra asm pote ops stows RE. Oran pt es Serer eens nie seo i esos TD Sk TO ‘en way rl ee ery be STAC FO Dr umatea heaton cag ayant re og pa Sa re hen MBA ‘np ee -136- ‘ain? THA gett Revd Te No SESS cae se cere oes eas Ser tata tem e eer eeemea ee Samet eeamacaeee Roomate nin Tehtronteepe woman Sate cae “137 APPENDIX 19 ‘Transfer of Control Procedure THAI == FLIGHT OPERATIONS MANUAL ou __ 06 42.381 MAINTAINING OUTSIDE VIGILANCE -ArlestoneCew Meer should einige allies Forclison aviance ‘puposes Crow Memberabeldscanthehorizo rote ali epi ntanor ‘henthe othe: Crew Member is prograing the TNS, GPS or FS. 42382 TRANSFER OF CONTROL, Whonte Plot Fling equa fesse ateton on ner tk other than ying ‘desea Hl eagush sol fe fight cory saying Youbave cen” ‘Thecter ltl espana Taco” 42383 KEEPING BOTH PILOT-INTHELOOP™ ‘Afra Crew Member unsold Deck afer xng set foray ras the ‘ot shale te ote pilton wht ages taken lac ae igi deck “hinghisabset ie, teueney chang cea. 42.384 CREWMEALPOLICY ‘Only one pilot on ight deck dy muy eat tine. The Captain nd Fit fice sould soteathe same rw ea fre achice, When alae provided om th ne ‘eodcandareof he same th ptr oat within 30 ima of ah ter Fight tends ara wed ates passenger mes and bevege sevieis ‘comple Fgh Atendan us xan fom passenger ew -138- APPENDIX 20 Stabilized Approach Control ‘ces = FLIGHT OPERATIONS MANUAL"! eae GO Revi: nat ae Dee: 20006 1.19 UNSCHEDULED LANDINGDDIVERSION OF AIRCRAFT ‘A. Ineuofennsal ign roandingof anal ces ein ‘thes lEngiering die mst ascent Toe Cam manera Cr sl render sistance btn be rogue byte ronda awh cians 'B. The Commit main a coe sion wit the Mastice Bin eg ing sevcebiytettcaionothe grande scat Alles dal bade ‘wings cretion meer comple thep win epost of ‘te figi and ute intone soon ep 1320 USEOFSror WATCH. ‘Te pocedue rte ofthe Stop Wats forengne car and kf wil beslié down inth respective AOM. Plats re enoonged oe Sp Walch ll che fh ons hr mig iota onan age on ake-of ring at ‘panel ci 1.321 STABILISED APPROACH Sli Appoacnst of xml the llowingn itera 10008AGL ‘ona Precision proach nn ite than S00 RAGIon avi eppoach Incas of [Non-recsion/Crcing Approx te ascaf sould be ceblidonetabishing be “Reed Visa Saga? aeavigg MDA 1. AiroafinLandegenagatins Ongena gideps publi aon precision poe whe aah (approx ages) hms bon esl visually td conten mvetecn ‘ato aw dscet tow heDA (DH) or MDA ODE) 1 Spostupto0kassof target sped V0, +10 {Rate ofdescntstinexcasof1000FPM (upto 200 fp ators ont res approach en conditons rogue) ander 0pm. 4 Thelndng game dow thang cick st mate competed ‘rt the OMAR on an ILS Appoah or he PAF on aNo-Proson ‘Aopoah orate VIN eaten ona Visual Approaches case stdin de Arca Opaaing ans. =139- = eS ee Deane GO mete hed Date: 29040 thesproich becomes dealin blo te iit aid down animmedi- ‘tego arvund mst be executed, Theexeation of gartnd frresoas of safety isa pradent manetver when the outcome ofan approach becomes ‘wei 1322 MANDATORY MISSED APPROACH, (Ona instrument speach the pits eet sn inmate isl aproc: 1, HaNovgnn Tensor fightinsromen fiecoocus whic wil athe aby sf cpl fe spproech nist cao. 2. When on Cat ILS epproac ihr locals orgie lope show te dots de- Aecinat S00 above MDA i TMC, OR ifnetct sain inthe rope stat $00‘sinter bh navi approach. 3. When Copan’ sand Fist fier prima fi instumnents show a sinfiant isigremen nC (eg ing wpa abe). 4. Theapproachisnotsabilsed lid down in para }.3.21 5. Wheneweindoitofnakingsaflaning 6 Thesis desabiised uring winder adore itis wbeto nan ‘he sief witn he prescribed igh pho proach. 7. Wheneve aGPWS pullup” warings geen Instrument Meters Conca) 1.323 SUBSEQUENTAPFROACHES Afr aise sproachoaly one subsequent approach emit. This approach will ‘beflowmby the commer ofthe iret ang, before stating the proach, shouldbe ‘oniden! tht the second approach has abih probably of sucess. Aer two mised sprosthesitismandsarytn divert. -140- THALL = FLIGHT OPERATIONS MANUAL Dele: “cam 1.8 UNSCHEDULED LANDINGIDIVERSION OF AIRCRAFT A tncucolunnscaluledindzganl gomiingofmsiealallarcrewcall_ renin at heir nil Erginring ees bemechanial satus of earl TheCom- ‘manda re shaleende al asistnce tht maybe rere ye pound inachcirimearees, 1. The Cormander sal mina acloelinizon with the Airport Manage epding sevisbilietiieason of gout. AlefTot shoidbe made oben theater erect, me or comple the sp within be provision fe ‘ight day ene ator sonable 13.19 USEOFSTOP WATCH “The procedure forthe ofthe Stop Watch fr engine startsand tke of willbe as aid oven nthe spective AOM. Plots are encouraged ue the Stop Watch onal ake ‘offeto ene ating snot oveaked on anengne on take-off one ste repeal poste 1.320 STABILISED APPROACH A Subilze proach consis ofacomplicing elon no er than 1000 AGL. tna Pracsion Approach ad olsterthan S001 AGL on avis sprouch Incae oF [Non-PesisonCiling Approsch the aie shoal be stblioedom establishing te “Rogue Vinal Sepentsleving MDA, Aen ening cafgaon: 14 On profile (ILS glteslope, published non precision profile, or when 1 ghidpath (approx degrees) has been established igual and ‘ondidons have ben met alow descend below the DA (DED or MDA Gauge ‘bh Spent opto 1Oknasof arpet speed "REF-0, +10 Rate ofesend nat inexces 100 FPM, (pt 1200 pn aus on pression approach when condos equi and ot stan 400 fm, ou THAI mee FLIGHT OPERATIONS MANUAL ate, sabes 4 Thelanding gear rst dovin an be anding check it muse completed prot OM/FAF on asILS Approach o tbe FAF ona Non rsision ‘Apwrotch oat the VERequvalectona Visual Approwh nls otic ‘stdin dhe Ara Operating Marsa Mie spproach becomes deli below heli aid down enirmal- se go around mate exerted. The exertion of g-reund fr ressone of ‘aft sapredent maneuver when the outcome aan spac becomes 1321 MANDATORY MISSED APPROACH Onalistavent approaches the pl shal exert an immediate approach, 1, aNnsigsion Testo fight ale coca which il eftthe stilt safe complete the apres inistument contions, 2. Whenon Catt approaches orgie slope show two dots eflee- fiona S00 above MDA inIMC. nt stalised inthe prope sla st 300 shimeter eight on vial pproach, ‘3. When Capsns and First Ofcen primary ight insruents show sinifcant

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