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http://www.investigateudom.com The Last Moments of OG 269 – Confirmed Information From The “Black Box”
From DCVR and DFDR
Flying pilot is First Officer Montri
Montri: “autopilot off”
Montri: “autothrottle on”
Someone confirmed ATC report of wind shear and heavy rain
Montri: “100”
Montri:“40”
“Sink Rate”
The aircraft descended below 50 ft
The aircraft rose above 50 ft
Montri announces a go around
(The throttle is already in retard mode)
(The TOGA is not engaged)
Engine EPR decreased
Montri: “flaps 15”
Landing gear selected up
Montri: “You have control”
(no acknowledgement from Arief and no further communication
from either pilot)
Engine thrust idle for 15 seconds
4 seconds before impact thrust was increased to close to
takeoff thrust.
Wind shear detected 1-2 seconds before impact
Wind shear warble noted just prior to loss of CVR (impact)
Comments from Investigators:
1) Pilots said very little
2) Winds were provided several times during the approach.
The last time, 4 minutes before the crash was winds
240Magnetic, 40-Knots.
Cause of the Crash:
Flight crew error
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Bonnie’s Synopsis:
1) The inexperienced First Officer, Montri is the flying
pilot. The 17-knot crosswind component for Runway 27
(265 Magnetic) and rain conditions would warrant a
careful assessment before deciding to land. (Orient
Thai permits landing an aggressive 30-knot crosswind in
wet conditions, where as American Airlines, for example,
permits only a 20-knot wet maximum crosswind landing.)
2) Upon deciding to attempt the landing after the reported
wind shear and heavy rain, Arief, the vastly more
experienced pilot, should have been far more engaged in
the landing, if not the flying pilot.
3) By the time of the “Sink Rate” warning, there had been 3
strong indications of wind shear - Reduced thrust (EPR
setting), higher than normal indicated airspeed
(indicated by the reduced throttles) and fluctuation in
vertical speed. Therefore, a go around should certainly
have been initiated by this time. However, the attempted
landing continues.
4) Upon finally declaring a go around, Montri should have
pushed the throttles forward at the same time as he
pushed the TOGA button. The TOGA was never engaged, and
the engine remained at idle for 15 seconds. Both pilots’
lack of situational awareness is further indicated by
the failure to initiate a wind shear recovery go around
(with Autothrottles OFF) rather than a standard go
around.
5) Finally, upon saying “You have control”, Montri
attempted to transfer control of the aircraft to Arief.
Arief never acknowledged the transfer, and no corrective
action was attempted to the aircraft’s configuration
until 4 seconds before impact. In layman’s terms: For
those 15 critical seconds, no one was flying the
airplane.
6) Add in the following contributory facts (likely
incomplete):
A. The flight rosters indicate extreme fatigue.
B. Orient Thai training manuals do not contain wind
shear recovery procedures. EDITED 6/13: Orient Thai
had NO training manual at all on September 16, 2007.
C. Fraudulent checkrides prevent assurance of skills
proficiency.
Contributory Causes of the Crash (likely incomplete):
• Failure of crew coordination
• Failure to follow standard procedures
• Failure of the Captain to maintain control of his
cockpit
• Failure to recognize indications of wind shear
• Failure of both pilots to maintain situational
awareness
• Failure of company to provide proper training
• Fatigue
• Failure of the company to comply and adhere to
regulatory standards
Topic: Information From The “Black Box” วัน ทู โก OG269 (Read 9455 times)
