Another 40 survived, many with severe injuries or burns.
As has been suggested, the results of the investigation appear to confirm that the pilot froze at the controls at a time when he needed to react to bad weather conditions.
The pilot did not following standard operation procedure for going around; he failed to hit the go-around button; he failed to respond to control alerts; co-ordination between the pilot and the co-pilot broke down; both pilots failed to react to the emergency.
The summary of the results also make the point that the pilots were suffering from an accumulation of stress and fatigue.
The airline, One-Two-Go, was advised to more closely review training procedures (cockpit resource management) and flight operations.
Limitations should be placed on the flight hours of the pilots and the aircraft; a safety management system (SMS) needs to be created.
Executives at all levels needed to set values in a corporate culture for following rules and regulations and report unusual developments.
Airports of Thailand was advised to provide a safety management system; Runways needed to be wider and safer; specific recommendations were made to improve the ability of rescue vehicles to move around Phuket International Airport.
The Department of Transportation was advised to make more thorough checks on One-Two-Go and its parent Orient Thai Airlines; coordination with the Bureau of Meteorology needed to be improved.
Release of the report came online at www.aviation.go.th with the Thai version released first. An English version is expected to be released shortly.
This article has been compiled from a translation of the Thai version which we will update as soon as more information becomes available.
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