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AirAsia pilot flies to Melbourne instead of Malaysia after navigation error (03/2015)

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  • AirAsia pilot flies to Melbourne instead of Malaysia after navigation error (03/2015)

    This report of a March 2015 incident is disturbing as according to the report the crew admitted to disregarding multiple warning signals.

    An AirAsia flight from Sydney to Malaysia ended up in Melbourne instead when the pilot entered the wrong coordinates into the internal navigation system, an air safety investigation has found.

    The Airbus A330 was scheduled to leave Sydney international airport at 11.55am on 10 March 2015, and arrive in Kuala Lumpur just under nine hours later.


    Instead, through a combination of data entry errors, crew ignoring unexplained chimes from the computer system, and bad weather in Sydney, it landed in Melbourne just after 2pm.


    The full ATSB report is linked below:


  • #2
    Originally posted by Graham2001 View Post
    This report of a March 2015 incident is disturbing as according to the report the crew admitted to disregarding multiple warning signals.





    The full ATSB report is linked below:

    http://www.atsb.gov.au/media/5771318...-029_final.pdf
    "ding ding ding"

    "What's was that?"

    "Eh, probably nothing."

    I'm surprised they didn't start pulling CB's this time. You won't catch me on this airline any time soon.

    Comment


    • #3
      The title is a bit misleading. After an innocent button-punching data entry error (19 instead of 109) (and missing 999 opportunities to detect the problem), they detected the navigation problem shortly after take-off and thought there was a problem with the navigation equipment. They wanted to return to Sydney but, because of deteriorating weather, they decided to divert to Melbourne.

      It's not like they were aiming for Malaysia and suddenly arrived to Melbourne.

      --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
      --- Defend what you say with arguments, not by imposing your credentials ---

      Comment


      • #4
        Originally posted by Gabriel View Post
        The title is a bit misleading. After an innocent button-punching data entry error (19 instead of 109) (and missing 999 opportunities to detect the problem), they detected the navigation problem shortly after take-off and thought there was a problem with the navigation equipment. They wanted to return to Sydney but, because of deteriorating weather, they decided to divert to Melbourne.

        It's not like they were aiming for Malaysia and suddenly arrived to Melbourne.
        But still very serious! The guidance error caused them to turn into the departure flight path of the parallel runway 16L!! And they didn't notice it at first!

        This is a CLASSIC example of how the role of piloting has changed and how airmanship alone is insufficient. The PIC had over 22,000 hours as an airman. He clearly was lost with these systems. A total reliance on ECAM during system anomalies should be insufficient for an A330 rating.

        Worse, the FO reacted by going to the UNRELIABLE AIRSPEED checklist. That man should be nowhere near an A330 cockpit.

        the FO turned ADIRU 1 and 3 OFF without clarifying the captain’s confirmation for the action. In response, several flight guidance and navigation systems degraded and the autopilot disengaged.
        This bit of UNINFORMED IMPROVISATION, SHUTTING DOWN MULTIPLE REDUNDANT SYSTEMS SIMULTANEOUSLY caused them to lose the autopilot, the autothrust and to revert to alrernate law. So here we have a crew with relatively low experience on type degrading the critical systems and putting themselves into manual flight without envelope protections on an aircraft without force-feedback.

        DOES THIS SOUND FAMILIAR?

        AirAsia definitely remaining on my no-fly list.

        Comment


        • #5
          Originally posted by Evan View Post
          But still very serious!
          Oh, I agree. I didn't intend to downplay the seriousness of the incident. Just that the title of the thread made it sound like they accidentally ended in X when going from A to B, when in fact X was the intended diversion airport.

          --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
          --- Defend what you say with arguments, not by imposing your credentials ---

          Comment


          • #6
            Originally posted by Evan View Post
            This is a CLASSIC example of how the role of piloting has changed and how an overly-dominating focus on systems and the magenta line to the detriment of traditional airmanship (navigation in this case) is problematic.
            Fixed.
            Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

            Comment


            • #7
              Originally posted by 3WE View Post
              Fixed.
              Can't you see how their ineptitude on systems degraded their situational awareness, introduced distraction and (being human beings) degraded their concentration on flying the plane? Can't you separate the cause from the effect? Because the cause causes the effect...

              Once they killed Otto. half the cockpit displays and most of the ADR's, they did a fine job of flying the plane by the proverbial stick n' rudder all the way to Melbourne.

              Comment


              • #8
                "Of all the lines of code in all the computers in the world..."

                Okay yeah the pilot made a mistake... then followed it with a few more.

                But consider this: I have to think that aircraft's navigation system has both GPS and INS components. While GPS is not flawless, I can't see any reason while sitting at the gate, the two systems can't compare info and put up a message saying "Hey bonehead, you just entered a position that's 11,000 km from where we actually are!". That simple measure most likely would have prevented this incident.

                You say bad pilots, I say bad systems.
                Be alert! America needs more lerts.

                Eric Law

                Comment


                • #9
                  Originally posted by elaw View Post
                  "Of all the lines of code in all the computers in the world..."

                  Okay yeah the pilot made a mistake... then followed it with a few more.

                  But consider this: I have to think that aircraft's navigation system has both GPS and INS components. While GPS is not flawless, I can't see any reason while sitting at the gate, the two systems can't compare info and put up a message saying "Hey bonehead, you just entered a position that's 11,000 km from where we actually are!". That simple measure most likely would have prevented this incident.

                  You say bad pilots, I say bad systems.

                  Concur


                  One thing I just don't get is why we are still stuck on all of the super crazy cryptic codes. Fixes are still 5 letter, strangely spelled code words. I get the time savings, but given that computers have got a whole 640K of RAM (if not more) these days, can't the data screen put a few extra words up to confirm the codes.

                  One of the memory checklist FCOM procedures needs to be that the navigation screen (in larger bold font)) says- "Flight Plan from Bum [expeletive] Egypt to Hayseed Nebraska"...and below that, show the magenta line- making sure that there isn't some wrong fix plugged in somewhere...

                  I'm sure those things are SORT OF in there now, but I bet a bottled water it's rather cryptic.
                  Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

                  Comment


                  • #10
                    Originally posted by 3WE's version of Evan's POST
                    Can't you see how their focus on cryptic systems degraded their situational awareness, introduced distraction and (being human beings) degraded their concentration from where it should have primarily been: on Aviation, Navigation and Communication? Can't you separate the cause from the effect? Because the cause causes the effect...

                    Once they killed Otto. half the cockpit displays and most of the ADR's, they did a fine job of flying the plane by the proverbial stick n' rudder all the way to Melbourne.
                    Unfortunately, you've never been able to, even though that second paragraph illustrates it very well.
                    Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

                    Comment


                    • #11
                      Originally posted by elaw View Post
                      "Of all the lines of code in all the computers in the world..."

                      Okay yeah the pilot made a mistake... then followed it with a few more.

                      But consider this: I have to think that aircraft's navigation system has both GPS and INS components. While GPS is not flawless, I can't see any reason while sitting at the gate, the two systems can't compare info and put up a message saying "Hey bonehead, you just entered a position that's 11,000 km from where we actually are!". That simple measure most likely would have prevented this incident.

                      You say bad pilots, I say bad systems.
                      Not 'bad systems', just outdated ones. Airbus updated this system on the A330 years ago to automatically align using GPS. They issued a service bulletin in 2013 (SB 34-3287) recommending the upgrade for existing aircraft. Thus far 46% of the fleet has been upgraded. But there is no AD or requirement to do this, and if you run a monkey-business airline like AirAsia you will probably never make the upgrade. In the meantime, the PROCEDURE is to use the up/down keys on the MCDU to set this manually. This way, a large deviation is not going to occur. But the pilot didn't follow procedure. He IMPROVISED, typed it in... Not the first time; there have been 12 other documented occurrences of this.

                      So poorly trained pilots, outdated system, bad airline.

                      No fly.

                      Comment


                      • #12
                        FYI - final report has been moved to here: http://www.atsb.gov.au/media/5771380...nal-report.pdf

                        Comment


                        • #13
                          Originally posted by Evan

                          So poorly trained pilots, outdated system, bad airline.

                          No fly.
                          May ask when the last time was that you were on an airplane? Any airplane in any capacity. I'm genuinely curious.

                          Comment


                          • #14
                            Originally posted by ATLcrew View Post
                            May ask when the last time was that you were on an airplane? Any airplane in any capacity. I'm genuinely curious.
                            I'd be happy to, as soon as you explain what that has to do with anything.

                            Comment


                            • #15
                              Originally posted by Evan View Post
                              I'd be happy to, as soon as you explain what that has to do with anything.
                              Why not just answer the question? What are you hiding and why?

                              Comment

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