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AirAsia issue SYD today?

Old 7th Sep 2016, 23:29
  #41 (permalink)  
 
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How one simple mistake turned an AirAsia X flight into a nightmare


An investigation into an AirAsia X flight that turned the wrong way after taking off from Sydney has revealed a litany of failures by the airline and crew.

Flight 223 to Kuala Lumpur on March 10, 2015 had to be guided to Melbourne to land after the captain inadvertently entered the wrong data in the flight computer.

An Australian Transport Safety Bureau report found the captain got the longitudinal position of the aircraft incorrect by 11,000 kilometres, sending the A330's on-board navigation system into a spin.

"Despite a number of opportunities to identify and correct the error, it was not noticed until after the aircraft became airborne and started tracking in the wrong direction." said the ATSB report.

"The ATSB also found that the aircraft was not fitted with an upgraded flight management system that would have prevented the data entry error via either automated initialisation or automatic correction of manual errors."


Air Traffic Control was forced to hold up an aircraft on another runway when the AirAsia X plane turned in its path.

The report noted that the flight crew attempted to "troubleshoot and rectify the situation while under heavy workload" but that only made the problem worse.

"Combined with limited guidance from the available checklists, this resulted in further errors by the flight crew in the diagnosis and actioning of flight deck switches," the report said.

The pilot requested to return to Sydney to land but deteriorating weather conditions meant it had to be diverted to Melbourne with the assistance of ATC for a visual landing.

The ATSB praised the performance of Air Traffic Control for "reducing the risk to the aircraft and other aircraft in the area". "This occurrence highlights that even experienced flight crew are not immune from data entry errors," the report said.

"However, carrying out procedures and incorporating equipment upgrades recommended by aircraft manufacturers will assist in preventing or detecting such errors."

In response to the incident AirAsia X made a number of changes, including the development of a new training bulletin and package for flight crews.

The airline also shared the lessons from its internal investigation with all pilots, and reviewed the recovery procedures required in the event of a similar occurrence.

AirAsia X began direct flights to Australia in 2007, and currently flies between Kuala Lumpur and the Gold Coast, Sydney, Melbourne and Perth.
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Old 8th Sep 2016, 01:54
  #42 (permalink)  

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An interesting article?

https://www.theguardian.com/australi...vigation-error

And ATSB Report:

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

That perhaps sounds similar to the occurrence which is the topic of this thread???

Oh, well, I guess everyone can have a bad day, not just LCC's??
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Old 8th Sep 2016, 02:06
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"In summary, it is likely that the disparity between the standby compass and the primary heading indications was not identified due to a combination of the:
• method of crosschecking the heading indications by use of the word ‘Check’ instead of verbalising the actual indication
• reduced prominence of the standby compass compared to the primary heading indications
• instrument panel check not being fully carried out during pre-flight in accordance with the FCOM, as the incorrect mode was selected on the NDs."


After lining-up they also didn't notice the >30 degree discrepancy between the indicated heading of 193'M and that they were on runway 16.
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Old 8th Sep 2016, 02:13
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After lining-up they also didn't notice the >30 degree discrepancy between the indicated heading of 193'M and that they were on runway 16.
From the report page 24
Recorded data indicated the captain had PLAN mode selected on his ND until after pushback and just prior to engine start. This precluded the ADIRS IRS align check being carried out in accordance with the FCOM. The FO had NAV or ARC mode selected on his ND for most of the pre-flight and then PLAN mode prior to pushback until engine start.

Based on the selected ND modes it is likely that the data integrity checks detailed in the pre-flight and taxi procedures were either omitted or conducted with the ND selected to an inappropriate mode and/or range that concealed the aircraft’s positional error.

The recorded data also indicated that the FO selected plan mode and every available ND range during the line-up/take-off roll. This may indicate that the FO was attempting to interpret an unusual display on the ND associated with the positional error.
The FO probably realised something serious was wrong with this picture...
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Old 8th Sep 2016, 03:13
  #45 (permalink)  
 
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Tailwheel - it's not so much the bad day they had. Bad days and mistakes can happen to anyone.

It's what these guys did airborne to make it worse ....

Last edited by compressor stall; 8th Sep 2016 at 03:27.
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Old 10th Sep 2016, 12:13
  #46 (permalink)  
 
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It can be very difficult to read through the politically correct unemotional language of the ATSB report and try to understand what indications the crew saw that may have led them to be suspicious prior to departure that all was not as it should be.

What is telling though on page 23

"It is likely that a message associated with failure of the GPS integrity check did appear on the engine warning display but the crew did not recall seeing one."
(They're talking about an ECAM caution here prior to takeoff, possibly more than one.)

Then the FO went trundling down the runway scrolling though the range selector on the ND while taking off.

A critical mind can infer the level of non normal awareness that the crew might have had.

The ATSB report, to my knowledge, does not go in to any detail about the relationship between the crew and and the associated command gradient that may have contributed to the incident. That seems like a wasted opportunity not only for them but for the rest of us too.
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Old 11th Sep 2016, 02:37
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What I find alarming is that after take-off, flying a SID with a reasonably significant right turn away from a parallel runway, the crew didn't question the fact that they were turning left.
Didn't something as fundamental as that at least encourage them to at worst, not turn left or was their situational awareness that corrupted?
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Old 11th Sep 2016, 02:42
  #48 (permalink)  
 
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Not good... :(

Unknowingly put themselves into 'alternate law' and once gear was down (gravity extension due turning ADIRS 1 + 3 off), into 'direct law' by intentionally turning off the ADR part!

IMHO, the FO was clueless in what he had done/ was doing and the Captain of similar ilk. What was wrong with a radar vectored, raw data approach back into Sydney after reviewing the initial situation? That's right, they went into the wrong fault diagnosis and further compounded the situation! Airbus pilots I work with, understand what was initially done is wrong.

Great. Now 'Everyone can Fly!' The Air Asia accident in Indonesia wasn't that long ago and due to unknowingly putting themselves into a diabolical situation. The travelling public doesn't understand the gravity of what second rate Airlines can potentially do.

Why are pilot's paid better at some Airlines and not others? Answer is, that better paying Airlines expect their safety and training standards' to be upheld by their pilot's, thus maintaining their better reputations.

Anyone can have a bad day out? Even more so, if they do not understand the aircraft they are flying!
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Old 11th Sep 2016, 13:12
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Snoop,

I'm not sure there is a strong link between pay and skills. I think it is clear that these pilots had no place in their respective seats but the question that is significant to me is how did they get to this position if that was the case.

I believe the check and training department has a lot to answer here as well as these poor souls.

As for the FO inexplicably switching off the ADIRU rotary selectors, it would be interesting to find out what the captain was thinking when he asked him to 'reset nav'
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