AirAsia flies to Melb instead of KL . Navigation error
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A comedy of errors so hilarious that you couldn't make it up. Thanks for a good laugh to start my day !
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Hard to believe really.
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Cheezus Christos!!!!!
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Yep, at one point after getting airborne the FO was going to cycle all three ADIRUs to OFF to 'reset the system'. The captain initially said nothing and the FO got as far as turning ADIRUs 1 & 3 off before the captain told him to stop! :ooh:
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"when autopilot engaged at 410 feet," says it all really. As many have suggested in this forum on previous occasions, what is wrong with hand flying the aircraft to (say) 10,000 feet or even transition altitude? Had one of them done this the other might have had time to reprogram the FMC from scratch providing, I suppose, the inbuilt systems in an A330 would allow the flight crew to do this once they were airborn?
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Obviously unable to fly using "old conventional " nav. & totaly "untrained" in the fmgc as their is an position update facility.
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Colour me stupid
One small planes, a normal check is to make sure the DI and compass are aligned as part of the start-up checks. When flying with a GPS a similar "does the reported position agree with where I am" sanity check during start-up is useful.
Now, colour me stupid, and I am not familiar on type, but if the inertial nav initialisation position is significantly different from the current GPS coordinates, should that not bring up a very large warning that one (or both) are not to be trusted? Or was that the initial warning that they ignored? |
And what were the Aussie ATC'ers doing when the flight departed radically from its filed route?
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ATC was the saving grace in this whole sorry episode. They picked up the aircraft's incorrect tracking immediately after take-off and then provided assistance to help the hapless crew get the aircraft back on the ground. The crew weren't able to do a visual approach back in to Sydney due to the weather, so ATC provided vectors all the way to Melbourne.
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Getting everyone else out of the way!
A review of the ATC response to this occurrence identified that the controllers carried out several tasks that reduced the risk to both the occurrence aircraft and other aircraft in the area. They were the first to notice and alert the crew to the tracking problem, and provided assistance to identify that the aircraft’s main heading indicators were erroneous. Additionally, ATC quickly resolved a possible conflict with another aircraft lined-up and ready to depart on the parallel runway. Subsequently, coordination with several ATC units and the availability of continuous radar coverage provided the crew with a safe diversion alternate and vectoring from Sydney all the way to final approach in Melbourne. The captain reported that ATC had prevented the situation becoming a ‘dire emergency’ and that in many ways they had ‘saved the day’. |
And what were the Aussie ATC'ers doing when the flight departed radically from its filed route? A few seconds later, ATC observed the aircraft turning left, contrary to the SID, and tracking towards the flight path for the active parallel runway, runway 16L. In response, ATC contacted the crew and requested confirmation that they were tracking via the SID and would be maintaining a heading of 155° before turning right. At the same time ATC held another aircraft in the line-up position for departure from runway 16L |
Don't these big jets have the equivalent of the RAF P12 compass ?How in laymans terms did a large airplane "get lost" after taking off from a large airport!!
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paperHanger
I am not familiar on type, but if the inertial nav initialisation position is significantly different from the current GPS coordinates, should that not bring up a very large warning that one (or both) are not to be trusted? Or was that the initial warning that they ignored? It's interesting to see (from the report, if I'm reading it correctly), that they manually entered the gate position as a lat/long even though it seems they had GPS. Certainly on a similar type I know of if GPS is available then you must line select the GPS position into the IRS/ADIRU present position "boxes" at the start of the align process ( basically copy and paste), without amendment, precisely to avoid the sort of finger trouble described in the report. TBH regardless of the above I'd have though there were plenty of other opportunites to catch the foul up before start, let alone takeoff (Gross distance checks, map display checks, etc....). |
Originally Posted by oldpax
(Post 9499632)
Don't these big jets have the equivalent of the RAF P12 compass ?How in laymans terms did a large airplane "get lost" after taking off from a large airport!!
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Children of the majenta line, of course, but will this industry ever wake up to the solution ? It is going to get much worse.
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The report also states that after almost 3 hours on the ground in Melbourne (during which time system checks found no unserviceability with the aircraft), the same crew flew on to Kuala Lumpur, for a total duty of 14 hours 53 minutes and total flight time of 10 hours 27 minutes.
Am I the only one who thinks it very unwise to continue a duty, obviously into discretion, after a significant incident? |
It will be interesting to learn of Air Asia's actions with the crew. Not only did they show a huge lack of procedural knowledge in the flight preparation, and discipline with disregard of warnings and mis-use of checklists, the F/O then exhibited huge lack of technical knowledge in his suggestion and subsequent attempt to realign the IRS's in the air. Not to mention that the view out of the side window after 400' is not what was expected.
"Oh, a/c is turning left and we expect to turn right. Why?" Heads down FMC-ing? Solution: disconnect, ask for vectors and clear critical airspace. As someone said, why can they not fly an instrument approach to Sydney. They still had 1 IRS it would seem for attitude information. It seems a little more than a re-training session is required. |
Are the Australian public happy with their government departments decision to allow this operator to share airspace with them?
It's beyond a joke. |
No but if we ban them they ban us. And we need their airspace to get anywhere more than they need ours. Same for Indo.
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Wow! And this happened 15 March last year. This should be being shouted from the tree tops by our press. How do the paying public get on these aircraft?
It seems the over-riding modus operandi of some airlines is: IF THE AUTOMATICS FAIL THE AIRCRAFT CANT OPERATE. Let alone all the warnings this crew overlooked to get airborne in the first place. the operational decision by this airline to allow the same crew to continue to their original destination, beggars belief! How can anyone describe Raw Data as a "dire emergency"? I say again Wow! |
Ben Sandilands is on to it, although I doubt that very many of the 'paying public' read his blog:
ATSB reports on cockpit cockup in AirAsiaX flight to KL |
It could have been worse... put them in a clockwork airplane and they would have ended up in London..
attempt to realign the IRS's in the air. |
Dodgy earmuffs => u/s GPWS
Could easily have led to more than just tea & biscuits, e.g. mountainous terrain IMC etc |
Sad story. But why were they entering coordinates in the first place, rather than airport designators and waypoints? (Not to mention the bit about them reading them from a piece of card held in front of the aircraft - reminiscent of Three Men in a Boat).
And why did entering the wrong coords cause a terrain alert? Luckily this just turned into an amusing story. But I wouldn't be in a big hurry to fly with Air Asia. |
why did entering the wrong coords cause a terrain alert? Edit to add, having just dug into the report: "An EGPWS alert activated at approximately 600 ft during the initial approach at Melbourne, seconds prior to the commencement of the go-around. An assessment of recorded parameters indicated that, as with the EGPWS alert departing Sydney, this was also a spurious warning associated with the aircraft’s incorrect position information." |
I think the EGPWS thought they were heading for Table Mountain. Without looking at it, I would suggest KL is a track in the region of 320 degrees. Actually about 298, but my guess would have had the aircraft going in the right direction. Set heading on the a/p, continue climbing, and sort it out when time permits. Or have ALL the old, basic skills gone?
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Cape Town is 18.5E, 15E is far out in the Atlantic Ocean, and flying SW goes even further offshore (nowhere near Table Mt). The lack of airports matching that location in the database would be more likely to trigger a warning (with gear down).
A rather similar navigation error (insufficient decimal digits) in Brazil in 1989 led to a much less happy outcome: https://en.wikipedia.org/wiki/Varig_Flight_254 |
The ATSB said “even experienced flight crew are not immune from data entry errors” and advised AirAsia to upgrade its flight systems to assist in preventing or detecting such errors in future. |
Faulty earmuffs? Seriously is that the only excuse they could come up with? Sounds more to me like the skipper didn't fancy doing the walk around in SYD because of the bad weather...
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Does this indicate that the ATSB think it better to make the machine smarter - rather than attempt to make the crew smarter ...? Had it have been QF/or other, might they have said something different? The Captain who made the initial data entry mistake had over 22,500 hrs. No matter how experienced you are, people must be expected to make mistakes at some point. There must be cross-checks, and in this case human & automated cross-checks / procedures all failed. While both pilots' performances were inadequate, there were also numerous issues with the Airbus system:
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How can anyone describe Raw Data as a "dire emergency"? But why were they entering coordinates in the first place, rather than airport designators and waypoints? |
The lack of airports matching that location in the database would be more likely to trigger a warning (with gear down). |
Didn't Polish LOT do something very similar in an old generation 737 possibly a 400 out of LHR.
Entered East into the FMC because that's where they mostly do all their flying on the 737, instead of West and with the IRSs not working correctly your down to STBY instrumentation. ATC talked them down with turn right 5' left 10' etc. We are all sky gods at home on the couch but are all just one flight away from a Disaster at work! Correct me if I'm wrong gents. Cheers Enos |
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Did the FO even check the FMC entries before departure I wonder? And why did the skipper manually enter the lat/long into the FMC from the sign at the gate? At my company we just copy the GPS coordinates and verify them against the airport/gate reference from the database or JEPS if required. I have stuffed up lat/long waypoint entry before on a long sector with about 10 manual waypoints to enter because ACARS didn't download them, but this is why the second crew member checks the FMC. The error was detected during the LEGS check and it turns out I had some finger trouble during entry and the waypoint was about 50 miles off track :O very stupid on my behalf and I learned a valuable lesson that day, now I go over my own work with a fine tooth comb before passing it over to the other guy. Having said that, departing with an incorrect alignment in this day and age should be impossible and ignoring all of the warnings is just insanity :confused:
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Originally Posted by RAT 5
(Post 9499686)
Not to mention that the view out of the side window after 400' is not what was expected.
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They had full VOR and ILS capability and could easily have flown the approach back to Sydney. I guess not having a magenta line scared them. Turning off intertial reference systems at the wrong time hasn't only happened to budget airlines. |
One very subtle point that I've found is that alignment of the IRS on my aircraft calculates its own latitude as a reasonableness check, but not it's own longitude. The manufacturer FCOM is very hazy on alignment and error codes (none are listed any more).
However, a well known third party publication states: Reasonableness tests - The IRU compares entered long with the last LAST POS stored in non-volatile memory -The IRU does not calculate its own longitude -If the the difference you enter is greater than 1°, the ALIGN annunciation flashes, status code 4 shows and ENTER IRS POSITION displays on the CDU -This could legitimately occur (i.e the entry is correct if the IRU was newly installed ... The IRU also compares entered latitude with the LAST POS latitude -The IRU calculates its own latitude -If the difference is greater than 1°, the ALIGN annunciation flashes I was unaware of this subtleties until this thread forced me to have a greater look at my own system knowledge and defences. The FCOM would not lead you to this understanding, and that is quite a large hole in the Swiss cheese. |
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