Air Asia problems linked to pilot error after Airbus upgrade was ignored.Back to Forum
From INSIDE MRO article
A captain’s data-entry error when programming an AirAsia X Airbus A330-300’s initial coordinates, which led to myriad navigation errors and an eventual diversion, would have been caught if an Airbus-recommended upgrade had been installed. But despite recurring problems with the old systems, the upgrade was not mandatory, Australian investigators found.
The March 10, 2015, incident began when the captain entered incorrect coordinates into the A330’s air data and inertial reference system (ADIRS). The longitude was incorrectly entered as 01519.8 east (15 deg. 19.8 min. E. Long.) instead of 15109.8 east (151 deg. 9.8 min. E. Long.). As a result, the aircraft’s systems placed it near Cape Town, South Africa, instead of at Sydney Airport’s International Terminal Gate 54.
“The magnitude of this error adversely affected the aircraft’s navigation functions, global positioning system (GPS) receivers and some electronic centralized aircraft monitoring alerts,” the Australian Transport Safety Bureau (ATSB) report on the incident states. “[D]espite 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.”
Less than half of eligible aircraft have undergone the recommended Airbus ADIRS avionics upgrade.
The flight crew did not realize it had a problem until a series of warnings upon takeoff en route to Kuala Lumpur. The crew then attempted to follow the course assigned by air traffic control, including a right turn. But the aircraft, operating on autopilot and guided by the erroneous starting coordinates, turned left instead, crossing the departure path of a parallel runway.
After nearly an hour of fruitless troubleshooting, the crew diverted to Melbourne Airport; weather at Sydney had deteriorated, and the AirAsia X crew, suspecting navigation problems, wanted a visual approach.
The incident’s cause was clear: The mistyped longitude triggered a series of events that led the flight crew to believe the aircraft had malfunctioning avionics. But extensive post incident troubleshooting concluded that the only problems were human factor-related: erroneous data entry and missed clues that would have highlighted the problem.
But the ATSB also highlighted a service bulletin (SB) detailing an ADIRS upgrade that became available in 2013 for the A330 and other Airbus models. The upgrade allows position initialization to occur automatically using GPS, or, “in the event the initialization is carried out manually, when the pilot-entered initialization position is crosschecked with the GPS position.”
The ATSB says about 515 aircraft were eligible for the SB upgrade, but only about half had undergone the work. AirAsia X, “for reasons that could not be determined,” was among the operators that upgraded their aircraft, it says.
“Airbus records suggest that approximately two occurrences are reported per annum that are attributable to position initialization error in aircraft that have not been upgraded,” the ATSB says.4 Oct 2016
I always find accident and incident reports fascinating to read. It is very rare for a single cause to be responsible and it is often a chain of events that need to take place for the accident to occur.
One of the saddest examples I’ve read was a Channel Express F27 cargo plane that stalled on approach to Guernsey airport in 1999. Reading the report, it is clear no one thing was responsible, it needed a combination of little things to go wrong for the accident to happen and kill the 2 pilots.4 Oct 2016
‘BathVIP’ – yes I agree, there is a fascination in them sometimes and yes it is clear that rarely is there one single factor that leads to an accident. When I was learning to fly many years ago my instructor always talked about the benefit of what he called, “taking a breath” when things started to go wrong, a brief pause before making the next input to give one time to think. This became particularly relevant later in my flying career when I began to fly supersonic aircraft where the consequences of errors very quickly build up.4 Oct 2016
Another issue might be cockpit resource management (CRM).
Asia generally operates in a status/ hierarchial culture whereby a senior person’s decision is rarely questioned by someone their junior – even where it’s clearly wrong. Prime example being the Garuda Jogjakarta crash where the cowboy captain landed too fast in bad weather killing half the passengers in the resulting crash.
If the input error was the Captain’s, even if the First Officer had realised – he/she may not have felt comfortable or confident alerting the Captain.
Thank goodness it wasn’t fatal. But imagine if they’d flown into the path of another aircraft as a result??
The problem isn’t limited to Asia though. AF 447 is another example of poor crew communication and training.
Reminder that human error happens. But for the Grace of God go I…4 Oct 2016
AlexF – an interesting point.
The crash of Asiana 214 in San Francisco back in 2013 could have been caused by the rigidity of Korean culture. An investigator said, “Social hierarchy and deference to elders are paramount in Korean culture.”
After the 1997 Korean Air crash in Guam, the airline was criticized for its “authoritarian culture in the cockpit,” and after a Korean Air cargo flight crashed near London it was revealed that junior officers were “so deferential to the captain that they failed to speak up before it was too late.”4 Oct 2016
The Asian culture issue should have been eradicated years ago. I can’t recall which crash it was but with NASA’s help a robust CRM system (Cockpit Resource Management) was implemented to head off repeat crashes of this nature. No doubt former/current pilots will correct me if I am wrong6 Oct 2016