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Analysis

Summary

The crew of the A320 set an incorrect heading into the FCU as they were turning onto the runway. They had discussed the need to turn left after takeoff and had correctly read back to the aerodrome controller the radar heading for this turn after takeoff. Both pilots had followed the company procedures required for setting the departure heading into the FCU, but the cross-check process did not detect the incorrect heading that had been set. It is possible that the training situation in the cockpit, lack of familiarity with the procedure, and the action of setting the heading whilst turning onto the runway had prevented the pilots from recognising that the heading they had set in the FCU was, in fact, the runway heading.

The aerodrome controller was unable to resolve the situation because when he determined that the A320 had not turned left, the A320 crew had already transferred to the Departures (S) frequency. Had the A320 crew remained on the tower frequency until established on the assigned departure heading, the controller would have been able to immediately instruct the crew to turn onto the correct heading.

The SODPROPS procedure was introduced to the Sydney Airport environment with neither the regulator nor the airservice provider having adequately analysed the risks associated with the implementation of the standard. CASA did not critically examine how the standard was developed by the FAA and did not determine if any restrictions were applied when the standard was utilised in the USA. Furthermore, CASA did not determine the extent to which this standard was used in other countries where the regulators' experience might have been able to influence the standard's development for use in Australia.

Although Airservices had agreed to comply with the requirements of the LIP until the document was signed into law by the Minister, the evidence indicated that the requirements for risk analysis of new procedures in the LIP were not complied with prior to the introduction of SODPROPS.

Airservices commenced the consultation process with industry less than 4 weeks prior to the planned implementation of the procedure. This period did not give the industry sufficient time to consider the procedure, or to develop and distribute internal procedures that incorporated the new operation. Because industry representatives were provided with details of the risk analysis 2 days before the operation was due to start, there was insufficient time for industry analysis of those details.

 
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