Aviation safety investigations & reports

Data entry and navigational issues involving Airbus A330-343X, 9M-XXM, Sydney Airport, NSW, on 10 March 2015

Investigation number:
AO-2015-029
Status: Completed
Investigation completed

Final Report

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What happened

On 10 March 2015 Airbus A330, registered 9M-XXM and operated by Malaysian‑based airline AirAsia X, was conducting a regular passenger service from Sydney, New South Wales to Kuala Lumpur, Malaysia. On departure from runway 16R the aircraft was observed by air traffic control to enter the departure flight path of the parallel runway 16L. Following advice from air traffic control, the flight crew identified a problem with the onboard navigation systems. Attempts to troubleshoot and rectify the problem resulted in further degradation of the navigation system, as well as to the aircraft’s flight guidance and flight control systems. The crew elected to discontinue the flight but were unable to return to Sydney as the weather had deteriorated in the Sydney area and the available systems limited the flight to approaches in visual conditions. The aircraft was instead radar vectored to Melbourne, Victoria and the flight completed in visual conditions.

What the ATSB found

The ATSB found that when setting up the aircraft’s flight management and guidance system, the captain inadvertently entered the wrong longitudinal position of the aircraft. This adversely affected the onboard navigation systems however, 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. 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.

The flight crew attempted to troubleshoot and rectify the situation while under heavy workload. 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.

Finally, the ATSB identified that effective monitoring and assistance by air traffic control reduced the risk to the occurrence aircraft and other aircraft in the area.

What's been done as a result

In response to this occurrence the aircraft operator undertook safety action, including:

  • the development of a training bulletin and package for its flight crews that emphasised the correct operation and alignment of the air data and inertial reference system
  • sharing the lessons learnt from the operator’s internal investigation with all pilots and reviewing the recovery procedures to be undertaken in the form of a flight safety notice.

Safety message

This occurrence highlights that even experienced flight crew are not immune from data entry errors. However, carrying out procedures and incorporating equipment upgrades recommended by aircraft manufacturers will assist in preventing or detecting such errors.

Additionally, the airborne management of this occurrence illustrates the importance of effective communication when dealing with an abnormal situation under high workload conditions. This is especially the case when there is limited guidance available to resolve the issue.

Photograph of A330-343 9M-XXM
A330-343 9M-XXM
Source: Airliners.net

Download Final Report
[Download  PDF: 1.73MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Sources and submissions

Appendices

Photo

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General details
Date: 10 March 2015   Investigation status: Completed  
Time: 1231 ESuT   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): near Sydney Airport    
State: New South Wales   Occurrence type: Avionics/flight instruments  
Release date: 07 September 2016   Occurrence class: Operational  
Report status: Final   Occurrence category: Incident  
Anticipated completion: 1st Quarter 2017   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus  
Aircraft model A330-343X  
Aircraft registration 9M-XXM  
Serial number 741  
Operator Air Asia X  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Sydney, NSW  
Destination Kuala Lumpur, Malaysia  
Last update 14 November 2018