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  • 37

Navigational error brings flight to Melburne instead of Kuala Lumpur

This might be the costliest navigational error in history. ( More...

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Looks like the series of events is something like:

1: Incorrect position entered into the IRS during Alignment. - Wonder why they don't use the GPS position instead of manually typing it in? Was the primary GPS 1 system offline? (it usually takes a couple of minutes after power is established to get the fix, but is generally accurate to within metres)

2: When the flightplan is entered, (via ACARS request? Co-Route? Manually!) the fact that "YSSY" is a few thousand miles from E015° there will be a position mismatch error that is independently displayed on both MCDU screens and has to be cleared on each. No pilot should be pressing buttons on "the other" pilot's CDU.

3: When taxying around, and lining up to the runway, the runway and green course line shouldn't be available. Distance to runway would be hundreds/thousands of miles away instead of, you know... less than 1.

4: After takeoff, the flight director wanted a left turn (probably from 16R) Correctly they noticed this and corrected the turn to a left turn. Not clear if this was using the side-stick or FCU heading mode.

5: They "Did something" which "Made things worse" so that they degraded the aircraft to only being able to accept a visual approach. Which probably means they switched all 3 ADIRS switches from NAV to ATT. This causes the attitude indicators to go black (all the blue/brown is gone) and the autopilot drops out and cannot be engaged - they are 100% flying with the sidestick now.

6: Sydney Tower says the airport's visibility/ceiling is below visual approach minima, and suggests they better head to Melbourne where the weather is better/above visual approach minima.

7: After a certain amount of time flying straight/level with the side-stick, the ADIRS will align 'enough' to provide attitude indication (and vertical speed info) but not enough to give navigation tracking information (this has to be done on the ground, stopped, and takes around 10 minutes).

8: With the ADIRS in ATT mode, the Autopilot can once again be engaged to maintain headings and altitudes and vertical speeds, but will not engage in complex navigation modes like lateral navigation.

9: Didn't say in the article, but I'm wondering if they were radar vectored all the way to Melbourne? Given the navaid rationalization project decommissioned many navigation aids (VOR's and NDB's etc) early this year (AIRAC 1606), and there is no more VOR at Sydney (Now RNAV waypoint TESAT) and many of the VOR's and NDB's between Sydney and Melbourne are gone now, I'm guessing 'traditional' navigation methods are not available in this configuration?

Not familiar enough with the airbus to remember if ATT mode is able to run the autopilot on an ILS approach? But you'd have thought a raw data handflown ILS is still available at Sydney? I know for a fact the ILS data is able to be viewed on the standby instrument that isn't effected by the ADIRS being in ATT mode one bit!

Yes, the big main "navigation screen" is displaying either nothing, or worse still... the wrong information (Hi You might actually be just south of Sydney right now, but the INS says you are near Port Moresby. :D ), but guess what: ILS systems are not driven by the INS or GPS. Use the raw data and turn off the flight director, and get the nav screen out of NAV and into displaying raw data ILS: problem solved(ish). The erronious "Terrain terrain, pull up" stuff might be annoying... which is probably a good enough reason to go somewhere you can see the ground you're flying over.

Remember, the plane thinks it is somewhere it isn't. It doesn't think it's nowhere. So trucking around at 1000ft on the ILS Centreline and glideslope, and the EGPWS thinks it's inside a mountain somewhere.
Tom Yablonski 1
Do you think they really lost their basic attitude indications, or was their decision to divert based just on a lack of confidence in the higher-level navigational capabilities? I imagine they wouldn't be too willing to put their trust it the ILS glideslope given that the other systems were telling them that they were inside of a mountain. Seems like a good cause for diversion to VFR, even if their attitude instrumentation was working fine.
Ronnie B. 5
I can think of several other navigation errors, that were much more costly.
People have paid with their lives.

Still an important reminder to perform cross checks.
mike SUT 5
Their first indication should have been the lack of their airport displaying on the Nav Display (ND). At my airline, the Pilot Flying puts the route in the FMC, when he's done,the Pilot not Flying goes through each waypoint, reading the lat/long and distance between them and then making a check on the flight plan to verify it's correct. The final check is when you get to the total distance for the flight it should be withing 20 or 30 miles depending on whether you pre-loaded the departure procedure. I'm surprised they were even able to put a runway into the FMC for departure and should have got an aural warning when they pushed the power up for takeoff as the Inertial Reference Systems do an update at that time. Reading the article, sounds like these guys disregarded pretty well everything and somehow made it back safely on deck without killing themselves and everyone else.
Todd Baldwin 4
Reading the report in AV Herald, they did get some audible warnings that they couldn't understand what they were for.
joel wiley 1
flee2013 posted link to the interim report elsewhere in the thread. Greater detail there.
Todd Baldwin 4
In my days as a navigator, it was a rookie mistake to forget to flip the INS switch from Init to Norm after keying in your coordinates. You would have to return to the pad or do an in-flight re-alignment to get things working again. That one usually cost the Nav a round of drinks or two at the next happy hour.
Billy Koskie 3
Here's a non-pilot question - why couldn't they disengage the flight computer and hand fly the plane to the correct destination?
Tom Yablonski 4
It sounds like the error was in the entering the initial coordinates for the inertial nav system (INS). By integrating the acceleration and rotation (both from high accuracy solid state sensors), the current position can be determined with surprising accuracy. Of course, that depends on an accurate initial position. This isn't common in smaller aircraft but it seems like the airliners still make heavy use of it since it works independent of any external systems like GPS. They certainly have GPS as well, and the fusion of those different systems is probably what caused all of the chimes and warnings.

As to why they couldn't hand-fly it, the cockpit displays that show the planes deviation from the flight path are driven by the same nav data used by the autopilot, so if the autopilot was confused the pilots probably couldn't have done any better by hand. Even though a handheld device might have worked, you can't use non-certified avionics to fly IFR, which is why they had to fly to Melbourne for a visual approach.
Cecil Clark 1
Seems like Asian pilots rely on the AP almost entirely..
Why only Asians ?
What about Americans ?
Who keeps NTSB busy ?
And FAA on its toes ?
Stop being a racist dear friend Cecil Clark !
Cecil Clark 2
Stating a fact isn't being racist. The last fatal American airline crash was in Feb 2009 in which 49 people were killed. Since then Asian airlines have suffered 27 fatal crashes with 786 dead. That doesn't include Malaysian #17 shot down over the Ukraine in which 298 people were killed.
Cecil Clark 0
I should've clarified "passenger airline" fatalities, since UPS and FEDEX have had several fatal crashes where their crews were killed.
Jesse Carroll 1
ER. One of my best friends is a retired 777 and other instructor. He spent many years in South Korea and South Asia teaching how to fly heavies!
When I asked him what happened with the 77 in SFO landing, he mentioned that almost all of the Asians, Japanese, etc: could not wait to hitting the AP as soon as possible. Even in landings they used the AP anytime they good.! Just saying!

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Todd Baldwin 0
You left out bug smashers Mr. Hartman (intended as humor). Your comment does bring to mind a question. In a air carrier (part 121) at what point does your personal IPad go from being a useful tool to a personal electronic device that might be regarded as a distraction?
Well said , Mr. Baldwin.
The lines of separation are thinner than a hair !
And it applies to all gadgets and tools used in any and every profession.
From pen to plane

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Todd Baldwin 1
I'm not disagreeing with you, my IPad is a great tool (I still have steam gauges). Seems like I read awhile back that while the crew can use an approved IPad (I'm talking 121 ops), if they used to, take a photo, for example, at that point it became a PED and was then illegal...i'm running on a faint memory of something I read, so feel free to fill in the details.

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WeatherWise 4
Yes, exactly when is FlightAware management going to permanently ban you? Excellent question, Esq.

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WeatherWise 4
Only the "fliers" who know what an a-hole you are.

[This poster has been suspended.]

WeatherWise 2
I'll take "my kind"...who know what YOU'RE all about...over "your kind" aggressive, blowhard, pseudo expert on all matters of the world...any day of the week. People could down vote you all day long and you would never get the message. You just keep spouting your long winded nastiness. A cockroach who though sprayed with Raid, just refuses to crawl away and disappear for good.
flee2013 4
The media loves to sensationalize these kinds of stories.

For the facts, please read the original ATSB report: Data entry and navigational issues involving Airbus A330-343X 9M-XXM
btweston 0
Sensationalized what? These dudes made a huge booboo and "the media" wrote an article about it.
Terrible.. Understand the Data ENTRY Error but why it requires to reach all the way to Melbourne and not Steer correct..? What happens if a Flight is re routed to other Airport due to bad weather etc?
Gordon Dewis 2
Grrr typos: Inertial not internal.
Todd Baldwin 3
That was the initial problem with this crew,
Todd Baldwin 2
Troll: In Internet slang, a troll is a person who sows discord on the Internet by starting arguments or upsetting people, by posting inflammatory, extraneous, or off-topic messages in an online community (such as a newsgroup, forum, chat room, or blog) with the deliberate intent of provoking readers into an emotional response or of otherwise disrupting normal on-topic discussion

I submit to the on-line community that we have a troll amongst us. One who has even had the nerve to say "...if you don't have anything nice to say, don't say it." The best way to handle an internet troll is to not feed them, they thrive on the discord that their posts creates, diverting the discussion away from the original subject and into a back and forth bickering between the troll and other commenters. I know, I've been a part of that. My choice, is to not respond to the troll, to not validate the troll's miserable existence (other than to use the eject function). If we, as a group, do not respond to the troll, he'll eventually get bored and go away.
I guess nobody uses maps anymore?

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joel wiley 3
I think the case at hand is a data entry rather than a navigation error. Consider this analogy. You are sitting on the taxiway at KPRC at 34.39N 112.25W and are plugging in GPS route and waypoints as Lat/Lon heading for KRNO. You inadvertently enter your initial point as 34.39N 11.225W into your garmin. After the rest is entered, you take off. You notice Garmin is telling you to head for a point somewhat SE of the Azores. Now my Garmin and I have occasional disagreements about 'best' routes. In this case you decline Garmin's advice and go Northerly. The difference between this scenario and the Squawk's case, is that the Bus's FMS with the erroneous data is driving.

I'm still wondering why an A330 required VFR conditions to return to Sydney. Was it the Bus, the airport, the aircrew, or something else.
joel wiley 1
After reading the report posted by Flee2013 my question on VFR was answered. The systems were not reliable for an IFR approach. Thanks for the report.
James Derry 1
I´ll have to understand what the systems are like on an airbus, then. As regardless of what they´ve managed to misprogramme into the FMS, neglect to check and then ignored all the warnings......they would STILL have ILS and VOR and these are completely independent systems, so I really have a hard time understanding all the issues!

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wingbolt 2
To let you know every flight using the North Atlantic Track require Lat/long entry because the tracks move daily. Lat/long input is also used widely outside the lower 48.

That's the real deal.
James Derry 3
Of course Lat/long are used in oceanic airspace, but this flight was using the Lat/long for the departure airport gate. I don´t know what FMS Airbus uses, but on ours, the position is verified by the dual GPS´and not by a manual entry of Lat/Long. Alternatively, the airport is listed on the first FMS POS INIT page. After putting the route in, there should be a total distance and total fuel. This would be checked with the flight plan. Obviously, none of these checks were done....and in my eyes, this is highly unprofessional.

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wingbolt 2
What part of "the tracks change daily" did you not understand. Since the tracks change the intersections on them change as well. The only option to enter them is via Lat/long. They set the tracks up daily to make the most of the given wind component. If you consider that backwards you are misguided. And I don't fly for an airline either but last time I tried to convey that to you you lost your mind and went on one of your rants.
wingbolt 2
But I will give you this. This is always included in the NAT messages.


There are certain procedures and checks that should be used to minimize garbage in/garbage out. The procedures are very specific and symbology is important between the crew to help minimize the errors. The waypoints are every 10 degrees of longitude and are abbreviated.
joel wiley 2
I believe in the report cited elsewhere, the ATSB noted that the preferred method for entering the position is similar to your moving map and pipper example. The PIC opted to enter the data via the scratchpad, which was not recommended due to the possibility of large errors.

As for 'squawk', that is what FA lists on their top level menu for these posts.
And in other terminology, when my late father was flying in the Alaskan bush, IFR meant "I follow the River". I still have a couple of his steam gauges on the shelf.

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James Derry 3
Peter, LAT/LONG will be needed once you are in Oceanic airspace. On your Garman, try tapping in something like 50West. That one "might" exist, but probably not. It will say Waypoint not found, do you want to create it. The default is the present location. (located at the bottom right) If you scroll down there and type in say N50.00.000 W040.00.000, then you will have entered a position. This would be a typical position off the coast of Canada and typical for an Oceanic position.
So if you head off......on your way to Iceland or Greenland, you will also open yourself to entering incorrectly. However, using the checks I mention elsewhere, you would have your flight plan showing, say 1355nm. Your Garmin should be showing the same.......and of course, you have a moving map display that will show you all the waypoints, Start and Destination.
It is unbelievable that these guys didn´t do that! Unprofessional!
joel wiley 1
My belief referred to recollection of text in the ATSB report. Re reading it found the following on page 19:
MANUAL POSITION INITIALIZATION (AIRCRAFT WITH OR WITHOUT MP S16804) The coordinates of the departure Airport Reference Point (ARP) are displayed on the MCDU INIT page. However, the most appropriate coordinates for IRS position initialization are the gate coordinates. In this case, and in order to avoid entry errors, the flight crew should use the slew keys successively for latitude and longitude, instead of inserting the coordinates on the scratchpad.

I think you and I both agree with the referenced document that hand entering is more error prone.

I thought use of the 'slew keys' was similar to your reference to 'moving map' and 'pipper'
David Strout 2
As I understand it the TL;DR is that their starting position was entered incorrectly, so when they took off and engaged the autopilot it thought they were 11,000km away from where they actually were. They decided to land to fix this, but since the navigation was off they requested a visual, which they couldn't do at Sydney because of weather. So they diverted to Melbourne and landed without an issue.

What definitely did NOT happen was they took off, flew for the ~8 hours that it would take to get to Kuala Lumpur, and then found out they were actually over Melbourne, which is what the headline might make you think.
sharon bias 1
Isn't this why there is a check list in the cabin? How about someone doing the extreme, and look out the window? Is this up to the level of criminal negligence? This seriously endangered people.
tim mitchell 1
Okay..I read the story...They didn't just blindly allow the plane to fly to the wrong destination. The navigation error was noticed right after they switched on the autopilot but were told to continue to Melbourne where the weather was suitable for a VFR landing...They will reprimanded and retrained but hopefully not fired.
joel wiley 1
33S 15E puts the 'assumed position' about 208 M WNW of Capetown South Africa.
Went to Melbourne due to Wx Sydey. Why they could only do VFR approach back to Sydney?
Looks to be a gross procedural problem. Pilot enters co-ordinates from office, Co-pilot enters co-ordinates individually. Mismatch bingo. Cockpit alerts, Bingo, route identification, Bingo. Not sure what ATC's role was in this???
Sorry, sticky fingers at work again, it should be Melbourne of course.
joel wiley 6
Same thing happened to the PIC, apparently.
While filing and approving flight plan,the approved flight plan may be loaded in a pen drive and given to the pilit/capton.He can just plug the same in to his aircraft flight navigator/auto pilot etc..and up load the data.In this pilot cannot make such mistakes as said in the report.
N.Janardhana rao
ADXbear 1
Interesting rationale. Im Wondering if flight 370 crew made a similar mistake and ended up in the middle of nowhere??
Edward Bardes 3
I doubt it. The 777 would've headed off in the wrong direction almost as soon as the autopilot was engaged, such was the case with Varig Flight 254 in 1989. But MH370 was on the proper course during the time that the crew was in contact with ATC. Not until the transponder went offline and radio communication was lost did the aircraft deviate from its intended route to Beijing. Seeing as those failures share no common point of operation beyond independent controls accessible to the pilots, it's most likely, the way I see it, that MH370 was deliberately flown off course by one of the pilots.
Highflyer1950 1
Well I am guessing here, but is there not (3) IRS and at least (2) FMS and you initialize the FMS to your present position (position init) either by Lat/long at the bridge or airport center (which is less accurate) and that gives the IRS's their position for the lasers to inititalize. We used to load all three FMS separately and then compare route mileage, etc to the flight plan. I get that the captain loaded the wrong position but that should have been caught before the door was closed! After departure and now figuring out this nav screw up, why couldn't they overfly a vor and do a position update, then the whole route would have fallen into place. Again, just guessing.
Tom Lull 1
The article gives the impression that it isn't possible, or was beyond the capabilities of the crew, to do an in-flight present-position-update. Being old-school - I find it strange they didn't generate a flight plan (headings/time/distance), as a backup in case the system failed. This gives me the impression that the people in the front need to be more GEEK than pilot. I doubt they will be replaced anytime soon, still need someone to raise and lower the gear.
The crew could be technically prepared to reset the navigation systems in flight, even though it might be a tad complicated due to the high speed of the aircraft. However a better question is "should they?" It would certainly violate every procedure in the book, and if they make a mistake they'd have to do a visual approach in some foreign airport, not necessarily the one they were going to. In the worst case they get lost in the ocean! It's not like their route was from Paris to Berlin. I think they did the safest thing possible, after all these errors: they landed in the nearest, likely familiar airport. The passengers haven't paid for a trip to $deity knows where, and they wouldn't be all that enthused learning that the pilots delivered them somewhere by Google Maps - even if a competent pilot theoretically, technically, probably could do so.
hamish kebb 1
Basic magnetic compass saves the day .Due to incorrect data entry electronic systems where off by
38 Deg. ATC had them fly basic magnetic compass heading and hand fly A/c 400 nm to Melbourne.
crk112 1
+1 on media over sensationalizing things... they realized the error as soon as they were in the air in Sydney and asked to land right away.. but ATC diverted them to Melburne due to weather.
An age old saying (but modernised)
To err is human , to blunder is divine.
Maher Chebib 3
Sorry better saying : to err is human but you need a computer to really f*** up
Todd Baldwin 0
I can almost picture the pilots looking at each other and asking "What's it doing now?"
They know Melbourne is better than $ydney, that is why they did it!
They should be commended for not going to that horrible place $ydney
linbb -7
Hope that the flight crew is fired and that ends all of there flight carriers forever before it kills someone.
sueridge307 -6
So much for Asian pilots and there excuses how on earth do they get a pilots licence? Out of the cornflakes packet. Lucky they weren't out at sea this could have disappeared as well like MH370?
U R xenophobic simpliciter.
Almost like a Nazi.
joel wiley 0
Thanks for my word of the day.
btweston -1
Who said modern airliners don't require Navigators then please?


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