[新聞] 亞航去年因導航資訊輸入錯誤轉降墨爾本

[yodi ( )]

[媒體名稱] the Guardian News          [新聞日期]  2016/09/07
[網址]  http://goo.gl/luU9Vu

簡言之:

* 2015年3月10日 D7-223 SYD - KUL

1. 機長因為沒有耳罩, 所以由副機長進行飛行前檢查
2. 機長在機艙輸入導航資訊時, 誤將 151°9.8’east 打成 15°19.8’east
3. 兩人忽略了前四次的警示, 第五次 "TERRAIN! TERRAIN!" 兩人發現, 但仍然決定起飛
4. 航機爬升至 410 ft., 自動導航接手導致偏離航道
5. 機長欲返航, 同時向ATC表示僅能目視進場, 因雪梨機場天氣狀況不佳, 改引導至墨爾本

原文如下:

AirAsia pilot flies to Melbourne instead of Malaysia after navigation error

Crew of Airbus A330 entered wrong coordinates for flight from Sydney to Kuala
Lumpur and had to divert after error was noticed

An AirAsia flight from Sydney to Malaysia ended up in Melbourne instead when
the pilot entered the wrong coordinates into the internal navigation system,
an air safety investigation has found.

The Airbus A330 was scheduled to leave Sydney international airport at
11.55am on 10 March 2015, and arrive in Kuala Lumpur just under nine hours
later.

Instead, through a combination of data entry errors, crew ignoring
unexplained chimes from the computer system, and bad weather in Sydney, it
landed in Melbourne just after 2pm.

Melbourne airport is 722km southwest of Sydney. Kuala Lumpur is 6,611km
northwest.

According to a report by the Australian Transport Safety Bureau (ATSB)
published on Wednesday, the problem occurred when faulty earmuffs prompted
the captain and first officer to swap their usual pre-flight checks.

Ordinarily, the report said, the captain would conduct an external inspection
of the plane while the first officer stayed in the cockpit and, among other
tasks, completed the position initialisation and alignment procedures.

On this day, however, the captain’s ear protection was not available so he
took over the cockpit tasks, which included entering their current
coordinates, usually given as the coordinates of the departure gate, into the
plane’s internal navigation system.

The report said that the captain manually copied the coordinates from a sign
outside the cockpit window into the system, and that later analysis showed a
“data entry error”.

Instead of entering the longitude as 151° 9.8’ east, or 15109.8 in the
system, he incorrectly entered it as 15° 19.8’ east, or 01519.8.

“This resulted in a positional error in excess of 11,000km, which adversely
affected the aircraft’s navigation systems and some alerting systems,” the
ATSB said.

The report said the crew had “a number of opportunities to identify and
correct the error” but did not notice it until they had become airborne and
started to track in the wrong direction.

Those opportunities included a flag or message that flashed up on the captain
’s screen during crosscheck of the cockpit preparations, which the first
officer later told ATSB investigators he had seen but not mentioned because
it was “too quick to interpret”; and three separate chimes which, because
they were not accompanied by a message from the computer, were ignored.

A fifth sign that something was wrong came in the form of an alert blaring: “
TERRAIN! TERRAIN!” This was not ignored – both pilots said it had “startled
” them. But, as that alert meant they were about to hit something and they
could see the way ahead was clear, and as the busy runways at Sydney airport
made the full response to such an alert “undesirable”, they pressed on.

However, when autopilot engaged at 410 feet, it tracked the plane left,
toward the flight path of another runway.

Both the captain and the first officer tried to fix the system but “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 ATSB said.

They requested to return to Sydney but told air traffic control they were
were only capable of making a visual approach – that is, landing without the
assistance of their navigation systems.

Air traffic control replied that since the weather and visibility had
worsened in Sydney, they should instead head to Melbourne.

The plane spent three hours on the ground in Melbourne fixing the problem
before departing for Kuala Lumpur, where it arrived at 10.20pm local time,
six hours behind schedule.

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.


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※ 文章網址: https://www.ptt.cc/bbs/Aviation/M.1473266637.A.CF2.html
→ vhygdih: 我覺得現代化的飛機可以給很多訊息駕駛艙,真的會降低平常
→ vhygdih: 的警覺心 另外太多false signal 也可能也會造成駕駛人員
→ vhygdih:  在重要時刻判斷錯誤, 那時候機師可能的想法會是我怎麼可
→ vhygdih: 能會犯這種錯....
推 techih: 在飛機上沒辦法改GPS導航嗎？
→ twflanker: 這是把MCDU玩壞了嗎...Orz
推 howard2010: 現代飛機一直有用GPS壓~ FMC整合IRS、GPS及導航台資料