Final report released from AirAsia A320 incident at Perth Airport

Photo by Ernest Leung | AeroNewsX

On November 24, 2017, an Indonesia AirAsia Airbus A320 bearing the registration PK-AZE, took off from Runway 21 at Perth Airport bound for Bali. Shortly after taking off, the aircraft banked left at about 223 feet AGL, which was below the minimum height for turns. There were 145 passengers and 6 crew on board. There were no reported injuries, and the flight carried on to Bali without any further incidents.

According to the final reports released, the first officer of the flight programmed the flight management guidance system (FMGS) using Runway 03, the runway they landed on. The first officer assumed that they were departing from the same runway as they had landed on.

The first officer programmed the FMGS before tuning into the automatic terminal information service (ATIS), which would provide the pilots with the correct runway usage and weather details. The ATIS information stated that runway 21 was in use but did not change the inputs of the FMGS.

The captain reported that he did not listen to ATIS as he was conducting his pre-flight exterior checks. The first officer then conducted the takeoff briefing, which he stated that the departure runway was 03. Both pilots felt uneasy about the FMGS inputs but continued with their preparation.

Photo by Ernest Leung | AeroNewsX

The report states that "despite the various cues available for the flight crew, including several air traffic control instructions for using runway 21 and airport signage, and the flight crew reporting feelings of unease about the flight preparations, the incorrect programming was not detected."

Once the aircraft took off at around 12:20 pm, the navigation displays showed that the next waypoint was MIDLA. Since the waypoint was behind, the flight director commanded a left turn, and thus the first officer made a left turn at 223 feet AGL. Air traffic controllers noticed the deviation and corrected the aircraft's heading afterward. Following the incident, AirAsia has rolled out training for "change of departure runway" scenarios and in the area of threat and error management.

The ATSB says that this incident "demonstrates that deviating from standard procedures, even slightly, can render them ineffective and result in errors." ATSB added saying this incident "highlights the significance of stopping and re-evaluating the situation while on the ground when there is a feeling of uncertainty about the flight, even if it results in undesirable delays. This provides an opportunity to detect errors before they affect operations. Once airborne, workload and time limitations become even more critical due to the rapidly changing situation.

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