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ASN Wikibase Occurrence # 236680
Last updated: 15 October 2021
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Date:24-NOV-2017
Time:12:22 LT
Type:Silhouette image of generic A320 model; specific model in this crash may look slightly different
Airbus A320-216 (WL)
Owner/operator:Indonesia AirAsia
Registration: PK-AZE
MSN: 5098
Fatalities:Fatalities: 0 / Occupants: 151
Other fatalities:0
Aircraft damage: None
Category:Incident
Location:near Perth Airport, WA -   Australia
Phase: Initial climb
Nature:Passenger - Scheduled
Departure airport:Perth Airport, WA (PER/YPPH)
Destination airport:Denpasar-Ngurah Rai Bali International Airport (DPS/WADD)
Investigating agency: ATSB
Narrative:
The Indonesia AirAsia Airbus A320 departed Perth, Australia on a scheduled passenger flight to Denpasar, Indonesia. Shortly after take-off from runway 21, the aircraft turned left, contrary to the cleared standard instrument departure, and at a height of about 223 ft above ground level, which was below the minimum height for turns specified by the operator. Air traffic control (ATC) assigned a series of headings to the flight crew. The aircraft was also turned through one of the headings assigned by ATC. An additional heading was subsequently issued by ATC to return the aircraft back to its planned track. The flight continued to Denpasar without further incident.

ATSB Findings:
From the evidence available, the following findings are made with respect to the data entry error related operational non-compliance of an Airbus A320, registered PK-AZE that occurred at Perth Airport, Western Australia, on 24 November 2017.
Contributing factors:
- Based on a recent landing, the first officer assumed runway 03 would be in use and programmed this runway for take-off into the flight management guidance system (FMGS) before listening to the automatic terminal information service (ATIS). Although the first officer copied runway 21 from the data recorded onto the flight plan, he did not notice this differed from what he had programmed into the FMGS and briefed the captain for a runway 03 takeoff.
- The captain did not obtain any independent information about the runway-in-use for pre-departure checks, including listening to the ATIS and reviewing data recorded on the flight plan, and likely relied on verbal information from the first officer.
- The incorrect programming of the FMGS was not detected before take-off despite numerous cues that the departure runway and flight path was different to what was briefed. Although the flight crew sensed there was something amiss with their pre-flight preparation, they continued without further checking.
- Shortly after take-off from runway 21, the aircraft was turned left at 223 ft above ground level. This was below the minimum allowable height of 400 ft stipulated by the operator, and well before and in the opposite direction to the cleared standard instrument departure.

Other factors that increased risk:
- The flight crew did not communicate the nature of the problem to air traffic control and so did not effectively utilise air traffic control as an available resource. This resulted in the captain unnecessarily reprogramming the FMGS at a time when workload was already high.

Sources:

ATSB

Accident investigation:
cover
  
Investigating agency: ATSB
Status: Investigation completed
Duration: 2 years and 6 months
Download report: Final report


Images:

Photo of PK-AZE courtesy AirHistory.net


Perth (YPPH / PER)
8 November 2019; (c) Kurt Finger


Revision history:

Date/timeContributorUpdates
03-Jun-2020 10:36 harro Added

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