No fatalities

2020-01-22: The Boeing Company 777-322ER (N2333U) — United Airlines — 2 km north Sydney Airport, New South Wales

2 km north Sydney Airport, New South Wales

On January 22, 2020, a The Boeing Company 777-322ER (registration N2333U) operated by United Airlines was involved in an aviation accident near 2 km north Sydney Airport, New South Wales. No fatalities were reported. Investigators recorded the probable cause as: The pilot flying incorrectly amended the flight management computer (FMC) for the cleared departure. The amended FMC setup was probably not effectively communicated to the crew or effectively cross-checked by the pilot monitoring or relief pilots. This summary draws on records from the Australian Transport Safety Bureau (ATSB); 5 related events involving the same aircraft type or operator are linked below.

Sourcesthe Australian Transport Safety Bureau (ATSB)Primary reportUpdated 1779785948Data APIEditorial standards
Aircraft registered N2333U
Aircraft registered N2333U. Photo: N509FZ / CC BY-SA 4.0, via Wikimedia Commons

A flight crew's incorrect reprogramming of the Flight Management Computer (FMC) during departure setup resulted in a loss of separation. The captain was unfamiliar with the radar transition procedure, leading to the removal of a necessary route discontinuity.

Event Summary

A foreign captain, anticipating a clearance via the SYD1 standard instrument departure, pre-programmed the Flight Management Computer (FMC) accordingly and briefed the other crew members. However, the actual pre-departure clearance from air traffic control specified a different procedure (RIC5). The captain's limited exposure to Sydney's varying departure procedures and unfamiliarity with the radar transition—due to prevalent procedural-based transitions in the United States—likely contributed to the discrepancy. The clearance required the FMC to be reprogrammed for the RIC5 procedure.

FMC Setup and Clearance

During reprogramming, the pilot flying (PF) removed a discontinuity automatically generated in the FMC flight path. This action would have been appropriate for many procedural transitions but not for a radar transition. The discontinuity was meant to represent controller-issued vectors beyond 12 NM northwest of Sydney. By removing it, the aircraft was reprogrammed to track directly to waypoint DIPSO after reaching the initial waypoint at 1,500 ft, where a left turn was expected. Instead, the aircraft turned right, causing a loss of separation.

Crew Coordination

Effective crew coordination depends on clear communication. The operator's procedures provided a framework for the flight crew to verify the FMC setup. The pilot monitoring (PM) and relief pilots in observer seats had opportunities to detect the error. However, the PM was unaware of the change to the radar transition, indicating the PF may not have clearly verbalised the amendment. The PM verified the FMC using only the summary RTE page, missing the waypoint sequencing error visible on the LEGS page. During the departure review, both pilots noticed a 'no transition' indication on the FMC RTE page but did not recognise it as inconsistent with the cleared radar transition.

Communication

Readbacks of clearances serve to acknowledge intent and content. The PM provided a truncated readback to air traffic control, which the controller did not challenge. This gave no assurance that the crew understood they were cleared for a radar transition, increasing the risk of FMC setup errors and potential confusion during the initial climb.