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Data Entry Blunders Force Air Asia Pilots To Land in Melbourne Instead of Malaysia (mashable.com)

A flight from Sydney to Malaysia ended up in Melbourne after the captain incorrectly entered the plane's location in its navigation system just before take-off, according to a safety investigation, whose conclusion was published this week. Mashable reports:The Air Asia pilots made several errors in entering data into the aircraft's navigation system, which caused them to follow an incorrect flight path out of Sydney, according to Australian transportation officials. While troubleshooting the incorrect flight path, the pilots were unable to fix the issue, and may have compounded it. The aircraft's systems would not allow the plane to be flown in instrument conditions and the weather also had deteriorated in Sydney by the time the pilots decided to turn back. They were directed via radar to a visual approach in Melbourne where they could land safely. The pilots did not believe the airport was located in Malaysia.

51 of 84 comments (clear)

  1. I feel slightly dumber by Anonymous Coward · · Score: 2, Insightful

    Mashable reports...

    That summary is such a hodge-podge of disconnected half-facts. A link to a publication written by trained journalists, or even trained monkeys, might be more coherent.

    1. Re:I feel slightly dumber by Len · · Score: 2, Funny

      That's because the Slashdot summary is a copy of the article's correction paragraph. *facepalm*

    2. Re:I feel slightly dumber by thegarbz · · Score: 1

      A link to a publication written by trained journalists, or even trained monkeys, might be more coherent.

      Before you blame Slashdot for half facts, remember trained and paid journalists are able to come up with headlines such as these:
      "AirAsia pilot ends up in Melbourne instead of Malaysia after navigation error"

      As bad as it is, Slashdot has produced better journalism than The Guardian's headline.

    3. Re:I feel slightly dumber by Zanadou · · Score: 1

      The actual Australian Transport Safety Bureau report

      The main take-away:

      When manually entering the coordinates of the aircraft's position using a data entry technique that was not recommended by the aircraft manufacturer, the longitude was incorrectly entered as 01519.8 east instead of 15109.8 east. This resulted in a positional error in excess of 11,000 km, which adversely affected the aircraft's navigation systems and some alerting systems.

  2. Actual link by Anonymous Coward · · Score: 1

    http://www.atsb.gov.au/publications/investigation_reports/2015/aair/ao-2015-029/

  3. "Initial Position" Error by tsqr · · Score: 1, Interesting

    Navigation grade inertial nav systems need to know their initial position in order to perform accurately. According to the Australian Transport Safety Bureau report, an erroneous longitude value was entered prior to takeoff. This is very curious, as initial position is supplied automatically from GPS, unless (1) GPS is not available; or (2) the system is very old and doesn't have that feature. If the latitude is correct but the longitude is wrong, the INS will probably align properly, but it really won't know where the heck it is.

    1. Re:"Initial Position" Error by GuB-42 · · Score: 5, Insightful

      From the investigation report :

      The ATSB also found that the aircraft was not fitted with an upgraded flight management system that would have prevented the data entry error via either automated initialisation or automatic correction of manual errors.

    2. Re:"Initial Position" Error by tsqr · · Score: 1, Interesting

      From the investigation report :

      The ATSB also found that the aircraft was not fitted with an upgraded flight management system that would have prevented the data entry error via either automated initialisation or automatic correction of manual errors.

      Yeah, I saw that. "Not fitted with an upgraded flight management system..." is a rather understated description, as every INS and FMS designed in the last 20 years features automated initialization. I wonder if they were having GPS issues.

    3. Re: "Initial Position" Error by Anonymous Coward · · Score: 1

      Isn't ATSB rx like $20

    4. Re:"Initial Position" Error by tsqr · · Score: 1

      Sounds reasonable.

      Care to try for why it can't fly on instruments?

      Sure, I'll give that a try. How about: you can't fly on instruments if your instruments don't know where the airplane is.

    5. Re: "Initial Position" Error by TroII · · Score: 1

      Assuming you mean ADS-B, you can build a capable receiver for around $150, but you won't be putting that on a commercial aircraft. An FAA or ICAO equivalent certified ADS-B in/out transceiver will cost you a few thousand dollars.

    6. Re:"Initial Position" Error by jbwolfe · · Score: 1

      every INS and FMS designed in the last 20 years features automated initialization. I wonder if they were having GPS issues.

      The automated part would not include aligning the inertial, only origin/destination, route and winds. The aircraft has GPS and it should have given them several warnings but the short taxi out may not have given enough time for them to display.

      From the report: "The aircraft-generated post-flight report indicated that faults associated with failure of GPS integrity checks occurred 14 and 9 minutes prior to take-off. These failures were the result of the positional error and occurred while the aircraft was being taxied for take-off. Both of these faults are designed to have an associated single chime master caution aural alert, and the respective GPS NAV (1, 2) FAULT should appear on the engine/warning display. There were no associated ECAM messages indicating faults to either GPS."

      --
      Have you ever noticed that anybody driving slower than you is an idiot, and anyone going faster than you is a maniac?
    7. Re:"Initial Position" Error by jbwolfe · · Score: 1
      In this case, the crew erroneously turned off ADIRS 1 and 3 while trying to troubleshoot which rendered the aircraft VMC only and in alternate law. They made it much worse for themselves. Had they not done that they could have used standby nav to manually tune and fly ground based navaids.

      From the report: "Once ADIRUs 1 and 3 were selected OFF, the captain's primary flight display (PFD) lost all information except accurate airspeed and vertical speed, and the captains ND displayed the GPS PRIMARY LOST, HDG and MAP NOT AVAILABLE warning flags. In addition to the information remaining on the captain's PFD, the FO's PFD continued to display accurate airspeed, vertical speed and attitude information, but the displayed heading information was incorrect. The FO's ND also displayed incorrect heading information and there was no usable map, waypoint or tracking information. The autopilot and autothrust systems were also unavailable, and the aircraft had reverted from normal law to alternate law."

      --
      Have you ever noticed that anybody driving slower than you is an idiot, and anyone going faster than you is a maniac?
  4. Re:MH370 by Anonymous Coward · · Score: 1

    That's a jumbled mess of nonsense but what i think you're trying to say is that the path MH370 took looked as if it was plotted with the goal of avoiding detection.

  5. Re: What? by tsqr · · Score: 1

    And ffs if they could fly the stick why didn't they just fly the stick to Malaysia?

    Right. They should have just followed the railroad tracks.

    Sydney to Kuala Lumpur is over 6600 km, lots of it over water. Sydney to Melbourne is about 700 km, all over land.

  6. Re:MH370 by Anonymous Coward · · Score: 1

    Combined with a sudden radio silence and switched off transponder? Not likely. If they were simply flying in the wrong direction ATC would see that immediately, as in this Air Asia case.

  7. Re:MH370 by Joe_Dragon · · Score: 1

    MH370 made an turn towards an airports. Like there was a fire on it and they turned to nearest safest airport

  8. Re:maybe the same thing happened by Anonymous Coward · · Score: 1

    Posts like yours make me wonder if people are trolls or just morons.

  9. Re:MH370 by Anonymous Coward · · Score: 3, Insightful

    Wow. You found us out. You are so smart. Now post something about Bilderberg and the Fed!!!

  10. Re:maybe the same thing happened by Anonymous Coward · · Score: 1

    Most people left on this site are morons. Usually IT guys who are looking for some excitement. Pathetic, but there ya go.

  11. Re:maybe the same thing happened by msauve · · Score: 1

    ...now explain why it flew along the correct route for about an hour, and then the lack of radio contact.

    --
    "National Security is the chief cause of national insecurity." - Celine's First Law
  12. Re:MH370 by Thelasko · · Score: 1

    I didn't read anything about air traffic control noticing the error in TFA. From how I read it, the copilot noticed.

    Now, I must admit TFA seems to be lacking quite a few details, plus the style sheet won't load for me.

    --
    One of our competitors trademarked the term "hypothesis". From now on, we will call them "boneheaded ideas".
  13. Varig Flight 254 by a25527691f · · Score: 2

    The same happened in Brazil almost 30 years ago (https://en.wikipedia.org/wiki/Varig_Flight_254):

    Varig Flight 254 was a Boeing 737-241, c/n 21006/398, registration PP-VMK, on a scheduled passenger flight from São Paulo, Brazil, to Belém, Pará, Brazil, with several intermediate stopovers, on 3 September 1989. Prior to takeoff from Marabá, Pará, towards the final destination, the crew entered an incorrect heading into the flight computer. Instead of flying towards its destination, the plane flew due west and after some time was over a remote area of the Amazon jungle. Attempts to reach an alternative airport were unsuccessful, and the plane eventually ran out of fuel. The pilot made a belly landing in the jungle, 1,050 mi (1,690 km) northwest of Rio de Janeiro. There were 54 occupants on board—48 passengers and a crew of six; 13 passengers died, and many more sustained serious injuries. The survivors were rescued two days later.

  14. In related news ... by PPH · · Score: 4, Funny

    ... an article posted on Slashdot went seriously off course after editors entered data from suspect sources into their publishing system. Search and rescue has been mobilized but it is feared that many readers are already hopelessly lost.

    --
    Have gnu, will travel.
  15. Re:maybe the same thing happened by Hognoxious · · Score: 1

    If they hadn't done that it would have been too obvious. (For pretty much any values of "they" and "it")

    --
    Confucius say, "Find worm in apple - bad. Find half a worm - worse."
  16. Re:MH370 by ColdWetDog · · Score: 2

    Umm, right. You don't just 'unhook' the autopilot and stuff in a new one. This is not a car stereo.

    I suppose you could just sneak a 777 off the tarmac a bit ('hey guy's, it's cool') and rip out the cockpit guts and stuff your new black box in, do extensive system checks, button up everything and sneak it back. Without anybody whatsoever noticing.

    But I doubt it.

    --
    Faster! Faster! Faster would be better!
  17. Re:Note To Self by Hognoxious · · Score: 2

    And everybody thinks they're crap at driving...

    --
    Confucius say, "Find worm in apple - bad. Find half a worm - worse."
  18. complicated by supernova87a · · Score: 4, Interesting

    This is a much more complicated and interesting story than the headline or first glance would suggest. (because as is common, the headline makes it sound like a bunch of bungling pilots from a LCC airline were flailing about stupidly, which is not the case)

    The omission of a trailing zero digit in the manual entry of longitude during system initialization caused serious autopilot/navigation problems that were not resolved by automated cross-checks that should've caught it. (Error #1)

    Then, as a result of trying to fix/diagnose the problem on the fly, the flight display/instruments were put into a failure/safe mode where only visual flight conditions could be handled (Error #2).

    It turned out ok in this case (just a diversion), but if the weather had been poor or other combinations of conditions existed, it could've easily gone wrong. Very interesting...

    1. Re:complicated by thegarbz · · Score: 1

      but if the weather had been poor

      The weather was poor, hence the diversion. But really this is a good example of noticing something is wrong on the fly, ending up in a degraded state and then initiating a well controlled emergency procedure complete with risk assessment that determined the airport they departed from was too risky to allow for a landing.

      There's as many successes in this story as failures.

    2. Re:complicated by geoskd · · Score: 1

      There's as many successes in this story as failures.

      Yes, but successes should outnumber failures hundreds of thousands to one, or more. That is why pilots train so extensively, and why they follow checklists with the fervor of an evangelist. Failing to do either of those things is one more failure in the chains that lead to disaster. Just because this outcome didn't involve any deaths does not make the errors involved any less ominous. Indeed, entering incorrect data and then either failing to follow the checklist that should have caught the error, or having a faulty checklist that did not include any double checks are the kinds of errors in aviation that kill people. Ultimately, 50% of accidents are caused by pilots doing multiple wrong things, and often that is due to inadequate training, or these days, inadequate understanding of the complex machines they operate.

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    3. Re:complicated by AHuxley · · Score: 1

      re The omission of a trailing zero digit in the manual entry of longitude during system initialisation caused serious autopilot/navigation problems that were not resolved by automated cross-checks that should've caught it.
      Recalls Varig Flight 254 https://en.wikipedia.org/wiki/...
      "This misinterpretation changed the general direction north (27) to west (270)."

      --
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    4. Re:complicated by thegarbz · · Score: 1

      I didn't say that the errors aren't bad, just that this is a good example of emergency procedures gone right.

    5. Re:complicated by yes-but-no · · Score: 1

      It did go wrong a few years ago. In South America, a plane crashed into the amazon because the coordinates entered were something like 270 degree rather than 27.0; so it flew near straight west instead of north-north-west. I think ti's because they introduced a 4 digit numbering 0270 was seen as 270 instead of 27.0 since the pilots were used to seeing only 3 digit code (like 270). There is an air crash investigation video about it. Not sure how this can be avoided -- may be every flight system should upload a read-only data to a central system to do a double check.

    6. Re:complicated by yes-but-no · · Score: 1

      that's north-north-east (not north-north-west)..seems they use a clock wise notation with north being 0, east 90, south 180, west 270. So 27 degree is close to north-north-east.

    7. Re:complicated by jbwolfe · · Score: 1

      I disagree. The crew seemed determined to fail. The inertial init procedure was the first error, followed by the crews' failure to recognize this in multiple crosschecks before getting airborne, and the final critical error was executing a procedure once airborne to correct unreliable airspeed which was not present. Turning off 2 air data inertial reference systems degraded the flight controls to alternate law and rendered a perfectly capable but positionally confused aircraft VMC only. The only "successes" were a properly functioning ATC system and luck. The resolution, once airborne, was a simple one- update the inertial position to actual position- this can be done manually.

      --
      Have you ever noticed that anybody driving slower than you is an idiot, and anyone going faster than you is a maniac?
    8. Re:complicated by thegarbz · · Score: 1

      The only "successes" were a properly functioning ATC system and luck.

      Luck doesn't land planes with degraded flight controls. Mind you the thing you claim is "only" successes also put all passengers and an intact aircraft back on the ground safety with little more than a delay getting to the destination. The success story here is that fall-backs work remarkably well.

      The resolution, once airborne, was a simple one- update the inertial position to actual position- this can be done manually.

      With the benefit of hindsight all solutions are simple.

    9. Re:complicated by jbwolfe · · Score: 1

      Luck doesn't land planes with degraded flight controls.

      Luck allows a crew that followed one error and multiple omissions with another even more grievous error in an attempt to correct the first (when they certainly should have known better) to have a suitable divert, VMC on top, and capable air traffic controllers sufficient to effect a successful landing.

      With the benefit of hindsight all solutions are simple.

      Hindsight for this crew would show they executed the wrong checklist and did it incorrectly to boot. To wit: rather than turn off ADRs as called for, the F/O turned off the ADIRS. Hindsight would not show they handled it the best they could.

      --
      Have you ever noticed that anybody driving slower than you is an idiot, and anyone going faster than you is a maniac?
    10. Re:complicated by thegarbz · · Score: 1

      That's wonderfully easy to say from the comfort of your chair.

  19. Sounds familiar... by Anonymous Coward · · Score: 2, Funny

    The Air Asia pilots made several errors in entering data...

    So are they former or future Slashdot editors?

  20. Re:What? by wonkey_monkey · · Score: 3, Informative

    This is because the paragraph above was posted as a correction to the article.

    Otherwise the article gives the impression that the pilots were so incompetent as to not even realise which country they were in.

    --
    systemd is Roko's Basilisk.
  21. Re:MH370 by aaarrrgggh · · Score: 1

    Technically, you would be playing with the avionics bay below the cockpit, but still.

    While it would be possible given sufficient access and knowledge, it would be a heck of a lot less effort to try and fly it away when "nobody is watching."

  22. Our robotic overlords by chrylis · · Score: 1, Insightful

    The aircraft's systems would not allow the plane to be flown

    checks article Yup, Airbus.

    1. Re:Our robotic overlords by Anonymous Coward · · Score: 2, Interesting

      This is kind of a false idea since a Boeing has the exact same error potential. I was on a flight one time where a navigator messed up the whole inertial reference system and we lost all positional awareness (just like in this article). We didn't get "lost" because I navigated by other means. However, it was on a Boeing airplane. Airbus and Boeing, and while we're at it: Embraer, Sukhoi, Canadair, etc. have the same mode of failure in their navigation systems.

      The Airbus is highly automated but it is very well thought out. In the worse case, it can be flown like a more traditional airplane (Boeing). In fact, all the systems revert to a "direct law" system where the pilots have full authority over all flight control systems and the pilots can break stuff by exceeding limits. Honestly, more pilot error happens with Boeings than with Airbus. Think of an older Boeing (e.g. 737) as an old circa 1980's chevy with electronic fuel injection but nothing more. Think of an Airbus as that plus systems such as automatic breaking that keep you from rear ending another car. Worse case, that automatic system can be shed so that you can crash into the car in front of you.

      These pilots made logical choices which ended in a null condition. Unfortunately, this is what happens when people only know their job and not the theory behind how everything works. I doubt these guys were airplane computer engineers so without the deep knowledge of the systems (e.g. at the code level), anything they would have attempted was probably a guess. The manuals also may not have been specific to this situation and thus might have put them in this negative condition.

      Nevertheless, I can't help but to wonder if they tried using traditional terrestrial navaids to determine their position or if they were simply in oceanic airspace and inertial reference was their only means of positional awareness.

    2. Re:Our robotic overlords by mjwx · · Score: 2

      The aircraft's systems would not allow the plane to be flown

      checks article Yup, Airbus.

      Nice selective quoting.

      What it actually said was "The aircraft's systems would not allow the plane to be flown in instrument conditions". This basically says the autopilot refused to kick in due to weather conditions and threw controls back to the pilots. The pilots didn't want to land in Sydney due to the aforementioned weather conditions and diverted to the nearest major airport... which was Melbourne.

      So Yep, Airbus... did it right.

      --
      Calling someone a "hater" only means you can not rationally rebut their argument.
    3. Re:Our robotic overlords by jbwolfe · · Score: 1

      What it actually said was "The aircraft's systems would not allow the plane to be flown in instrument conditions".

      From the report: "The FO stated that, in the absence of any ECAM or STATUS messages his initial reaction was to reference the UNRELIABLE AIRSPEED INDICATION checklist in the quick reference handbook (QRH).

      Turns out they did to themselves. The aircraft was fine, just positionally lost. There was no failure of aircraft systems, rather a series of procedural errors that led to the loss of aircraft capabilities.

      --
      Have you ever noticed that anybody driving slower than you is an idiot, and anyone going faster than you is a maniac?
  23. Complicated systems need user-friendly confirmatio by Solandri · · Score: 2

    e.g. You plug in all the numbers for your flight path. It should then display a world map with your flight path overlaid, so you can easily check that the numbers you entered have you at least landing on the right continent. This sort of sanity-checking is common in other fields, like accountants check to see if a discrepancy is divisible by 9 to quickly identify a transposition error.

    This is one of the reasons I still advocate doing navigation in nautical miles instead of km. One nautical mile is defined as 1 arc-minute of longitude at the equator, which is also pretty close to 1 arc-minute of latitude anywhere on Earth. So basically you look on your big navigation chart with latitude lines labeled in degrees and minutes, and you immediately have a sense of scale in terms of nautical miles (each degree is 60 nm). You do a bunch of complex navigation calculations in nautical miles, plot it on the chart, and say, "Hey that doesn't look right. My destination is over 30 arc-minutes away, but my calculations say I'll only be sailing less than 30 nm. I must've made a math error somewhere..." Whereas if you do it in km, the sense of scale is not as intuitive and you may not uncover the error until you're far along the route and wondering why the landmarks you were expecting aren't showing up.

  24. Re: MH370 by hackwrench · · Score: 1

    No, it's worse, it's sotftware. You buy a signing key from an unscrupulous employee, write some code, plug in a USB stick and the computer replaces the autopilot itself.

  25. Re:MH370 by Anonymous Coward · · Score: 1

    Further researching the incident I guess my information source (apparently an old documentary series called "Mayday") was a tad bias, they appear to have taken the pilots view to heart that the fly by wire system delayed increasing power and when he pulled back on the controls the aircraft failed to even attempt to climb (possibly an anti-stall measure as you mentioned). The pilot had every reason to remember events that put him in a better light, that said though some pretty shady things patiently happened during the "investigation", including a possibility of 4 seconds coming up missing from the fight recorders and the black boxes that were at the trial being proven to not be the ones from the aircraft. Chances are that this was a combination of the pilot doing a risky maneuver and an some kind of system fault. It should also be noted that this is not the first time Frances Air Safety agency (BEA) has been caught trying to protect Airbus by putting the blame solely on the pilots, a 2009 Air France crash resulted in both the pilots union and representatives for the victims families both saying they had lost faith in the investigatory agency after it claimed that faulty airspeed sensors had nothing to do with a crash instead suggesting that "authorities re-examine the content of training (for pilots) and in particular make mandatory the creation of regular specific exercises aimed at manual aeroplane handling".

  26. A map would have been nice by blindseer · · Score: 2

    http://www.gcmap.com/featured/...

    It would have been nice to see a map in the news article to give some idea to those reading it unfamiliar with the area just how big of a "blunder" this was. From the Great Circle Mapper website I linked to above we see that KUL is about 4000 miles from SYD, and SYD is less than 500 miles from MEL. Given the typical cruising speed of a jetliner they were in the air for perhaps not much more than an hour on a flight that would have lasted 8 or 9 hours. Since they knew right away something was wrong I doubt they were flying much longer than that, maybe 3 hours. If they were flying much longer than that I suspect they would have landed much further from either SYD or MEL, or we'd be reading about a plane lost at sea.

    The article makes a big deal about "landing in the wrong country" which I suppose is a big deal if you take off in the USA, headed for Canada, but end up in India. Much less of a deal if you take off from USA while headed for Canada but a technical problem means you have to land back in USA.

    --
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  27. Re: What? by michelcolman · · Score: 5, Informative

    OK, here's what really happened:

    The captain entered the wrong coordinates into the Inertial Reference System, which is the airplane's primary reference for position. Normally, there are several ways the system could have detected this:

    - It is normally updated by GPS, but if the difference between the two is too large, the sytem considers the GPS to be faulty. Some warning messages were given, but these warnings often occur during normal operation on the ground and then disappear afterwards, so pilots are sort of "trained" by experience to disregard them.
    - When applying take-off thrust, the system normally realigns to the coordinates of the runway. But, thanks to genius Airbus programming as usual, the system did not perform the update because the error was too large.
    - If an incorrect latitude is entered, the system can detect the error because it measures the earth's rotation vector and the gravity vector during IRS alignment while the airplane is still parked. In this case the longitude was incorrect, which cannot be detected by the system. The earth rotates the same at any longitude.

    After Take-off, two problems arose:
    1. The position was way off, the plane actually thought it was somewhere close to South Africa
    2. The Enhanced Ground Proximity Warning System activated, yelling "Terrain, terrain!", based on the incorrect position (not a big problem, but confusing as hell and creating extra stress for the pilots).
    3. The heading indication was incorrect, because the IRS internally knows only the true heading (relative to true north) while heading indications on aircraft systems are relative to magnetic north for historical reasons. The IRS converts between the two using local magnetic variation (the difference between magnetic north and true north) but, because it thought it was near South Africa, it used the wrong value for the variation and therefore displayed an incorrect magnetic heading. This caused the autopilot to turn the wrong way.

    The pilots, fearing that something was wrong with the entire Air Data Reference system, applied a procedure for unreliable airspeed (they did not know which instruments they could trust anymore) and turned off two of the three ADR computers. This resulted in a further loss of information displayed on their screens which was not exactly helpful to their situation. The procedure exists to disable certain safety protections that might accidentally activate based on erroneous data (if two of the three computers say the airplane is stalling, the flight control computers will push the nose down and override the pilots' sidesticks) but in this case this procedure was not necessary and actually made their life harder.

    Now, if you've lost half your instruments, you don't know which instruments you can trust and which you can't (with the heading being wrong for certain), it's not a good idea to fly on instruments through clouds at low altitude. Certainly not an approach to a runway without being able to see it. So they needed to go to an airport where the visibility and cloud base allowed a visual landing. The closest suitable airport with good weather was Melbourne, so that's where they went.

  28. Re:Complicated systems need user-friendly confirma by jbwolfe · · Score: 1

    You plug in all the numbers for your flight path. It should then display a world map with your flight path overlaid

    This in fact was accomplished but the process only displays the route in map mode that does not include a aircraft symbol. The route wasn't the problem, the initial position was. One crosscheck they missed was route distance which would have been off considerably.

    This is one of the reasons I still advocate doing navigation in nautical miles instead of km.

    In aviation, nautical miles are the only standard. Kilometers are never used. Unfortunately, meters are still used in some parts of the world for altitude assignments.

    --
    Have you ever noticed that anybody driving slower than you is an idiot, and anyone going faster than you is a maniac?