In-flight upset - 154 km west of Learmonth, WA, 7 October 2008,

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4.2.4 Events after the second upsetImmediately following the second upset, one of the flight attendants in the frontgalley secured herself into the Left 1 cabin crew seat and the CSM secured herselfinto the Left 2 seat. The CSM helped the first officer remain secured near the Left 2seat until he was requested by the other flight crew to return to the flight deck. Oneflight attendant in the centre section continued to provide some assistance topassengers before securing himself in the Right 3 seat. The off-duty CSM in therear galley provided medical assistance to the injured flight attendant and passengerin the rear galley before securing the injured flight attendant into the Right 4 seatand the injured passenger into the Left 4 seat. She subsequently secured herself intoa passenger seat at the rear of the aircraft.During the remainder of the flight, the flight crew made several publicannouncements to the passengers and crew, instructing them to remain seated withtheir seat belts fastened. The operating CSM ensured that relevant information wasprovided to the flight crew regarding the status of the cabin and also ensured thatother cabin crew were kept informed of the situation. The flight crew advised thecabin crew that they had to remain seated due to the potential risk of another upsetevent.Prior to and after the second event, the cabin crew provided instructions topassengers to be seated and to keep their seat belts fastened. Some passengersrequested medical assistance but the cabin crew advised them that they were unableto leave their seats. Some passengers provided medical attention to other passengersseated close to them, and cabin crew provided advice from their seats to somepassengers about medical treatment. Towards the end of the flight, cabin crew andpassengers in some areas cleared the aisles of debris and bags within their reach andwithout leaving their seats.Details of the public announcements and other significant communications to andfrom the flight crew regarding cabin safety issues are provided in Table 29. Theseevents do not include communications between cabin crew.4.2.5 Events after landingAfter the aircraft landed at 0532, the cabin crew moved through the cabin to assessthe situation and start providing assistance to injured passengers. The CSMinformed the flight crew about the extent of the injuries, and the first officer theninformed air traffic control (and, via the controller, emergency response personnel)that there was at least one broken arm, one broken leg, several concussions and asignificant number of head lacerations on board.The crew agreed that the best course of action was for medical personnel to boardthe aircraft and start treating the most seriously-injured passengers and crew beforedisembarking the other passengers. At 0541, the first officer made a publicannouncement for the passengers to remain seated and to keep the aisles clear sothat medical personnel could attend to the most seriously injured. Shortly after theaircraft arrived at the terminal at 0542, medical personnel boarded the aircraft.Passengers and crew reported that medical treatment was promptly provided tothose who were injured.- 166 -
Table 29: Significant cabin communications (based on the CVR)TimeEvent0442 First pitch-down event. Second officer made a public announcement, telling allpassengers and crew to be seated and to fasten seat belts immediately.0445 Second pitch-down event.0446 Captain made public announcement, advising that the crew were dealing withflight control problems, and telling everyone to remain seated with their seatbelts fastened.0447 Second officer called the flight attendant who was seated at Left 1, and askedher to send the first officer to flight deck. The flight attendant contacted theCSM at Left 2 to pass on the request. The CSM called the second officer toadvise that the first officer was on his way.0448 First officer arrived on the flight deck, and advised that people in the cabinwere injured. Flight crew decided to make a PAN broadcast.0449 First officer made a PAN broadcast to air traffic control, advising that theaircraft had flight control computer problems and that some people wereinjured. He requested a diversion to Learmonth.0451 Second officer called the flight attendant at Left 1, asking her to obtaininformation about the injuries in the cabin. The flight attendant advised that shecould not see all of the cabin. The second officer told her not to get out of herseat but to call the mid-section to obtain more information.0452 First officer contacted air traffic control, requesting the controller to organisemedical assistance at Learmonth.0453 Off-duty CSM in rear galley called the flight deck, advising the second officerthat a flight attendant and two passengers were seriously injured. Secondofficer told the off-duty CSM to be seated with her seat belt fastened as thecrew could not guarantee that another upset would not occur. Based on theinjury information, the captain asked the first officer to declare a MAYDAY.0454 First officer made a MAYDAY broadcast to air traffic control, advising that theyhad at least one broken leg and some cases of severe lacerations.0457 CSM (at Left 2) called the flight deck, advising the second officer that therewas extensive damage to the ceiling and some injuries. Second officer advisedthe CSM that they were diverting to Learmonth. CSM stated that she wouldbrief the other cabin crew and gather further information.0500 Captain made public announcement, advising that the flight crew knew peoplewere injured. He also advised that they were diverting to Learmonth, expectingto arrive in 10 to 15 minutes, and that medical assistance would be waiting. Hetold everyone to remain seated with their seat belts fastened.0502 CSM contacted the flight deck to ask whether they should close the overheadlockers. The first officer advised her that it was safest to stay seated with seatbelts fastened. He also advised it was not an emergency landing, and that nocabin preparation was needed and no public announcement was requiredabout preparing for landing.0527 CSM made a public announcement, telling passengers to follow any directionsprovided by the crew.0527 First officer made a public announcement, advising that the aircraft would landin 3 to 4 minutes, the crew did not anticipate any further problems, and thatpassengers should listen for any crew instructions.0532 Aircraft touched down at Learmonth.- 167 -
Page 1:
ATSB TRANSPORT SAFETY REPORTAviatio
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Published by: Australian Transport
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3 FACTUAL INFORMATION: AIR DATA INE
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DOCUMENT RETRIEVAL INFORMATIONRepor
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TERMINOLOGY USED IN THIS REPORTOccu
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CSMCSSCVRDADSDCDGACDMCDMUEASAECAMED
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RAMRTCASATCOMSAESAOSDSECSEESEUSSASS
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FCPC design limitationAOA is a crit
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- xviii -
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associated with a master caution ch
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Figure 2: Aircraft track and key ev
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The crew decided that they needed t
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1.3 Damage to aircraftThere was sig
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• The flight crew provided inputs
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exceeding a predefined safe flight
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Table 1: Examples of ADIRU flight d
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Inertial reference partThe IR part
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ADIRS switching controlsIn normal o
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Processing by ADIRUs and FCPCsEach
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The information presented on the fl
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A system could flag its output data
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Table 4: Summary of indications for
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Figure 17: ECAM engine / warning di
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Table 6: Required actions associate
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For internal aircraft communication
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Table 7: Sequence of events (from t
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In summary, the source of most of t
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Summary of IR data for the occurren
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Figure 22: QAR plot showing oscilla
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QAR dataOverall, the QAR recorded 4
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Flight crew pitch inputsDuring manu
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They provided information for maint
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Table 11: Cockpit effect messages d
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Table 13: Troubleshooting data rela
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position 1 on QPA. Further details
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class 1 fault messages shown in Tab
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If there was a discrepancy between
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1.15 Survival aspectsInformation on
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did not identify any faults. The BI
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Comparison of the three occurrences
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1.17.2 Processes for reporting and
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2 FACTUAL INFORMATION: ELECTRICAL F
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monitored external systems that pro
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Each FCPC used a number of paramete
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AOA computation logicThe FCPC softw
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Figure 29: FCPC processing of sever
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Table 19: Characteristics of elevat
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Simulation of AOA values for the fi
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2.2.2 Review of recorded flight con
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second PRIM 3 FAULT. The role of ma
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The ACJ was built around the princi
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• It stated that the identificati
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The second part of the V-cycle invo
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• Functional requirements. These
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2.4.5 Safety assessment activitiesG
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equipment software and aircraft ins
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2.5.4 Factors associated with the i
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it is very difficult if not impossi
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applicable to highly-integrated or
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Ongoing developmentsA range of rese
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To conduct an effective fault tree
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According to this model, accidents
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3 FACTUAL INFORMATION: AIR DATA INE
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• inertial reference input/output
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3.3 Examination of data-spike patte
Page 135 and 136: Figure 38: ARINC 429 word for an AO
Page 137 and 138: 3.3.4 Data-spike patterns for the 7
Page 139 and 140: Figure 43: Qualitative correlation
Page 141 and 142: etween the values of any of the fou
Page 143 and 144: 3.4.3 Calculating parameter valuesA
Page 145 and 146: 3.4.5 Packaging the ARINC 429 wordT
Page 147 and 148: 3.4.8 Transmitting data to other sy
Page 149 and 150: ARINC 429 packaging analysisThe ADI
Page 151 and 152: component configurations of differe
Page 153 and 154: manufacturer reported such BITE dat
Page 155 and 156: 3.6 Potential trigger types3.6.1 Ba
Page 157 and 158: such as liquids or small loose frag
Page 159 and 160: wires). The electric 144 field stre
Page 161 and 162: Although the investigation could no
Page 163 and 164: 3.6.6 Single event effectsBackgroun
Page 165 and 166: until a few years ago, were not dir
Page 167 and 168: Unit testingIn 2005, as part of the
Page 169 and 170: that involved a NAV IR and/or NAV A
Page 171 and 172: EMI from other aircraft systems (su
Page 173 and 174: from ADIRU 1 was not correctly reco
Page 175 and 176: • Detected failure. Any failure w
Page 177 and 178: The ADIRU manufacturer’s analysis
Page 179 and 180: the aircraft and ADIRU manufacturer
Page 181 and 182: 4 FACTUAL INFORMATION: CABIN SAFETY
Page 183 and 184: Summary details of the cabin crew
Page 185: section, and the ninth flight atten
Page 189 and 190: Figure 48: Example of damage to the
Page 191 and 192: 4.3.2 Seat belt examinationsSix pas
Page 193 and 194: The flight crew’s procedures requ
Page 195 and 196: takeoff, landing or when the seat-b
Page 197 and 198: Table 31: Levels of injuryInjury le
Page 199 and 200: 4.6.4 Injuries to seated occupants
Page 201 and 202: The percentage of occupants who wer
Page 203 and 204: Statistical analyses 197 were done
Page 205 and 206: passengers reported that they had h
Page 207 and 208: that seat belts should be worn only
Page 209: 4.8.2 Handholds in the cabinThe FAA
Page 212 and 213: Figure 53: Overview of the 7 Octobe
Page 214 and 215: process needs to ensure that there
Page 216 and 217: and determine whether they could le
Page 218 and 219: useful in this case. If the EFCS sp
Page 220 and 221: 5.3.2 Risk associated with the fail
Page 222 and 223: • All three events occurred in a
Page 224 and 225: place. Although aviation manufactur
Page 226 and 227: equiring cabin crew to enforce the
Page 228 and 229: With the information available to t
Page 230 and 231: ADIRU 1 affected the operation of a
Page 233 and 234: 6 FINDINGSFrom the evidence availab
Page 235: • As of April 2010, the LTN-101 a
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did not illuminate. The new OEB (A3
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modifications were made to its guid
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this advice. At the time of the fir
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APPENDIX A: VERTICAL ACCELERATIONST
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APPENDIX B: FLIGHT RECORDER INFORMA
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APPENDIX C: POST-FLIGHT REPORTThe f
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APPENDIX D: OTHER DATA-SPIKE OCCURR
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Occurrence on 27 December 2008Overv
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Figure D2: FDR data for the 27 Dece
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ADIRU informationADIRU 1 was the sa
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APPENDIX E: ADIRU TESTINGTest plan
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Visual inspectionsExternal visual i
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(ADR) output databuses. Loading on
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Unit 4167 passed 2,223 of 2,272 tes
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dwells (sustained testing at a fixe
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APPENDIX F: AIRCRAFT LEVEL TESTINGI
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APPENDIX G: ELECTROMAGNETIC RADIATI
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cannot be ‘decoded’ by the rece
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APPENDIX H: SINGLE EVENT EFFECTSNot
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Factors affecting SEE exposureAn ai
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portions of memory are constantly b
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Depending on the form of EDAC, sing
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• crew actions: the passenger’s
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The questionnaire respondents were
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was centred across the passenger’
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Previous occurrencesThe seat belt m
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Australian turbulence eventsThe mos
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APPENDIX L: SEAT BELT USE IN ROAD V
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Table L1: Recent seat belt use rate
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US Federal Aviation AdministrationT
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APPENDIX N: SOURCES AND SUBMISSIONS
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Hanson, RJ 1987, Conducted electrom
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Tvaryanas, AP 2003, ‘Epidemiology
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In-flight upset - 154 km west of Le
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In-flight upset - 154 km west of Learmonth, WA, 7 October 2008,

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