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

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Supplementary information on probe heat faultsFigure C1 shows the specific bits used in the ADR discrete word #1 parameter toindicate specific probe heat faults. To trigger the message on the PFR indicating allprobes had heating faults (A.ICE CAPT PROBES HEAT) required bits 12, 14, 15,16 and 17 all to be ‘0’ (that is, all of the individual probe heat fault discretes neededto indicate a ‘Fault’).Figure C1: Bit allocation for ADR discrete word #1 (label 270)- 234 -
APPENDIX D: OTHER DATA-SPIKE OCCURRENCESOccurrence on 12 September 2006On 12 September 2006, an A330-303 aircraft, registered VH-QPA (QPA) and beingoperated as Qantas flight 68, was on a scheduled passenger transport service fromHong Kong to Perth, Western Australia. At 2052 Universal Time Coordinated(UTC), or 0452 local time, while the aircraft was in cruise at FL410, there was afailure of air data inertial reference unit (ADIRU) 1. The ADIRU was the same unit(serial number 4167) as on the 7 October 2008 flight.The operator’s maintenance watch log recorded that the flight crew contactedmaintenance watch and reported that they had a NAV IR 1 FAULT and ‘continuousECAM messages’ that could not be stopped, and that the problem was eventuallyresolved when the crew selected the air data reference (ADR) 1 pushbutton OFF.The flight crew entered the problem into the aircraft’s technical log, noting thatthere had been a NAV ADR 1 FAULT and that they had received numerouselectronic centralized aircraft monitor (ECAM) messages. Maintenance recordsstated that, in accordance with the manufacturer’s maintenance procedures for therelevant post-flight report (PFR) fault messages, an ADIRU re-alignment wasconducted and a system test of both the inertial reference (IR) and ADR parts wasconducted. No faults were found and the aircraft was returned to service.Following the 7 October 2008 occurrence, further information was provided by theflight crew regarding the 12 September 2006 occurrence. The crew reported that:• The event occurred at night and the aircraft was in clear conditions at the time ofthe event. The first officer was the pilot flying and autopilot 2 was engaged. Theautopilot and autothrust remained engaged throughout the event.• There were numerous ECAM messages, and the messages changed rapidly andcould not be properly read or actioned. There were also numerous stall warningsand overspeed warnings.• Discussions with maintenance watch could not resolve the issue. However, ascan of the overhead panel identified a very weak and intermittent ADR 1 faultlight, and the crew decided to turn the ADR 1 off. Following that action, thewarning and caution messages ceased and the flight continued without furtherincident. At no stage was there any effect on the aircraft’s flight controls.The post-flight report (PFR) was very similar to the PFR for the 7 October2008 occurrence. The cockpit effect messages from both occurrences aresummarised in Table D1, together with the cockpit effect messages for the thirdoccurrence on 27 December 2008. Key aspects of the PFR were:• a NAV IR1 FAULT at 2052, together with a series of other messages starting atthe same time• a NAV ADR 1 FAULT at 2122, probably associated with the crew selecting theADR 1 pushbutton OFF• no autopilot disconnection message, consistent with autopilot 2 being engagedrather than autopilot 1, and no flight control primary computer (FCPC,commonly known as PRIM) faults, consistent with there being no in-flightupset.- 235 -
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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
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Figure 38: ARINC 429 word for an AO
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3.3.4 Data-spike patterns for the 7
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Figure 43: Qualitative correlation
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etween the values of any of the fou
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3.4.3 Calculating parameter valuesA
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3.4.5 Packaging the ARINC 429 wordT
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3.4.8 Transmitting data to other sy
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ARINC 429 packaging analysisThe ADI
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component configurations of differe
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manufacturer reported such BITE dat
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3.6 Potential trigger types3.6.1 Ba
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such as liquids or small loose frag
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wires). The electric 144 field stre
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Although the investigation could no
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3.6.6 Single event effectsBackgroun
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until a few years ago, were not dir
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Unit testingIn 2005, as part of the
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that involved a NAV IR and/or NAV A
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EMI from other aircraft systems (su
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from ADIRU 1 was not correctly reco
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• Detected failure. Any failure w
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The ADIRU manufacturer’s analysis
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the aircraft and ADIRU manufacturer
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4 FACTUAL INFORMATION: CABIN SAFETY
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Summary details of the cabin crew
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section, and the ninth flight atten
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Table 29: Significant cabin communi
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Figure 48: Example of damage to the
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4.3.2 Seat belt examinationsSix pas
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The flight crew’s procedures requ
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takeoff, landing or when the seat-b
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Table 31: Levels of injuryInjury le
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4.6.4 Injuries to seated occupants
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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
Page 238 and 239: did not illuminate. The new OEB (A3
Page 240 and 241: modifications were made to its guid
Page 242 and 243: this advice. At the time of the fir
Page 245 and 246: APPENDIX A: VERTICAL ACCELERATIONST
Page 247 and 248: APPENDIX B: FLIGHT RECORDER INFORMA
Page 249 and 250: APPENDIX C: POST-FLIGHT REPORTThe f
Page 251 and 252: - 231 -
Page 253: - 233 -
Page 257 and 258: Occurrence on 27 December 2008Overv
Page 259 and 260: Figure D2: FDR data for the 27 Dece
Page 261 and 262: ADIRU informationADIRU 1 was the sa
Page 263 and 264: APPENDIX E: ADIRU TESTINGTest plan
Page 265 and 266: Visual inspectionsExternal visual i
Page 267 and 268: (ADR) output databuses. Loading on
Page 269 and 270: Unit 4167 passed 2,223 of 2,272 tes
Page 271 and 272: dwells (sustained testing at a fixe
Page 273 and 274: APPENDIX F: AIRCRAFT LEVEL TESTINGI
Page 275 and 276: APPENDIX G: ELECTROMAGNETIC RADIATI
Page 277 and 278: cannot be ‘decoded’ by the rece
Page 279 and 280: APPENDIX H: SINGLE EVENT EFFECTSNot
Page 281 and 282: Factors affecting SEE exposureAn ai
Page 283 and 284: portions of memory are constantly b
Page 285: Depending on the form of EDAC, sing
Page 288 and 289: • crew actions: the passenger’s
Page 290 and 291: The questionnaire respondents were
Page 292 and 293: was centred across the passenger’
Page 294 and 295: Previous occurrencesThe seat belt m
Page 296 and 297: Australian turbulence eventsThe mos
Page 299 and 300: APPENDIX L: SEAT BELT USE IN ROAD V
Page 301: 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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