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

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No flight data was available for the 12 September 2006 flight. The location of theaircraft at the time of the NAV IR 1 FAULT was estimated using positions reportedby aircraft communications, addressing and reporting system (ACARS) messagestransmitted before and after the fault occurred. That technique gave a position 980km (530 NM) north of Learmonth, Western Australia (Figure 26).Table D1: Cockpit effect messages for the three data-spike occurrences 203Cockpit effect message12 September20067 October200827 December2008AUTO FLT AP OFF - +02 +00NAV IR 1 FAULT +00 +00 +00NAV ADR 1 FAULT +30 +33 +01NAV GPWS FAULT +00 +00 +00NAV GPWS TERR DET FAULT - +01 -NAV GPS 1 FAULT +00 +00 +01NAV GPS 2 FAULT +03 +00 +01NAV FM/GPS POS DISAGREE - +00 +08NAV IR NOT ALIGNED +05 +02 +01FLAG ON CAPT ND MAP NOT AVAIL +00 +00 +00EIS DISPLAY DISCREPANCY - +05 -A. ICE L CAPT STAT HEAT +03 +00 +01A. ICE R CAPT STAT HEAT +03 +05 +01A.ICE CAPT PITOT HEAT +03 +16 -A.ICE CAPT AOA HEAT - +28 -A.ICE CAPT PROBES HEAT - +08 -BRAKES AUTO BRK FAULT - +02 -CAB PR LPO DIFF PR - +48 -MAINTENANCE STATUS IR 1 +00 +00 +00MAINTENANCE STATUS ADR 1 +00 +00 +00MAINTENANCE STATUS LGCIU1 +30 +51 +01MAINTENANCE STATUS LGCIU2 +30 +51 +01MAINTENANCE STATUS EFCS1 +00 +00 +00MAINTENANCE STATUS EFCS2 +00 +00 +00F/CTL PRIM 1 PITCH FAULT - +02 -F/CTL PRIM 3 FAULT - +02 -F/CTL PRIM 2 PITCH FAULT - +05 -F/CTL ALTN LAW - +05 -203Numbers indicate the time (in minutes) that the message occurred after the first related message.- 236 -
Occurrence on 27 December 2008OverviewOn 27 December 2008, an Airbus A330-303 aircraft, registered VH-QPG (QPG)and being operated as Qantas flight 71, was on a scheduled passenger transportservice from Perth to Singapore. The aircraft departed Perth at 0750 UTC(1550 local time) and reached its cruise altitude of FL360 at 0814. At 0829(1729 local time), ADIRU 1 failed.The flight crew reported that:• The autopilot (autopilot 1) disconnected and the ECAM started providing aseries of caution messages, including a NAV IR 1 FAULT.• They actioned the relevant operational procedure 204 by selecting theIR 1 pushbutton to OFF and the ADR 1 pushbutton to OFF, and both OFF lightsilluminated.• They continued to receive multiple ECAM messages, and those messages wereconstantly scrolling on the display. One of the ECAM messages was a NAV IR1 FAULT, and the recommended crew action was to switch the ATT HDGswitch to the CAPT ON 3 position. They completed this action, but it did notstop the ECAM messages.• They returned to Perth and conducted an uneventful landing. At no stage wasthere any effect on the aircraft’s flight controls.At the time that the autopilot disconnected, the aircraft was about 480 km (260 NM)north-west of Perth and about 650 km (350 NM) south of Learmonth (Figure 26).The PFR for the 27 December 2008 flight contained a series of messages associatedwith ADIRU 1 that were very similar to those for the PFR from the 7 October2008 occurrence (Table D1). Consistent with there being no in-flight upset, therewere no PRIM FAULTS or PRIM PITCH FAULTS.Flight recordersThe flight data recording system fitted to QPG on 27 December 2008 differed fromthe system fitted to QPA. QPG had a single box system (Teledyne FDIMU partnumber 2234340-02-02) with two separate processors to handle both the FDR andACMS (QAR) functions. However, the source of ADIRU parameters for the FDRand QAR was the same as for QPA (section 1.11).The overall pattern of ADR and IR data from the recorders was very similar to thatfor the 7 October 2008 event. A summary of key events from the FDR is presentedin Table D2. The FDR data is presented in Figure D1 and D2, and QAR data ispresented in Figure D3.204This procedure was different to that which applied at the time of the 7 October 2008 occurrence.The relevant procedure at the time of the 27 December 2008 occurrence was based on AirbusOperations Engineering Bulletin (OEB) 74-3 issued in December 2008 in response to the7 October 2008 accident (section 7.1.1).- 237 -
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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
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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
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Page 255: APPENDIX D: OTHER DATA-SPIKE OCCURR
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
Page 304 and 305: 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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