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

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The recorded data showed that the failure mode started at 0828:52. In terms of theADR data, the crew selected ADR 1 OFF 28 seconds after the failure mode started(at 0829:20). Consequently, ADR 1 ceased transmitting data and the FDR switchedits source for the ADR parameters, except angle of attack (AOA) 1 and AOA 2,from ADR 1 to ADR 3. 205 When the crew switched the source of ADR parametersfor the captain’s displays to ADR 3 (0831:25), the FDR’s source of AOA 1 alsoswitched to ADR 3. During the brief period that ADR 1 data was recorded:• There were no spikes in AOA 206 or Mach.• There were two spikes for altitude, and two spikes for static air temperature.There were also four small changes (10 kts) in computed airspeed.ADIRU 1 flagged all of these anomalies as valid data.In terms of the IR data:• Although the crew reported switching IR 1 off, the QAR data showed that theIR 1 parameters continued to be transmitted by the ADIRU until after landing.• From the start of the event until after the aircraft landed, the QAR recordednumerous spikes in pitch attitude, drift angle, body lateral acceleration, inertialvertical speed, and magnetic heading. 207• In addition to the data spikes, all of the IR parameters showed persistentdeviations from their expected values. For most of these parameters, thedeviations showed oscillatory behaviour. The groundspeed parameter increasedto 1,000 kts, where it remained for the rest of the flight, except for a number oflower-value data spikes.• With only brief exceptions, ADIRU 1 flagged all of the IR 1 data after the startof the event (0828:52) as invalid.There were no stall warnings recorded (consistent with no spikes on the captain’sAOA) and no overspeed warnings recorded (consistent with only small changes oncomputed airspeed). However, there were repetitive master cautions recorded afterthe failure mode commenced, consistent with the occurrence of ECAM messages.205206207At this time the QAR stopped recording any ADR parameters from ADIRU 1. Computed airspeedwas defined as a switchable parameter, and its source switched to ADIRU 2 at this time.Some oscillations were observed in the recorded data for AOA 1 after the ADR Fail parametercommenced indicating Fail. These oscillations were examined and matched the no computed datacycling behaviour expected when ADR 1 was no longer outputting data, consistent with it beingswitched off (Appendix B).As with the 7 October 2008 occurrence, the FDR only recorded a small number of spikes at thebeginning of the event. For most of the IR parameters, the FDR switched its source if the ADIRUflagged its data as invalid. However, the QAR always sourced its data from ADIRU 1.- 240 -
ADIRU informationADIRU 1 was the same model (LTN-101) but a different unit (serial number 4122)to that involved in the 12 September 2006 and 7 October 2008 events.Following the incident on 27 December 2008, the unit was removed from theaircraft and sent to the manufacturer’s facility for downloading of the BITE dataand testing. The results of the tests were effectively the same as for unit 4167 fromthe 7 October 2008 occurrence. That is:• The BITE data showed no recorded faults, even though several fault messagesshould have been recorded.• Several routine messages normally stored in BITE were either not recorded orhad anomalies. The pattern was slightly different to that for the 7 October2008 flight (Table D3).• Subsequent examination and testing identified no problems with the unit(Appendix E).Table D3: Comparison of the BITE results for ADIRUs 4167 and 4122BITE dataFault recordsRoutine NAV Updaterecord on shutdown7 October 2008 flightADIRU 4167None recorded during theflight.Not recorded.27 December 2008 flightADIRU 4122None recorded during the flight.Not recorded.Routine elapsed timeinterval (ETI)timestampsThe ETI observed at turn on atthe manufacturer’s test facilitywas about 0.7 hours aftertakeoff. The ADIRUs were infact on for 14.8 hours.After landing, the system wasgiven a full alignment; however,the ETI reverted to the value forthe previous alignment inSingapore (the previous flight).Routine temperaturerecords (every hour)None recorded after the startof the event.None recorded but the incidentflight was only about one hour longSearch for other data-spike occurrencesFollowing the 27 December 2008 occurrence, Airbus conducted a review of PFRsusing its AIRcraft Maintenance ANalysis (AIRMAN) database. AIRMAN is aground-based software tool that assists operators of Airbus aircraft to optimise linemaintenance and troubleshooting of aircraft. Fault data is downloaded in real-time,and PFRs are stored and available for subsequent analysis.The use of AIRMAN was an operator-based decision, with most Airbus operatorselecting to use the tool. Airbus advised that at the end of 2008, there were about900 A330/A340 aircraft in operation, and 397 had Northrop Grumman LTN101ADIRUs. AIRMAN data was available for 248 of those aircraft in the 2005 to2008 period. The sample of 248 aircraft included 48 operators, and included severalairlines that operated flights to and from Australia.Airbus searched the AIRMAN database for PFRs that contained a similar pattern offault messages as those recorded on the 12 September 2006, 7 October 2008 and27 December 2008 flights. The search looked for all PFRs with ‘NAV GPS *- 241 -
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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
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passengers reported that they had h
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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 and 256: APPENDIX D: OTHER DATA-SPIKE OCCURR
Page 257 and 258: Occurrence on 27 December 2008Overv
Page 259: Figure D2: FDR data for the 27 Dece
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
Page 307 and 308: APPENDIX N: SOURCES AND SUBMISSIONS
Page 309 and 310: 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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