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

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Table E1: Summary of testing performed on the ADIRUsTest ADIRU 4461(exemplarunit)ADIRU 4167 ADIRU 4122Visual inspectionsExternal visual inspection Passed Passed PassedInternal visual inspectionDetailed microscopic and X-rayinternal inspectionFunctional testsUnpowered ground integritytestsOperational flight program(software) version and integrityverificationBasic power-on test with BITEdownloadPassedNo relevantfailuresPassedNot conducted Passed Not conductedPassed Passed Not conductedPassed Passed Not conductedPassed Passed PassedMaintenance test procedure Passed Passed PassedAcceptance test procedure Not conducted Passed PassedDatabus output waveformmeasurement and datamonitoringModule-level testingEnvironmental testsContinuous maintenance testprocedure with heat shroudDO-160C environmental testsExtended EMI testsEnvironmental stress screeningHighly accelerated stressscreeningPassedNot conductedNot conductedNo relevantfailuresNo relevantfailuresPassedNo relevantfailuresNo relevantfailuresNo relevantfailuresNo relevantfailuresNot conductedNo relevantfailuresNot conductedNo relevantfailuresNot conductedNot conductedNot conductedNot conductedPassed Passed Not conductedFollowing the 27 December 2008 occurrence, ADIRU 1 (serial number 4122) wasremoved and sent to the ADIRU manufacturer’s facilities for testing. That unit wassubjected to many of the same examinations as unit 4167, although some tests werenot considered necessary given the results already obtained through testingunit 4167. ADIRU 2 (serial number 5275) and ADIRU 3 (serial number 4354) werenot removed or tested as there was no evidence that there were any problems witheither of these units (Appendix D).- 244 -
Visual inspectionsExternal visual inspectionAn initial inspection was conducted to establish the shipping container conditionand unit identification using part and serial numbers. The units were then inspectedexternally for signs of damage, corrosion, contamination, correct fit and sealing,and quality control seal integrity. The connector pins were inspected forcontamination and damage. No problems were identified.Internal visual inspectionThe units were inspected internally following the removal of the top and bottomcovers to determine whether the modules and motherboard were correctly seatedand the mounting fasteners were correctly torqued (tightened), and to check forsigns of internal damage due to overheating, foreign objects, or other causes. Noproblems were identified.Detailed microscopic and X-ray internal inspectionEach module and motherboard was subjected to a detailed, visual inspection using amicroscope, as well as internal inspection using X-ray imagery. No problems wereidentified.Functional testsUnpowered ground integrity testsThe units’ connector pins for angle of attack (AOA) AOA input and ARINC429 databus output were measured for direct current (DC) resistance to powersupplies and ground. No problems were identified.Operational flight program (software) version and integrity verificationThe units were installed on a dedicated test station that powered up the system andperformed a cyclic redundancy check (CRC) on the unit’s operational flightprogram (software) to verify its integrity. In addition, ARINC 429 databusparameters were analysed for anomalies. No problems were identified.Basic power-on test with built-in test equipment downloadThe units were installed on a dedicated test station that powered up the system,performed some basic integrity checks, and performed a non-destructive downloadof the system built-in test equipment (BITE) data. A second download of the systemBITE data was conducted following the maintenance test procedure describedbelow. Numerous other BITE data downloads were performed following many ofthe other tests. The BITE data was then decoded for study and evaluation.All of the BITE downloads were completed successfully. As discussed insection 1.12.6, the BITE for ADIRU 4167 contained no fault messages from theoccurrence flight and there were anomalies in the recorded data for routine- 245 -
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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
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4.8.2 Handholds in the cabinThe FAA
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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 and 254: - 233 -
Page 255 and 256: APPENDIX D: OTHER DATA-SPIKE OCCURR
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: APPENDIX E: ADIRU TESTINGTest plan
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
Page 311 and 312: Tvaryanas, AP 2003, ‘Epidemiology
Page 313: 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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