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

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1.3 Damage to aircraftThere was significant damage to overhead fittings in the cabin, consistent withpassengers or crewmembers being thrown around the cabin during the first in-flightupset. A more detailed description of the cabin damage is provided in section 4.3.No other damage to the aircraft was identified during an inspection at Learmonth(see also section 1.12.1).1.4 Other damageNo structures or objects external to the aircraft were damaged.1.5 Personnel informationLicence 23Captain First Officer Second OfficerATPL, issued14 May 1992ATPL, issued10 Oct 2001CPL, issued8 Dec 2004Total flying hours 13,592 11,650 2,070Total command hours 7,505 2,020 1,400Total A330 hours 2,453 1,870 480Hours last 90 days 165 198 188Hours last 30 days 64 78 62Hours last 7 days 29.7 29.7 29.7Hours last 24 hours 4.4 4.4 4.4A330 endorsement 17 Feb 2004(command)7 Oct 2005(command)4 Jan 2008(copilot)Last cyclic proficiency check 26 Jul 2008 6 Aug 2008 15 Aug 2008Class 1 Medical Certificateexpiry23 Jun 2009 29 Jul 2009 18 Nov 2008All of the crew were appropriately qualified and licensed to conduct the flight.In addition to 2,453 hours in command on A330 aircraft, the captain also had3,272 hours in command on Boeing 767 aircraft, and experience as a first officer onBoeing 747 and 767 aircraft. He had command endorsements on the A330 (2004)and Boeing 757/767 (1993), and first officer endorsements on the 747 (1991),757/767 (1993), and 747-400 (1993).The first officer had a command endorsement on the A330 (2005) and 1,870 hoursas a first officer on the aircraft type. He also had a command endorsement onBoeing 737-300/800 aircraft (2001), a first officer endorsement on 747-400 aircraft(1996), and previous experience as a first officer on both aircraft.serious injury is defined as ‘an injury that requires, or would usually require, admission to hospitalwithin 7 days after the day when the injury is suffered’.23ATPL: Air Transport Pilot (Aeroplane) Licence. CPL: Commercial Pilot (Aeroplane) Licence.- 8 -
The second officer had a first officer endorsement on the A330 and 480 hoursexperience as a second officer on the aircraft type.All of the flight crew operated a flight from Brisbane to Singapore on 5 October2008, with 36 hours rest before commencing duty for the QF72 flight on 7 October2008. Each of the crew reported that they had at least 7 hours sleep the night beforethe occurrence flight and a similar amount of sleep the night before.None of the flight crew reported any medical or physiological problems, and nosuch problems were evident on the cockpit voice recording for the flight. A reviewof medical records held by the Civil Aviation Safety Authority (CASA) identifiedno problems.Information on the qualifications and experience of the cabin crew is provided insection 4.1.3.1.6 Aircraft information1.6.1 General informationAircraft type Airbus A330-303Manufacturer’s serial number (MSN) 0553Year of manufacture 2003RegistrationVH-QPACertificate of Registration 31 October 2003Certificate of Airworthiness 26 November 2003 24Total airframe hours 20,040Total airframe cycles 3,740The Airbus A330 is a large capacity, wide-body, twin-engine aircraft, which is usedfor medium-to-long-range air transport operations. The A330 was developed at thesame time as the four-engine A340, and most of the aircraft systems were commonto both aircraft types. The A340 was first certified in Europe in December 1992 andthe A330 was first certified in Europe in October 1993 (see also section 2.3.1). Asof October 2008, about 570 A330s and 360 A340s had been manufactured.1.6.2 Overview of aircraft systemsFigure 3 provides a very simplistic overview of the relationship between some ofthe aircraft systems used for controlling the aircraft’s flightpath. In basic terms:• The electrical flight control system (EFCS) controlled the operation of theaircraft’s flight control surfaces (such as the elevators and ailerons).24The aircraft was delivered new to the operator as an A330-301 model in November 2003. Theoriginal Certificate of Airworthiness was dated 26 November 2003. In December 2004 the aircraftwas modified from a -301 to a -303 model, and a new Certificate of Airworthiness was issued on10 December 2004.- 9 -
Page 1: ATSB TRANSPORT SAFETY REPORTAviatio
Page 4 and 5: Published by: Australian Transport
Page 6 and 7: 3 FACTUAL INFORMATION: AIR DATA INE
Page 9 and 10: DOCUMENT RETRIEVAL INFORMATIONRepor
Page 11: TERMINOLOGY USED IN THIS REPORTOccu
Page 14 and 15: CSMCSSCVRDADSDCDGACDMCDMUEASAECAMED
Page 16 and 17: RAMRTCASATCOMSAESAOSDSECSEESEUSSASS
Page 18 and 19: FCPC design limitationAOA is a crit
Page 20 and 21: - xviii -
Page 22 and 23: associated with a master caution ch
Page 24 and 25: Figure 2: Aircraft track and key ev
Page 26 and 27: The crew decided that they needed t
Page 30 and 31: • The flight crew provided inputs
Page 32 and 33: exceeding a predefined safe flight
Page 34 and 35: Table 1: Examples of ADIRU flight d
Page 36 and 37: Inertial reference partThe IR part
Page 38 and 39: ADIRS switching controlsIn normal o
Page 40 and 41: Processing by ADIRUs and FCPCsEach
Page 42 and 43: The information presented on the fl
Page 44 and 45: A system could flag its output data
Page 46 and 47: Table 4: Summary of indications for
Page 48 and 49: Figure 17: ECAM engine / warning di
Page 50 and 51: Table 6: Required actions associate
Page 52 and 53: For internal aircraft communication
Page 54 and 55: Table 7: Sequence of events (from t
Page 56 and 57: In summary, the source of most of t
Page 58 and 59: Summary of IR data for the occurren
Page 60 and 61: Figure 22: QAR plot showing oscilla
Page 62 and 63: QAR dataOverall, the QAR recorded 4
Page 64 and 65: Flight crew pitch inputsDuring manu
Page 66 and 67: They provided information for maint
Page 68 and 69: Table 11: Cockpit effect messages d
Page 70 and 71: Table 13: Troubleshooting data rela
Page 72 and 73: position 1 on QPA. Further details
Page 74 and 75: class 1 fault messages shown in Tab
Page 76 and 77: 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
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process needs to ensure that there
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and determine whether they could le
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useful in this case. If the EFCS sp
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5.3.2 Risk associated with the fail
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• All three events occurred in a
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place. Although aviation manufactur
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equiring cabin crew to enforce the
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With the information available to t
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ADIRU 1 affected the operation of a
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6 FINDINGSFrom the evidence availab
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• 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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- 231 -
Page 253 and 254:
- 233 -
Page 255 and 256:
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
Page 269 and 270:
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
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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