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

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Previous occurrencesThe seat belt manufacturer, aircraft manufacturer, aircraft operator, andinvestigation and regulatory agencies associated with the investigation 229 , had notpreviously been aware of this inadvertent release scenario associated with the seatarmrest.A review of a sample of investigation reports into turbulence accidents identifiedonly two cases where a passenger reported being seated with the seat belt fastenedand that the seat belt became unfastened during the event. In those cases:• Passenger one reported that he checked that his belt was fastened during theflight because it did not seem to tighten well, but no information was providedregarding whether the belt was fastened loose or tight at the time of theturbulence. No problems were found with the belt in a subsequent inspection. 230• Passenger two was carrying a bag on her lap, and examinations found that sucha bag could, if moved sideways, contact the buckle cover and release the seatbelt. 231Relevance to the occurrence flightThe inadvertent release scenario could not occur to a tightly-fastened seat belt, andtherefore the scenario did not occur for at least three of the six passengers whoreported having their belts fastened but were not restrained. However, whether theinadvertent release scenario occurred for any of the other three passengers could notbe determined based on the available information. It is worth noting that there wasno previous knowledge of this scenario actually occurring during an in-flight upset,despite the widespread use of this type of seat belt throughout the aviation industry.It is also worth noting that a seat belt had to be very loosely fastened before thescenario could occur. Seat belts that were loosely fastened would pose a significantinjury risk even if they remained fastened. They would be difficult to keeppositioned across the passenger’s pelvis, and they would also allow significantmovement of the passenger before restraint.Although the six passengers reported that they had their seat belts fastened at thetime of the first in-flight upset, the investigation could not confirm that this was thecase. It is possible that their seat belts may have been inadvertently released prior tothe upset during their movement in the seat during the flight. It is also possible thatthe seat belts inadvertently released due to the movement of their arms or otherobjects located close to the buckle at the time.229230231The investigation agencies included the ATSB, the US National Transportation Safety Board, andthe French Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile. The regulatoryagencies included the Australian Civil Aviation Safety Authority (CASA), the United StatesFederal Aviation Administration (FAA), and the European Aviation Safety Agency (EASA).Irish Air Accident Investigation Unit report 2002/007 (ATR 42-300, EI-CPT, Mt Errigal,2 December 2001).Japan Transport Safety Board report AA2008-01 (Boeing 767-300, JA611J, 27 km south-east ofNarita, 27 October 2007).- 274 -
APPENDIX K: INJURIES DURING IN-FLIGHT UPSETSAustralian in-flight upsets with serious injuriesDuring the period 1991 to 2009, there were seven in-flight upset events resulting inat least one serious injury in Australia or that involved Australian operators. 232Details of these occurrences are provided in Table K1. The A330 accident nearLearmonth on 7 October 2008 was the most serious event. Consistent with the7 October 2008 accident, the injuries in the other six events occurred to occupantswho were not seated or who were seated and not wearing their seat belts.Table K1: Australian in-flight upsets resulting in serious injuries, 1991-2009Date30 March19926 July19965 December199627 October20008 April200223 May20077 October2008AircrafttypeBoeing 747Boeing 747Airbus A340Boeing 747Boeing 767Boeing 747Airbus A330DetailsTurbulence event. Seat-belt sign not on.One flight attendant (unseated) seriously injured.Turbulence event. Seat-belt sign not on.Six flight attendants injured (one seriously) and24 passengers injured (two seriously). All of the injuredoccupants were unrestrained, although the availableinformation did not state how many of the passengers wereseated or not seated.Autopilot disconnection and aircraft pitch-up (followingincorrect control selection by the crew). Seat-belt sign not on.Three flight attendants injured and eight passengers injured(one seriously). All of the injured occupants wereunrestrained, although the available information did not statehow many were seated or not seated.Turbulence event. Seat-belt sign not on.Two passengers (not seated) seriously injured.Autopilot disconnection and aircraft pitch-up (associated withwindshear). Seat-belt sign not on.One flight attendant (not seated) seriously injured.Turbulence event. Seat-belt sign not on.One passenger (not seated) seriously injured.Autopilot disconnect and aircraft pitch-down (due to systemproblems). Seat-belt sign not on.Twelve occupants seriously injured and at least 107 receivedminor injuries. Most of those injured were not seated orseated without their seat belts fastened.232All of the events involved high capacity aircraft (that is, more than 34 seats). In addition toin-flight upsets, there were four other events involving high capacity operators during the periodthat resulted in serious injuries; all occurred on the ground. Three of the events involved oneinjury only, and in the other event four occupants were seriously injured during an emergencyevacuation.- 275 -
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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
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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
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 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 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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