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

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US Federal Aviation AdministrationThe United States Federal Aviation Administration (FAA) website also containedseat belt information on a webpage regarding turbulence, including the following: 239While turbulence is normal and happens often, it can be dangerous. Its bumpyride can cause passengers who are not wearing their seat belts to be thrownfrom their seats without warning. But, by following the guidelines suggestedon this site, you can help keep yourself and your loved ones safe whentraveling by air.To keep you and your family as safe as possible during flight, FAAregulations require passengers to be seated with their seat belts fastened:• When the airplane leaves the gate and as it climbs after take-off.• During landing and taxi.• Whenever the seat belt sign is illuminated during flight.Why is it important to follow these safety regulations? Consider this:• In nonfatal accidents, in-flight turbulence is the leading cause of injuriesto airline passengers and flight attendants.• Each year, approximately 58 people in the United States are injured byturbulence while not wearing their seat belts.• From 1980 through 2008, U.S. air carriers had 234 turbulence accidents*,resulting in 298 serious injuries and three fatalities.• Of the 298 serious injuries, 184 involved flight attendants and114 involved passengers.• At least two of the three fatalities involved passengers who were notwearing their seat belts while the seat belt sign was illuminated.• Generally, two-thirds of turbulence-related accidents occur at or above30,000 feet.The FAA website also contained a video that simulated the effects of turbulence onseated passengers who were wearing and not wearing seat belts. Although theg-forces associated with the simulated event were not available, the video provideda very useful depiction of the benefits of wearing a seat belt and also having otherobjects restrained in the cabin. 240239240Obtained from www.faa.gov/passengers/fly_safe/turbulence (updated 4 August 2009).The video was available at the following link:www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/turbulence/media/cabin_turbulence.wmv- 284 -
Australian Transport Safety BureauIn June 2008, the ATSB published an Aviation Safety Bulletin for passengers aboutkeeping safe during turbulence. 241 The document included the following advice forpassengers:1. Put your seatbelt on, and keep it fastened when you are seatedYour seat belt is the best defence against injuries. Keep it fastened low andtight around your waist.Almost all turbulence injuries involve people who are not properly seated anddo not have their seat belt fastened.When the seat belt sign is on, you are required by law to have your seat beltfastened for your own safety. The pilots or cabin crew will not always haveenough time to warn you to put your seat belt on before turbulence hits.When the seat belt sign is off, you should continue to keep your seat beltfastened. When moving around the cabin to use the restroom facilities and toexercise during long flights, hold on the seat backs as you walk. This will helpsecure you if the aircraft moves unexpectedly.241ATSB Research and Analysis Report AR-2008-034, Staying safe against turbulence. Availablefrom www.atsb.gov.au/media/27791/ar2008034.pdf.- 285 -
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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
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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
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 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 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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