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

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NASA 1995, Formal methods specification and verification guidebook for softwareand computer systems, Volume 1: Planning and technology insertion,Washington DC.Normand, E 1996, ‘Single-event effects in avionics’, IEEE Transactions on NuclearScience, vol.43, pp.461-474.Normand, E Vranish, K Sheets, A Stitt, M and Kim, R 2006, Quantifying thedouble-sided neutron SEU threat, from low energy (thermal) and high energy(>10 MeV) neutrons, IEEE Transactions on Nuclear Science, vol. 53,pp. 3587-3595.Olsen, J Becher, PE Fynbo, PB Raaby, P & Schultz, J 1993, ‘Neutron-inducedsingle event upsets in static RAMs observed at 10 km flight altitude’, IEEETransactions on Nuclear Science, vol. 40, pp. 74-77.Papadopoulous, Y McDermid, J Sasse, R & Heiner, G 2001, ‘Analysis andsynthesis of the behaviour of complex programmable electronic systems inconditions of failure’, Reliability Engineering and System Safety, vol. 71,pp. 229-247.Parker, A 2006. Public attitudes, perceptions and behaviours towards cabin safetycommunications, Research and Analysis Report B2004/0238, Australian TransportSafety Bureau.Pumphrey, D 2001, Requirements for improving the safety process on complexsystems and definition of the tools integration concepts, Technical Report WP1 forEnhanced Safety Assessment for Complex Systems (ESACS).Redmill, F 2002, ‘Exploring subjectivity in hazard analysis’, EngineeringManagement Journal, vol. 12, pp. 139-144.Rushby, J 1995, Formal methods and their role in digital systems validation forairborne systems, Contractor report 4673, NASA Langley Research Centre,Hampton, Virginia.Saleh, JH Marais, KB Bakolas, E & Cowlagi, RV 2009, ‘Highlights from theliterature on accident causation and system safety: Review of major ideas, recentcontributions, and challenges’, Reliability Engineering and System Safety, vol. 95,pp. 1105-1116.Silvera, DH Kardes, FR Harvey, N & Cronley, ML 2005, ‘Contextual influences onomission neglect in the fault tree paradigm’, Journal of Consumer Psychology,vol. 15, pp. 117-126.Strigini, L 1996, Engineering judgement in reliability and safety and its limits:What can we learn from research in psychology, Centre for Software ReliabilityTechnical Report, City University, London.Storey, N 1996, Safety-critical computer systems, Addison-Wesley, Harlow UK.Traverse, P Lacaze, I & Souyris, J 2004, Airbus fly-by-wire: A total approach todependability, Proceedings of the 18 th Congress of the International Federation forInformation Processing, pp. 191-212.Tribble, AC Miller, SP & Lempia, DL 2004, Software safety analysis of a flightguidance system, Contractor report CR-2004-213004, NASA Langley ResearchCentre, Hampton, Virginia.- 290 -
Tvaryanas, AP 2003, ‘Epidemiology of turbulence-related injuries in airline cabincrew, 1992-2001’, Aviation, Space, and Environmental Medicine, vol. 74, pp.970-976.SubmissionsUnder Part 4, Division 2 (Investigation Reports), Section 26 of the Transport SafetyInvestigation Act 2003 (the Act), the Australian Transport Safety Bureau (ATSB)may provide a draft report, on a confidential basis, to any person whom the ATSBconsiders appropriate. Section 26 (1) (a) of the Act allows a person receiving a draftreport to make submissions to the ATSB about the draft report.A draft of this report was provided to the:• Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile (BEA,France)• National Transportation Safety Board (NTSB, US)• aircraft operator• aircraft manufacturer• ADIRU manufacturer• seat belt manufacturer• flight crew and cabin crew on VH-QPA on the 7 October 2008 occurrence• Civil Aviation Safety Authority (Australia)• European Aviation Safety Agency• Federal Aviation Administration (US)• Australian Department of Defence.Submissions were received from the BEA and aircraft manufacturer, the NTSB andADIRU manufacturer, the operator, and some of the crew members. Thesubmissions were reviewed and where considered appropriate, the text of the reportwas amended accordingly.BEA commentIn accordance with International Civil Aviation Organization (ICAO) requirements,if the State conducting the investigation receives comments on the draft final reportfrom other States involved in the investigation, it is required to include thesubstance of the comments in the final report or, if a State providing the commentsdesires, append the comments to the final report.In this case, the BEA requested the following comment relating to a finding insection 6.1 to be appended to the report:The ADIRU manufacturer’s failure mode effects analysis and otherdevelopment processes did not identify the data-spike failure mode.The BEA disagrees with this statement, as it considers that this safety factorrefers to a characteristic of an organisation which has the potential to affectfuture safety. As consequence, this safety factor should be considered as a“safety issue”, with a level of associated risk classified as “Minor”.- 291 -
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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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APPENDIX D: OTHER DATA-SPIKE OCCURR
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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 304 and 305: US Federal Aviation AdministrationT
Page 307 and 308: APPENDIX N: SOURCES AND SUBMISSIONS
Page 309: Hanson, RJ 1987, Conducted electrom
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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