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

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 -