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

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ADIRS switching controlsIn normal operation, ADIRU 1 provided information for the captain’s flightdisplays and ADIRU 2 provided information for the first officer’s flight displays. Inthe event of a failure of ADIRU 1 (or ADIRU 2), the flight crew could manuallyswitch the source of the information for the captain’s (or first officer’s) displays toADIRU 3. This was achieved using either the ATT HDG switch for IR parameters(see the left control in Figure 11) and/or the AIR DATA switch for ADRparameters (see the second left control in Figure 11).The ADIRS switches were located on the pedestal panel in the flight deck (see thelower part of Figure 10).Figure 11: ATT HDG and AIR DATA switches1.6.5 Processing of angle of attack informationAngle of attackAngle of attack (AOA) is an important air data parameter that the EFCS uses tocontrol the aircraft’s pitch. AOA is a measurement of the vertical angle of a wing(using a nominal reference line known as the ‘chord line’) relative to the airflow(Figure 12). The AOA is not the same as the aircraft’s pitch angle, which is theangle of the aircraft’s body relative to the horizon. 30Figure 12: Angle of attackAs the aircraft’s AOA increases, the airflow over the wing eventually becomesmore turbulent, reducing the amount of lift produced by the wing. The lift reducesrapidly as the angle is further increased; a condition known as ‘aerodynamic stall’.The angle at which the amount of lift starts to reduce is known as the ‘critical angle’or ‘stall angle’. Stall prevention is accomplished by limiting the AOA, and stallrecovery can be accomplished by reducing the AOA (by pitching the aircraft nosedown).30The chord line is typically inclined slightly relative to the aircraft’s body.- 18 -
For an A330, the typical operational range of AOA was 1 to 10° during all phasesof flight. During normal cruise flight, AOA was typically about 2 to 3°.Angle of attack sensorsThe three AOA sensors (AOA 1, AOA 2, and AOA 3) were installed on the forwardfuselage. AOA 1 and AOA 2 were installed on the left and right sides of thefuselage respectively, and AOA 3 was installed below AOA 2 (Figure 13). TheAOA 1 sensor sent data to ADIRU 1, the AOA 2 sensor sent data to ADIRU 2, andthe AOA 3 sensor sent data to ADIRU 3.Figure 13: AOA sensor locationsEach sensor had a vane that aligned with the airflow past the aircraft, and measuredthe vertical angle of this airflow relative to the aircraft’s body. The vane angle had arange limit of +65 to -65°. Figure 14 shows the AOA sensors of QPA.Figure 14: AOA sensors of QPA- 19 -
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 28 and 29: 1.3 Damage to aircraftThere was sig
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 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
Page 78 and 79: 1.15 Survival aspectsInformation on
Page 80 and 81: did not identify any faults. The BI
Page 82 and 83: Comparison of the three occurrences
Page 84 and 85: 1.17.2 Processes for reporting and
Page 87 and 88: 2 FACTUAL INFORMATION: ELECTRICAL F
Page 89 and 90:
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 -
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- 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
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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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