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

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A system could flag its output data as invalid by using a specific value in thesign/status matrix (SSM) field of the data. The available SSM values are listed inTable 2.Table 2: SSM values for output dataStatus Validity DescriptionFailurewarning (FW)No computeddata (NCD)Functional test(FT)Normaloperation (NO)InvalidInvalidValid (on ground)Invalid (in-flight)ValidThe transmitting (source) system detected afailure that made one or more of its output datawords unreliable.The transmitting system was unable to computereliable output data for reasons other than itsown failure.The transmitting system conducted somefunctional tests while the aircraft was on theground. If this SSM value occurred in flight, thenthe data was considered to be invalid.The transmitting system detected no problemswith the output data.Externally-detected faultsA receiving system could detect when a source system either stopped providingdata, or flagged its output data as invalid (Table 2).If a source system (such as the ADIRUs) provided incorrect data to a receivingsystem (such as the EFCS or FMGES), and this data was not flagged as invalid,then this fault could have safety consequences. Accordingly, some receivingsystems had additional processes for monitoring input data. For example, the EFCSand FMGES compared the values of some flight data parameters that were providedby the three ADIRUs.If a receiving system detected a problem with a source system, then it could recorda fault message and provide it to the CMS.1.6.9 Flight warning systemThe aircraft’s FWS monitored other aircraft systems, detected failures and unsafeflight conditions, and provided the flight crew with operational assistance fornormal and abnormal aircraft system configurations. It performed these functionsby:• receiving ‘failure’ messages from other systems• monitoring the data outputs of some systems (such as the ADIRUs)• generating ECAM warning and caution messages• activating master warning and master caution lights• generating aural alerts and synthetic voice messages.The FWS provided warning and caution indications that were classified at three‘failure levels’, with each level based on the consequences of the fault. Moreserious conditions were provided with more salient aural alerts and visualindications, as outlined in Table 3.- 24 -
Table 3: Failure level classifications and associated indicationsLevel Significance Aural alert Visual indication3 Red warning: configuration or failurethat required immediate flight crewaction.Included aircraft in dangerousconfiguration or flight condition, or asystem failure affecting flight safety.2 Amber caution: configuration or failurethat did not require immediate action,but the flight crew should be madeaware. Time and situation permitting,the crew should consider the cautionswithout delay to prevent furtherdegradation of the affected system.Included system failures without anydirect consequence on flight safety.1 Amber caution: situation that requiredcrew monitoring.Included system failures leading to aloss of redundancy or systemdegradation.Continuousrepetitive chime,specific sound orsynthetic voiceSingle chimeNoneMaster warning lightWarning message onECAM (red)Automaticpresentation of therelevant system pageon the ECAM’ssituation displayMaster caution lightCaution message onECAM (amber)Automaticpresentation of therelevant system pageon the ECAM’ssituation displayCaution message onECAM (amber),generally without anyrequired actionsFor a level 3 failure, the FWS illuminated the red, flashing master warning lightsthat were located on both sides of the glareshield. The FWS also produced acontinuous repetitive chime or other continuous aural alert. For example, a stallwarning was associated with a synthetic voice stating ‘STALL STALL’ followedby a ‘cricket’ noise. The aural alert for a level 3 failure continued until the failurecondition no longer existed or the crew had cancelled the warning. Some level 3failures, such as stall and overspeed warnings, were not associated with an ECAMmessage.For a level 2 failure, the FWS illuminated the amber, steady master caution lightson both sides of the glareshield. It also produced a single aural chime. The mastercaution chimes could not be cancelled by the crew.Some types of system faults were also associated with the presentation of a localfault light on the overhead panel. In that case, the light was illuminated by therelevant system itself, rather than the FWS. If the underlying condition was notresolved, the fault light generally remained illuminated, even after the associatedECAM message was cancelled by the crew.Table 4 provides examples of the aural alerts and visual indications for faultsrelevant to the 7 October 2008 occurrence.- 25 -
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 38 and 39: ADIRS switching controlsIn normal o
Page 40 and 41: Processing by ADIRUs and FCPCsEach
Page 42 and 43: The information presented on the fl
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
Page 91 and 92: Each FCPC used a number of paramete
Page 93 and 94: AOA computation logicThe FCPC softw
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Figure 29: FCPC processing of sever
Page 97 and 98:
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
Page 247 and 248:
APPENDIX B: FLIGHT RECORDER INFORMA
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APPENDIX C: POST-FLIGHT REPORTThe f
Page 251 and 252:
- 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
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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
Page 269 and 270:
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
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
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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
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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