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

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$a947-1 flexplate fracture forward flexible coupling main rotor drive ...$

3 FACTUAL INFORMATION: AIR DATA INERTIAL REFERENCEUNITS .......................................................................................................... 1093.1 LTN-101 ADIRU history ................................................................. 1093.2 LTN-101 ADIRU design .................................................................. 1103.3 Examination of data-spike patterns .................................................. 1133.4 Data flow analyses ............................................................................ 1213.5 Review of ADIRU configuration and service history ...................... 1303.6 Potential trigger types ....................................................................... 1353.7 ADIRU built-in test equipment operation ........................................ 1513.8 ADIRU safety analysis ..................................................................... 1543.9 ADIRU in-service performance ........................................................ 1574 FACTUAL INFORMATION: CABIN SAFETY ..................................... 1614.1 Overview of cabin, crew and passengers .......................................... 1614.2 Sequence of events in the cabin ........................................................ 1644.3 Cabin examinations .......................................................................... 1684.4 Seat belt requirements ...................................................................... 1714.5 Posture and seat belt use ................................................................... 1754.6 Injuries .............................................................................................. 1764.7 Factors influencing the use of seat belts ........................................... 1814.8 Additional cabin safety matters ........................................................ 1885 ANALYSIS .................................................................................................. 1915.1 Overview .......................................................................................... 1915.2 FCPC design limitation .................................................................... 1925.3 ADIRU data-spike failure mode ....................................................... 1995.4 Seat belts ........................................................................................... 2055.5 Other aspects .................................................................................... 2065.6 Final comments and lessons for new systems .................................. 2106 FINDINGS ................................................................................................... 2136.1 Contributing safety factors ............................................................... 2136.2 Other safety factors ........................................................................... 2146.3 Other key findings ............................................................................ 2147 SAFETY ACTION ...................................................................................... 2177.1 Flight control primary computer issues ............................................ 2177.2 Air data inertial reference unit issues ............................................... 2207.3 Use of seat belts ................................................................................ 221- iv -
7.4 Single event effects ........................................................................... 222APPENDIX A: VERTICAL ACCELERATIONS .......................................... 225APPENDIX B: FLIGHT RECORDER INFORMATION .............................. 227APPENDIX C: POST-FLIGHT REPORT ...................................................... 229APPENDIX D: OTHER DATA-SPIKE OCCURRENCES ............................ 235APPENDIX E: ADIRU TESTING .................................................................... 243APPENDIX F: AIRCRAFT LEVEL TESTING ............................................ 253APPENDIX G: ELECTROMAGNETIC RADIATION ................................. 255APPENDIX H: SINGLE EVENT EFFECTS .................................................. 259APPENDIX I: PASSENGER QUESTIONNAIRE .......................................... 267APPENDIX J: EXAMINATION OF POTENTIAL FORINADVERTENT RELEASE OF SEAT BELTS ...................................... 271APPENDIX K: INJURIES DURING IN-FLIGHT UPSETS ......................... 275APPENDIX L: SEAT BELT USE IN ROAD VEHICLES ............................. 279APPENDIX M: PUBLIC SAFETY INFORMATION ABOUTWEARING SEAT BELTS ON AIRCRAFT ............................................ 283APPENDIX N: SOURCES AND SUBMISSIONS ........................................... 287- v -
Page 1: ATSB TRANSPORT SAFETY REPORTAviatio
Page 4 and 5: Published by: Australian Transport
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 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
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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
Page 247 and 248:
APPENDIX B: FLIGHT RECORDER INFORMA
Page 249 and 250:
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
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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
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
Page 277 and 278:
cannot be ‘decoded’ by the rece
Page 279 and 280:
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
Page 307 and 308:
APPENDIX N: SOURCES AND SUBMISSIONS
Page 309 and 310:
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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