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

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Table 11: Cockpit effect messages due to problems with ADIRU output dataTime Cockpit effect message Interpretation0442 58 AUTO FLT AP OFF The autopilot disconnected and the disconnectionwas not commanded by the crew. This was due to adiscrepancy between data that was sourced fromthe different ADIRUs (section 1.12.8).0440 NAV GPWS FAULT The GPWS required ADIRU parameters such astrue track angle, computed airspeed, true airspeedand roll attitude, and it was only connected toADIRU 1. A problem with ADIRU 1 resulted in a lossof the GPWS function.0440 FLAG ON CAPT ND MAPNOT AVAIL0440 NAV FM/GPS POSDISAGREE0441 NAV GPWS TERR DETFAULT0442 BRAKES AUTO BRKFAULT0451 EIS DISPLAYDISCREPANCYDue to a loss of heading information, the map thatwas usually shown on the captain’s navigationdisplay (ND) was unable to be displayed.Consequently a red warning flag was displayed onthe ND but there was no ECAM message.There was a latitude and longitude cross-checkerror between the GPS and FMGES data (based onIR information).There was a loss of GPWS functionality due to aloss of data from ADIRU 1 (see NAV GPWS FAULTabove).The autobrake required ADIRU parameters toperform its function (that is, providing a setdeceleration level during landing). A loss ofADIRU 1 data resulted in a loss of the autobrakefunction.One of the DMCs detected a problem with IR data(pitch, roll or heading) or ADR data (altitude) whichtherefore affected the electronic instrument system(EIS).0528 CAB PR LO DIFF PR A low differential pressure between the cabin andexternal-to-aircraft conditions was detected by thecabin pressure controllers. The automatic cabinpressure control was lost as ADR data (altitude andvertical speed) was required from ADIRU 1.The remaining cockpit effect messages were considered to be spurious. That is,ADIRU 1 provided incorrect information on its fault parameters regarding several,related systems (see also section 3.7.4). These messages are listed in Table 12.58Although the time shown on the PFR was 0442, the FMGES BITE and FDR data showed that thismessage would have first occurred at 0440.- 48 -
Table 12: Cockpit effect messages due to spurious fault messages fromADIRU 1Time Cockpit effect message Interpretation0440 NAV GPS 1 FAULT ADIRU 1 detected the GPS function to be faulty.No faults were recorded in the BITE data for themulti-mode receiver that included the GPS unit.0440 NAV GPS 2 FAULT As above for NAV GPS 1 FAULT.0440 A.ICE L CAPT STAT HEAT This message was due to corrupted data outputfrom ADR 1 (section 1.12.9).0442 NAV IR NOT ALIGNED This message indicated that IR 1, IR 2 or IR 3 was‘not aligned’. The aircraft manufacturer advisedthat it was a spurious message resulting from theanomalous behaviour of ADIRU 1.0445 A.ICE R CAPT STAT HEAT As above for A.ICE L CAPT STAT HEAT.0448 A.ICE CAPT PROBES HEAT As above for A.ICE L CAPT STAT HEAT.0456 A.ICE CAPT PITOT HEAT As above for A.ICE L CAPT STAT HEAT.0508 A.ICE CAPT AOA HEAT As above for A.ICE L CAPT STAT HEAT.1.12.3 Troubleshooting data from the aircraft systemsThe PFR only showed a summary of the warning/caution and maintenance faultmessages. The most detailed level of maintenance fault data that could be obtainedfrom the CMS was troubleshooting data (TSD). 59 The TSD showed eachmaintenance message that was received by the CMS in a raw numerical format thatcould be printed out and decoded using relevant documentation.Based on an initial examination of the FDR data, and to minimise the possibilitythat data might be lost when power was reapplied to the aircraft, the aircraftmanufacturer recommended removing ADIRU 1 and probe heat computer (PHC) 1before conducting any data downloads or testing of the aircraft’s systems. Theseunits were replaced with spare units before data downloads or functional testingcommenced.The TSD for several aircraft systems was downloaded, and subsequent analysisfound it to be generally consistent with the PFR data. The key result was thatseveral aircraft systems detected problems with the data being provided byADIRU 1, but no problems were detected with the data being provided byADIRU 2 or ADIRU 3 (Table 13). The TSD was generally not accurate enough todetermine which ADIRU parameters were involved or the exact nature of theproblem that triggered the fault messages.59To obtain all possible BITE data, some LRUs were removed from the aircraft and downloaded bythe unit manufacturer.- 49 -
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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
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
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 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
Page 95 and 96: Figure 29: FCPC processing of sever
Page 97 and 98: Table 19: Characteristics of elevat
Page 99 and 100: Simulation of AOA values for the fi
Page 101 and 102: 2.2.2 Review of recorded flight con
Page 103 and 104: second PRIM 3 FAULT. The role of ma
Page 105 and 106: The ACJ was built around the princi
Page 107 and 108: • It stated that the identificati
Page 109 and 110: The second part of the V-cycle invo
Page 111 and 112: • Functional requirements. These
Page 113 and 114: 2.4.5 Safety assessment activitiesG
Page 115 and 116: equipment software and aircraft ins
Page 117 and 118: 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
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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
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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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