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

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Table 13: Troubleshooting data relating to the ADIRUsUnitsADIRUconnectionsResultsFCPC 1,FCPC 2,FCPC 3FMGEC 1,FMGEC 2ADIRU 2,ADIRU 3All 3 ADIRUsAll 3 ADIRUsAll 3 ADIRUsAt 0440, problem detected with ADIRU 1 data (IR andADR). Subsequent problems also detected.No problems with ADIRU 2 or ADIRU 3 data.At 0440, problem detected with ADIRU 1 data.No problems with ADIRU 2 or ADIRU 3 data.At 0440, problem detected with altitude and/or trueairspeed data not being received from ADIRU 1 at thedesigned rate (section 1.12.6).No problems with ADIRU 2 or ADIRU 3 data.GPWS ADIRU 1 At 0440, problem detected with ADIRU 1 data.LGCIU 1,LGCIU 2ADR1 and ADR 3At 0531, problem detected with loss of computedairspeed from ADR 1.No problems with ADR 3 data.1.12.4 Functional testing of aircraft systemsAfter the PFR and TSD data were downloaded, functional tests were performed onseveral aircraft systems at Learmonth in accordance with the aircraft manufacturer'srecommendations. The systems included the EFCS, ADIRS, FMGES, PHCs, multimodereceivers (which included the GPS receivers), and the electrical powergeneration system.All of the functional tests were successfully completed except for a single EFCStask that involved the reconfiguration of the elevator servo-controller to anothercomputer. The aircraft manufacturer advised that this was a previously identifiedanomaly that was only triggered under a very specific set of circumstances and wasnot related to the occurrence. 601.12.5 Aircraft wiring examinationsThe data-spike failure mode affected data that was transmitted on multiple,segregated wires out of the ADIRU (and based on information obtained frommultiple, segregated wires into the ADIRU). A simultaneous problem with multiple,segregated wires was considered very unlikely.Nevertheless, a range of testing was conducted on the aircraft wiring, and noproblems were found. More specifically:• Due to the extent of damage to the ceiling panels in the cabin, all the panelswere removed and the wiring looms were visually inspected while the aircraftwas at Learmonth. No defects were observed.• After the aircraft was ferried to a maintenance base in Sydney, the operatorconducted precautionary checks of the aircraft’s ADIRU interface wiring that60The anomaly only occurred during the performance of functional tests. It appeared with theintroduction of a particular FCSC software version.- 50 -
involved continuity, short circuit, electrical bonding and shielding tests. Noproblems were found.• In November 2008, the operator conducted integrity and time domainreflectometry tests on the aircraft’s ADIRU 1 databus wiring, and verification ofdatabus signals using a bus analyser. No problems were found.• In May 2009, the aircraft manufacturer and the operator conducted additionalchecks of the ADIRU 1 installation and configuration. The checks includedventilation, electrical bonding to the aircraft structure, input and output databuswiring isolation, input and output databus waveforms, discrete input signals(power and mode selection), AOA input signal waveforms, and alternatingcurrent (AC) and direct current (DC) power supply waveforms. No faults werefound that were relevant to understanding the occurrence or otherwiseconsidered significant.• In May/June 2009, the aircraft underwent a scheduled C-check. No aircraftwiring or configuration problems were identified during that check.1.12.6 ADIRU examinationsService historyThe aircraft was fitted with three LTN-101 ADIRUs, manufactured by NorthropGrumman Corporation. The basic details of the ADIRUs are provided in Table 14.Table 14: Details of the aircraft’s ADIRUsADIRU 1 ADIRU 2 ADIRU 3Model number LTN-101 LTN-101 LTN-101Part number 465020-0303 465020-0303 465020-0303Serial number 4167 4687 4663Date of manufacture Aug 2002 Jan 2004 Dec 2003Date installed in QPA Feb 2004 Apr 2006 Jul 2008Date installed in position Mar 2006 Apr 2006 Jul 2008Software version 0316 0316 0316Total operating hours 30,282 26,985 25,423All three units had been removed from aircraft during their operational life due toreported faults, which was not abnormal for units with similar operating hours (seesection 3.9 for more details on ADIRU reliability). More specifically:• unit 4167 was examined and repaired in May 2003• unit 4687 was examined and repaired in February 2006• unit 4663 was removed for examination on two previous occasions (October2007 and May 2008) but, on both occasions, no fault was found.None of those reported problems were related to the 7 October 2008 occurrence.A review of all the operator’s technical log entries related to ADIRUs identified oneprevious event involving similar ADIRU behaviour as that on 7 October 2008. Thatevent occurred on 12 September 2006 and involved the same ADIRU (unit 4167) in- 51 -
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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
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FCPC design limitationAOA is a crit
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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 68 and 69: Table 11: Cockpit effect messages d
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
Page 119 and 120: 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 -
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
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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
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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
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Hanson, RJ 1987, Conducted electrom
Page 311 and 312:
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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