- 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 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 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
- Page 121 and 122: applicable to highly-integrated or
- Page 123 and 124:
Ongoing developmentsA range of rese
- Page 125 and 126:
To conduct an effective fault tree
- Page 127 and 128:
According to this model, accidents
- Page 129 and 130:
3 FACTUAL INFORMATION: AIR DATA INE
- Page 131 and 132:
• inertial reference input/output
- Page 133 and 134:
3.3 Examination of data-spike patte
- Page 135 and 136:
Figure 38: ARINC 429 word for an AO
- Page 137 and 138:
3.3.4 Data-spike patterns for the 7
- Page 139 and 140:
Figure 43: Qualitative correlation
- Page 141 and 142:
etween the values of any of the fou
- Page 143 and 144:
3.4.3 Calculating parameter valuesA
- Page 145 and 146:
3.4.5 Packaging the ARINC 429 wordT
- Page 147 and 148:
3.4.8 Transmitting data to other sy
- Page 149 and 150:
ARINC 429 packaging analysisThe ADI
- Page 151 and 152:
component configurations of differe
- Page 153 and 154:
manufacturer reported such BITE dat
- Page 155 and 156:
3.6 Potential trigger types3.6.1 Ba
- Page 157 and 158:
such as liquids or small loose frag
- Page 159 and 160:
wires). The electric 144 field stre
- Page 161 and 162:
Although the investigation could no
- Page 163 and 164:
3.6.6 Single event effectsBackgroun
- Page 165 and 166:
until a few years ago, were not dir
- Page 167 and 168:
Unit testingIn 2005, as part of the
- Page 169 and 170:
that involved a NAV IR and/or NAV A
- Page 171 and 172:
EMI from other aircraft systems (su
- Page 173 and 174:
from ADIRU 1 was not correctly reco
- Page 175 and 176:
• Detected failure. Any failure w
- Page 177 and 178:
The ADIRU manufacturer’s analysis
- Page 179 and 180:
the aircraft and ADIRU manufacturer
- Page 181 and 182:
4 FACTUAL INFORMATION: CABIN SAFETY
- Page 183 and 184:
Summary details of the cabin crew
- Page 185 and 186:
section, and the ninth flight atten
- Page 187 and 188:
Table 29: Significant cabin communi
- Page 189 and 190:
Figure 48: Example of damage to the
- Page 191 and 192:
4.3.2 Seat belt examinationsSix pas
- Page 193 and 194:
The flight crew’s procedures requ
- Page 195 and 196:
takeoff, landing or when the seat-b
- Page 197 and 198:
Table 31: Levels of injuryInjury le
- Page 199 and 200:
4.6.4 Injuries to seated occupants
- Page 201 and 202:
The percentage of occupants who wer
- Page 203 and 204:
Statistical analyses 197 were done
- Page 205 and 206:
passengers reported that they had h
- Page 207 and 208:
that seat belts should be worn only
- Page 209:
4.8.2 Handholds in the cabinThe FAA
- Page 212 and 213:
Figure 53: Overview of the 7 Octobe
- Page 214 and 215:
process needs to ensure that there
- Page 216 and 217:
and determine whether they could le
- Page 218 and 219:
useful in this case. If the EFCS sp
- Page 220 and 221:
5.3.2 Risk associated with the fail
- Page 222 and 223:
• All three events occurred in a
- Page 224 and 225:
place. Although aviation manufactur
- Page 226 and 227:
equiring cabin crew to enforce the
- Page 228 and 229:
With the information available to t
- Page 230 and 231:
ADIRU 1 affected the operation of a
- Page 233 and 234:
6 FINDINGSFrom the evidence availab
- Page 235:
• As of April 2010, the LTN-101 a
- Page 238 and 239:
did not illuminate. The new OEB (A3
- Page 240 and 241:
modifications were made to its guid
- Page 242 and 243:
this advice. At the time of the fir
- Page 245 and 246:
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
- Page 257 and 258:
Occurrence on 27 December 2008Overv
- Page 259 and 260:
Figure D2: FDR data for the 27 Dece
- Page 261 and 262:
ADIRU informationADIRU 1 was the sa
- Page 263 and 264:
APPENDIX E: ADIRU TESTINGTest plan
- Page 265 and 266:
Visual inspectionsExternal visual i
- Page 267 and 268:
(ADR) output databuses. Loading on
- Page 269 and 270:
Unit 4167 passed 2,223 of 2,272 tes
- Page 271 and 272:
dwells (sustained testing at a fixe
- Page 273 and 274:
APPENDIX F: AIRCRAFT LEVEL TESTINGI
- Page 275 and 276:
APPENDIX G: ELECTROMAGNETIC RADIATI
- Page 277 and 278:
cannot be ‘decoded’ by the rece
- Page 279 and 280:
APPENDIX H: SINGLE EVENT EFFECTSNot
- Page 281 and 282:
Factors affecting SEE exposureAn ai
- Page 283 and 284:
portions of memory are constantly b
- Page 285:
Depending on the form of EDAC, sing
- Page 288 and 289:
• 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
- Page 299 and 300:
APPENDIX L: SEAT BELT USE IN ROAD V
- Page 301:
Table L1: Recent seat belt use rate
- Page 304 and 305:
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