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-   -   QF 72 Diverted to Learmonth (http://www.yssyforum.net/board/showthread.php?t=1648)

Anthony J 10th November 2008 03:32 PM

It is in Sydney and will be back in service in December.

Philip Argy 13th November 2008 12:15 PM

ATSB preliminary report due out tomorrow
 
This media release just out from ATSB:

Quote:


ATSB Preliminary Report: Qantas Airbus A330-303 In-flight Upset on 7 October 2008

13 November 2008


On Friday, 14 November 2008 at 10.00 am AEDT (local time), the ATSB will conduct a media conference to release its preliminary safety investigation report into the circumstances surrounding the in-flight upset accident of an Airbus A330-303 aircraft near Learmonth in Western Australia on 7 October 2008.
When: Friday 14 November 2008
Where: 62 Northbourne Avenue, Canberra City ACT (New ATSB Headquarters)
Time: 10.00 am AEDT (local time)


Daniel F 14th November 2008 10:57 AM

http://www.atsb.gov.au/publications/...200806143.aspx

Philip Argy 14th November 2008 12:33 PM

Actual report is at: http://www.atsb.gov.au/publications/...070_prelim.pdf

Not materially different from the initial report. More detailed investigation of the ADIRU-1 failure and its impact on other systems is about to be conducted on a multi-agency (Australian, French and USA) basis.

It seems to me that there is a logic bug or multiple logic bugs in the A330's avionics such that redundant components are not switched in, or their input is not preferred, when a fault has been detected in a primary component. The aircraft had 3 ADIRUs only one of which was determined to be faulty, yet the faulty ADIRU-1 was not thereafter ignored and the two working redundant ADIRUs were not utilised in the way that one would have expected the system to operate. Basically the physical redundancy was not utilised by the avionics logic as a consequence of which spurious data spikes continuously interfered with various components of the avionics, including aural and visual warning alarms on an ongoing basis until landing in Learmonth. These included concurrent stall and overspeed alarms and warnings, and an ECAM with a display that continued to scroll multiple warnings and information so fast that the flight crew was unable to interact with them.

This is truly a scary scenario that, no matter how low the probability of recurrence exists, requires exhaustive investigation and, in my view, a rethink of how these systems are tested before certification.

Tom Lohdan 14th November 2008 04:11 PM

Quote:

Originally Posted by Philip Argy (Post 16185)
This is truly a scary scenario that, no matter how low the probability of recurrence exists, requires exhaustive investigation and, in my view, a rethink of how these systems are tested before certification.

You forgot the mention of:

The ATSB has received many suggestions from members of the public to consider the effect of various external sources of electromagnetic interference on the aircraft, particularly any transmissions by the Harold E. Holt very low frequency transmitter near Exmouth, WA. Initial analysis suggests it is unlikely that any transmissions from this facility could affect systems on board an aircraft flying near the vicinity. However, further assessment of this possibility and other possible sources of external electromagnetic interference will be examined.

With a transmission power of 1000 kilowatts, it is the most powerful transmission station in the Southern hemisphere.

When it happened I did look into the station and researched many other boards, but everyone came back with it would not cause issues with an aircraft.

Now the ATSB has included it.

Philip Argy 2nd January 2009 04:08 PM

Another A330 ADIRU error!
 
This appeared on the ATSB website this afternoon:

Quote:

Qantas Airbus A330 incident, 480km North West of Perth on 27 December 2008

02 January 2009


The Australian Transport Safety Bureau was advised on 27 December 2008 of an occurrence that day involving a Qantas Airbus A330-300 aircraft while in cruise at FL360 (36,000 ft) enroute from Perth to Singapore.
At about 0829 UTC (1729 Local Time), the autopilot disconnected and the crew received an ECAM message (NAV IR 1 Fault) indicating a problem with ADIRU Number 1. The crew actioned the Airbus Operations Engineering Bulletin (OEB) procedure by selecting the IR 1 push-button to OFF and the ADR 1 push-button to OFF. Both OFF lights illuminated. The crew elected to return to Perth and an uneventful overweight landing was conducted. At the time that the autopilot disconnected, the aircraft was approximately 260 nautical miles (NM) North-West of Perth airport and approximately 350 NM South of Learmonth airport.
It is very early in the investigation and too soon to draw any conclusions as to specific causal factors involved in this incident. As it appears to be a similar event to a previous event involving an A330 aircraft (AO-2008-070 on 7 Oct 2008) it will be included as part of the earlier investigation. The ATSB investigation will explore all aspects of the operation of the aircraft, including examination of recorded data, and any commonalities with past occurrences.
While the investigation is likely to take a number of months, the ATSB has been working with a number of national and international parties on this investigation and plans to release an Interim Factual report by about mid-February 2009.

This is now more serious than before and requires deeper investigation of what could be shaping up as Australia's own Bermuda Triangle!

Bob C 2nd January 2009 04:24 PM

This appears to be the third such event as a B777 of Malaysia Airlines had problems on 1 August 2005 ; http://aviation-safety.net/database/...0801-1&lang=fr refers.

It does seem odd that two QANTAS A330s have been affected in such a short time and I wonder why other carriers are not experiencing similar problems as I presume this is happening on a major airway to Singapore.

Could there be quality control problems at Airbus, QANTAS or the manufacturer which have failed to detect faults in the nav system ? Or perhaps new equipment has been installed at the Harold E Holt Communications Station which may be under test or when operational under certain circumstances MAY be affecting the nav systems in the QF aircraft. Are these unique to QF or are the same systems installed in other aircraft ?

Whatever the causes, an investigation should be conducted immediately but I very much doubt that the USN would be too forthcoming about any
equipment at its base.

Montague S 2nd January 2009 04:35 PM

perhaps our American friends can stick their spying equipment on the recently retired USN John. F Kennedy and stick it in the middle of the Indian Ocean?

Rhys Xanthis 2nd January 2009 07:59 PM

Quote:

Originally Posted by Montague S (Post 18872)
perhaps our American friends can stick their spying equipment on the recently retired USN John. F Kennedy and stick it in the middle of the Indian Ocean?

Diego Garcia? Or does the US know something we don't about it's effect on aircraft

me smells a conspiracy:p

Philip Argy 2nd January 2009 09:35 PM

Bermuda triangle shaping up?
 
This News Limited report makes the Harold Holt transmission issue seem less likely, despite the fact that to this day more mystery still surrounds the real Harold Holt's disappearance than any X-files episode:

Quote:

Last week, a Royal Australian Air Force transport aircraft was forced to return to Learmonth air base after the cabin filled with fumes.

The RAAF said the C-17 Globemaster was heading for the Edinburgh base in Adelaide with a number of people on board when fuel vapours began leaking into the cabin.

The aeroplane returned to Learmonth where police said the problem had been rectified.

And for those who are taking a greater interest in the Very Low Frequency transmission base, here's some background of unvouched accuracy:
http://www.globalsecurity.org/milita...ty/exmouth.htm

Chris Griffiths 2nd January 2009 10:11 PM

Geez, Phillip
Can you explain to us mere mortals the link between that story, the QF incident and your reference to Portsea 1967?

Philip Argy 2nd January 2009 10:24 PM

Mystery is the missing link
 
From the link in my previous post:

Quote:


In 1963, the US leased an area of North West Cape, Exmouth, Western Australiahttp://images.intellitxt.com/ast/adT...lass_10x10.gif, for the establishment of a VLF Communications Station, as part of its world wide nuclear submarine force communications network. It was subsequently named the Harold Holt US Navy Communications Base, named after the former Prime Minister of Australia - who mysteriously drowned while he was in office.

One of the issues the ATSB is investigating is whether the VLF transmissions from the HHUNCB could adversely affect the avionics which has behaved erroneously on two occasions within two months within 350 km of the base.

The C-17 story is of interest because of its proximity to the HHUNCB and the fact that VLF transmissions appear not to have been implicated, thus increasing the mystery of the frequency of unusual incidents occuring within 400 km of the HHUNCB.

Sorry if the common thread was too obscure - perhaps you're too young to remember HH's drowning mystery? Popular mythology is that he was taken by a foreign sub - the kind that communicates via VLF.

Hmmm ...

Bob C 2nd January 2009 10:47 PM

A report on another Board mentioned that the C17A was carrying 70 pax and equipment from Learmonth to Townsville when fumes & leaking fuel were
discovered coming from a vehicle onboard the aircraft. Hence the return to Learmonth.

WA Today had coverage and local radio 882 6PR also reported the incident.

And the RAAF activated Learmonth as an operational base a few days before Christmas and sent several hundred personnel and two P3C Orions there to provide an enhanced surveillance and response capability, as part of Operation Resolute, after several incidents of unauthorised boat arrivals and illegal fishing activities in Australia's territorial waters.

So I think we can rule out interference from North West Cape.

And re the disappearance of Harold Holt. I was a teenager living in Melbourne at the time and familiar with the Portsea Back Beach and Cheviot Beach where Holt disappeared. That area can be nasty at the best of times and I just think that Holt got into difficulties and drowned, his body being swept away. He wasn't the first nor was he the last to disappear in those treacherous seas.

Ash W 2nd January 2009 10:49 PM

Pretty scary if the VLF transmitter is effecting a/c like this! Wonder what else they are doing at HEH because there are many VLF sites around the world that seem to operate without too much trouble and thounsands of airbus a/c that operate without issue.

Indeed HMAS Harman in Canberra (Belconnen site) was once the site of a VLF transmitter and was directly under one of the outbound paths a/c used to take from CBR-MEL. Ansett A320's regularly flew through this area.

It does seem as if there is some interferance problem with something that is going on up that way.

Ash W 2nd January 2009 10:52 PM

Quote:

Originally Posted by Bobby C (Post 18897)
...

So I think we can rule out interference from North West Cape.

...

What do you base that one? Still sounds pretty likely to me. It isn't as if these faults in A330's are regular occourances, yet here are two in the same general location within a short period of time. I was once taught once is bad luck, twice a co-incidence, 3 times enemy action.

Bob C 2nd January 2009 11:46 PM

Hi Ash

I referred specifically to the incident involving the C17 which returned to Learmonth after fumes and leaking petrol came from a vehicle onboard.

I didn't make any mention whatsover of the incidents involving the A330s which appear totally unrelated to that with the C17.

Ash W 3rd January 2009 12:59 AM

Quote:

Originally Posted by Bobby C (Post 18900)
Hi Ash

I referred specifically to the incident involving the C17 which returned to Learmonth after fumes and leaking petrol came from a vehicle onboard.

I didn't make any mention whatsover of the incidents involving the A330s which appear totally unrelated to that with the C17.


Oh yeah, cannot see how anyone could have ever linked the two. Now if the C17 was the same type of incident then maybe.

Philip Argy 6th March 2009 10:23 AM

ATSB report just released
 
The ATSB has released an updated report this morning:
http://www.atsb.gov.au/publications/...70_interim.pdf

Robert S 6th March 2009 11:18 PM

Quote:

Originally Posted by Philip Argy (Post 23520)
The ATSB has released an updated report this morning:
http://www.atsb.gov.au/publications/...70_interim.pdf

Damn that's a lot to take in... and continues to raise new questions as well as a very sobering reminder about not just keeping your seatbelt fastened but not being overly liberal with the meaning of "fastened loosely" as some pax seem to do, ie. loosening it as much as they can.

David Wilkie 9th March 2009 03:23 PM

http://www.zdnet.com.au/news/hardwar...ic&omnRef=1337

Philip Argy 16th November 2009 12:27 PM

Second interim ATSB report
 
The ATSB will be releasing its second interim factual report on Wednesday morning: http://www.atsb.gov.au/newsroom/2009/alert/2009_14.aspx

The first report foreshadowed the contents of the second report:

Quote:

The next phase of the investigation will further interrogate the aircraft's primary flight control computer and two secondary computers. The ATSB had identified problems with the secondary computers' ability to action commands sent from the primary. The investigation will examine the computers' software development cycle, such as design, hazard analysis, testing and certification.
The US manufacturer of the ADIRU units, not disclosed in the report, is also conducting a theoretical analysis of the device's software and hardware to identify possible fault origins, the ATSB said.

Philip Argy 18th November 2009 09:48 AM

ATSB 2nd interim factual report released
 
http://www.atsb.gov.au/media/748444/ao2008070_ifr_2.pdf

Extract from the report:

Quote:

Despite extensive testing and analysis, the reason why the ADIRU started providing erroneous data (spikes) during the 7 October 2008 flight (or the 27 December 2008 flight) has not been identified to date. Nevertheless, the crew operational procedures that were provided by Airbus in October 2008 (and modified in December 2008 and January 2009) significantly reduced the chance of another in-flight upset by limiting the time that a faulty ADIRU could output angle of attack spikes. Airbus is also modifying the FCPC software used in the A330/A340 fleets to prevent angle of attack spikes leading to an in-flight upset.

Philip Argy 20th September 2010 09:50 AM

Legal action against Airbus & Northrop-Grumman
 
This news story out today about a class action commenced in USA against Airbus as well as Northrop-Grumman (the maker of the ADIRU):
http://www.abc.net.au/news/stories/2...20/3015989.htm.

The 'evidence' they apparently plan to use is the second interim ATSB factual report at: http://www.atsb.gov.au/media/1363394...8070_ifr_2.pdf

The action has been filed now before the 2 year statute of limitations expires on 7 October.

Bernie P 20th September 2010 11:09 AM

What I find wierd though is, it has been filed by a US Attorney in a US Court as, under US Law, they can get more compensation.
Quote:

"One thing about US law which is interesting is that you can recover against these manufacturers for psychological injuries," he said.

"Everyone on that plane has experienced some type of trauma. Everybody who has ever flown before knows the feeling in the pit of your stomach when you have turbulence.

"Now think about a plane going into a dive twice, with people flying up into the air, hitting their heads on the overhead bins, carts flying around, the debris.

"Just an absolute state of panic and terror in that aircraft."

Mr Wisner says the statute of limitations in the US is about to expire on the second anniversary on October 7 and after that people will not be able to join the class action.

He says passengers from Australia, Singapore, Sri Lanka and Great Britain are all involved in the action.

He says Airbus wants the case to be heard in Australia, where the law would not allow people to claim anywhere near as much as they can under US law.
Source: - YAHOO

Montague S 20th September 2010 07:00 PM

Quote:

Originally Posted by Bernie P (Post 50524)
What I find wierd though is, it has been filed by a US Attorney in a US Court as, under US Law, they can get more compensation. Source: - YAHOO


the part in question was manufactured in the US...I think you will find that this is integral to the case.

http://www.abc.net.au/pm/

check tomorrow, there was a segment on the case tonight on ABC radio.

Bernie P 20th September 2010 08:56 PM

Ahhh... ok... I hadn't thought of that side of things... I just thought of it being a French AC with an Australian Operator over Australia that it wierd to be heard in a US Court!

Radi K 20th September 2010 09:42 PM

there was a story on the 7.30 report about it too

Philip Argy 19th December 2011 02:29 PM

ATSB final report released
 
Access via this link:
http://www.atsb.gov.au/publications/...-2008-070.aspx

Adam J 20th December 2011 08:53 AM

Seems to me that the crew did a great job in dealing with this emergency, both tech Crew and Cabin Staff.

Pilots with a lot of experience between them. Did I read right where it indicated one of the cabin crew had 37 years experience. That is a mighty knock in anyones book. He or she would have started back in the 70's.

I am firmly in the camp that subscribes to the theory that pilots must be and continue to be adequately paid to reflect the huge responsibility they carry each and every time they fly. I am a bloody nervous flyer and I want my pilots well paid and well trained.

Good job

Philip Argy 20th December 2011 07:11 PM

Great airmanship
 
No question - very well handled when they couldn't trust what the instruments were telling them. The fundamental rule was followed - someone needs to fly the plane! And that's exactly what the Captain did while others attended to other duties.

As I commented early in this thread, fly by wire is great until the wire 'breaks'. Hopefully safety critical avionics software will be vastly better in the future as a result of this very conscientious ATSB report - all 313 pages of it.

Kirk C 22nd December 2011 07:02 PM

To be honest i think the only ones that can claim for physical injury are ones that were not seated.

Any one that was seated, knows as stated by almost every airline that they have their seat belt on, for this very reason.

Philip Argy 22nd December 2011 10:20 PM

Faulty avionics was the cause
 
Not wearing a seat belt during cruise might be contributory negligence but it is not disentitling, especially given that there had been not a skeric of turbulence.

Kirk C 22nd December 2011 10:56 PM

At least 60 of the aircraft’s passengers were seated without their seat belts fastened at the time of the first pitch-down. Consistent with previous in-flight upset accidents, the injury rate, and injury severity, was substantially greater for those who were not seated or seated without their seat belts fastened.
Passengers are routinely reminded every flight to keep their seat belts fastened during flight whenever they are seated, but it appears some passengers routinely do not follow this advice. This investigation provided some insights into the types of passengers who may be more likely not to wear seat belts, but it also identified that there has been very little research conducted into this topic by the aviation industry

MarkR 13th May 2017 12:31 PM

Bit of a look at the human side of the incident

http://www.brisbanetimes.com.au/good...10-gw26ae.html

Also a good account of the concerns many pilots have of Airbus's computer priorities over humans design.

Philip Argy 13th May 2017 10:01 PM

ATSB questions still unanswered ...
 
http://yssyforum.net/board/showpost....&postcount=148 :confused:

Neil L 3rd July 2019 09:58 AM

If you have not read Captain Kevin Sullivan book on QF72. I would suggest you get a copy. It is an easy book to read and an amazing story. A very courageous crew


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