The Australian Transport Safety Bureau's investigation into the
accident involving an Airbus A330-300 aircraft operating as Qantas
flight 72 on a flight from Singapore to Perth on 7 October 2008 is
progressing well. The ATSB has scheduled the media conference this
evening to coincide with the release of an Operators Information
Telex/Flight Operations Telex, which is being sent by Airbus to
operators of all Airbus aircraft. The aim of that telex is to:
- update operators on the factors identified to date that led to
the accident involving QF72,
- provide operational recommendations to mitigate risk in the
event of a reoccurrence of the situation which occurred on
QF72.
To assist in understanding the following information, I would
just like to refer you quickly to the diagrams projected on the
screen specifically, the term angle of attack which refers to the
difference in angle between the aircraft and its control surfaces,
and the air stream as the aircraft moves through the air.
The next diagram is a simple representation of the aircraft and
the components relevant to this explanation, which include the
angle of attack sensors located on the outside of the aircraft, the
Air Data Inertial Reference Units (ADIRUs), of which there are
three, located in the avionics compartment inside the aircraft, the
Flight Control Primary Computers of which there are also three
located in the avionics compartment, and the elevators, located on
the aircrafts horizontal stabiliser. In the context of this
occurrence, the angle of attack sensors send raw data to the
ADIRUs, which provide processed angle of attack information to the
Flight Control Primary Computers, which in turn command the
elevator position.
Returning to the circumstances of the 7 October flight,
preliminary analysis of the Flight Data Recorder data, Post Flight
Report data and Built-in Test Equipment data has enabled the
investigation to establish a preliminary sequence of events this
information is also contained in the Airbus telex.
The aircraft was flying at FL 370 or 37, 000 feet with Autopilot
and Auto-thrust system engaged, when an Inertial Reference System
fault occurred within the Number-1 Air Data Inertial Reference Unit
(ADIRU 1), which resulted in the Autopilot automatically
disconnecting. From this moment, the crew flew the aircraft
manually to the end of the flight, except for a short duration of a
few seconds, when the Autopilot was reengaged. However, it is
important to note that in fly by wire aircraft such as the Airbus,
even when being flown with the Autopilot off, in normal operation,
the aircrafts flight control computers will still command control
surfaces to protect the aircraft from unsafe conditions such as a
stall.
The faulty Air Data Inertial Reference Unit continued to feed
erroneous and spike values for various aircraft parameters to the
aircrafts Flight Control Primary Computers which led to several
consequences including:
- false stall and overspeed warnings
- loss of attitude information on the Captain's Primary Flight
Display
- several Electronic Centralised Aircraft Monitoring system
warnings.
About 2 minutes after the initial fault, ADIRU 1 generated very
high, random and incorrect values for the aircrafts angle of
attack.
These very high, random and incorrect values of the angle attack
led to:
- the flight control computers commanding a nose-down aircraft
movement, which resulted in the aircraft pitching down to a maximum
of about 8.5 degrees,
- the triggering of a Flight Control Primary Computer pitch
fault.
The crew's timely response led to the recovery of the aircraft
trajectory within seconds. During the recovery the maximum altitude
loss was 650 ft.
The Digital Flight Data Recorder data show that ADIRU 1
continued to generate random spikes and a second nose-down aircraft
movement was encountered later on, but with less significant values
in terms of aircraft's trajectory.
At this stage of the investigation, the analysis of available
data indicates that the ADIRU 1 abnormal behaviour is likely as the
origin of the event.
The aircraft contains very sophisticated and highly reliable
systems. As far as we can understand, this appears to be a unique
event and Airbus has advised that it is not aware of any similar
event over the many years of operation of the Airbus.
Airbus has this evening, Australian time, issued an Operators
Information Telex reflecting the above information. The telex also
foreshadows the issue of Operational Engineering Bulletins and
provides information relating to operational recommendations to
operators of A330 and A340 aircraft fitted with the type of ADIRU
fitted to the accident aircraft. Those recommended practices are
aimed at minimising risk in the unlikely event of a similar
occurrence. That includes guidance and checklists for crew response
in the event of an Inertial Reference System failure.
Meanwhile, the ATSB's investigation is ongoing and will
include:
- Download of data from the aircraft's three ADIRUs and detailed
examination and analysis of that data. Arrangements are currently
being made for the units to be sent to the component manufacturer's
facilities in the US as soon as possible and for ATSB investigators
to attend and help with that testing, along with representatives
from the US National Transportation Safety Board, The French Bureau
dEnquêtes et dAnalyses (BEA) and Airbus.
- In addition, investigators have been conducting a detailed
review of the aircraft's maintenance history, including checking on
compliance with relevant Airworthiness Directives, although initial
indications are that the aircraft met the relevant airworthiness
requirements.
- Work is also ongoing to progress interviews, which will include
with injured passengers to understand what occurred in the aircraft
cabin. The ATSB plans to distribute a survey to all
passengers.
There has been close and frequent communication between the
ATSB, Qantas, Airbus, the BEA, and CASA. That close communication
will continue as the investigation progresses to ensure that any
additional safety action can be instigated as soon as possible
should critical safety factors be identified. The ATSB expects to
publish a Preliminary Factual report in about 30 days from the date
of the accident.
Media Contact: 1800 020 616