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being no in-flight upset, there were no PRIM FAULTS or PRIM PITCH FAULTS
on the 12 September 2006 PFR. The NAV ADR 1 FAULT, which was recorded 30
minutes after the NAV IR 1 FAULT, may have been associated with the crew
action of turning ADR 1 off.
32 ACARS: Aircraft communications, addressing and reporting system. ACARS transmits
maintenance and operational messages at intervals throughout a flight.
- 33 -
VH-QPG, 27 December 2008
Sequence of events
On 27 December 2008, an Airbus A330-303 aircraft, registered VH-QPG, was on a
scheduled passenger transport service (QF71) from Perth to Singapore. At about
0829 UTC (1729 local time), while the aircraft was in cruise at 36,000 ft, the
autopilot (autopilot 1) disconnected and the crew received an ECAM message
(NAV IR 1 FAULT). ADIRU 1 was the same model but a different unit (serial
number 4122) to that involved in the 12 September 2006 and 7 October 2008
events. Table 5 presents a summary of the sequence of events based on FDR and
QAR data.
Table 5. VH-QPG sequence of events
Time (UTC)
(hh:mm:ss)
Time relative
to event
(hh:mm:ss)
Event:
07:49:55 -00:39:01 Takeoff at Perth
08:14:01 -00:14:55 Aircraft reached top of climb (36,000 ft or FL360)
08:28:55 -00:00:01
IR 1 Fault indication commenced. Sampled once every
four seconds.
08:28:56 00:00:00 Autopilot 1 disconnect (involuntary)
08:29:20 00:00:24
ADR 1 Fault indication commenced. Sampled once
every four seconds.
08:30:21 00:01:25 Autopilot 1 re-engaged
08:32:25 00:03:29 Captain’s PFD source switched to IR 3
09:25:45 00:56:49
Touchdown at Perth (aircraft gross weight was 195.3
tonnes)
The crew reported that they actioned the relevant operational procedure33 by
selecting the IR 1 push-button to OFF and the ADR 1 push-button to OFF. Both
OFF lights illuminated.
The crew also reported that, even though the procedure had been completed, they
continued to receive multiple ECAM messages. Those messages were constantly
scrolling on the display. The ECAM procedure for the NAV IR 1 FAULT was
displayed and it recommended switching the IR rotary mode selector to the ATT
position. The crew reported that they completed this action (see Table 5, 0832:25),
but it was unsuccessful in preventing further ECAM messages. The crew elected to
return to Perth and an uneventful overweight landing was conducted. The crew
reported that at no stage was there any effect on the aircraft’s flight controls.
Examination of the FDR/QAR data showed that at 0829:20, there was an ADR 1
Fault indication recorded on the FDR, which was consistent with the crew turning
off ADR 1. Recorded data confirmed that the ADR 1 was selected OFF and was not
providing further data to the aircraft’s systems from that time. However, even
33 This procedure was different to that which applied at the time of the 7 October 2008 occurrence.
The relevant procedure at the time of the 27 December 2008 occurrence was based on Airbus
Operations Engineering Bulletin (OEB) 74-3 issued in December 2008 (see SAFETY ACTION).
- 34 -
though the IR 1 push-button had also been selected OFF, the IR 1 continued to
supply erroneous data to the aircraft’s systems.
At the time that the autopilot disconnected, the aircraft was approximately 260 NM
north-west of Perth Airport and approximately 650 km (350 NM) south of
Learmonth Airport (Figure 11).
The PFR for the 27 December 2008 flight contained a series of messages associated
with ADIRU 1 which were similar to the PFR for the 7 October 2008 flight.
Consistent with there being no in-flight upset, there were no PRIM FAULTS or
PRIM PITCH FAULTS. There was a NAV ADR 1 FAULT recorded 1 minute after
the NAV IR 1 FAULT, and this was associated with the crew action of turning
ADR 1 off.
Examination of ADIRU 1 from VH-QPG
Following the incident on 27 December 2008, the ADIRU initially remained on the
aircraft but was unpowered. The unit was later removed from the aircraft and sent
to the manufacturer’s facility in Los Angeles. It was received on 8 January 2009
and was locked in a secure storage room while a test plan was developed.
The investigation team agreed that the ADIRU should undergo a standard
manufacturer’s test procedure and BITE download and the results analysed.
Examination of the BITE data showed anomalous results that were similar to those
obtained from the BITE download of ADIRU 1 from VH-QPA. More specifically:
• BITE data was recovered but it did not contain information from the time period
relating to the anomalous ADIRU behaviour
• several routine BITE messages that were expected to have been stored were not
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