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• The ADIRU manufacturer is conducting a theoretical analysis of ADIRU
software and hardware to identify possible fault origins.
• The aircraft manufacturer is conducting a detailed analysis of differences in
aircraft configuration between the operator’s A330 aircraft and other operators’
A330 aircraft with the same type of ADIRU. The results of these configuration
comparisons may lead to additional ADIRU testing requirements.
• A detailed analysis is being conducted of whether there were any commonalities
in operational, environmental or maintenance aspects of the flights/aircraft that
were involved in the occurrences.
Flight control system
The investigation is examining various aspects of the PRIM software development
cycle including design, hazard analysis, testing and certification.
Electronic centralized aircraft monitor (ECAM)
The investigation is examining the performance of the ECAM and its effectiveness
in assisting crews to manage aircraft system problems.
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Cabin safety
Further work on cabin safety aspects is ongoing, including the following:
• Further analysis of information obtained from passengers to determine patterns
related to the occurrence or severity of injuries.
• Further examination of the potential for inadvertent seatbelt release associated
with loosely fastened seatbelts. The examination will consider the scope of the
problem across different types of aircraft, as well as relevant design
requirements for seatbelts and seats.
• Review of relevant aviation industry requirements regarding the use of seatbelts.
Flight recorders
Examination of CVR, FDR and QAR information from VH-QPA is on-going and
includes the following:
• analysis of CVR audio regarding aural warnings, crew actions, aircraft handling
and crew/cabin communications during the pitch-down events and the
subsequent approach and landing at Learmonth
• analysis of QAR data to assist in evaluating the performance of aircraft systems
• analysis of FDR data to produce a detailed sequence of events and assist in
evaluating the performance of aircraft systems
• a review of the earlier flights recorded by the FDR and QAR for any evidence of
anomalous performance of aircraft systems.
Examination of FDR and QAR information from VH-QPG is on-going and includes
the analysis of data to assist in evaluating the performance of aircraft systems and to
produce a detailed sequence of events.
The aircraft manufacturer and the operator are examining the feasibility of
recording additional parameters from ADIRUs 1 and 2 on the QAR. This would
require wiring changes to the operator’s A330 aircraft to access an additional
ADIRU databus and modifications to the aircraft condition monitoring system
(ACMS) software.
Other activities
The ATSB is aware that a post-incident multi-agency debrief has been conducted.
The debrief included representatives from all available private, government and
non-government organisations involved in the emergency response to the accident
and the Westralia Airports Corporation is coordinating actions from that meeting.
The ATSB will review those outcomes in relation to information obtained at
interviews and from responses to the passenger questionnaire.
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SAFETY ACTION
Aircraft manufacturer
Operational procedures
On 14 October 2008, as soon as a preliminary analysis of the occurrence was
conducted, Airbus published Operator Information Telex (OIT) / Flight Operations
Telex (FOT) SE 999.0083/08/LB (‘A330 in-flight incident’). The telex was issued
to Airbus operators, who were asked to distribute it to all A330/A340/A340-
500/A340-600 flight crews without delay. The telex provided brief details known
about the occurrence. It also provided operational recommendations applicable for
A330/A340 aircraft fitted with Northrop Grumman air data inertial reference units
(ADIRUs). The telex stated that, pending final resolution, Airbus would issue an
OEB [Operations Engineering Bulletin] 74-1 that would instruct flight crew to
select OFF the whole ADIRU in the case of an inertial reference (IR) failure,
instead of switching OFF only the IR part.
On 15 October, OEB-A330-74-1 was dispatched, applicable to all A330 aircraft
fitted with Northrop Grumman ADIRUs. The OEB stated that, in the event of a
NAV IR FAULT (or an ATT red flag being displayed on either the captain’s or first
officer’s PFD), the required procedure was for the crew to select OFF the relevant
ADR and then select OFF the relevant IR. A compatible temporary revision was
issued to the Minimum Master Equipment List at the same time. The procedure in
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