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the OEB was subsequently issued as an Emergency Airworthiness Directive by the
European Aviation Safety Agency (EASA) (No. 2008-0203-E) effective on 19
November 2008 and the Civil Aviation Safety Authority (CASA) (AD/A330/95)
effective on 20 November 2008.
The OEB procedure was subsequently amended in December 2008 to cater for a
situation where the IR and ADR pushbuttons are selected to OFF and the OFF
lights did not illuminate. If the lights did not illuminate, the new OEB (74-3)
required crews to select the IR rotary mode selector to the OFF position. This OEB
was subsequently issued as an Emergency Airworthiness Directive by EASA (No.
2008-0225-E) effective on 22 December 2008 and CASA (AD/A330/95
Amendment 1) effective on 22 December 2008.
Following the 27 December 2008 event, Airbus issued another OEB (74/4) on 4
January 2009. This OEB provided a different procedure for responding to a similar
ADIRU-related event to ensure erroneous data would not be used by other aircraft
systems. The procedure required the crew to select OFF the relevant IR, select OFF
the relevant ADR, and then turn the IR rotary mode selector to the OFF position.
The modified procedure was subsequently issued as an Emergency Airworthiness
Directive by EASA (No. 2009-0012-E) effective on 19 January 2009 and CASA
(AD/A330/95 Amendment 2) effective on 19 January 2009.
Similar OEBs were issued by Airbus for A340 aircraft, and the EASA
Airworthiness Directives also applied to A340 aircraft.
- 46 -
Flight control system
Airbus is in the process of developing a modification to its PRIM software to make
it more robust to AOA spikes.
Aircraft operator
On 15 October 2008, in response to the Airbus releases, the operator issued Flight
Standing Order 134/08 for its A330 operations. On 24 October 2008, this order was
replaced by Flight Standing Order 136/08, which incorporated the material from the
Airbus OEB. In addition, a program of focussed training during simulator sessions
and route checks was initiated to ensure that flight crew undertaking recurrent or
endorsement training were aware of the contents of the Flight Standing Order.
Subsequent Flight Standing Orders were issued in response to the modified OEBs
in December and January 2009.
Seatbelt reminders
In its media statements providing updates on the investigation on 8 and 10 October
2008, the ATSB noted that this accident served as a reminder to all people who
travel by air of the importance of keeping seatbelts fastened at all times when seated
in an aircraft.
On 27 October 2008, the Australian Civil Aviation Safety Authority issued a media
release that stated that the occurrence was as a timely reminder to passengers to
‘remain buckled up when seated at all stages of flight’. The media release also
highlighted the importance of passengers following safety instructions issued by
flight crew and cabin crew, including watching and actively listening to the safety
briefing given by the cabin crew at the start of each flight.
- 47 -
APPENDIX A: ELECTRONIC INSTRUMENT SYSTEM
This appendix provides general background information on the A330 electronic
instrument system. It is based on information contained in the operator’s A330
Flight Crew Operating Manual, Volume 1: Systems Description. The information is
not exhaustive.
Figure A1 shows the general layout of the electronic instrument system. Key
components of the system are the electronic centralized aircraft monitor (ECAM)
and the primary flight display (PFD).
Figure A1: Overview of electronic instrument system
Failure mode classifications
Failures of an aircraft system are classified at three levels:
• Level 3 failure or ‘warning’, associated with the colour red. The configuration
or failure requires immediate action by the flight crew.
• Level 2 failure or ‘caution’, associated with the colour amber. The flight crew
should be aware of the configuration or failure, but need not take immediate
action.
• Level 1 failure or ‘caution’, associated with the colour amber. Requires crew
monitoring.
For a level 3 warning, the MASTER WARN red light flashes (or specific red light
illuminates), and a continuous repetitive chime (or other specific aural signal)
sounds in the cockpit. For a level 2 caution, a steady MASTER CAUT amber light
illuminates and there is a single chime. The lights and signals cease when the
warning/caution situation no longer exists or when the flight crew press the
respective ‘attention getter’ light or press other controls on the electronic
centralized aircraft monitor (ECAM).
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