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investigations involving Australian registered aircraft and ships. A primary concern
is the safety of commercial transport, with particular regard to fare-paying
passenger operations.
The ATSB performs its functions in accordance with the provisions of the
Transport Safety Investigation Act 2003 and Regulations and, where applicable,
relevant international agreements.
Purpose of safety investigations
The object of a safety investigation is to enhance safety. To reduce safety-related
risk, ATSB investigations determine and communicate the safety factors related to
the transport safety matter being investigated.
It is not the object of an investigation to determine blame or liability. However, an
investigation report must include factual material of sufficient weight to support the
analysis and findings. At all times the ATSB endeavours to balance the use of
material that could imply adverse comment with the need to properly explain what
happened, and why, in a fair and unbiased manner.
Developing safety action
Central to the ATSB’s investigation of transport safety matters is the early
identification of safety issues in the transport environment. The ATSB prefers to
encourage the relevant organisation(s) to proactively initiate safety action rather
than release formal recommendations. However, depending on the level of risk
associated with a safety issue and the extent of corrective action undertaken by the
relevant organisation, a recommendation may be issued either during or at the end
of an investigation.
The ATSB has decided that when safety recommendations are issued, they will
focus on clearly describing the safety issue of concern, rather than providing
instructions or opinions on the method of corrective action. As with equivalent
overseas organisations, the ATSB has no power to implement its recommendations.
It is a matter for the body to which an ATSB recommendation is directed (for
example the relevant regulator in consultation with industry) to assess the costs and
benefits of any particular means of addressing a safety issue.
About ATSB investigation reports: How investigation reports are organised and
definitions of terms used in ATSB reports, such as safety factor, contributing safety
factor and safety issue, are provided on the ATSB web site www.atsb.gov.au.
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ABBREVIATIONS
ACARS Aircraft communications, addressing and reporting system
ADIRS Air data and inertial reference system
ADIRU Air data inertial reference unit
ADR Air data reference
AIRMAN AIRcraft Maintenance ANalysis database
AOA Angle of attack
AP Autopilot
ATSB Australian Transport Safety Bureau
BEA Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation
civile (France, Bureau of Investigations and Analysis for the Safety
of Civil Aviation)
BITE Built-in test equipment
CASA Civil Aviation Safety Authority
CMC Central maintenance computer
CMS Central maintenance system
CVR Cockpit voice recorder
EASA European Aviation Safety Agency
ECAM Electronic centralized aircraft monitor
EMI Electromagnetic interference
FAA Federal Aviation Administration (US)
FCPC Flight control primary computer (also known as PRIM)
FCSC Flight control secondary computer (also known as SEC)
FDR Flight data recorder
FL Flight level
FMGEC Flight management guidance envelope computer
GPS Global positioning system
HF High frequency
IR Inertial reference
ICAO International Civil Aviation Organization
NTSB National Transportation Safety Board (US)
OEB Operations engineering bulletin
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PED Personal electronic device
PFD Primary flight display
PFR Post flight report
PRIM Common name for flight control primary computer (FCPC)
QAR Quick access recorder
SEC Common name for flight control secondary computer (FCSC)
UTC Universal time, coordinated
VLF Very low frequency
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FACTUAL INFORMATION
This interim report provides a summary of factual information that has been
derived from the continuing investigation of the subject occurrence – building upon
the information presented in the preliminary report (ISBN 978-1-921490-84-2). As
the investigation is ongoing, readers are cautioned that there is the possibility that
new evidence may become available that alters the circumstances as depicted in the
report.
History of the flight
At 0932 local time (0132 UTC1) on 7 October 2008, an Airbus A330-303 aircraft,
registered VH-QPA, departed Singapore on a scheduled passenger transport service
to Perth, Australia. On board the aircraft (operating as flight number QF72) were
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