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Flight recorders ............................................................................................... 44
Other activities................................................................................................ 44
SAFETY ACTION ............................................................................................... 45
Aircraft manufacturer...................................................................................... 45
Operational procedures....................................................................... 45
Flight control system .......................................................................... 46
Aircraft operator ............................................................................................. 46
Seatbelt reminders........................................................................................... 46
APPENDIX A: ELECTRONIC INSTRUMENT SYSTEM............................. 47
Failure mode classifications ............................................................... 47
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Electronic centralized aircraft monitor (ECAM)................................ 48
Primary flight displays ....................................................................... 48
APPENDIX B: FLIGHT DATA RECORDER PLOTS.................................... 49
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DOCUMENT RETRIEVAL INFORMATION
Report No.
AO-2008-070
Publication date
6 March 2009
No. of pages
53
ISBN
097-1-921602-20-7
Publication title
In-flight upset, 154 km west of Learmonth, WA, 7 October 2008, VH-QPA, Airbus A330-303
Prepared by
Australian Transport Safety Bureau
PO Box 967, Civic Square ACT 2608 Australia
www.atsb.gov.au
Reference No.
Mar2009/INFRA-08418
Acknowledgements
Figure 4, Figure 9, Figure 10 and diagrams included in Appendix A by permission of Airbus.
Abstract
At 0932 local time (0132 UTC) on 7 October 2008, an Airbus A330-303 aircraft, registered VHQPA,
departed Singapore on a scheduled passenger transport service to Perth, Australia. On board
the aircraft (operating as flight number QF72) were 303 passengers, nine cabin crew and three
flight crew. At 1240:28, while the aircraft was cruising at 37,000 ft, the autopilot disconnected.
From about the same time there were various aircraft system failure indications. At 1242:27,
while the crew was evaluating the situation, the aircraft abruptly pitched nose-down. The aircraft
reached a maximum pitch angle of about 8.4 degrees nose-down, and descended 650 ft during the
event. After returning the aircraft to 37,000 ft, the crew commenced actions to deal with multiple
failure messages. At 1245:08, the aircraft commenced a second uncommanded pitch-down event.
The aircraft reached a maximum pitch angle of about 3.5 degrees nose-down, and descended
about 400 ft during this second event.
At 1249, the crew made a PAN urgency broadcast to air traffic control, and requested a clearance
to divert to and track direct to Learmonth. At 1254, after receiving advice from the cabin of
several serious injuries, the crew declared a MAYDAY. The aircraft subsequently landed at
Learmonth at 1350.
One flight attendant and 11 passengers were seriously injured and many others experienced less
serious injuries. Most of the injuries involved passengers who were seated without their seatbelts
fastened or were standing. As there were serious injuries, the occurrence constituted an accident.
The investigation to date has identified two significant safety factors related to the pitch-down
movements. Firstly, immediately prior to the autopilot disconnect, one of the air data inertial
reference units (ADIRUs) started providing erroneous data (spikes) on many parameters to other
aircraft systems. The other two ADIRUs continued to function correctly. Secondly, some of the
spikes in angle of attack data were not filtered by the flight control computers, and the computers
subsequently commanded the pitch-down movements.
Two other occurrences have been identified involving similar anomalous ADIRU behaviour, but
in neither case was there an in-flight upset.
The investigation is continuing.
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THE AUSTRALIAN TRANSPORT SAFETY BUREAU
The Australian Transport Safety Bureau (ATSB) is an operationally independent
multi-modal bureau within the Australian Government Department of
Infrastructure, Transport, Regional Development and Local Government. ATSB
investigations are independent of regulatory, operator or other external
organisations.
The ATSB is responsible for investigating accidents and other transport safety
matters involving civil aviation, marine and rail operations in Australia that fall
within Commonwealth jurisdiction, as well as participating in overseas
　
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