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303 passengers, nine cabin crew and three flight crew2 (captain, first officer and
second officer). The captain was the handling pilot for the flight.
The flight crew reported that the departure and climb-out from Singapore proceeded
normally. By 1001, the aircraft was cruising at 37,000 ft (flight level 370) in
automatic flight mode with the autopilot number 1 and autothrust systems engaged.
The flight crew reported that the weather was fine and clear and there had been no
turbulence during the flight. At about 1239, the first officer left the flight deck for a
scheduled rest break. The second officer then occupied the right control seat.
At 1240:28, the autopilot disengaged. The crew reported that there was an
associated ECAM3 warning message (AUTO FLT AP OFF) and that they also
started receiving master caution chimes. The captain took manual control of the
aircraft using the sidestick. He reported that he attempted to engage autopilot 2 and
then autopilot 1, but neither action was successful.4 The flight data recorder (FDR)
showed that, during this period, the aircraft’s altitude increased to 37,200 ft before
returning to the assigned level.
The crew reported that they cleared the AUTO FLT message from the ECAM. They
then received a NAV IR1 FAULT message on the ECAM.5 The crew were also
receiving aural stall warning indications at this time, and the airspeed and altitude
1 UTC: Universal time, coordinated (previously Greenwich Mean Time or GMT). Local time in
both Singapore and Western Australia was UTC plus 8 hours.
2 The A330 was designed to be operated by two pilots (captain and first officer). Depending on the
length of the sectors on a trip, second officers were carried to relieve the captain and first officer
during long sectors. On this day, the flight crew were rostered to operate the Singapore-Perth
flight and then a Perth-Singapore flight. Second officers do not normally occupy either of the
control seats during landing or takeoff.
3 ECAM: Electronic centralized aircraft monitor (see Appendix A).
4 The flight data recorder shows that autopilot 2 did engage for 16 seconds. The recorder also
indicated that the disconnection was initiated by the crew. The captain could not recall receiving
any indication that autopilot 2 had engaged.
5 NAV: navigation systems. IR: inertial reference part of the air data inertial reference unit
(ADIRU) (see Aircraft information).
- 2 -
indications on the captain’s primary flight display (PFD) were also fluctuating.
Given the situation, the captain asked the second officer to call the first officer back
to the flight deck.
At 1242:27, while the second officer was using the cabin interphone to ask a flight
attendant to send the first officer back to the flight deck, the aircraft abruptly
pitched nose-down. The captain reported that he applied back pressure on his
sidestick to arrest the pitch-down movement. He said that initially this action
seemed to have no effect, but then the aircraft responded to his control input and he
commenced recovery to the assigned altitude. The aircraft reached a maximum
pitch angle of about 8.4 degrees nose-down during the event, and a maximum g
loading of -0.80 g6 was recorded. The aircraft descended 650 ft during the event.
The flight crew described the pitch-down movement as very abrupt, but smooth. It
did not have the characteristics of a typical turbulence-related event and the
aircraft’s movement was solely in the pitching plane. They did not detect any
movement in the rolling plane.
During the initial upset event, the second officer activated the seatbelt sign to ON
and made a public address for passengers and crew to return to their seats and
fasten their seatbelts immediately.
The flight crew reported that, after returning the aircraft to 37,000 ft, they
commenced actions to deal with multiple ECAM messages. They completed the
required action to deal with the first message (NAV IR1 FAULT) by switching the
captain’s ATT HDG (attitude heading) switch from the NORM position to CAPT
ON 3 position, and then cleared that message. The next message was PRIM 3
FAULT.7 The crew completed the required action by selecting the PRIM 3 off,
waiting 5 seconds and then selecting it on again.
At 1245:08, shortly after the crew selected PRIM 3 back on, the aircraft
commenced a second uncommanded pitch-down event. The captain reported that he
again applied back pressure on his sidestick to arrest the pitch-down movement. He
said that, consistent with the first event, that action was initially unsuccessful, but
the aircraft then responded normally and he commenced recovery to the assigned
altitude. The aircraft reached a maximum pitch angle of about 3.5 degrees nosedown,
　
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