Qantas flight 72 in-flight upset final report available

[KiloMikePapa]

Investigation: AO-2008-070 - In-flight upset - Airbus A330-303, VH-QPA, 154 km west of Learmonth, WA, 7 October 2008 (http://www.atsb.gov.au/publications/investigation_reports/2008/aair/ao-2008-070.aspx)

Coupled sidesticks anyone :}?

[alph2z]

WOW 313 pages even though no crash. Go Aussies...

[NigelOnDraft]

Coupled sidesticks anyone ?? Cannot see anything in the report to do with Flight Crew Control inputs v problems, hence why would side stick coupling be any use/relevance here?

[lakerman]

Agree with you, NigelOnDraft, re the coupled sticks. Probably too complicated for a PA38 pilot to understand;)

What is interesting is it could have happened to either A or B and it could happen on either Litton or Honeywell.

[KiloMikePapa]

I was simply referring to the fact that the sidestick issue seems to come up, rightly or wrongly, in about all threads concerning Airbus aircraft (see AF447 and Emirates EK407)

This :} emoticon was supposed to express some cynicism.

"Probably too complicated for a PA38 pilot to understand"
:= Are you always so fast in jumping to conclusions? And BTW: I have never flown a PA38. Hopefully your "engineering" was of a higher standard than your typing.

[NigelOnDraft]

What is interesting is it could have happened to either A or B and it could happen on either Litton or HoneywellNot could - did happen to a B (SQ 777).

KMP - did wonder about the "emoticon" hence did not wade in with both feet :)

[CONF iture]

What is interesting is it could have happened to either A or B and it could happen on either Litton or Honeywell.
No no, only the A with its 'protections' could have sent the pax flying in the cabin.

[CONF iture]

Not could - did happen to a B (SQ 777).
It did happen a malfunction on one ADIRU, correct, but the following upset was Autopilot and Pilot induced, not Protection induced.

[Capn Bloggs]

Not could - did happen to a B (SQ 777).
AND an MH 777! :}

[nlarbale]

From reading the report, the FCPC commanded a pitch down for 2 seconds, during which time the captain was unable to counteract the pitch down using stick back commands. Thus this incident was due to erroneous protection activation, which the flight crew was unable to override.

this is the key difference between the 777 indicidents and the A330 incident.

Obviously both systems are very safe, but the efficacy of flight control systems, should, IMHO, be continually reevaluated and changed if required, and this report seems to well serve this purpose.

[Bumps]

Question to all the bus drivers;

In 1.1.5 it is written "The crew advised that, because the autotrim was not working, they thought the flight control system was in direct law."

Previously they also said that the crew received an ECAM warning advising them they were in Alternate law. Is that the only indication the crew gets when the aircraft goes from one law to another? A ECAM message that could be buried below the rest if the crew don't deal with them? Or is there some kind of clear other indication when switching laws?

Note that the aircraft never went in to direct law but remained in alternate law for the rest of the flight.

[NigelOnDraft]

Normal / Altn / Direct Law indicated on PFD...

To be frank, there isn't a lot you're going to do different between Normal & Altn. Direct you need to trim, and the PFD message reminds you as much ;)

[PAXboy]

The magazine Information Week, has an assessment that references the same final report and highlights the software programming error:

... according to the final report on the incident from the ATSB, the problem wasn't just a faulty ADIRU, but also a programming error involving the flight computers. In particular, the airplane software wasn't written to handle an event in which an ADIRU began outputting erroneous data at regular intervals.

Notably, the flight computers averaged the angle of attack data from two of the ADIRUs to compute the airplane's true angle of attack. If the data from the two ADIRUs significantly differed, however, then the flight computers discarded the values and used the one they'd computed 1.2 seconds prior. But investigators said that the algorithm couldn't handle an episode in which an ADIRU began feeding erroneous information at 1.2-second intervals. That led to the flight computers computing an incorrect angle-of-attack reading, causing it to execute the two dives, one of which subjected passengers to forces of 0.8 G. They then report on the rarity of the event but programming was a key factor of the upset, once the initial failure had occurred.

The article is here: Software Bug Triggered Airplane Dive Emergency - Security - Application Security - Informationweek (http://www.informationweek.com/news/security/app-security/232300919)

[mickjoebill]

ABC (Australia) news reporting today that a payout of up to US$400k has been offered to injured passengers.
Some passengers have said that they would refuse the payout and take a class action to the aircraft manufacturer and Northrop Grumman for "millions of $"


Passengers compensated over mid-air drama - Business (Australian Broadcasting Corporation) (http://www.abc.net.au/news/2011-12-30/passengers-compensated-over-midair-drama/3752362?section=business)

[JohnMcGhie]

Those must be overseas passengers :-) Australian residents would know that class actions make lawyers rich, and then they'll get $1,000 (maybe...).

$400,000 for being too stupid to wear the seatbelt? I must try leaving mine off.

It's those deadly "plunges" that bring the money in :-)

Happy New Year All

[Phalanger]

Leaving your seat belt is for your own protection against natural courses. It is not rectification for foreseeable injury caused by normal use of the aircraft (aka if they know the data is wrong 1.2 seconds ago, why did it use it 1.2 seconds later instead of the closest correct data to that point). That is a foreseeable problem for any reasonable programmer in their position designing that system. This is different from how it is not reasonably possible to make a perfect system.

There can be contribution from a person, but it would not be reasonable to expect a person to sit there for the whole flight never getting out of the seat. Also they did not add to the cause of the aircraft inflicting damage. It would be minimal contribution by the people at best.

Think of it like a car. If I make a case where it does not break under conditions because of a 0.00001P chance when the system could have been reasonable designed and foreseeable against this flaw, then the fact the guy is not wearing a helmet to stop head injuries is irreverent.

[Capn Bloggs]

Leaving your seat belt is for your own protection against natural courses. It is not rectification for foreseeable injury caused by normal use of the aircraft
And if the reason to keep your seatbelt on is not given? Passengers wilfully disobeying a company direction to keep their seatbelt on "for their own comfort and safety"?

[Phalanger]

That's like saying run quickly now because I'm going to fire an RPG at you. The fact I told you to run quickly does not change the fact I fired an RPG at you.

A considerable reason in this is people are not meant to sit still for a long haul flight. DTV is a prime example of this. Your bladder too. While it is a good safety requirement to protect against the unknown external forces, it is not a defense against an accidence of their own cause.

Another way to think of it is I drive a wide load truck down the street with a at 5am every day. Some day I will be going down one street and hit something because the truck is too big. The fact I had lights flashing on top does not mean I am not responsible for the damage. If someone walked in front of the truck, then no as that would be a proactive contribution. I will have to anticipate this cost will occur sometime, that's why I get insurance from an insurance company (which for tax purposes is actually very similar to an investment fund). I could counter this by placing sensors all over the truck, and doing so may be able to lower my insurance costs.

[Di_Vosh]

Minor point

Some of the injured passengers may have been in their seats with their belts securely fastened but were injured by passengers who weren't.

[training wheels]

I'd be interesting if those passengers injured by other passengers not wearing their belts file law suits against them for negligence. If successful, this may then encourage more people to fasten their belts when seated.

[lurker999]

Bloggs,

even in 1st and business you still need to get up to go to the loo, unless something has changed in the last month where the CC bring the necessary items or the seats are now so advanced that you can go in your seat. :uhoh:

also you might want something from the overhead locker, etc etc try proving that this wasn't the case. no hope.


so unless Q want to employ double the CC and supply all pax with private seats that include a loo, then pax will have to move around in the cabin.


the pax can in no way be responsible for poor aircraft design, which is what this is. that's why airbus and northrop are paying, not qantas.

[ORAC]

I'd be interesting if those passengers injured by other passengers not wearing their belts file law suits against them for negligence. If successful, this may then encourage more people to fasten their belts when seated. Dead or alive, the one's not wearing their seat belts are liable if the case is heard in the USA (http://www.pprune.org/jet-blast/472952-victim-sued-over-flying-body-parts.html)........ :rolleyes:

[hcornea]

Under Au law, I understand damages are very limited for psychological angst and suffering, hence choosing a more favourable legal system.

It is pertinent, no doubt, whether or not this software vulnerability should have been evident with reasonable programming and testing. Lots of aircraft, very few episodes ... But it's all in the spin.

As with most things, lawyers will have us believe everything is obvious in retrospect.

I don't believe the Rocket propelled grenade analogy is either helpful, or relevant. No-one was trying or intending to hurt anyone, here.

Blame is endemic, and unhelpful ...

It remains to be seen whether there is evidence for cash as a cure for injury ... But that is another matter, entirely.

Back to usual programming. (be nice, it's my first post)

[Phalanger]

I'd be interesting if those passengers injured by other passengers not wearing their belts file law suits against them for negligence. If successful, this may then encourage more people to fasten their belts when seated.
As the cause of being thrown about is the aircraft, not simply being on the flight, it would not be worth bring the case. Additionally you never attempt to sue a injured party like this, your on the back foot from the beginning (establishing reasonable, foreseeable and standard practice).

[Phalanger]

Dead or alive, the one's not wearing their seat belts are liable if the case is heard in the USA (http://www.pprune.org/jet-blast/472952-victim-sued-over-flying-body-parts.html)........ :rolleyes:That case is very different and not really reliant here. The biggest difference is that in that case he caused the accident by covering his view in a rush. In this case the manufacture(s) are the reliant party. This is the application of extremely old torte law from the UK which is also in the Australian legal system. It is hard to see how a different result would occur for these facts in an Australian case. We have had very similar cases which had much wider results. For example the loss of income to the family members of that person who was killed in a road accident is considered foreseeable and reasonable.

An interesting aspect will be if the other manufactures are sued successfully. This does not stop them having recourse against Airbus for improper use of their products.

[Phalanger]

Under Au law, I understand damages are very limited for psychological angst and suffering, hence choosing a more favourable legal system.

It is pertinent, no doubt, whether or not this software vulnerability should have been evident with reasonable programming and testing. Lots of aircraft, very few episodes ... But it's all in the spin.

As with most things, lawyers will have us believe everything is obvious in retrospect.

I don't believe the Rocket propelled grenade analogy is either helpful, or relevant. No-one was trying or intending to hurt anyone, here.

Blame is endemic, and unhelpful ...

It remains to be seen whether there is evidence for cash as a cure for injury ... But that is another matter, entirely.

Back to usual programming. (be nice, it's my first post) It is actually more for legal requirements than merchant. Any damages leveraged by a court against a company can only be enforced in that jurisdiction. For a company like Airbus which has little presence in Australia, bring a legal case in Australia could be futile as the court could not enforce it. That would then require the overseas court to enforce the case, which is very very hard to achieve. They are much better off bringing the case to action in a country where the company has a large establishment. In this case as the US is based on the common law system, meaning it makes much more sense to bring a case there than in a civil law system.

This is very different from arbitration which when following the international conventions can be enforced in foreign states. The reason for these cases to not be brought in arbitration could be multiple.

These cases are most likely the most extreme end of the scale, and involve lingering injuries (including head trauma) which may effect the person's income and care requirements for the future. Till recently most international aviation agreements actually work servilely in favour of the aviation industry, this was to try and grow it while it was young. But newer agreements have started to remove these protections recognising they are not required for public policy any more as the industry is extremely competitive. One of the first protections removed was injury to human life and costs inflected to those people.

If someone has head trauma and requires care for life with little income ability, it is extremely expensive.

[PlaneWhisperer]

has anyone seen these photos yet, not sure if they're in the report, they're about almost 2/3 the way down the page on this link
Airbus and EMF (http://www.next-up.org/Newsoftheworld/Airbus_Uk.php)

[Swiss Cheese]

Airbus and Northrop Grumman have been sued in State Court in Chicago, Illinois by 175 pax and crew. The case was first filed over 18 months ago.

Access to Courts is much easier and cheaper in the US than Australia or the UK. Don't believe the garbage on here to the contrary by armchair lawyers.

The liability theories centre around the defective ADIRU, its software programming, and its effect on the flight control computers.

Damages and compensation is considerably higher in the US than Oz or the UK, because a jury gets to hear the story and to allocate money by way of compensation. The aviation insurers of the manufacturers pick up the bill.

It is accurate that many passengers have resolved their claims. It is also an open question as to whether Airbus and Northrop will not contest liability for the remaining claims. This issue was addressed in open court this month.

If you are still interested, you can sit in at the next status hearing in the Chicago Court.

[unworry]

There's a lengthy article in today's Sydney Morning Herald about the incident.

The untold story of QF72: What happens when 'psycho' automation leaves pilots powerless? (http://www.smh.com.au/good-weekend/the-untold-story-of-qf72-what-happens-when-psycho-automation-leaves-pilots-powerless-20170510-gw26ae.html)

Does anyone know how the lawsuits against Airbus and NG are progressing?

[PastTense]

For the first time, the captain of the imperilled Qantas Flight 72 [October, 2008] reveals his horrific experience of automation's dark side: when one computer "went psycho" and put more than 300 passengers at risk.The untold story of QF72: What happens when 'psycho' automation leaves pilots powerless? (http://www.smh.com.au/good-weekend/the-untold-story-of-qf72-what-happens-when-psycho-automation-leaves-pilots-powerless-20170510-gw26ae.html)

[pax britanica]

Just a gentle reminder that its QANTAS , all caps and no 'u'

[atakacs]

Those on board QF72 are in dire trouble. There are no ejection seats like the combat jets Sullivan flew in the US Nav

Seriously?

There is a point to be made (IMHO) about failing automation in modern jetliners. But this "article" is just a pile of nonsense.

[barit1]

The incompetent media missed the bit about them narrowly missing a crowded schoolyard, hospital, and refinery (to say nothing of the neighborhood pub)

[DaveReidUK]

So the 300-page investigation report by the ATSB doesn't count, then?

In-flight upset - Airbus A330-303, VH-QPA, 154 km west of Learmonth, WA, 7 October 2008 (https://www.atsb.gov.au/media/3532398/ao2008070.pdf)

[megan]

One thing the article addresses very well is the possible psychological effects upon crew having endured a notable event. Something all who survive such encounters need to be cognisant of, ditto managers. An area official reports don't delve into.

[CONF iture]

... But this "article" is just a pile of nonsense.
I see nothing wrong with that article.
It reports how traumatic that event has been on the crew.
I can only recommend its reading.

[lurker999]

If you want the dry technical explanation of why/how that A330 went rogue and the dry technicalities of the crew response. ATSB.

If you want to know how it effected the actual humans involved. read the article.

[RickNRoll]

Seriously?

There is a point to be made (IMHO) about failing automation in modern jetliners. But this "article" is just a pile of nonsense.

Standard journalistic fail on technicalities but the story from the point of view of the crew is interesting. You don't get that in a technical report.

You also wouldn't get the priceless description of the passenger nearly choking to death because the put on a life preserver incorrectly and then proceeded to inflate it inside the aircraft.

[Airbubba]

Just a gentle reminder that its QANTAS , all caps and no 'u'

All caps? Are you shure? ;)

More discussion from the daily posting of this article link here:

http://www.pprune.org/australia-new-zealand-pacific/346566-qantas-a330-emergency-landing-learmonth-18.html#post9770302

[rottenray]

All caps? Are you shure? ;)

"Shure" is registered trade name commonly associated with professional sound equipment. Notably, high end microphones.

I appreciate your humor here, and love the chance to pick on you a bit.

"Quantas." It bugs me, too.

"Queensland and Northern Territory Aerial Services"

Hence, abbreviation: QANTAS

It's like typing Raaf, or Usaf, which you find people doing.

DavidReid writes:
So the 300-page investigation report by the ATSB doesn't count, then?

It does.

The linked article is great in a touchy-feely way, but is sparse on technical facts.

Folks, that's why I come here.

Cheers!

[Airbubba]

"Queensland and Northern Territory Aerial Services"

Hence, abbreviation: QANTAS

It's like typing Raaf, or Usaf, which you find people doing.


They use caps in some logos and liveries but usually otherwise brand themselves as Qantas without the all caps, take a look:

https://www.qantas.com/us/en.html

[oleary]

Having been through an event like this I can confirm that it will change you in ways you cannot predict.

[biggles61]

They use caps in some logos and liveries but usually otherwise brand themselves as Qantas without the all caps, take a look:

https://www.qantas.com/us/en.html

I thought they had white caps;)

[cappt]

Captain PTSD and lawsuits in the U.S. against Airbus and Northrup Grumman? OK.

[onetrack]

Why is it that no definitive testing for Navy VLF signal generation interference with commercial aircraft FCPC's and ADIRU operation, has ever been raised or carried out?

Why is it that not one, but two commercial aircraft have had FCPC/ADIRU "upsets" within the vicinity of the Harold E Holt Naval Communication station at Exmouth? Pure co-incidence? I personally think not.

It is also known that electricity transmitted in this way (Navy VLF signal generation) can be 'strong' enough to recharge (submarine) on-board high-voltage batteries known as plasma-dynamic storage cells

The Harold E Holt Naval Communications base, Exmouth (http://www.australiaforeveryone.com.au/wa/nw-cape-base.htm)