Accident Report Finds Problems with Airbus Software
Labels: aircraft, defence technology, Safety Critical Systems, Western Australia
Labels: aircraft, defence technology, Safety Critical Systems, Western Australia
... The ATSB has scheduled the media conference this evening to coincide with the release of an Operators Information Telex/Flight Operations Telex, which is being sent by Airbus to operators of all Airbus aircraft. The aim of that telex is to:
- update operators on the factors identified to date that led to the accident involving QF72,
- provide operational recommendations to mitigate risk in the event of a reoccurrence of the situation which occurred on QF72.
... The aircraft was flying at FL 370 or 37, 000 feet with Autopilot and Auto-thrust system engaged, when an Inertial Reference System fault occurred within the Number-1 Air Data Inertial Reference Unit (ADIRU 1), which resulted in the Autopilot automatically disconnecting. ...
The faulty Air Data Inertial Reference Unit continued to feed erroneous and spike values for various aircraft parameters to the aircrafts Flight Control Primary Computers which led to several consequences including:
- false stall and overspeed warnings
- loss of attitude information on the Captain's Primary Flight Display
- several Electronic Centralised Aircraft Monitoring system warnings.
About 2 minutes after the initial fault, ADIRU 1 generated very high, random and incorrect values for the aircrafts angle of attack.
These very high, random and incorrect values of the angle attack led to:
- the flight control computers commanding a nose-down aircraft movement, which resulted in the aircraft pitching down to a maximum of about 8.5 degrees,
- the triggering of a Flight Control Primary Computer pitch fault.
The crew's timely response led to the recovery of the aircraft trajectory within seconds. During the recovery the maximum altitude loss was 650 ft.
The Digital Flight Data Recorder data show that ADIRU 1 continued to generate random spikes and a second nose-down aircraft movement was encountered later on, but with less significant values in terms of aircraft's trajectory.
At this stage of the investigation, the analysis of available data indicates that the ADIRU 1 abnormal behaviour is likely as the origin of the event. ...
Related Documents: | Audio file of media conference, 14 October 2008 (18 MB)
From: "Qantas Airbus A330 accident Media Conference", Media Release, Australian Transport Safety Bureau, 2008/43, 14 October 2008
Labels: aircraft, Safety Critical Systems, Transport
The Australian Transport Safety Bureau (ATSB) released a final report on the grounding of the ship Pasha Bulker at Newcastle on 8 June 2007. This is a clearly written technical report into what happened and what to do to stop it happening again. Fortunately there was no loss of life. Perhaps similar independent reports should be prepared where there is any major incident which risks public safety, or large financial loss.
Bodies, such as the coroner's court only have jurisdiction where there is an actual death. Also physical injury may only play a small part in many incidents which could have a large and detrimental impact on the public. At present it is necessary to rely on an uncoordinated array of overlapping investigative agencies and ad-hoc inquiries. Major incidents may require a special public inquiry, but a government may be reluctant to launch an inquiry which may find them at fault. Something like a more general version of the ATSB, can carry out an independent investigation, would be useful.
ps: Perhaps some time could be saved by calling the public inquiry into the Sydney Nort West Metro Project now. This project is quite clearly a disaster in the making. ;-)
Occurrence Details
Marine Safety Investigation Report - Final
Independent investigation into the grounding of the Panamanian registered bulk carrier Pasha Bulker on Nobbys Beach, Newcastle, New South Wales on 8 June 2007
Occurrence Number: 243 Location: Nobbys Beach, Newcastle Occurrence Date: 08 June 2007 State: NSW Occurrence Time: 0951 (UTC +10) Highest Injury Level: None Occurrence Category: Incident Investigation Type: Occurrence Investigation Occurrence Class: Investigation Status: Completed Occurrence Type: Grounding Release Date: 23 May 2008
Vessel Details
Vessel: Pasha Bulker Flag: Panam IMO: 9317729 Type of Operation: Bulk carrier Damage to Vessel: Substantial Departure Point: Newcastle anchorage Departure Time: 0748 local time Destination: To sea
On 23 May 2007, the Panamanian registered bulk carrier Pasha Bulker anchored 2.4 miles off the coast near Newcastle, New South Wales. The ship had sufficient water ballast on board for the good weather at the time, and was not expected to load its coal cargo for about three weeks.
At midday on 7 June, Pasha Bulker's master veered more anchor cable after a gale warning was issued. The weather deteriorated and shortly after midnight, the wind had reached gale force.
At 0500 on 8 June, the wind had increased to strong gale force and the weather was severe. At 0625, Pasha Bulker started to drag its anchor. The master decided to put to sea and at 0748, the anchor was aweigh. The ship was now 1.2 miles from the shore and, with the southeast wind fine on the starboard bow, it made good a north-easterly course. At 0906, the master altered the ship’s course to starboard to put the wind on the port bow in an attempt to make good a southerly course on a south-southeasterly heading. However, its heading became south-westerly and, with the wind on the port beam, the ship started to rapidly approach the coast.
At 0931, with Nobbys Beach 0.8 of a mile away, the master attempted a starboard turn. The manoeuvre did not succeed and at 0946, with grounding imminent, he requested assistance from authorities ashore. At 0951, Pasha Bulker grounded on Nobbys Beach and the ship's momentum carried it further onto the beach. The crew were evacuated by helicopter during the afternoon.
On 2 July, Pasha Bulker was successfully refloated. The ship was temporarily repaired in Newcastle and on 26 July, taken in tow to Vietnam to undergo permanent repairs.
The report identifies a number of safety issues and issues recommendations or safety advisory notices to address them.
Download complete report [4.6 MB PDF]
Marine Safety Recommendations
[MR20080009] [MR20080010] [MR20080011] [MR20080012] [MR20080013] [MR20080014] [MR20080015] [MR20080016] [MR20080017] [MR20080018] [MR20080019]
Safety Advisory Notices
[MS20080015] [MS20080016] [MS20080017] [MS20080018]
Related Links: | Media release | Media conference audio file .avi 55 MB |
Labels: disaster management, Safety Critical Systems, Transport
Labels: Defence IT, Safety Critical Systems, Software Engineering, spacecraft
NICTA LC SEMINAR
Improved Air Traffic Control with Cooperative Surveillance Techniques
Stephan Schulz (Comsoft GmbH)
DATE: 2008-08-06
TIME: 16:00:00 - 17:00:00
LOCATION: NICTA - 7 London Circuit
ABSTRACT:
Aircraft in controlled airspace are flying under the direction of air traffic controllers, which are responsible for safe, orderly, and expeditious traffic flow. In particular, maintaining proper aircraft separation is not left to individual pilots, but subject to air traffic control.To support controllers in their task, surveillance systems are used to provide an air situation picture. The quality of the air situation picture determines both the workload of the controller and the safe separation limits of aircraft, and hence significantly influences the safe capacity of the air space. Most of todays surveillance systems are based on rotating antenna radars. However, radars are expensive to build and operate. They have a relatively low update rate and limited scalability.
New surveillance techniques rely on cooperative aircraft to overcome this disadvantage. Multilateration systems use a scalable array of small, low-cost sensors to determine aircraft position and parameters from the time difference of arrival of aircraft transponder signals. They achieve high accuracy, can provide updates several times per second, and provide secondary information about the aircraft based on the content of the received messages.
An even more radical departure from classical radar is Automated Dependent Surveillance - Broadcast. With ADS-B, the aircraft determines its own position using a global navigation satellite system. It broadcasts this position and auxiliary information, typically several times per second. The signal can be received by a low-cost ADS-B ground station with a simple omni-directional antenna. Thus, a small, passive sensor can provide a high-quality air situation picture.
In 2005 he joined Comsoft GmbH, a German provider of solutions in he field of air traffic control, where he now is responsible for research and development of future surveillance technologies.
BIO:
Stephan Schulz studied computer science and physics at the University of Kaiserslautern and graduated (Dipl. Inform.) in 1995. In the same year he joined the Automated Reasoning Group at the Technical University Munich. In 2000 he obtained a Ph.D. in computer science for his work on learning search control strategies for first-order deduction. He has contributed to the development of several high-performance deduction systems. Dr. Schulz is best known for developing E, one of the most friendly theorem provers for first-order equational logic. He taught at TU Munich, the University of Miami, and the University of the West Indies.
Labels: aircraft, NICTA, Safety Critical Systems, Transport
Labels: Ombudsman, Safety Critical Systems, Telecommunications
13th Australian Conference on
Safety Related Programmable SystemsUniversity House
Australian National University
CANBERRA, 21-22 August 2008
Regulating for Safety – is it enough?
The Australian Safety Critical Systems Association (aSCSa) announces its 13th National Conference on Safety Related Systems. The 2008 conference will be held in Canberra, ACT at University House, (Map), The Australian National University and its theme will be the role of regulation in the development and deployment of safety-related software intensive systems. Apart from specific hazardous industries where some level of regulation exists, the only direct governance for the development and deployment of safety-related software intensive systems is occupational health and safety legislation which is often applied after the fact. Tort (Common) Law could also be considered as an after-the-fact control.
Continuing the very successful format of recent annual conferences, international and local keynote speakers will address this topical issue. The keynote speakers include:
John McDermid Professor of Software Engineering Science at the University of York, UK
Frank McCormick President (Certification Services, Inc., USA) and FAA Consultant DER
Paul Cheeseman Deputy Technical Director, Asset Management, Lloyd’s Register Rail, UK
A “Call for Papers” has been issued. A programme for the conference is expected to be available July 2008 following the notification of acceptances. The two-day conference will commence at 9.00am Thursday 21 August 2008.
To complement the conference a course and a tutorial are offered. Prof John McDermid will present a short course on evidenced-based approaches for safety, commencing 2.00pm Wednesday, 20 August 2008. To register, please complete the registration form: [Editable Form] [Paper-based]
Want more information about the conference?
For questions about the Conference Program, please contact:
...
Dr Tony Cant (Program Chair)
Trusted Computer Systems Group
Information Network Division
Defence Science and Technology Organisation
PO Box 1500 Edinburgh SA 5111 Australia
Email: tony.cant(a)dsto.defence.gov.au
Labels: ACS, Canberra, Safety Critical Systems
From: Whole-of-Government review of e-security, Attorney-General and the Minister for Broadband, Communications and the Digital Economy, Australian Government, 3 July 2008Joint media release
The Hon Robert McClelland MP
Attorney-GeneralSenator the Hon Stephen Conroy
Minister for Broadband, Communications and the Digital Economy
Deputy Leader of the Government in the Senate
Whole-of-Government review of e-security
The Attorney-General Robert McClelland and the Minister for Broadband, Communications and the Digital Economy Senator Stephen Conroy today announced a whole-of-government review of e-security.
Australia’s ever-increasing reliance on information and communications technology and the threat of a hostile online environment has prompted the review, which will assist the development of a national framework for securing Australia’s electronic networks.
“New and networked systems increasingly underpin our business and social interactions, but they also provide fertile ground for exploitation by cyber criminals”, Mr McClelland said.
“The e-security review is an opportunity to look at what help the Government can provide to develop a more secure and trusted electronic operating environment for both the public and private sectors. The review will also consider whether Commonwealth programs can be better focused to deal with the ever increasing range of online threats.”
Senator Conroy said that the review of e-security was a vital step towards fostering confidence in using the internet for personal and business activities.
“A secure online environment trusted by the community coupled with the Government’s rollout of the National Broadband Network is critical to our nation’s continued social and economic prosperity,” Senator Conroy said.
A multi-agency team, led by the Attorney-General’s Department, will conduct the review, which will be completed by the end of this year.
The terms of reference for the review are attached. Details of how the public and industry can contribute to this review are available at: www.ag.gov.au/esecurityreview
Date: 3 July 2008
Media Contact:
Adam Sims, Mr McClelland’s office 0419 480 224
Tim Marshall, Senator Conroy’s office 0408 258 457E-SECURITY REVIEW 2008
TERMS OF REFERENCEThe Attorney-General's Department is to lead a review of the Australian Government’s e‑security policy, programs and capabilities, assisted by other agencies represented on the E‑Security Policy and Coordination Committee. The review will take account of both the threat from electronic intrusions into Australian networks and the threat from complementary attacks on their physical, administrative or personnel security arrangements.
The purpose of the review is to develop a new Australian Government E-Security Framework in order to create a secure and trusted electronic operating environment for both the public and private sectors.
The review will:
- develop a new Australian Government policy framework for e-security, covering the span of e-security issues across government, business and the community
- examine current programs, arrangements and agency capabilities and capacities that contribute to e-security, including:
- those being implemented by agencies under the E-Security National Agenda
- incident response and crisis management arrangements for e-security, including the recommendations from Australia’s participation in Exercise Cyber Storm II, and
- other relevant information and communications technologies (ICT) initiatives being undertaken by the Commonwealth and by state and territory governments to establish their suitability and effectiveness to achieve the policy objectives of the new Framework.
- address emerging e-security issues including:
- those resulting from technological change, including roll-out of the National Broadband Network, and
- an increasingly hostile online security environment, which does not respect traditional jurisdictional boundaries
- consider opportunities provided by international cooperation, including engagement with similar economies and like-minded governments
- bring forward recommendations, prioritised in accordance with an assessment of risk, for consideration by Government to:
- tailor programs and agency capabilities and capacity to achieve the policy objectives of the new Framework
- address current and emerging threats, and
- determine how to measure the success of each approach
- principally focus on measures to be effective in the period to mid-2011, but also take into account longer term considerations, and
- consult with relevant stakeholders and experts in government, business, academia and the community.
The review is to be completed for Government consideration by October 2008.
An executive committee comprising senior representatives of the Attorney-General’s Department, the Defence Signals Directorate, ASIO, the Department of the Prime Minister and Cabinet, the Department of Broadband, Communications and the Digital Economy, the Australian Federal Police and the Australian Government Information Management Office will provide oversight of the Review.
Labels: Australian Government, ICT Policy, Safety Critical Systems, Security
The seaman lookout on board Pride of Bilbao at the time of the incident was 60 years of age. He had worked on board the vessel for 10 months and had sailed previously on board similar vessels for many years. He was, therefore, an experienced lookout.
He had a valid ENG 1 certificate of health, which includes a requirement for regular eyesight tests.
His eyes had been tested privately in 2005, after which he was prescribed glasses to adjust his slight short-sighted vision. As a consequence, he purchased a pair of reactolite, or photochromic lensed glasses, that he could wear both during the day and at night because they darkened only in reaction to daylight or ultra violet (UV) light.
Following the accident, the MAIB had the lookout’s eyes examined once again and his prescription was found to be still correct. His eyes were also tested for other defects or anomalies that might have affected his vision or night time adaptation, but none were found.
2.5.3 The seaman lookout’s glasses
... The lookout’s photochromic glasses were sent to University College London’s Institute of Ophthalmology to assess whether they might have had an adverse effect upon his night vision.
The glasses were examined and a report was prepared (Annex 1), which concluded that the optical transmission of the lenses was no more than 80% efficient and, taking into account all of the other known factors, was probably less at the time of the accident. This compares to 94.7% and 99.4% optical transmittance of ordinary uncoated and coated lenses, respectively. This was a startling result as the consequences of such a reduction in night vision had not been fully appreciated by opticians and ophthalmologists before the investigation of this accident.
The report also stated that it would be correct to assume that a uniform reduction in brightness due to the optical density of the lenses would decrease the likelihood that a subject would detect the lights of shipping vessels.
It appears, therefore, that the lookout’s glasses would have been a contributory factor when considering why Ouzo’s lights were not seen earlier. However, there are no rules or guidelines concerning the wearing of such glasses on the bridge of a vessel at night.
This incident has raised a serious concern that glasses fitted with photochromic lenses are inappropriate for use by lookouts on the bridge of merchant vessels. It also raises the question of applicability of use by operators in other modes of transport.
The MAIB also requested the Institute of Ophthalmology to test lenses from the major tinted photochromic lens manufacturers to determine whether the concerns raised in the initial report regarding the lookout’s glasses were widespread, and not just applicable to that particular pair or manufacturer (see Annex 2). The report concluded that all of the photochromic lenses tested showed significant reductions in the amount of transmitted light.
However the lenses of the glasses supplied for test by the MAIB were significantly inferior to the other currently commercially available lenses indicating that either manufacturers have improved the performance of their photochromic materials, or that the performance of photochromic glasses is reduced with time. As at least one manufacturer only guarantees the performance of lenses for 2 years, the latter reason may be the most likely.
This is obviously an additional concern regarding photochromic lens glasses, however it is outside the scope of this investigation. ...
From: Report on the investigation of the loss of the sailing yacht Ouzo and her three crew South of the Isle of Wight during the night of 20/21 August 2006, Report No 7/2007, Marine Accident Investigation Branch, United Kingdom, April 2007
Labels: Safety Critical Systems, Transport
Labels: Defence IT, f-35, Safety Critical Systems, UAV
Railways use very stringent safety standards, so it would be interesting to see how they made the case that WiFi would be reliable enough for controlling trains. It may be that the article is wrong and a WiFi-like systems is being used, perhaps using different dedicated frequencies. As an example of that European railways use a modified form of the GSM phone standard, adapted for railway requirements, called GSM-Railway (GSM-R). This uses separate frequencies from the GSM phone networks and has special features for safety and reliable working. Alternatively the railway might use several different commercial networks (as has been proposed in Australia).Increasingly, moving block train control systems are being used, operating as communication-based train control (CBTC) systems. Modern CBTC systems require up to 1Mbps (megabit per second) of uninterrupted communication between the trackside automation equipment and fast-moving trains.
Because most rail operators in Asia demand a high local content, it seems appropriate to use international radio standards and commercial off-the-shelf radio components, which can provide the necessary bandwidth. This is generally achieved by using standards and technologies for wireless local area networks (WLAN), and typical CBTC systems are based on the well-known 802.11b standard. ...
From: Wireless technology takes off in Asia, International Railway Journal, July 2007
It is not clear how different the technology Alcatel is from ordinary office and home WiFi.
Alcatel is pioneering the implementation of an open standards RF communications technology (802.11 Frequency Hopping Spread Spectrum (FHSS)) for trains moving in excess of 120km/h. Whether it’s used for Communication-Based Train Control (CBTC) or Closed Circuit Television (CCTV), 802.11 remains the preferred choice since it’s the only standard that supports mobility and defends against obsolescence. Alcatel adopted 802.11 FHSS technology in 1999 and has performed several trials and demonstrations since then.
From: Open Standards for CBTC and CCTV, Radio-Based Communication, Ed Kuun, date: ????
Labels: railways, Safety Critical Systems, WiFi
Labels: Defence IT, Safety Critical Systems, UAV
Labels: Defence IT, f-35, Safety Critical Systems, UAV