Safety First

The Airbus Safety Magazine

# 03 December 2006
 1
Safety First # 03 December 2006

Editorial # 03 December 2006

The Airbus Safety Magazine

Yannick MALINGE
Vice President
Safety First
Flight Safety The Airbus Safety Magazine
For the enhancement of safe flight through

Content increased knowledge and communications.

Safety First is published by the Flight Safety Department requirements or technical orders. The contents do not
of Airbus. It is a source of specialist safety information supersede any requirements mandated by the State of
Last October we held the 13th Airbus Flight Safety for the restricted use of flight and ground crew members Registry of the Operator’s aircraft or supersede or amend
Conference. This was an opportunity to share
information for the 125 attendees (out of which about
The Airbus Safety Magazine ......... 1 who fly and maintain Airbus aircraft. It is also distributed
to other selected organisations.
any Airbus type-specific AFM, AMM, FCOM, MEL
documentation or any other approved documentation.
30% attended for the first time) representing 80 Airbus
operators. News Material for publication is obtained from multiple sources Articles may be reprinted without permission, except where
The feedback we received was very positive,
highlighting in particular the very open and fruitful
C. Courtenay ..................................... 2 and includes selected information from the Airbus Flight
Safety Confidential Reporting System, incident and
copyright source is indicated, but with acknowledgement
to Airbus. Where Airbus is not the author, the contents of
accident investigation reports, system tests and flight the article do not necessarily reflect the views of Airbus,
exchange of information, not only between Airbus
Dual Side Stick Inputs
and You, our Operators, but also between Operators
themselves. Notably 7 airlines shared their experiences
either on crisis management or on safety related
F. Combes ......................................... 3 tests. Material is also obtained from sources within the
airline industry, studies and reports from government
agencies and other aviation sources.
neither do they indicate Company policy.

Contributions, comment and feedback are welcome. For

technical reasons the editors may be required to make editorial
events. Trimmable Horizontal All articles in Safety First are presented for information changes to manuscripts, however every effort will be made
We can consider this as a clear indication that the Stabilizer Damage only and are not intended to replace ICAO guidelines, to preserve the intended meaning of the original. Enquiries
Airbus Flight Safety Conference became what we
hoped for 13 years ago: “our Operators” Safety
M. Baillon .......................................... 7 standards or recommended practices, operator-mandated related to this publication should be addressed to:

Conference. Airbus
Pitot Probes Obstruction
Similarly, the Airbus Safety Magazine, the extension
of our Safety Conference, has to become as well
“our Operators” Safety Magazine.
A. Urdiroz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Flight Safety Department (GSE)
1, rond point Maurice Bellonte
31707 Blagnac Cedex - France
E.mail: [email protected]
Therefore we hope receiving articles from you that A340 Thrust Reverser Unlocked
can be published in our next Safety First magazine
to share Safety experience as we have done together
V. Swiderski, O. Guenzel ................. 14 Fax: +33 (0)5 61 93 44 29

during the last 13th Safety Conferences.

Residual Cabin Pressure Safety First
I hope you will enjoy reading this 3rd issue of Safety
First and feel free to widely distribute it throughout
your organisation.
M. Palomerque ................................. 18 # 03 December 2006
Safety First is published
by Airbus S.A.S
Yours sincerely Cabin Operations Flight Operations 1, rond point Maurice Bellonte

Yannick MALINGE
C. Keegan, C. Lemozit . . . . . . . . . . . . . . . . . . . . . 27 31707 Blagnac Cedex / France

Editors:
© Airbus S.A.S. 2006 – All rights reserved. Confidential and proprietary documents.

Yannick Malinge, By taking delivery of this Brochure (hereafter “Brochure”), you accept on behalf of your
Vice President Flight Safety
Hypoxia an Invisible Enemy Vice President Flight Safety company to comply with the following guidelines:

H. Asshauer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Christopher Courtenay,

Director of Flight Safety
3 No other intellectual property rights are granted by the delivery of this Brochure than the
right to read it, for the sole purpose of information.
Concept Design by 3 This Brochure and its content shall not be modified and its illustrations and photos shall
HCSGM 20061317
Airbus Flight Safety not be reproduced without prior written consent of Airbus.

Contacts/Organisation ................... 36 Producted by Quat’coul

Copyright: GSE
3 This Brochure and the materials it contains shall not, in whole or in part, be sold,
rented, or licensed to any third party subject to payment.
Photos copyright Airbus This Brochure contains sensitive information that is correct at the time of going to press.
Photos by ExM: This information involves a number of factors that could change over time, effecting the
Hervé Berenger true public representation. Airbus assumes no obligation to update any information contained
Philippe Masclet in this document or with respect to the information described herein.
Hervé Goussé
Airbus SAS shall assume no liability for any damage in connection with the use of this
Printed in France Brochure and of the materials it contains, even if Airbus SAS has been advised of the
likelihood of such damages.
2 3
Safety First
The Airbus Safety Magazine
# 03 December 2006

News
13th Flight Safety Dual Side
Conference Your articles
Another annual Flight Safety Conference has been
very successfully completed and we hope you all
As already said this magazine is a tool to help share
information. Therefore we rely on your inputs. We
Stick Inputs
benefited from the information sharing between are still looking for articles from operators that we
us all. can help pass to other operators through the
We have received some requests to use the magazine.
presentations internally within some airlines, so if If you have any inputs then please contact us.
you want to do this or you want more information
By: Frédéric COMBES
on the conference content then contact us on the Contact: Chris Courtenay e-mail
e-mails below. [email protected] Flight Safety Manager
Phone: +33 (0) 562110284
We are already planning next year’s conference Mobile: +33 (0) 616036422
from October 15th to 18th. We will inform everyone
as usual for registration. 1 Introduction Before the event the aircraft was in climb to FL
As always we will be asking for your inputs for the Distribution 320. The airplane had a weight of 61,2t. and was
conference. The more operator presentations the One of the basic task sharing principle for any in the following configuration:
better so if you have ideas then let us know but If you have any questions about the distribution of aircraft operation is that one pilot is Pilot Flying at G Clean with AP 2 engaged (CLIMB / NAV) and

also if there are specific subjects you would like the magazine either electronically or in hard copy a time. Therefore, if the Pilot Not Flying disagrees ATHR Engaged & Active in Thrust mode.
to see in the conference then also get in touch then please contact us. with the Pilot Flying inputs, he/she has to verbally G Managed Mach target was 0,78

with us. request corrective actions or, if deemed necessary, G Both ND CPT & FO were selected in ARC Mode

As Yannick Malinge says in his editorial this is your Contact: Mrs Nuria Soler to take over the controls by clearly announcing with a range of 160NM
conference. e-mail: [email protected] “I have controls”.
fax: +33 (0) 561934429 This will mean that he/she becomes Pilot Flying The aircraft began an uncommanded roll to the right,
from that moment and the other Pilot Not Flying. which was initially counteracted by the Auto Pilot.
Airbus Flight Safety Nevertheless, the feedback gained from line However, at a speed above 250 kts, Auto Pilot
operations monitoring indicates that dual inputs orders on ailerons are limited at 8°. Therefore, due
Office still occur and are also sometimes involved in to the high turbulence the roll reached a value of
operational incidents analyzed by Airbus. 40° to the right.
In the back of the magazine you will find pictures This was the case for the below described event, Both pilots reacted with full LH stick orders and
and information on the Flight Safety Team. Since experienced on an A320 during turbulence 10° LH rudder pedals.
the last issue of the magazine there are two new This induced the disengagement of the Auto Pilot.
Flight Safety managers: During the next 20 seconds, the Captain and First
Frederic COMBES and Nicolas BARDOU 2 Summary of Officer applied dual stick inputs, which lead to roll
Both are bringing their experience from wide but values oscillating between 33° to the left and 49°
different backgrounds in Airbus. the event to the right, as well as to a loss of 2400 feet altitude.
The Captain then re-engaged the Auto Pilot,
Also please note that many of our mobile phone While climbing to FL 320 at about Mach 0.78, an selected Flight Level 310, and the flight resumed
numbers have changed A320-200 encountered significant turbulence that without noticeable event.
led roll to increase up to 40°.
The Pilots reacted to this roll departure by various
dual sticks inputs in pitch and roll. The Auto Pilot
disconnected consequently to stick input.
4 5
Safety First
The Airbus Safety Magazine
# 03 December 2006

3 Types of dual 4 Operation of

stick input the sidestick
Analysis of reported dual side stick inputs events, The two sidesticks are not mechanically linked as
reveals that there are three types of occurrences: they are on older types of aircraft.
This means that both sticks may be operated
The “Spurious” Dual Stick inputs independently one of the other.
Typically due to an inadvertent movement of the When one sidestick is operated it sends an
stick by the PNF. electrical signal to the Fly By Wire computers.
For example when grabbing the FCOM or when When both sticks are moved simultaneously, the
pressing the R/T. system adds the signals of both pilots algebraically.
A spurious dual stick input only marginally affects
the aircraft behavior due to only time limited & small The total is limited to the signal that would result
inputs. from the maximum deflection of a single sidestick.

The “Comfort” Dual Stick inputs To avoid both signals being added by the system, A green light will come on in front of the pilot
Typically due to short interventions from the PNF a priority P/B is provided on each stick. By pressing who has taken control if the other stick is not
who wants to improve the aircraft’s attitude or this button, a pilot may cancel the inputs of the in neutral position.
trajectory: other pilot.
These are generally experienced in approach,
during a capture (altitude localizer), or in flare, and Take Over PB
have minor effects on the aircraft’s altitude/trajectory.
However, as the PF is not aware of the PNF’s
interventions, he may be disturbed and may With autopilot (AP) engaged, the sidesticks are 5 Operational
counteract the PNF’s inputs. kept in the neutral position, with no possibility of
simultaneous inputs from either pilot. procedures
The “Instinctive” Dual Stick Inputs
Typically due to a “reflex” action on the part of the Indeed, when the A/P is engaged, it is normally Simultaneous inputs by both PF and PNF on the
PNF on the stick. This instinctive reaction may Radio disconnected by pressing the priority P/B (the pilot sidesticks must be avoided. Thus, if the PNF feels
come about when an unexpected event occurs, An audio signal will indicate which sidestick has takes priority over the A/P) or instinctively at any he must intervene, he must do so by pressing the
like for example an AP disengagement, an priority, time by a firm action on the stick: typically 5kg in Priority P/B while saying “I have controls”.
overspeed situation or a dangerous maneuver. pitch, 3.6kg in roll.
Such interventions are more significant in terms These rules are reminded in the Flight Crew Training
of stick deflection and duration. Usually in such Manual 01.020 – Flight Controls and Flight Crew
situations, both pilots push the stick in the same Operating Manual 1.27.40 – Flight Controls:
direction, which may lead to over control, a situation Controls and Indicators”
illustrated by the above occurrence.

and a red light comes on

in front of the pilot whose
stick is deactivated
6 7
Safety First
The Airbus Safety Magazine
# 03 December 2006

A330-300
6 Dual Sidestick inputs Trimmable Horizontal
warning system DUAL

In order to warn the crew in case of dual sidestick

operations, Airbus has designed a package of dual
INPUT
Stabilizer Damage
input indicators and audio warning.
These operate when both side sticks are deflected
By: Marc BAILLION
simultaneously by more than 2°.
These visual and aural warnings have proved to Flight Safety Manager
be efficient means to inform the pilot of dual inputs.

Visual indication The visual and audio indications are designed to

When a dual input situation is detected, the two provide the crew with a progressive alert. 1 Introduction 2 Description
green priority lights located on the cockpit front
panel flash simultaneously. Experience has shown, that these warnings are This article describes an uneventful flight, during of the event
very effective to: which, the aircraft was in an unsafe condition. As
The visual indication is an ADVISORY of a dual G “Educate” the pilots to respect the basic task a result of what was erroneously considered as a On 21st of August 2004 upon landing, the subject
input situation sharing principle; minor damage, the limit loads of the THS were no airplane was found with a torn lower skin of the
G Reduce drastically the number of dual input more sustainable. This resulted from a wrong right hand THS Lateral Box. This damage was
occurrences. appreciation of composite structure damage. thought to be due to a Foreign Object Damage
The objective of this article is to highlight the (FOD) and resulted in a leaking Trim Tank.
CPT F/O The activation of these dual input warnings has paramount importance of building a good
no repercussion in term of : knowledge of composite structure damage and A missing water servicing door (164AR) was
G Crew training; repair. suspected to have caused the damage.
G Mixed fleet flying. Composite structure training is available at Airbus The damage was inspected externally only.
training center. The external cut was measured to be about 330mm
The Structure Repair Manual’s (SRM) procedures length by 3mm width, in line of flight, located at
must be respected and, if outside SRM limits, the THS bottom skin panel, just behind second
Airbus must be contacted to always ensure aircraft THS inboard handhole access panel.
structural integrity.
The visible damage is shown on the picture:
Based on external visual findings, the operator
Aural Indication HOW TO UPGRADE performed a temporary repair, by filling the damage
After the visual indication has been triggered, a YOUR SA AND LR AIRCRAFT ?
synthetic voice “DUAL INPUT” comes up every
5 sec, as long as the dual input condition persists. The light and aural indicators are basic, A
and free of charge on retrofit, on the A320 family
The synthetic voice is a WARNING of a dual input and A330/A340.
situation
Note: This audio has the lowest priority among the synthetic It requires FCDC and FWC to be at a given
voice audio alerts. standard already available on production line:
• A320: FWC E2 Standard - FCDC 53 Standard
• A330/A340: FWC K3/L7 Standard - FCDC
M11/L14 Standard

Pin programs are activated on Operator

request Location of the damage
8 9
Safety First
The Airbus Safety Magazine
# 03 December 2006

4 Actions Launched See Airbus customer portal, structure training

catalogue available:
The aircraft required immediate appropriate repair,
as the temporary repair did not restore the required Composite structure NDT inspection (XSB2)
structural integrity of the THS. Composite repaire for technicians - basic
Stringer (XSA2)
Rib
An OIT was issued (reference SE 999.0115/04 Advanced composite repari for technicians
dated 15th Oct. 2004) for A310/A300-600/A300- (XSA3)
600ST/A318/A319/A320/A321/A330/A340. And a new course:
OIT recommendations are as follows: Structure repair for engineers composite
External view of the damage structures (XSC3)
“In case of damage, composite structure degrades
The operator issued then an engineering note in a different way compared to metallic structure. For more information, please connect to:
for: In the particular case of impact with a foreign object https://w3.airbus.com/crs/A233_Train/0500_catalog
G Performing a close visual inspection upon the internal damage might be larger than the visible s/Structure_MENU.htm
next aircraft landing, to confirm that there external damage. On monolithic structure, impact
was no repair deterioration, crack propa- damage will usually result in delamination around
gation or any other adverse findings; perforation and damage to structure underneath” 5 Conclusion
G Ensure that the trim tanks of the horizontal

stabilizer were inop as per A330 AMM; “…AI instructions for inspection and repair of G Internal damage might be larger than the visible
G Repeat close visual inspection at every transit composite structure given in the SRM are to be external damage on composite structure
G Perform permanent repair at next B check followed, to detect damage in its full extent, and (monolithic, sandwich, CFRP, GFRP);
(2 months later). to prevent […] inappropriate repair” G Airbus instructions related to repair of composite
structure given in the SRM are to be followed,
When informed, Airbus requested immediate Composite structure courses are available at Airbus to detect damage in its full extent, and to prevent
damage assessment (including NDT) inside training department to provide specific knowledge inappropriate repair;
the THS trim tank before next flight (as per with regard to maintenance and repair of composite G SRM repair procedure to be respected or, if
standard SRM requirement), in order to define structure. outside SRM limits, contact Airbus to always
a valid repair. ensure aircraft structural integrity;
G Composite structure courses are available at
Airbus training department to provide specific
3 Damage knowledge with regard to maintenance and repair
of composite structure.
Description
Stringer As per the inspection, the monolithic CFRP
Resulting internal delamination panel was found cracked throughout the cut
length, with large delaminations in the
surrounding area.
with adhesive (EA934) and covered with two Two stringers located on the THS bottom skin
layers of Glass Fiber Reinforced Polymer panel had been severely damaged.
(GFRP) plies. Trim tanks were emptied and
a/c was flown back under MEL. Internal views of the THS are shown opposite.
10 11
Safety First
The Airbus Safety Magazine
# 03 December 2006

Pitot Probes
Obstruction 3 Systems architecture CAS3 being accurate during subject event, and
over speed warning being computed on the basis
and response
on Ground The following sketch presents the typical
of an «OR» condition of CAS1, 2 & 3 versus
VMO/MMO, the over speed situation indicated by
the Flight Warning System was actual.
architecture valid for all Airbus aircraft.
FWC
Low speed
CAS1
Low speed
By Albert URDIROZ CAS2
Overspeed
Flight Safety Manager CAS3

1 Introduction Prior to the flight, the aircraft spent a few hours on

the stand. Storm conditions prevailed during the
ground time. Pitot probes were not protected with
Airspeed is such a key parameter in aerodynamics, covers and became obstructed. This was not ADR1 ADR3 ADR2
that the systems and indicators of Airbus aircraft noticed before take-off. 3.2. The particular case where 2 airspeeds
use 3 independent airspeeds as inputs to the pilots’ are identically affected
displays as well as to the standby indicator. Aircraft During the take-off run, CAS1 (Computed Air Speed)
systems also use these 3 data. and CAS2 were indicating too low speed. However, A particular situation would arise if 2 pitot probes
Probe 1 Probe 3 Probe 2
the take-off was continued. were identically affected, which would result in 2
At the source of the information chain are the pitot of the 3 airspeeds being equally low to the detriment
probes. Feedback from in-service experience Later investigation of the flight data recordings and Normal Display of the 3rd and sole accurate one. This hypothesis
indicates that: crew report resulted in the following information Reconfigurations
is not unrealistic, and was encountered in service
G Incorrect maintenance of these probes is the about the lift-off speeds: when probes were clogged by dust or insects'
most common cause for unreliable airspeed nets. Besides, the above event was close to this
information; G Ground speed was above 160kt; In the event referred to above, no reconfiguration situation, since CAS1 and CAS2 were "only"
G Take-offs are sometimes pursued in spite of one G CAS1 was about 60kt; to ADR3 was reported, and the information displayed deviating of about 20 knots, while CAS3 was in
or two airspeed indications being unreliable. G CAS2 was estimated to be below 80kt; on the standby indicator was the sole reliable. the range of 80 knots higher.
G CAS 3 was reportedly reliable.
Consequently, this article aims at reminding ground Note: V1 and Vr of the flight are unknown to Airbus. 3.1. Systems behavior during the event For the sake of this demonstration, we will consider
staffs of the efforts to be made in order to protect that CAS1 and CAS2 are identical and too low.
pitot probes on ground, and at recommending After lift-off, the following cockpit effects occurred: The behavior of the systems described in paragraph
crews to accurately check the condition of pitot 2 resulted from the AFS (Auto Flight Systems) and AFS and EFCS airspeed monitoring relies on a
probes before flight, and to abort their take-offs G «NAV ADR DISAGREE» warning triggered; EFCS detecting the discrepancy between the 3 comparison of airspeeds. In our example, CAS3
when airspeed indication is detected unreliable. G EFCS (Electrical Flight Control Systems) reverted airspeeds. Since the monitoring is based on a would then be rejected, and computers would use
to alternate law; comparison of the different speeds, and since all the erroneous airspeeds from CAS1 & CAS2.
G Auto-thrust disengaged; 3 were different, the systems could not recognize
2 Investigation of an G Flight directors became unavailable; CAS3 as being the reliable speed. CAS3 being EFCS & AFS

in-service occurrence
For the purpose of this review we will refer to an
G Later in flight, with slats and flaps still extended,
VFE was exceeded, so that OVERSPEED warning
triggered.
the odd among the 3 airspeeds, it was rejected
at first. In this case, however, all 3 data were rapidly
rejected by EFCS for computation till the end of
the flight.
CAS1 consistent with CAS2
CAS1 much lower than CAS3
CAS2 much lower than CAS3 } CAS3
=> considered
unreliable

event that was recently experienced on an A330. Eventually, an in-flight turn back was initiated and
However, this type of event could have happened an uneventful landing completed.
on any other Airbus aircraft.
12 13
Safety First
The Airbus Safety Magazine
# 03 December 2006

Flight controls surfaces gain In addition, Airbus has improved

efficiency with speed. For the maintenance program with A319/A320/A321 STANDARD OPERATING PROCEDURES 3.03.05 P 2
instance, the roll rate achieved the reduction of the interval EXTERIOR INSPECTION SEQ 001 REV 24
FLIGHT CREW OPERATING MANUAL
with 5 degrees of aileron from 2C to 1C-check for
deflection will be much higher draining and flushing the pitot 2 NOSE SECTION
if aircraft flies at VMO/MMO than pressure lines.
at low speed. This implies that, * - Pitot probes…………………………………………………………… CONDITION
when AFS and EFCS use a too These recommendations are
low airspeed: highlighted in a Service 2
G Orders to the flight controls Information Letter (SIL 34-084)
would be too strong and may that Airbus has issued and
cause over-reaction, either in which is regularly updated 3

manual or automatic flight; in order to optimize the 1 4

G Limitation of rudder deflection maintenance of pitot probes.

will not be adapted to
5
airspeed (Refer to sketch). 4.2. Operations 20
19 7 8
21
Possible consequences in this Precautions during operations 6
16 11
extreme situation are loss of start with the pre-flight exterior 18 9
control or exceedance of design check, when pitot probes 17

loads. Given these risks, all inspection is requested. Crews

12
efforts should be made to should pay particular attention 10
maintain reliable operation of to them, bewaring of any signs
15
airspeed indication systems, or of obstructions.
flight should be cancelled as
soon as unreliable airspeed Then, after take-off thrust
condition is detected. setting, both crewmembers
should scan airspeed 13

Max. deflection 4 Maintenance indications. In case of detection

of an unreliable condition of
Full and operational one of the airspeeds before
14

V1, take-off should be aborted.

recommendations
G Adhering to improved pitot maintenance program;
4.1. Maintenance 5 Conclusion G Checking pitot reliable condition during the pre-
flight walk around check;
Protecting pitot probes with covers any time foreign Airbus recommends that ground and flight crews G Aborting take-off when unreliable airspeed
Airspeed objects are likely to penetrate is the main precaution be reminded of the possible consequences of flight condition is detected before V1.
to be taken. As indicated in the introduction, the with pitot probes obstructed:
0
most recurrent reasons for obstruction of probes G Loss of control; To complete the subject of pitot probes obstruction,
is accumulation of dust, animal’s remains, insects’ G Exceedance of design loads. we will address the unreliable airspeed condition
nets etc. This recommendation should not only in flight in a future article.
be adhered to in case of long time parking. In sand Consequently, all efforts should be made to avoid
storm conditions, for instance, covers should be flying in such conditions by:
placed even when parking for a few minutes. G Protecting pitot probes with covers as soon as

necessary;
14 15
Safety First
The Airbus Safety Magazine
# 03 December 2006

A340
Thrust Reverser 3 Thrust Reverser The primary lock
It is the main locking element. It consists of a rotating
system description
Unlocked The CFM56-5C Thrust Reverser is hydraulically
cam located on the Thrust Reverser’s forward
frame, which hooks on a roller fitting fixed on the
pivoting door.
By: Vincent SWIDERSKI commanded. Each pivoting door is motioned by
A340 Propulsion System Engineer CFM56-5C an actuator and secured in closed position by a The secondary lock
locking system. It ensures that the door stays closed in case the
Per-Oliver GUENZEL
The selection of the Thrust Reverse mode sends primary lock fails.
A330/A340 Flight Safety Coordinator hydraulic pressure, which opens the locking system It is composed of 4 integrated “locking fingers”
and deploys the pivoting doors actuators. located in the pivoting door actuator body.
A340 CFM56-5C Reverser Unlocked Event Rate Trend
0.3 The locking system is composed of 2 mechanical
retention means (Fig 2):
0.25
Rate per 1000 EFC

0.2

0.15

0.1

Pivoting Door
0.05
Roller Fitting

0
93 94 95 96 97 98 99 00 01 02 03 04 05
n- n- n- n- n- n- n- n- n- n- n- n- n-
Ju Ju Ju Ju Ju Ju Ju Ju Ju Ju Ju Ju Ju
Secondary
Fig 1: Trend of the “Rev Unlock” event rate since Entry Into Service
Lock

1 Introduction 2 History
Primary Lock
The CFM56-5C engine (fitted on A340-200 and Since Entry Into Service, various operators are
and Stow Switch
300) has a Thrust Reverser with 4 pivoting doors. impacted by Rev Unlocked warnings. Airbus, CFM,
As soon as one incorrectly locked thrust reverser Goodrich and Aircelle are carrying out a continuous
door is detected, an “ENG X REV UNLOCKED” improvement of the system. It began in August Actuator
warning comes up on the ECAM warning display. 1996 with issuance of the “ATO package” Service
Bulletin (Ref A). This SB provided a first answer to Fig 2: Actuation and locking
In the past, most “ENG X REV UNLOCKED” the Rev Unlock phenomenon knowledge at that systems of a CFM56-5C
warnings were spurious. This is not the case any time. It has been followed by several other SB and Thrust Reverser pivoting door
more, as this phenomenon has been understood led to decrease the Rev Unlock rate to under 0.05
and cured. events per 1000 Engine Flight Cycles.

Today, most of the events are actual ones and the However, this rate has been rising again in the last
repetitive occurrences are due to a lack of 2 years, as highlighted on Figure 1.
troubleshooting as detailed hereafter.
16 17
Safety First
The Airbus Safety Magazine
# 03 December 2006

4 “ENG X Rev The continuous feedback from the operators

allowed identifying that the primary lock rotating
If the need to operate the aircraft does not allow
any troubleshooting, the Thrust Reverser should
7 Conclusion
Unlocked” cam can fail to hook the roller-fitting due to: be deactivated as per the MEL (Ref F). Airbus permanent effort on the “Rev Unlocked”
warning has eliminated the spurious triggering
root causes G An insufficient actuator stroke; known from the early days of the A340-300.
G An incorrect rigging of the roller fitting; 6 Preventive
When the locking system is not pressurized, the G A primary lock contamination, which can prevent Today, the majority of the events are due to actual
secondary lock is engaged, ready to retain the the rotating cam from moving freely; maintenance and Thrust Reverser door unlocks. Therefore:
actuator in its almost full-retracted position.
If the primary lock fails, the door will extend slightly
G An undesirable hydraulic pressure spike in the
actuation system, which can prevent the primary permanent solution G Adhere strictly to the ECAM procedure, which

instructs to select idle on the affected engine,

above the flush position before the secondary lock lock from hooking completely. even if that engine has already been automatically
engages. In that case, the stow switch sensor is The various investigations emphasized the reduced to idle by the FADEC;
released (Fig 3), which leads to the generation of importance of adhering to several maintenance G Apply proper troubleshooting before the next

an “ENG X REV UNLOCKED” warning on the practices in order to prevent the “Rev Unlocked” flight to avoid re-occurrence, or deactivate the
ECAM. 5 Operational impact events. Thrust Reverser if you can not complete the
CFM/Goodrich have released the Best Practices troubleshooting;
and maintenance Manual (BPM) in January 2005. G Perform preventive maintenance, in the form of
Thrust Reverser
Stow switch
Roller fitting
Pivoting Door actions It has proven to be very effective when applied at
every C-check, but it was only applied by 25% of
a MPD task every ‘C’ check, to minimize the
operational interruptions due to “Rev Unlocked”
the operators. events.
Primary The above-described root causes usually lead to To ensure a fleet-wide application, the BPM has
Lock
an unstable position of the primary lock between been included in a Service Bulletin (Ref C) that is
open and closed position. This unstable position referenced as a scheduled maintenance task at REFERENCES
switches to the open position (secondary lock each ‘C’ in the MPD (ref. H).
activated) during the following flight due to engine A) SB RA34078-27
FAN acceleration/vibration. In most cases this happens In addition to those practices, a final solution will B) SB RA340A78-56
during the takeoff run. An “ENG X REV UNLOCKED” introduce a set of improvements to the locking C) SB RA34078-88
AIRFLOW warning is triggered and the crew performs a system by addressing the above root causes. See D) TSM tasks 78-31-00-810-
Rejected Take Off. also ref. G for further information. 967/968/969/970
Stow switch release E) Goodrich AOL A340/CFM56-04-047
Maintenance will find a pivoting door ajar on the REVISION 1
affected engine. Pushing the door back in its closed F) MEL 78-30-01
position will engage the primary lock and clear the G) TFU 78.30.00.052
issue for the next takeoff. But as the root cause H) MPD task 783241-C4-1
has not been addressed it is likely that an “ENG
X REV UNLOCKED” will appear after some thrust
reverser actuations.
FAN This is why troubleshooting has to be done in
accordance with Ref. D or E in order to find the
AIRFLOW root cause and to apply the appropriate corrective
action.

Fig 3: Release of the stow switch with Primary lock open

18 19
Safety First
The Airbus Safety Magazine
# 03 December 2006

Residual Cabin
Pressure 3 Cabin pressure 3.2. Cabin pressure system

review The following generic principles apply to all

AIRBUS A/C :
3.1. RPWS (Residual Pressure Warning
By: Michel PALOMEQUE System) a) Control and regulation
Flight Safety Advisor of the cabin altitude:
In case of cabin residual pressure differential, a The cabin altitude is managed and controlled by
A318/A319/A320/A321 program
warning light flashes red at each door, as long as a semi or fully automatic system, which ensures
Dp > 2.5 hPa, provided that one engine (two on seamless and rate-limited changes of the cabin
A340) is stopped and the slide is not armed at this altitude as the A/C climbs or descends, with an
door. absolute limitation at 8000 ft maximum cabin
1 Introduction 2 In service experience This Residual Pressure Warning System (red light)
altitude. This system performs the management
and control of the internal cabin (in fact, cabin,
This document intends to describe the experience In service experience shows that several events is basic on A320 Family & A330/A340. cockpit, cargo) air pressure by tuning at each
regarding the in service residual cabin pressure, of residual cabin pressure have been reported and moment the position of outflow valves
the consequences and the different scenarios for led to violent door opening with potential for serious (OFV), which let air escape from the cabin.
this residual cabin pressure. injuries. In case of failure of the automatic systems,
For that purpose, a short review of the system is Most of the cases have been reported on A300 the crew must ensure the cabin pressure
presented. and were related to ground tests or ground air cart management manually, thanks to direct
It will further describe the procedures and actions supplying the aircraft, where ground mechanics control of the outflow valves at slow closing
already in place to cover these scenarios from the opened a cabin door while the aircraft was still or opening speeds, by means of an UP /
operational point of view (FCOM) and training. pressurized. DN control switch: UP for cabin altitude
Then, it will introduce the new safety enhancements, Nevertheless, the latest events resulted from up (open OFV), DN for cabin altitude down
which have been developed to allow the automatic misapplication of the Manual mode procedure after (close OFV).
release of this residual cabin pressure when in landing:
manual pressure mode by an automatic opening These events have driven the safety enhancements, Should the cabin altitude exceed limits:
of the outflow valve and also the logics for a new which have been developed for the Flight By Wire positive: about + 8.8 PSI above external
red ECAM warning in case of residual cabin (FBW) aircraft. ambient pressure,negative: about - 1 PSI
pressure. below external ambient pressure, safety
valves will open to protect A/C structure
MAN mode Failure and passengers/crew.
11% 9% RPWS does not cover all the scenarii; it remains
inhibited if:
G The slides are still armed (emergency evacuation)
Ground air Test or T/S
supply 32% or
14% G Engines are running.

In addition, the RPWS is only a passive protection;

it also relies on cabin crew compliance to procedures.

Throttle
pushed
11%

unknown
23%
20 21
Safety First
The Airbus Safety Magazine
# 03 December 2006

3.3. Operational cases where a residual because of A/C damage, a slight ∆P may be
cabin pressure may develop kept (if the CPCS was in auto mode, ~10 hPa
CRUISE or less). Obviously, if the erroneous landing field
- RTO followed by an emergency evacuation: elevation selector was not in auto, and an
Actual A/C altitude the A/C is still pressurized (for instance, 15 hPa erroneous selection was set, a larger ∆P may
on WB, and 7 hPa on SA & LR). The level of exist and a significant amount of time may be
residual ∆P at A/C stop will depend on several necessary for A/C depressurization.
factors:
G Whether or not the CPCS is still electrically Notes: same as above for RTOs.
supplied and functioning with necessary inputs
(like landing gear signals which may be lost) - After use of the MAN mode:
to send the OFVs opening control signals; (i.e. emergency descent or CPCS failure), bad or
Automatic complet G Wwhether or not the system integrity is sufficient incomplete application of the ECAM or QRH
opening of the OFV
Cabin altitude sec. after touchdow
(possible OFV damage, loss of elec power, …) procedure during landing / A/C return to gate on
and if yes, whether or not enough time is left A/C not yet having the automatic outflow valve
for the control ( x sec. after touch down) of an opening on the ground in MAN mode.
effective full OFV opening. (in the same conditions as above, on A/C equipped
with automatic outflow valve opening on the ground
Slight over- Notes: in MAN mode, failure of this function).
Pre-pressurization pressurization De-pressurization
on the ground at TO before landing after landing * If the crew is not disabled, as said earlier, they can open
the cockpit sliding windows for A/C depressurization, but - Non deliberate selection of the DITCHING
this is possible only if ∆P is < 0.2 PSI. function:
* In an emergency evacuation situation, the door slides will G Untimely DITCHING control signal;
be kept armed, so the local warnings at each door (RPWS), G DITCHING mode used (e.g. for AEVC reset on
b) Typical cabin pressurization c) Cockpit sliding windows: signalling a residual cabin pressure > 2.5 hPa, will not be the A320) then not de-selected after use.
schedule on the ground and in flight: Each AIRBUS A/C has cockpit-sliding windows, given. A cabin ∆P will build up if valves are fully or
This chart identifies the characteristic phases of which may be opened to cope with some partially closed, doors are closed, and airflow
the automatic A/C cabin pressurization schedule, emergency situations (for instance, smoke removal). enters the cabin.
in particular those which may participate to a They may be used to depressurize the A/C, but - At landing, in case of runway overrun or
residual cabin pressure build-up on the ground: their opening is possible only if Delta P is below a lateral excursion followed by an emergency - A/C operation under MEL condition:
certain value (typically, 0.2 PSI at 180 kt), due to evacuation: the aft valve must be closed, and more time is
G Pre-pressurization on the ground at TO (to avoid the force exerted on them because of the Delta P. the ground depressurization sequence may not needed for the A/C depressurization on the
slight pressure bump at A/C rotation, due to the be complete, (or even not performed in case of ground, particularly if the operational procedure
high angle of attack and air cushion effect on d) Cabin fuselage drain valves : landing gear damage with flight / ground signals is not followed (sel. one pack OFF immediately
the aft OFV, which would cause reverse airflow A number (approximately 15) of piston-type drain lost), or, if the outflow valves remain closed after A/C touch down).
entering the cabin through the OFV); valves are fitted along the bottom line of the
G Slight over-pressurization before landing (for the fuselage, to drain condensation water or other fluid
same reason as above); leaks. They close when ∆P between the cabin
G De-pressurization after A/C touchdown; pressure and the outside ambient air pressure
G Automatic control of the complete opening of exceeds a certain value (between 1 and 2 PSI,
the outflow valves x seconds after A/C i.e. 70 to 140 hPa). But their effective section is
touchdown. small (about 50 mm2 each).
22 23
Safety First
The Airbus Safety Magazine
# 03 December 2006

5 Safety enhancement: Before Mod.

CPCS ATA21

modification CPC 2
(Auto)
FWD
OFV
description
Cockpit CPC 1 AFT
2 modifications have been launched, both for A320 Panel (Auto) OFV
family and A330/A340, to cope with cases of
inappropriate compliance of the procedures in Man
manual mode after landing. Mode

5.1. Automatic outflow valve opening

After Mod.
in manual mode
CPCS ATA21

This ground logic unit is an electronic box containing CPC 2 FWD

(Auto) OFV
hardwired-programmed logic

It will be supplied from the DC ESS bus, and will force Cockpit CPC 1 AFT
the automatic opening of the outflow valves on the Panel (Auto) OFV
4 Review of the FCOM During flight crew training concerning an emergency
evacuation, the accent is put particularly on the
ground in cabin pressure manual mode, or in failure
cases. It drives 2 relays, one per outflow valve, to
procedures in aborted takeoff following an engine fire or an APU provide electrical power directly to their manual mode
Man
Mode
fire. The check of the delta P is highlighted: The electrical motor, taking over their control.
manual mode delta P should be at zero before the evacuation So this new function will mitigate against the hazard
order is given to the cabin crew of flight crew using the MAN pressure mode in RPCU
In case of dual system failures, an ECAM warning flight and then not following the FCOM procedure Electric ENGINES
is triggered and a procedure requests to control Cabin crew training: after landing, i.e. fully open the OFVs. It will take ATA24 ATA73
manually the cabin pressure. The training for cabin crew highlights that before over the control of the OFV automatically by means
In addition, the system page will show that the opening any passenger door, the cabin crew has of providing electrical power directly to their manual Landing
Navigation Doors
Gear
system 1 & 2 are inoperative. to check the cabin pressure indicator. motors using external relays. ATA34 ATA52
ATA32
This manual control is done through the MAN V/S He/she must inform the cockpit crew if the red It will also mitigate against the hazard of
CTL. light flashes. maintenance personnel being interrupted in the
Before any opening of the door, he/she must accomplishment of a pressurization test on the
Depending on the failure mode, it is possible that hold the door assist handle. ground, or CPCS failure / power supply cut-off.
this procedure may not allow the depressurization.
In any case, it is clearly requested through a caution If, on ground, in auto mode, few minutes after This new device is installed on The logic for the RPCU is as follows:
to check that delta P is zero before opening doors. landing (3 minutes on A330/A340) the outflow A320 family aircraft through modification Briefly, each outflow valve will fully open if:
valve is not fully open, ”CAB PRESS OUTFLOW 34673 / SB 21-1154 and G Landing gear shock absorbers compressed or

If for any reason, there is still significant cabin VALVE NOT OPEN” ECAM warning is displayed: parking brake applied;
pressurization, it is possible to refer to the cabin It requests to open it in manual mode, or to switch on A330/A340 through modification 53145: G Thrust levers is in TO position;

overpressure procedure. (Only on the A320 family, off the packs if unsuccessful. SB 21-3113 for A330 G No engine is running above idle and no ADIRS

due to single outflow valve configuration - paper SB 21-4122 for A340 basic delivers Vc > 70 kt;
procedure) SB 21-5021 for A3456 G The valve is in MAN control and both CPCs are

Wiring: in stby;
SB 21-3112 for A330 G The valve angle is < 100°

SB 21-4121 for A340

SB 21-5020 for A3456
24 25
Safety First
The Airbus Safety Magazine
# 03 December 2006

5.2. New red ECAM warning in case of In case of excessive cabin residual pressure after The second table shows the ECAM procedure with the FWC logic in case
residual cabin pressure independent engines OFF, on ground for more than 7 seconds, of residual cabin pressure.
of the pressurization system CAB PR EXCES RESIDUAL PR red warning will
be activated after a time delay of 5 seconds.
In addition to this hardware device, a new red The ∆P sensor used for this new warning is
ECAM warning has been created in case of that of the RPWS.
impossibility to release the cabin pressure (blanket, The tables here below show the ECAM
manual motor jam, misapplication of the manual procedures without and with this new red
procedure…): ECAM procedure.

CAB PR EXCES RESIDUAL PR

The first table shows the existing procedure in case of residual cabin pressure.

This new red ECAM warning is available for

G A330/A340 with FWC through modification
G A320 family with FWC H2F3 (A318 PW - Mod 52306/ SB 31-4083 for A340/ 200-300
certification)through modification - Mod 51973 / SB 31-5015 for A340/ 500-600
- Modification 35220/ SB 31-1267 - Mod 51790 / SB 31-3066 for A330
26 27
Safety First
The Airbus Safety Magazine
# 03 December 2006

Cabin Operations
6 Conclusion
In service experience shows that several events
Even if it is always possible for a customer to ask
for the non-embodiment of these safety enhan-
cements on a brand new aircraft, in particular the
Flight Operations
of residual cabin pressure have been reported and
led to violent door opening with potential for serious
injuries.
installation of the RPCU, it is Airbus position that
both modifications will bring an additional safety
net.
Briefing Notes
Most of the cases have been reported on A300 Consequently, Airbus highly recommends the A Tool For Cabin Operations Safety Enhancement
and were related to ground tests or ground air cart installation of the RPCU and of the relevant FWC,
supplying the aircraft, where ground mechanics as described here below:
opened a cabin door while the aircraft was still
pressurized. Automatic opening of the outflow valve even Caroline KEEGAN
in manual mode when on ground. Cabin Operational Standards, Customer Services
The latest events resulted from misapplication of It will be supplied from the DC ESS bus, and will and Christophe LEMOZIT
the Manual mode procedure after landing: force the automatic opening of the outflow valves
Manager Flight Operations Safety Enhancement, Customer Services
on the ground in cabin pressure manual mode, or
In case of dual pressure system failures, an ECAM in failure cases
warning is triggered and a procedure requests to This new device is installed on
control manually the cabin pressure. G A320 family aircraft through modification 34673 1 Introducing the Flight G Adverse weather operations
In addition, the system page will show that the / SB 21-1154 and (e.g.: Optimum Use of Weather Radar, …),
system 1 & 2 are inoperative. G A330/A340 through modification 53145: Operations Briefing G Runway and surface operations
This manual control is done through the MAN V/S SB 21-3113 for A330, SB 21-4122 for A340 (e.g.: Preventing runway incursions, …),
CTL. basic, SB 21-5021 for A3456 Notes Concept G Supplementary techniques
(e.g.: Preventing altitude deviations, …),
In any case, several procedures are in place in New red ECAM warning in case of residual The Flight Operations Briefing Notes (FOBN) have G Takeoff and departure operations
order to allow the release of the residual cabin cabin pressure been designed to allow an eye-opening and (e.g.: Revisiting the stop or go decision, …),
pressure, if any. In addition, it is clearly requested In case of excessive cabin residual pressure on self-correcting accident-prevention strategy. G Descent management
through a caution to check that delta P is zero ground 7 seconds after engines OFF, CAB PR Since 2004, the effort has aimed at covering the (e.g.: Energy Management, …),
before opening doors. EXCES RESIDUAL PR red warning will be activated. entire flight profile and at addressing the main G Approach techniques
In case of cabin pressure double failure, the The ∆P sensor used for this new warning is that threats and hazards to flight operations safety: (e.g.: Flying stabilized approaches, …),
procedures must be followed up to the end (manual of the RPWS. G Landing techniques
opening of the outflow valve and control of the G Standard operating procedures (e.g.: Crosswind landings, …),
cabin pressure on ground). This new red ECAM warning is available for (e.g.: Conducting effective briefings, …),
G A320 family with FWC H2F3 (A318 PW G Human Performance In 2006, the very first Flight Operations Briefing
To cope with non compliance with the above certification)through modification (e.g.: Error management, …), Notes addressing threat and hazards to cabin
manual procedures, 2 new modifications have . Modification 35220/ SB 31-1267 G Operating environment operations safety have been released.
been developed for FBW aircraft: the outflow valve G A330/A340 with FWC through modification (e.g.: Bird strike threat awareness, …),
opens automatically on ground, and an ECAM Mod 52306/ SB 31-4083 for A340/ 200-300,
warning warns of residual cabin pressure. Mod 51973 / SB 31-5015 for A340/ 500-600,
Both modifications are installed and activated on Mod 51790 / SB 31-3066 for A330
production aircraft.
28 29
Safety First
The Airbus Safety Magazine
# 03 December 2006

2 Cabin Operations Line cabin crew should review and compare the
recommendations, guidelines and awareness
If you have access rights, go to «Secure area» (top
left of home page) / «Customer login» / «Flight
Domain information with their current practices and enhance Operations (Home)» (on left). To obtain access
their techniques and awareness level, as required. rights, contact your IT administrator or refer to
This new Cabin Operations domain of the Flight «Registration information» (top left).
Operations Briefing Notes has been created to The cabin operations domain is an ideal
meet the respective needs of cabin crewmembers complement of the Getting to Grips with Cabin The Flight Operations Briefing Notes are also
first, then of flight crewmembers and of other flight Safety brochure released in 2005. released on the Safety Library room of the Airbus
operations personnel. Safety First website
Such safety awareness references provide operators http://www.airbus.com/en/corporate/ethics/safety_lib/
The cabin operations domain provides an overview with guidance to implement their own cabin safety
of the following aspects that need to be understood program.
and mastered in order to enhance cabin operations
safety: Where to consult/download them?

G Effective Briefings for Cabin Operations The Flight Operations Briefing Notes and all other
G Crew Communication safety and operational expertise publications
G Dangerous Goods (e.g. Getting to Grips with …) are regularly
G Ground Operations Safety released on the Flight Operations Portal,
G Cabin Smoke Awareness which can be found in the secure area of
G Managing In-Flight Fires www.airbusworld.com.
G Ditching
G Decompression
G Turbulence
G Planned Ground Evacuation CONTACT DETAILS
G Unplanned Ground Evacuation
G Precautionary Evacuation AIRBUS
Cabin crew managers and training instructors Caroline KEEGAN
should review, customize (as required) and Cabin Operational Standards
implement the recommendations, guidelines and Customer Services,
awareness information, in the following domains: Flight Operations Support & Services
Tel:+33 (0)5 67 19 03 59
G Cabin operational documentation Fax: +33 (0)5 61 93 29 68
G Training [email protected]
G Information (Cabin crew bulletins, Airline’s safety
magazine articles, Classroom lectures; and/or Christophe LEMOZIT
Stand-alone reading). Manager Flight Operations Safety
Enhancement
Customer Services,
Flight Operations Support & Services

Tel.:+33 (0)5 62 11 82 90
Fax: +33 (0)5 61 93 29 68
[email protected]
30 31
Safety First
The Airbus Safety Magazine
# 03 December 2006

Human physiology
Hypoxia an Within the lungs the alveola provide the interface between air and blood.
The blood which is returned from the body tissue into the alveolae has

Invisible Enemy
Cabin depressurization effects
the situation, he donned his oxygen mask. The
captain, who had been talking with a passenger
given away most of its oxygen so that the oxygen partial pressure in
the lungs is higher than in the arriving blood. A process of diffusion
then drives oxygen through the thin alveolar wall into the blood.

on human physiology who was visiting the flight deck, attempted to don GENERAL BLOOD CIRCULATION
his oxygen mask too, but in doing so he knocked
his glasses to the floor. When trying to retrieve
Hartwig Asshauer them he lost consciousness and slumped forward.
Certification Manager The first officer attempted to help the captain but
was unable to do this, so initiated a descent to
Hydro-Mechanical & Air Systems
25,000ft. A short time later the first officer asked
Airbus Engineering the senior flight attendant to assist the captain. To
enter the flight deck the flight attendant had to
remove her oxygen mask connected to the fixed
This article first appeared in
issue 38
1 Introduction cabin oxygen system. She decided not to use the
portable oxygen equipment and went straight to
Operating at high altitude without adequate the flight deck. Before being able to assist the
When public air transportation first became understanding, training or equipment protection captain she collapsed onto the floor. Once again,
commonly available, flights did not reach can be dangerous as shown by the following the first officer attempted to put on the oxygen
altitudes that represented a significant risk of extracts from two accident reports: mask for the captain, this time successfully. Soon
reduced oxygen supply - called hypoxia - to afterward, the captain regained consciousness
either passengers or crew. However, in the ‘One of the first encounters with the dangers of and was unaware he had been unconscious, which
late 1940s and 1950s aircraft were developed high altitude flight was reported in 1862 when a is a typical reaction from a victim of hypoxia.’
that allowed safe transport of the flying public balloon flight was made to study the effects of low
at altitudes around 40,000ft, which have ambient pressure. The balloon ascended to The most important parameters for the oxygen diffusion process are
remained relatively constant since then. approximately 29,000ft and during the flight a series the oxygen percentage and barometric ambient pressure. Changing
of “strange” symptoms, notably loss of visual and 2 The hypoxia effects these parameters changes immediately the oxygen saturation level
in blood and with it the oxygen supply to the body tissue. Unfortunately,
hearing capability, paralysis of arms and legs, and
finally, unconsciousness occurred. The team could of a quick cabin there is no significant storage of oxygen in the human body, unlike
many other chemical substances necessary to maintain life. The
have been lost, but was saved by one member
pulling the balloon valve rope with his teeth (his depressurization blood is the only storehouse for oxygen, and its capacity is very
limited. Hence, the human body lives only a hand-to-mouth existence
with its oxygen supply.
arms were already paralysed), to descend the
balloon. The team recovered as the balloon During a quick depressurization the partial pressure As the pressure of air in the atmosphere decreases with increasing
altitude, the partial pressure of oxygen in the air reduces and with
descended, but this marked for the first time the of oxygen in the lungs/alveolae reduces rapidly it the diffusion of oxygen into the body. Reduction of oxygen
DEFINITIONS OF HYPOXIA risk of low ambient pressure.’ with the effect of reverse diffusion. This means that availability in the body results in loss of functions ranging from
once the oxygen partial pressure in the alveolae slight impairment up to death. It is the nervous system, in particular
Hypoxia is separated into four types: ‘In 1998 a decompression incident occurred on has reached a level that is below the level in the in the higher centres of the brain, and the eyes which have a high
• Hypoxic hypoxia is a condition caused by reduced metabolism with no oxygen reserve. These are most sensitive to
barometric pressure, affecting the body's ability to an aircraft at 35,000ft. Both the captain and the blood, the blood oxygen moves out of the body oxygen depletion and therefore are the first to be affected by a
transfer oxygen from the lungs to the bloodstream. first officer had received altitude-chamber training back into the ambient air. This effect of reverse reduced oxygen supply.
• Histotoxic hypoxia can be induced by the introduction during their previous military careers and knew diffusion unfortunately further reduces the already For healthy persons altitude exposure up to 15,000ft is usually not
of substances like alcohol or drugs into tissue, about the effects of low cabin pressure. The first very limited oxygen storing capability of blood and hazardous since cardiovascular and respiratory compensatory
reducing its ability to accept oxygen from the officer attempted to control the cabin rate of climb supports hypoxia effects. Holding of breath cannot mechanisms (faster breathing and increased pulse rate/blood circulation)
bloodstream. act to maintain adequate oxygenation at the cellular level.
by switching to the standby pressurization system. stop the reverse flow since the pulmonary gas
• Hypaemic hypoxia (or anaemic hypoxia) is a result The effects of reduced oxygen supply to the body (hypoxia) vary
of the blood being unable to carry oxygen, e.g. caused When use of the standby system failed to improve expansion would lead to serious lung injury.
between persons, depending on health, physical fitness, age, activity
by exposure to carbon monoxide. level and statistical scatter with the population. Pilots and flight
• Stagnant hypoxia results from the body's attendants usually require more oxygen during an emergency than
inability to carry oxygen to the brain, which can result healthy, seated passengers and might therefore suffer earlier from
from high gravity-forces causing blood to pool in the hypoxia effects.
lower extremities of the body.
32 33

* Dalton’s Law
Safety First
The Airbus Safety Magazine
# 03 December 2006

(1766 -1844)
In 1801, the English
astronomer and chemist, John
Dalton, discovered the
pressure relationship among
gases in a mixture. Dalton's
Law states that the pressure
exerted by a mixture of gases
is equal to the sum of the
pressures that each would
exert if it alone occupied the 3 Oxygen partial pressure breathing is able to increase additionally
the oxygen partial pressure by around 20 to 30mbar
space filled by the mixture.
pressure provided that the overpressure condition is limited
to some minutes only. This means that at 40,000ft
Severe hypoxia caused by a significant reduction The concentration of oxygen in the atmosphere is it requires 100% oxygen concentration of the
in cabin pressure is very dangerous for flight crew constant at 20.95% at altitudes up to 100,000ft, breathing gas combined with positive pressure
because: which means that according to Dalton's Law* the breathing to achieve sea level equivalent conditions.
G The victims of hypoxia rarely notice that they are oxygen partial pressure at sea level is 212mbar Positive pressure breathing requires some training
about to pass out. (20.95% of 1013mbar where 1013mbar is the and is tiring and inconvenient, which is the rationale
G Usually there is quickly a loss of critical judgment standard atmospheric pressure at sea level). for having so far provided this protection feature
G Most victims often experience a mildly euphoric to flight crew only (for short time use only). Flight crew oxygen mask *
state As altitude increases above sea level the partial
G Thinking is slowed, muscular coordination is pressure of the component gases decreases
impaired consistent with the decrease in total atmospheric 4 Time of Useful 5 Time of Safe
pressure. For example, the partial pressure of
The only effective means of protection is the oxygen at 40,000ft is reduced to 39mbar only, Consciousness Unconsciousness
quick donning of oxygen masks as the first which is far too inadequate to support human
action - before troubleshooting! metabolism. In the 'World of Hypoxia' the Time of Useful Some experts believe that for passengers - in
Consciousness (TUC) is a very important parameter. contradiction to the flight crew - a short period of
One means to increase oxygen partial pressure is For low ambient pressure conditions it indicates unconsciousness during cabin depressurization
to increase the oxygen concentration in breathing the time available to perform purposeful activities, can be tolerated since they are not performing an
air. At 40,000ft cabin altitude an oxygen partial such as oxygen mask donning or aircraft control. operational task. Unconsciousness is a clear sign
pressure of maximum 188mbar can be achieved Beyond this time frame mental and physical of insufficient oxygen supply to the brain and it is
by breathing pure oxygen (100% oxygen capabilities are dangerously impaired and finally obvious that this time can only be very short before
concentration without overpressure). result in unconsciousness and potentially death. permanent brain damage occurs. So far, it has not
been possible to associate a specific time frame
Another additional means for hypoxia protection As shown in the table on the right, TUC is negatively for the safe time of unconsciousness.
is positive pressure breathing, which is usually correlated with altitude. It is important to note that
found in modern crew oxygen masks and means even if activities are performed within the TUC time The uncertainties in extrapolation of animal data
the delivery of pure oxygen under pressure into frame there is a significant deterioration of work and the wide variability in individual tolerances have
the respiratory tract. For civil applications positive rate and mental capability, which is correlated with so far prevented determination of a commonly
the time spent at low pressure conditions (at the agreed value for Time of Safe Unconsciousness
end of the TUC time frame, performance is much (TSU) among human physiology experts. It is
lower than at the beginning). believed that a safe time of unconsciousness is
The TUC is the 'Window of Opportunity' for donning somewhere between 90 seconds and 4 minutes.
an oxygen mask and can be very limited so must
take overriding precedence over any other activities.
These data on TUC
TIME OF USEFUL are averaged values
CONSCIOUSNESS based on tests with
20,000ft All unacclimatized persons lose healthy individuals when
useful consciousness within breathing ambient air
10 minutes (no supplemental oxygen
Early type of shaped oxygen mask for passengers provided).
25,000ft Useful consciousness is lost A large individual
after 2.5 minutes or less variation in the effects
30,000ft TUC: approx. 30 seconds of hypoxia has been
found. There is evidence
37,000ft TUC: approx. 18 seconds that TUC is shorter for
45,000ft TUC: approx.15 seconds people exposed to stress
conditions.
Current oxygen mask for passengers Mask straps inflated Mask in place * Manufacturer EROS
34 35
Safety First
The Airbus Safety Magazine
# 03 December 2006

6 Oxygen equipment Effect on human physiology

on civil aircraft of moderate cabin altitude
On modern aircraft oxygen equipment is installed Very large numbers of aircrew and passengers have been exposed to
breathing air at cabin altitudes up
to provide adequate protection against the to 8,000ft over the last 60 years without significant deleterious effects.
damaging effects of hypoxia in case of cabin Although exposure to this altitude reduces the oxygen partial pressure
depressurization: in the pulmonary tract the tissues of the body are maintained well
above the required level.
For flight crew there are usually quick donning Some airlines still allow smoking in the aircraft cabin, which results
oxygen masks installed, which can be donned with
one hand in less than 5 seconds. The mask straps
in carbon monoxide inhalation with the smoke. Carbon monoxide has
a 240-times greater tendency than oxygen to attach to red blood 7 Airworthiness which makes hypoxia very dangerous for flight
crew. This is highlighted also in the FAA Special
haemoglobin, thus inactivating a large amount of haemoglobin as an
are combined with elastic tubes that inflate and oxygen carrier. It has been found that the hypoxia effects from carbon
monoxide and altitude are additive; hence chronic smokers are at a
requirements Certification Review that was issued some years
stiffen when the mask is taken from its stowage, ago on the effects of cabin depressurization.
higher equivalent altitude than non-smokers in terms of blood oxygen
allowing the mask to be easily put over the head supply. The Airworthiness authorities have identified the
with one hand. Once the grip on the mask is Also, alcohol poisons body tissues in such a manner that they cannot risk of hypoxia and have created requirements (see Moreover, in case of rapid cabin depressurization
released, the tubes deflate and their elastic use oxygen properly. Usually, it is noticed by passengers that the table on the left). a quickly accomplished emergency descent is often
characteristics ensure a perfect fit. The required physiological effect of alcohol consumed during flight is more intense Also, after an accident in the USA the FAA initiated the only means of fast re-oxygenation of passengers
than at sea level, which is due to the additive hypoxia effects of alcohol
oxygen concentration of the breathing air is and altitude.
a Special Certification Review (SCR) on pressuri- that were unable to protect themselves against
automatically adapted to the cabin pressure. zation systems. The SCR recommends that the hypoxia by using the passenger oxygen masks
aircraft flight manual (for aircraft certified for flights provided. Severe hypoxia is very dangerous for
For the passenger oxygen supply above 25,000ft) require in the emergency unprotected passengers and requires a quick return
the continuous flow concept is used Extract of the prime requirements procedures the donning of oxygen masks as the to an adequate cabin pressure or where not possible
on all Airbus aircraft. Oxygen is first crew action after a cabin altitude warning. (above high terrain), it requires a check by the flight
delivered continuously to an GENERAL attendants that the passenger oxygen masks are
expandable oxygen bag where it • CS/FAR 25.841 (a): Maximum cabin pressure altitude under normal operation: 8,000ft This highlights again the importance of immediate correctly used.
• CS/FAR 25.841 (a): Maximum cabin pressure altitude after any probable failure condition in the
is conserved during exhalation, so donning of oxygen masks when cabin depres-
pressurization system: 15,000ft
it is available during the next • FAR 25.841 (a) (2) (i): Maximum exposure time to cabin pressure altitude exceeding 25,000ft: surization occurs. For a long time transport aircraft have been
inhalation to supplement the steady 2 minutes equipped with oxygen systems for flight crew and
oxygen flow. • FAR 25.841 (a) (2) (ii): Exposure to cabin pressure altitude that exceeds 40,000ft: Not allowed passengers that provide an adequate protection

CABIN OCCUPANTS
8 Conclusion against hypoxia. As long as these oxygen systems
It was decided at an early stage are used according to their simple procedures the
• CS/FAR 25.1443 (c): Provides oxygen system performance data on oxygen flow and required
in passenger oxygen mask partial pressure of oxygen The first step for any flight crew member faced invisible enemy hypoxia poses little danger to flight
development that the untrained • CS/FAR 25.1447 (c) (1): The total number of masks in the cabin must exceed the number with cabin depressurization should be the immediate crews and passengers.
civilian population should not be of seats by at least 10% donning of an oxygen mask. Any delay in donning
expected to recognize the correct • CS/FAR 25.1443 (d): Defines oxygen flow for first-aid oxygen equipment (for cabin a mask will significantly increase the risk of losing
orientation for a shaped mask, and depressurization treatment) consciousness before cabin pressure is regained. CONTACT DETAILS
• JAR OPS 1.760/FAR 121.333 (e) (3): Requires first-aid oxygen for at least 2% of passengers
it was required that a mask should Severe hypoxia leads usually to the loss of critical
• JAR OPS 1.770 (b) (2) (i)/FAR 121.329 (c): Defines the percentage of passengers that need
be operable in any position in which to be provided with supplemental oxygen (cabin pressure altitude dependent) judgement combined with a mildly euphoric state, Hartwig Asshauer
it might be donned by the user. Certification Manager
A second basic requirement was FLIGHT CREW Hydro-Mechanical
a universal size, which finally defined • CS/FAR 25.1443 (a) & (b): Provides oxygen system performance data on oxygen flow and & Air Systems
the well-known cylindrical mask required partial pressure of oxygen Airbus Engineering
• CS/FAR 25.1447 (c) (2) (i): For aircraft operating above 25,000ft quick donning oxygen masks Tel: +33 (0)5 62 11 04 98
body. are required for the flight crew which can be donned with one hand within 5 seconds Fax: +33 (0)5 61 93 31 55
• FAR 121.333 (c) (2) (i) (A): One flight crew member needs to wear permanently his oxygen [email protected]
mask when the aircraft is operated above FL410
• FAR 121.333 (c) (3): In case one flight crew member leaves the controls the remaining pilot
needs to use his oxygen mask when the aircraft is operated above 25,000ft
36 37
Safety First
The Airbus Safety Magazine
# 03 December 2006

The Airbus Flight Safety Team Fligth Safety Advisors to Chief Engineers

Yannick MALINGE Nuria SOLER Michel PALOMEQUE Jacques KUHL

Vice-President Flight Safety Assistant to Flight Safety Dept. Flight Safety Advisor Flight Safety Advisor
Phone + 33 (0)5 61 93 43 60 Phone + 33 (0)5 61 93 45 19 To Single Aisle Chief Engineer To Wide Body Chief Engineer
Fax + 33 (0)5 61 93 44 29 Fax + 33 (0)5 61 93 44 29 Phone + 33 (0)5 62 11 02 85 Phone + 33 (0)5 62 11 03 90
E-mail [email protected] E-mail [email protected] Fax + 33(0)5 61 93 44 29 Fax + 33 (0)5 61 93 48 28
Mobile +33 (0)6 29 80 86 52 E.Mail - [email protected] E-mail [email protected]
Mobile +33(0)6 23 08 06 38 Mobile +33(0)6 20 61 35 21

Thierry THOREAU Armand JACOB Jérôme PAULHET

Deputy Vice President Flight Safety Test Pilot Flight Safety Advisor
Head of International Cooperation Operational Advisor to the To Long Range Chief Engineer
Phone + 33 (0)5 61 93 49 54 Vice-President Flight Safety Phone + 33 (0)5 62 11 01 91
Fax + 33 (0)5 61 93 44 29 Phone + 33 (0)5 61 93 47 92 Fax + 33 (0)5 61 93 27 60
E-mail [email protected] Fax + 33 (0)5 61 93 29 34 E-mail [email protected]
Mobile +33 (0)6 16 93 87 24 E-mail [email protected] Mobile +33(0)6 23 08 06 26
Mobile +33(0)6 22 10 36 09

Albert URDIROZ Jean DANEY

Flight Safety Manager Director of Flight Safety
Phone + 33 (0)5 62 11 01 20 Head of In-Service Safety
Fax + 33 (0)5 61 93 44 29 & Incident Investigation
E-mail [email protected] Phone + 33 (0)5 61 93 35 71
Mobile +33 (0)6 23 98 01 13 Fax + 33 (0)5 61 93 44 29
E-mail [email protected]
Mobile +33 (0)6 23 98 01 16

Marc BAILLION Christopher COURTENAY

Flight Safety Manager Director of Flight Safety
Phone + 33 (0)5 67 19 14 75 Head of Safety Information
Fax + 33 (0)5 61 93 44 29 Dissemination
E-mail [email protected] Phone + 33 (0)5 62 11 02 84
Mobile +33 (0)6 23 98 01 10 Fax + 33 (0)5 61 93 44 29
E-mail [email protected]
Mobile +33 (0)6 16 03 64 22

Frederic COMBES Panxika CHARALAMBIDES

Flight Safety Manager Flight Safety Manager
Phone + 33 (0)5 62 11 97 42 Phone + 33 (0)5 62 11 80 99
Fax + 33 (0)5 61 93 44 29 Fax + 33 (0)5 61 93 44 29
E-mail [email protected] E-mail [email protected]
Mobile +33 (0)6 16 93 87 37 Mobile +33 (0)6 23 98 01 63

Armand GASTELLU
Crisis Logistic Support Manager
Nicolas BARDOU
Flight Safety Manager
Flight Safety hotline
Phone + 33 (0)5 61 93 41 79 Phone + 33 (0)5 67 19 02 60
Fax + 33 (0)5 67 19 12 26
E-mail [email protected]
Fax + 33 (0)5 61 93 44 29
E-mail [email protected]
06 29 80 86 66
Mobile +33(0)6 23 98 00 86 Mobile +33 (0)6 23 98 01 71