Hi gents, This a translation of a service note (in French) of Air Carabe of December 2008.

Translation was performed by me with no proofread so excuse the 'frenchglish' and probably some 'lost in translation' issues but I hope you'll find it interesting anyway. Otherwise, hey learn French after Chinese should be easy :-)))))

Dear colleagues, End August and beginning September our 2 Airbus 330-200 experience severe icing. As causes and consequences are similar, please find hereafter the detailed report of the flight Port-au-Prince to Paris-Orly by the F-OFDF. Phase 1 : deviation to avoid weather At 22:11, 'HDG' mode is selected on 'FMA'. At 22:22, in accordance with the 'Weather deviation procedure for Oceanic controlled airspace' , the crew climbs from 35,000 ft to 35,300 ft. This gain of 300 feet doesn't improve the conditions so the crew decides to return to FL350. Phase 2 : application of 'Severe turbulence procedure' QRH 5,01 At 22:22:09, in application of the 'Severe turbulence procedure', the Mach is reduced to M,80 and 'A/THR' is disconnected. Based on a weight of 206T and FL350, the pilot flying adjust the N1 between 81 and 82 %. Phase 3 : Probes icing Between 22:22:20 and 22:22:36, the TAT raises from -14c to -5c. This raise of temperature is typical of severe icing condition, the recorded temperature being the temperature of the ice on the probe. From 22:22:36 to 22:23:00, the TAT indication remains stable at -5c. At 22:22:45, engine anti-ice is selected ON. At 22:22:59, a very rapid decrease of CAS, Mach and altitude (Mach correction) is recorded. These parameters respectively decrease to 85kts from 273kts, M.26 from M.80 and 34.700ft from 35.000ft. At the same time, FD1+2 and AP2 disconnected with associated ECAM red warning 'AUTO FLT AP OFF', Master Caution light and 'cavalry charge' aural warning. During the same period, six additional ECAM warning are displayed: F/CTRL ADR DISAGREE; F/CTRL ALTN LAW; F/CTR RUDDER TRV LIMIT FAULT; AUTO REAC W/S DET FAULT; ENG1 EPR MODE FAULT; ENG2 EPR MODE FAULT. Each message is associated with Master Caution light illumination and 'single' chime. Moreover, the red flags 'SPD LIM' are displayed on both PFD. From 22:23:36 to 22:23:45, the 'STALL' aural warning is activated with 'Cricket' aural warning and Master Caution light illumination. From 22:23:00 to 22:23:54, the TAT indication slowly returns to -14c. At 22:24:25, the CAS raises from 111kts to 275kts, Mach returns to M.80 and altitude abruptly raises from 34.200ft to 34.500ft.

At 22:24:40, both FD1+2 are re-engaged and at 22:24:41 AP2 is re-engaged Phase 4 : crew reaction From 22:22:59 for 1 minute 26 seconds, indications of CAS, Mach and altitude are unreliable. The pilot flying is in full manual mode without FD, FPV or A/THR. During the same period, numerous ECAM warnings, Master Cautions, Master Warnings, 'Cavalry charge', 'Single chime' ans stall alarms are recorded. In this very busy context, the crew is concentrating on the application of the 'Unreliable airspeed indication' procedure (QRH 2,01). With reference to the 'cruise' part of the procedure, it is obvious that this is been greatly eased by the previous application of the 'Severe turbulence' procedure that put A/THR OFF and select an average N1. As requested by QRH 2,21, the crew can then put its whole attention on the control of altitude and trajectory using GPS altitude and GPS ground speed as reference. The PNF then place probe/window heat switch on. Note that taking into account the short time frame it was impossible for the crew to apply to 2,23 'AFFECTED ADR IDENTIFICATION'. Finally, the difficulty for the crew to apply the 'TECHNICAL RECOMMENDATIONS' of 2,22 must be stressed. The PF is indeed convinced that the 'Stall' alarms are inappropriate and it is purposely that he disregard the sentence 'RESPECT STALL WARNING AND DISREGARD 'RISK OF UNDUE STALL WARNING' STATUS MESSAGE IF DISPLAYED ON ECAM'. Phase 5 : events analysis and consequences Initially, following the icing of the PITOT and TAT probes the 'FLIGHT CONTROLS PRIMARY COMPUTERS' reject one ADR due to excessive difference with the average of the 3 ADR. During a second step, the ECAM warning, F/CTRL ADR DISAGREE' is triggered, by the PRIM computers due to significant difference between the two remaining ADR's. At that time, these two ADR's are also rejected. The associated procedure with 'SPD DISAGREE' condition request from the crew the application of the 'ADR CHECK PROC' checklist. This checklist warns about the risk of 'RISK OF UNDUE STALL WARNING' and about the switching to 'F/CTL ALTERNATE LAW (PROT LOST)'. The procedure on page 3,02,64 page 16 warns that 'F/CTL ALTERNATE LAW (PROT LOST)' condition is latched if the ADR DISAGREE is detected by the PRIM's. The reset of the PRIM computers in this case does not permit recovery of the normal law and/or associated protections. Nb1: One ADR rejection threshold values: Altitude : 3000ft during 1 second Mach 0,05 during 10 seconds CAS : 16 kts during 10 seconds TAS: 16 kts during 10 seconds Total pressure 20 Hpa during 10 seconds Static pressure 5 Hpa during 1 second AOA : 3,6 during 1 second

Nb2: the two remaining ADR rejection threshold values: Altitude : 3000ft during 1 second Mach 0,05 during 1 second CAS : 16 kts during 1 second TAS: 16 kts during 1 second Total pressure 20 Hpa during 1 second Static pressure 5 Hpa during 1 second AOA : 3,6 during 1 second In that case, a double protection exist; the 'ELECTRICAL FLIGHT CONTROL SYSTEM' monitored any CAS variation. In case of rapid variation of this parameters, the 3 ADR's are disregard and the 'piloting laws' reconfigured in 'F/CTRL ALTERNATE LAW (PROT LOST)'. NB3: Threshold for ADR elimination by EFCS: 30kts CAS difference for 1 second. Apparition of red 'SPD LIM' flag The red 'SPD LIM' flag and VLS information lost is the result of the elimination of CAS information by the EFCS. With all protection being lost with the exception of 'Load Factor', the 'FLIGHT ENVELOPPE' part of the 'FMGEC' are considered inoperative with associated partial or total lost of VLS, S, F, Green Dot, Vtrend, Vmax, VFEnext, Vsw 'F/CTRL RUDDER TRV LIMIT FAULT' warning It should be noted that 'RUDDER TRV LIMIT' is in the list of inop items of 'F/CTRL ADR DISAGREE' checklist. In order to reduce the aerodynamic stress of the fin, the system limit the action of rudder pedals based on the CAS value. The lost of this speed by the ADR rejection triggered this alarm with a limitation of rudder deflection to roughly 10. The full authority of the rudder is restored at slats extension. Following the alarm 'F/CTRL ADR DISAGREE', the warning 'F/CTRL ALTN LAW' is also triggered at 22:22. Piloting laws are then significantly changed switching from 'normal' laws to 'alternate laws2'. Flight controls: On pitch, the governing parameter remains the load factor; in roll, the roll rate is abandoned for a 'direct law'. There is a direct relationship between action of the pilot on the side stick and the position of the ailerons and spoilers. In yaw, the 'turn coordination' is lost while in clean configuration. Protections LOAD FACTOR LIMITATION : This protection is maintained. The load factor is thus limited between +2,5g and -1 in clean configuration and +2g and 0g with slats extended. PITCH ATTITUDE PROTECTION Pitch is normally limited between +30 pitch up and -15 pitch down. At low speed this limit became +25 pitch up. In alternate law 2, this protection is lost. HIGH ANGLE OF ATTACK PROTECTION In normal law, when angle of attack became higher than PROT, the piloting law in pitch is modified. 'Load factor' governing parameter is abandoned for angle of

incidence. Pilot action on the side stick then orders directly a value of '', but still limited by Max. Moreover with a stick released, incidence is reduced in order to stabilize at PROT. In case of technical problem and following a reconfiguration in 'alternate law 1', another speed protection exist called 'LOW SPEED STABILITY'. It activated between 5 and 10 kts above stall. The pitch law became 'direct law' and an order (that can be override by the pilot) to lower the pitch is introduced to maintain a margin with the actual stall. The 'STALL' aural warning is also activated. On the PFD, the VPROT and VMax are replaced by VSW Finally, it must be stressed, that the icing of the PITOT and TAT probes triggered an 'F/CTRL ADR DISAGREE' message with the switching to 'alternate law 2' and the lost of the low speed stability protection. HIGH SPEED PROTECTION In normal law, depending on exact conditions (low pitch, high acceleration,...) the protection activated for speed equals or higher than Vmo/Mmo. The angle of roll is then limited at 45 and aircraft returns to zero roll rate for a released side stick. In order to reduce the speed a increasing pitch order is systematically introduced. Autopilot disconnect and 'Overspeed' aural warning is triggered at Vmo+4kts and/or Mmo+0.006. Following a technical problem and a reconfiguration in 'alternate law 1', here also a new protection is introduced called 'HIGH SPEED STABILITY'. A 'nose-up' order (that the pilot can override) is then introduced to avoid excessive speed. The 'high speed protection symbol' at Vmo+4 disapears. The aural warning remains available. As before, the 'F/CTRL ADR DISAGREE' due to the icing of PITOT and TAT probes forced a switching to 'alternate law 2'. In that case, the 'HIGH SPEED STABILITY' protection is not available. BANK ANGLE PROTECTION This protection is lost in case of 'alternate law 2'. LOW ENERGY WARNING This is mainly an approach warning in config 2, 3 or full and with radio-altimeter height between 100 and 2000 feet. An aural warning 'Speed, Speed' sounds every 5 seconds to warn the pilot that power must be increase in order to maintain a positive flight path. This protection is also lost in 'alternate law 2'. AUTO FLT AP OFF The auto flight system compares continuously the values provides by the three ADR's. This mandatory control became impossible due to the lost of two ADR which in turn triggered the AP and FD disconnection. By design, any brutal variation of the CAS, altitude or Mach result in one ADR rejection. Following the icing of the PITOT and TAT probes, we indeed experienced a very rapid decrease of CAS, Mach and altitude. Nb4 : threshold value for ADR rejection : CAS: 20 kts during 0,45s Mach : 0,04 during 0,45s Altitude : 400 ft during 0,45s

 AUTO FLT REAC W/S DET FAULT This detection is available for configuration equals or higher than 1 and radio-altimeter value lower than 1.300ft. The activation results on WINDSHEAR red label on both PFD and three 'windshear' aural warning through the loudspeakers. This activation is based on the energy level of the aircraft. When the prediction of the aircraft energy determined by an angle of attack falls below a predetermined threshold value called 0 , the warning is activated. Based on the wind gradient in front of the aircraft, the system computes a probable variation of the angle of attack called that is added to the actual value of . The warning is triggered when + >= 0 . The AUTO FLIGHT system having rejected the ADR this warning is not available anymore. The difference of pressure between the PITOTS total pressure and P2 or more directly the icing of the probe P2 and T2 are responsible for the ECAM message ENG 1(2) EPR MODE FAULT. The system reconfigured automatically in N1 RATED in case of loss of SENSED EPR or ratio of P5 (LP TURBINE EXIT TOTAL PRESSURE) on P2 ( ENGINE INLET TOTAL PRESSURE) . In that case, FADEC determines N1 based on 'TLA' , altitude and T2 (ENGINE INLET TOTAL TEMPERATURE). These last two parameters being most probably not available, the FADEC reconfigures in N1 UNRATED mode. N1 is then based only on 'TLA', limited by the FADEC to the lower of N1max or N1REDLINE is T2 is available. In N1 UNRATED mode, N1Limit, N1TLA and N1max indication are lost. The 'STALL' warning is triggered when angle of attack is above a value determined by configuration, speed, Mach, and piloting law (normal, alternate1 or alternate 2). this result in Master Warning light illumination, 'cricket' sound and 'stall' aural warning through the loudspeakers. During the event, the alarm was triggered twice with AOA of respectively 4,48 and 4,31. Nb5 : threshold for AOA stall is 4,2 Phase 6 resets At 22:50 and 22:53, the ECAM messages AUTO FLT FM1(2) FAULT are recorded. The cautions are the result of the resets of the FMGEC trying to recover from the red flag 'SPD LIM' and VLS information on PFD. Phase 7 modification of the PITOT probes Following these two incident, the direction of the company decides to increase the safety of the flights and PITOT probes of the whole fleet have been modified from Thales PN C16195AA to Thales C16195BA. These last are equipped with a very effective drain system and performed much better in case of heavy precipitation or severe icing Phase 8 Airbus meeting A meeting with Airbus has been organized in October in Toulouse. The engineers presented the last technical report of these two incident. Our training officer raised the difficulty to apply the unreliable airspeed checklist in this situation: On the page 17 of 3.02.24, the checklist states : RELY ON THE STALL WARNING THAT COULD BE TRIGGERED IN ALTERNATE OR DIRECT LAW. IT IS NOT

AFFECTED BY UNRELIABLE SPEEDS, BECAUSE IT IS BASED ON ANGLE OF ATTACK. The TECHNICAL RECOMENDATIONS (QRH 2,22) states : RESPECT STALL WARNING AND DISREGARD 'RISK OF UNDUE STALL WARNING' STATUS MESSAGE IS DISPLAYED ON ECAM. But icing of the probes result to the ADR DISAGREE ECAM message with switching in alternate law (PROT LOST), with in the status page : RISK OF UNDUE STALL WARNING and UNDUE STALL WARNING MAY MAINLY OCCUR IN CASE OF AOA DISCREPANCY. The crew has managed to manage this contradictory recommendation during the two spurious stall occurrence. Airbus engineers have recognized the difficulty face by the crew and are looking at a possible modification of the 'unreliable airspeed checklist'. Hopes this answer your questions, good flights to all Hughes Houang Flight Safety Officer