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were not unambiguous.
• Contrary to the instructions not all of the inspection modes available were used for the
checks.
• Due to deficiencies in the quality system of the maintenance organisation, errors in the organisation
and the accomplishment of work remained undetected.
• The operator had not performed the audits in the maintenance organisation required by
JAR-OPS thus the deficiencies in the maintenance organisation could not be realized.
• The LBA had not recognized deficiencies in the quality system of the operator and the
maintenance organisation.
• The flight crew of the A 320 was adequately licensed to conduct the flight.
• After start-up of the powerplants, the lateral control of the aeroplane was checked in accordance
with the “AFTER START CHECKLIST“ only for full deflection but not for the correct
direction of deflection.
• During lift-off the aeroplane assumed a slight bank angle to the left. The attempt to counteract
this tendency was not successful due to the left sidestick being incorrectly connected.
The bank angle even increased to approx. 22°.
• The First Officer took over the control of the aeroplane and immediately restored the normal
flight attitude.
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 29
3.2 Causes
The BFU has come to the conclusion that the serious incident is due to the fact that:
• during repair work on the plug of the Elevator Aileron Computer (ELAC) no. 1 two pairs of
wires had been connected inverted
• the error remained undetected
• the error was not recognized by the flight crew during the “FLIGHT CONTROL CHECK“.
Contributing factors were:
• an unclear and difficult to handle documentation so that a wrong wiring diagram was
used
• diversion from the manufacturer’s data by the Maintenance Support
• manufacturer’s instructions which are not formulated unambiguously
• functional check by the cross checking staff member was carried out incorrectly
• iinsufficient functioning of the quality assurance
• the lack of supervision of the maintenance organisation by the operator
• a quantitatively and qualitatively insufficient supervision of the maintenance organisation
and the operator by the supervising authority.
• deficiencies in the “AFTER START CHECKLIST“ for the conduct of the “FLIGHT
CONTROL CHECK“.
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 30
4. Safety Recommendations
4.1 Immediate Actions
As an immediate action the BFU issued the following safety recommendation to the LBA and to the
aircraft operator concerned:
Recommendation no. 09/2001
The procedures and checklists for all fly by wire aeroplanes should be amended in such a way that
during the flight control check attention is paid to the correct direction of movement of the ailerons
and roll spoilers as recommended also by the manufacturer.
4.2 Actions during the investigation
4.2.1 Internal actions by the maintenance organisation
Due to the serious incident a series of internal immediate actions were initiated in order to preclude
as far as possible that such an occurrence will happen again. A large number of medium and longterm
actions have mostly been realized already in the course of investigation. They shall contribute
to the creation of new working conditions and human relations as well as to the bulding up of a
more distinct sense of responsibility.
• As an immediate action an instruction has been issued that the functional and control system
checks on fly by wire aeroplanes must always be performed from both sidesticks. The
Standard Practices Manual (SPM) as well as the Job Cards have been amended accordingly.
Airbus Industrie have been requested to correspondingly amend unclear wordings in
the “AIRCRAFT MAINTENANCE MANUAL“. The staff members involved in this process
have received instruction.
• Within the scope of the short-term actions mainly internal processes, quality assurance
procedures and the rules for the documentation of maintenance actions have been
checked and modified. The continuation training of the staff members has been intensified.
• Within the scope of medium term actions an improved familiarization of newly employed
personnel with all necessary operational procedures has been achieved and accordingly
documented. The exchange of information should be improved. An anonymous reporting
system similar to that in flight operations has been installed, in order to allow staff members
to complain about inacceptable requirements or technical and other conditions without
　
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