曝光臺 注意防騙 網曝天貓店富美金盛家居專營店坑蒙拐騙欺詐消費者

may serve as a basis for the subsequent entering of the data into a digital system for the administration
of complaints and meet the requirement for the production of evidence pursuant to the provisions
for JAR-145 maintenance organisations.
1.19 Useful or effective investigation techniques
Special investigation techniques have not been applied.
2. Analysis
2.1 Operator
JAR-OPS 1.890 specifies operators’ responsibility for maintenance. In accordance with JAR-OPS
1.900, Subpart M, operators are obliged to monitor that maintenance contracts are complied with.
For this purpose an audit plan, which has to be approved, must be submitted to the LBA once a
year. According to the investigations of the BFU, the operator had not audited the maintenance
organisation and thus the quality system of the operator was not in a position to recognize systematic
faults with the procedural organisation in time. The quality system of the operator is obliged to
monitor the maintenance organisation, to supervise, assess and, if necessary, to demand the quality
of the work performed.
The fact that the malfunction had not been recognized during the flight control check by the crew is
due to the fact that the ailerons had only been checked for full deflection, as described in the check
list, but not for the correct direction of deflection. The BFU have issued a corresponding safety recommendation
to the operator concerned and to the LBA for operators of fly by wire aeroplanes to
amend their check lists accordingly; such an amendment is also in compliance with the recommendations
given by the manufacturer.
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 22
On the basis of the investigation the BFU assume that the immediate and prudent action of both
flight crew members at the time of the incident had prevented an accident. The philosophy of a flat
cockpit hierarchy between both pilots which is taught and practised in the operator’s fleets may
have decisively contributed towards the prevention of an accident.
On the part of the manufacturer there was an attempt to explain the fact that during the flight control
check following the delivery of the aeroplane to the maintenance organisation the ailerons
moved correctly for a short time before they deflected in the opposite direction. The conditions on
which this explanation was based, however, existed neither on the ground nor in the air.
2.2 Maintenance Organisation
After the conversion to JAR-145 the maintenance organisation had successively transferred the
inspection tasks. These had previously been reserved to the inspection organisation, into the production
sections in the scope of a transition programme continuously communicated to the LBA.
JAR-145 does not define precise criteria for the qualification of maintenance personnel, but requires
only a qualification system to be specified in the maintenance organisation's exposition.
For personnel in charge of the release of aircraft and/or the maintenance of components, JAR-145
required at that time the application of national regulations until the coming into force of JAR-66. In
the Federal Republic of Germany have never been national requirements for certifying staff. Articles
104 through 111 of the Personnel Licencing Order, which was effective at the time of the incident,
only describe the qualification requirements for inspectors of aeronautical products, whose
tasks pursuant to the Approval of Aeronautical Products Order only consisted in technical inspections,
i.e. a sub-quantity of maintenance tasks. According to national aviation regulations the release
certification of maintenance work was at that time reserved to persons "authorized to sign"
who were not necessarily also inspectors of aeronautical products as for that has never been a legal
basis either.
When the first JAR-145 approvals were issued to JAR-145 organisations it would have been necessary
to amend the Approval of Aeronautical Products Order, in order to preclude problems of
interpretation. This synchronous amendment of the Approval of Aeronautical Products Order was
omitted at that time, meanwhile the Approval of Aeronautical Products Order is no longer effective.
There were several shortcomings concerning the organisation and the accomplishment of work as
well as the quality assurance of the responsible maintenance organisation.
The elimination of this technical complaint was a complex action on the control system, as defined
in the relevant procedural instruction. Prior to starting repair work on 19 March 2001 a maintenance
job order would have had to be established which describes the work, the checks and the documentation
have to be made. This maintenance job order was established on 20.03.2001, after the
　
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