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sidestick and the ELAC plug was not realized by the mechanics probably because of the
complicated documentation.
• The work of the late shift on the plug segment AB was inadmissibly entered into the same
field of the GLB in which already the work of the morning shift on the plug segments AA,
AD and AE had been copied, instead of being entered into a separate column.
• The malfunction “PITCH TRIM FAULT“ which had occurred during ground scanning after
completion of the work was not related to the confused wires.
• The technical personnel was adequately licensed to accomplish the work.
• The qualification of the B2 or the mechanic III personnel having attended a one day additional
training course to obtain the cross-check rating cannot be equated with the qualification
of an inspector of aeronautical products or of certifying staff under JAR-66.
• The cross checking staff member did not carry out an independent cross-check as he had
incorrectly used the documents of his colleague who had done the previous work.
• The measuring of the individual wires was considered unnecessary by Maintenance Support
and therefore omitted.
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 28
• The duplicate inspections, i.e. functional check pursuant to the AMM and control system
check pursuant to the Job Order was conducted incorrectly due to the fact that the provisions
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
　
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