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1.17.2 Maintenance Organisation....................................................................................................... 18
1.17.3 Supervision of the maintenance organisation by the Luftfahrt-Bundesamt ................................... 19
1.18 Additional information.............................................................................................................. 19
1.18.1Documentation....................................................................................................................... 19
1.19 Useful or effective investigation techniques............................................................................... 21
2. Analysis ............................................................................................................................... 21
2.1 Operator................................................................................................................................ 21
2.2 Maintenance Organisation....................................................................................................... 22
2.3 Documentation ....................................................................................................................... 25
2.4 Supervision by the LBA ........................................................................................................... 25
2.5 Illustration of the causal chain.................................................................................................. 26
3. Conclusions......................................................................................................................... 27
3.1 Findings ................................................................................................................................ 27
3.2 Causes ................................................................................................................................. 29
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 II
4. Safety Recommendations..................................................................................................... 30
4.1 Immediate Actions .................................................................................................................. 30
4.2 Actions during the investigation................................................................................................ 30
4.2.1 Internal actions by the maintenance organisation ....................................................................... 30
4.3 Safety recommendations following the completion of the investigation........................................ 31
5. Enclosures:.......................................................................................................................... 31
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 3
Abbreviations
AMM Aircraft Maintenance Manual
AOC Air Operator’s Certificate
AWL Aircraft Wiring List
AWM Aircraft Wiring Manual
BFU Bundesstelle für Flugunfalluntersuchung
BMVBW Bundesministerium für Verkehr, Bau- und Wohnungswesen
(Federal Ministry of Transport, Building and Housing)
CVR Cockpit Voice Recorder
ECAM Electronic Centralized Aircraft Monitoring
EFCS Electronic Flight Control System
ELAC Elevator Aileron Computer
FAC Flight Augmentation Computer
FZE Flugzeugelektroniker (Aircraft Electronic Technician)
GLB Ground Log Book
JAA Joint Aviation Authorities
JAR Joint Aviation Requirements
LBA Luftfahrt-Bundesamt (Federal Office of Civil Aeronautics)
MEL Minimum Equipment List
QM Qualitätsmanagement (Quality Management)
QMH Qualitätsmanagementhandbuch (Quality Management Handbook)
QS Qualitätssystem (Quality System)
ROD Reliability-Data on Demand
SB Service Bulletin
SEC Spoiler-Elevator Computer
SfB Sammelblatt für Beanstandungen (list of complaints)
SPM Standard Practices Manual
SSFDR Solid State Flight Data Recorder
TLB Technical Log Book
UTC Universal Time Coordinated
VA Verfahrensanweisung (Procedural Instruction)
WD Wiring Diagram
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 4
Synopsis
On 21 March 2001 at 18:10 hrs1, the Federal Bureau of Aircraft Accidents Investigation (hereafter
referred to as BFU) was informed of a serious incident at Frankfurt/Main airport.
An Airbus A 320 had departed at 11:00 hrs UTC from runway 18 for a flight to Paris. 115 passengers and
6 crew members were aboard the aeroplane. Immediately following the lift-off the aeroplane assumed a
slight bank angle to the left. The commander, who was the pilot flying, tried to correct the attitude by a
slight input on the left sidestick. However, the bank angle increased continuously up to approx. 22°. With
　
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