ASN Wikibase Occurrence # 147094
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| Date: | Tuesday 20 March 2001 |
| Time: | 12:00 |
| Type: |  Airbus A320-211 |
| Owner/operator: | Lufthansa |
| Registration: | D-AIPW |
| MSN: | 137 |
| Year of manufacture: | 1990 |
| Engine model: | CFMI CFM56-5A1 |
| Fatalities: | Fatalities: 0 / Occupants: 121 |
| Aircraft damage: | None |
| Location: | Frankfurt International Airport (FRA/EDDF) -
 Germany
|
| Phase: | Take off |
| Nature: | Passenger - Scheduled |
| Departure airport: | Frankfurt International Airport (FRA/EDDF) |
| Paris (unknown airport) | |
| Investigating agency: | BFU |
| Confidence Rating: |  Accident investigation report completed and information captured |
The Airbus 320 hit turbulence just after rotation from runway 18 and the left wing dipped. The captain responded with a slight sidestick input to the right but the aircraft banked further left. Another attempt to correct the attitude of the plane resulted in a left bank reaching ca 22deg. The first officer then said "I have control", and switched his sidestick to priority and recovered the aircraft. The left wingtip was reportedly just 0.5m off the ground. The aircraft climbed to FL120 where the crew tried to troubleshoot the problem. When they found out that the captain’s sidestick was reversed in roll, they returned to Frankfurt. Investigation revealed that maintenance had been performed on the Elevator Aileron Computer no. 1 (ELAC). Two pairs of pins inside the connector had accidentally been crossed during the repair.
URSACHEN:
Die BFU kommt zu dem Schluss, dass die schwere Störung darauf zurückzuführen ist, dass
- bei Instandsetzungsarbeiten am Stecker des "Elevator-Aileron-Computers" (ELAC) Nr. 1 zwei Kabelpaare vertauscht wurden
- der Arbeitsfehler unentdeckt blieb
- der Fehler beim "FLIGHT CONTROL CHECK" durch die Besatzung nicht erkannt wurde
Beitragend zu den Ursachen waren:
- eine unübersichtliche, schwer handhabbare Dokumentation in deren Folge ein falsches "Wiring-Diagram" benutzt wurde
- ein Abweichen von den Herstellervorgaben durch "Maintenance Support"
- nicht eindeutig formulierte Herstelleranweisungen
- eine unkorrekte Durchführung der Funktionskontrolle durch den Zweitkontrollierenden
- eine unzureichend funktionierende Qualitätssicherung
- eine fehlende Überwachung des Instandhaltungsbetriebes durch das Luftfahrtunternehmen.
- eine quantitativ und damit auch qualitativ nicht ausreichende Überwachung des Instandhaltungsbetriebes und des Luftfahrtunternehmens durch die Aufsichtsbehörde
- Mängel in der "AFTER START CHECKLIST" für die Durchführung des "FLIGHT CONTROL CHECK"
PROBABLE CAUSES: (unofficial translation)
The BFU comes to the conclusion that the serious incident occurred because:
- during maintenance of the ELAC Nr. 1 connector, two cable pairs were crossed
- the error remained undetected
- the error with the "FLIGHT CONTROL CHECK" was not recognized by the crew
Contributing to the causes were:
- an unclear, with difficulty manageable documentation because of which a wrong "Wiring Diagram" was used
- a deviation from the manufacturers regulations by "maintenance support"
- unclear formulated manufacturers manual
- an uncorrect execution of the functioning check
- an insufficiently functioning quality assurance
- a failing monitoring of the maintenance organisation by the airline.
- a quantitatively and consequently qualitatively insufficient monitoring of the maintenance organisation and the airline by the authorities
- a shortcoming in the "AFTER START CHECK LIST" for the execution of the "FLIGHT CONTROL CHECK"
Sources:
Flight International 22.05.2001
https://www.bfu-web.de/DE/Home/homepage_node.htmlDE/Publikationen/Untersuchungsberichte/2001/Bericht_5X004-01.pdf?__blob=publicationFile
Accident investigation:
 |
|
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 26-Jul-2012 07:20 | harro | Added |
| 04-Jul-2014 06:04 | Anon. | Updated [Source, Narrative] |
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