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ASN Wikibase Occurrence # 147094
Last updated: 16 September 2019
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Date:20-MAR-2001
Time:12:00
Type:Silhouette image of generic A320 model; specific model in this crash may look slightly different
Airbus A320-211
Owner/operator:Lufthansa
Registration: D-AIPW
C/n / msn: 137
Fatalities:Fatalities: 0 / Occupants: 121
Other fatalities:0
Aircraft damage: None
Location:Frankfurt International Airport (FRA) -   Germany
Phase: Take off
Nature:International Scheduled Passenger
Departure airport:Frankfurt International Airport (FRA)
Destination airport:Paris (unknown airport)
Investigating agency: BFU Germany
Narrative:
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

Safety recommendations:

Safety recommendation 05/2003 issued 19 May 2003 by BFU to LBA
Safety recommendation 06/2003 issued 19 May 2003 by BFU to Lufthansa
Safety recommendation 07/2003 issued 19 May 2003 by BFU

Accident investigation:
cover
  
Investigating agency: BFU Germany
Status: Investigation completed
Duration: 2 years and 2 months
Download report: Final report


Images:

Photo of D-AIPW courtesy AirHistory.net


Düsseldorf - International (EDDL / DUS)
13 August 2017; (c) Aad van der Voet

Revision history:

Date/timeContributorUpdates
26-Jul-2012 07:20 harro Added
04-Jul-2014 06:04 Anon. Updated [Source, Narrative]

Corrections or additions? ... Edit this accident description