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Command Channel and the Monitor Channel.
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
1 Unless otherwise specified, all times are indicated in local time.
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 5
• 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 6
1. Factual information
1.1 History of the flight
In Frankfurt the crew performed a scheduled aircraft change. For the crew it was already the third
flight whereas the aeroplane was to be used for the first time that day following repair work.
Approx. 50 minutes prior to departure the crew was at the aeroplane. In the “TECHNICAL
LOGBOOK“ (TLB) all complaints entered had been checked off as settled. The aeroplane had
been released for the flight in accordance with the regulations by a “RELEASE TO SERVICE“.
The preparations for the flight were completed on time. After the power plants had been started,
prior to taxiing to runway 18, the “FLIGHT CONTROL CHECK“ was conducted by means of the
“AFTER START CHECKLIST“. According to the statements of the crew, this check was accomplished
pursuant to the valid procedures. During the check no irrecularities were found.
The aeroplane taxied via taxiway “N-South“ to the take-off position of runway 18. During the takeoff
run no abnormalities were found. During rotation the pilot-in-command noticed an increasing
bank angle to the left. He tried to correct the bank angle through an opposite input on the left
sidestick, but it grew increasingly larger.
The First Officer reported that he instinctively made an input to the right on his sidestick, which prevented
the bank angle from increasing even further, but did not lead to an improvement of the
situation. Only after he had pressed the “TAKE OVER PUSH BUTTON“ on his sidestick, he regained
full control of the aeroplane and was in a position to restore the normal flight attitude. He
switched on the autopilot no. 2 and had the aeroplane climb to flight level 120. At FL 120, the crew
cautiously checked the behaviour of the aeroplane control system.
The autopilot no. 2 was switched off and the First Officer checked the aeroplane control system
with the right-hand sidestick. The aeroplane reaction was in accordance with the control inputs.
Afterwards the pilot-in-command took over the control. He slowly moved the sidestick to one side
and after a short shaking movement the aeroplane unexpectedly moved to the opposite side. When
it had become clear that the aeroplane reaction to control inputs on the left-hand sidestick was opposite
to the inputs, the flight was discontinued. The First Officer landed the aeroplane safely on
Frankfurt/Main airport.
After the delivery of the aeroplane to the maintenance organisation a FLIGHT CONTROL CHECK
was carried out in the presence of the crew, during which the symbols of the ailerons on the ECAM
monitor first and for a very short moment moved into the corresponding direction, as if everything
were alright, before the ailerons moved into the opposite direction.
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 7
1.2 Injuries to persons
There were no injuries to persons.
1.3 Damage to aircraft
There was no damage to the aircraft.
1.4 Other Damage
There was no other damage.
1.5 Personnel information
1.5.1 Crew
Pilot-in-command: 41 years/male
Licences: Airline Transport Pilot Licence (ATPL)
Ratings: - as a pilot-in-command of single piston engined
landplanes up to 2000 kg maximum take-off mass
　
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