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amend their check lists accordingly; such an amendment is also in compliance with the recommendations
given by the manufacturer.
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 22
On the basis of the investigation the BFU assume that the immediate and prudent action of both
flight crew members at the time of the incident had prevented an accident. The philosophy of a flat
cockpit hierarchy between both pilots which is taught and practised in the operator’s fleets may
have decisively contributed towards the prevention of an accident.
On the part of the manufacturer there was an attempt to explain the fact that during the flight control
check following the delivery of the aeroplane to the maintenance organisation the ailerons
moved correctly for a short time before they deflected in the opposite direction. The conditions on
which this explanation was based, however, existed neither on the ground nor in the air.
2.2 Maintenance Organisation
After the conversion to JAR-145 the maintenance organisation had successively transferred the
inspection tasks. These had previously been reserved to the inspection organisation, into the production
sections in the scope of a transition programme continuously communicated to the LBA.
JAR-145 does not define precise criteria for the qualification of maintenance personnel, but requires
only a qualification system to be specified in the maintenance organisation's exposition.
For personnel in charge of the release of aircraft and/or the maintenance of components, JAR-145
required at that time the application of national regulations until the coming into force of JAR-66. In
the Federal Republic of Germany have never been national requirements for certifying staff. Articles
104 through 111 of the Personnel Licencing Order, which was effective at the time of the incident,
only describe the qualification requirements for inspectors of aeronautical products, whose
tasks pursuant to the Approval of Aeronautical Products Order only consisted in technical inspections,
i.e. a sub-quantity of maintenance tasks. According to national aviation regulations the release
certification of maintenance work was at that time reserved to persons "authorized to sign"
who were not necessarily also inspectors of aeronautical products as for that has never been a legal
basis either.
When the first JAR-145 approvals were issued to JAR-145 organisations it would have been necessary
to amend the Approval of Aeronautical Products Order, in order to preclude problems of
interpretation. This synchronous amendment of the Approval of Aeronautical Products Order was
omitted at that time, meanwhile the Approval of Aeronautical Products Order is no longer effective.
There were several shortcomings concerning the organisation and the accomplishment of work as
well as the quality assurance of the responsible maintenance organisation.
The elimination of this technical complaint was a complex action on the control system, as defined
in the relevant procedural instruction. Prior to starting repair work on 19 March 2001 a maintenance
job order would have had to be established which describes the work, the checks and the documentation
have to be made. This maintenance job order was established on 20.03.2001, after the
had already started, indicating a certain carelessness in the realization of the prescribed working
procedures.
In the morning shift on 19 March 2001 an aircraft electronic technician holding a B2 qualification
was to replace the plug segment AE according to the “ONE by ONE” method with the assistance of
an aircraft electronic technician B1. During this action it was determined that the new segment (AE)
was incompatible with the three remaining segments of the plug. The possibility to find a fitting plug
segment within an adequate period of time would generally have been an alternative, but for internal
reasons another decision was made. If only the segment AE would have had to be replaced
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 23
only the pair of wires 0603 of the monitor channel could have been interchanged on this segment,
the pair of wires 0597 of the Command Channel on the segment AA would have remained untouched
and with a high probabiltiy an error message would have appeared on the display of the
electronic centralized aircraft monitoring system (ECAM).
The reconnection of more than 420 pins of the whole plug was connected to a high risk of errors.
Thus it would have been necessary to measure each individual wire (continuity check) as required
by the manufacturer’s instruction AMM 20-52-10 for major actions on the control system. In reply to
the enquiry of the mechanics to staff members of the Maintenance Support Department, whether
　
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