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taking a risk of personal disadvantages.
• The long term objective is a positive change in the attitude to work and working ethics intended
to lead to an improved working culture.
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 31
4.2.2 Actions of the Luftfhart-Bundesamt (Federal Office of Civil Aeronautics)
To improve the situation of the supervision of the operators’ maintenance systems the LBA in
agreement with the BMVBW has shifted the emphasis of work to the supervision of the approved
maintenance systems. This action which is at the cost of other tasks is for the present limited until
mid 2003.
At the same time additional funds for personnel have been requested and promised for the budgetary
year of 2003.
4.3 Safety recommendations following the completion of the investigation
Recommendation no. 05/2003
The actions initiated by the Luftfahrt-Bundesamt should be continued for an unlimited period beyond
the year 2003 in order to achieve a permanent qualitative and quantitative improvement of the
audits to be performed with the aircraft operators and the maintenance organisations.
Recommendation no. 06/2003
The aircraft operator should provide the organisational and personnel conditions in order to ensure
compliance with the quality requirements for the maintenance of aircraft in the maintenance organisation
in accordance with the requirements of JAR-OPS 1.035 (Subpart B) in conjunction with JAROPS
1.890, 1.895, 1.900, 1.905 (Subpart M).
Recommendation no. 07/2003
The systerm of the procedural instructions in the maintenance organisation should be amended
and re-arranged so that procedural instructions are clear, unambiguous and readily findable for all
users.
5. Enclosures:
The enclosures have been included in the text.
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 32
Braunschweig, 19.05.2003
Bundesstelle für Flugunfalluntersuchung (Federal Bureau of Aircraft Accidents Investigation)
by order
Müller
Investigator-in-charge
The following BFU staff members have contributed to the investigation:
J. Reuß
A. Thiel
Factual Information
Kind of occurrence: Serious incident
Date: 05.04.1998
Location: near Frankfurt/Main Airport
Aircraft: transport category aeroplane
Manufacturer/type: Airbus / A320-200
injuries to persons: none
material damage aircraft not damaged
other damage: no other damage
History of the flight
On a scheduled flight from Lyon to Frankfurt in a
holding pattern the airspeed indications in both primary
flight displays (PFD) and for a short time in the standby
indication system failed. In conjunction with this failure,
the automatic flight control systems switched off and the
electronic centralized aircraft monitor showed several
warning and error messages. The pilot-in-command
immediately took over the controls from the candidate
captain who up to the moment of the occurrence was
the pilot flying. When he had stabilized the aeroplane
manually at an altitude of 10000 ft on the basis of pitch
angle and powerplant output (PITCH and POWER), the
airspeed indications reappeared on all three
instruments. As a precaution, the PIC manually
switched the pitot tube heating on (PROBE/WINDOW
HEAT on the overhead panel from AUTO to ON).
At the moment of the incident, IMC with severe icing,
rain showers and turbulence were prevailing. For the
landing, the autopilot and autothrottle were available
again.
Investigation
The incident was reported to the BFU (Federal Bureau
of Aircraft Accidents Investigation) by the operator on
April 7th, 1998 by telefax. In the following, the Director of
the BFU charged a staff member with the investigation.
The investigation by the BFU was accomplished in
cooperation with the operator and the maintenance
organisation. During the investigation the BFU was in
contact with the aircraft manufacturer and the
manufacturer of the pitot tubes installed.
Since the aeroplane had already been returned to flight
service by the operator, first of all, the
documents/evidence concerning the complaints
entered in the flight log were inspected and the flight
data recorder was evaluated. The FDR had recorded
only the system 1 airspeed indication, and in the ECAM
system (MAINTENANCE POST FLIGHT REPORT =
MPFR) only the error messages of system 1 and the
standby systen had been stored. These recordings do
not directly confirm the reported course of the incident.
According to the FDR recordings, the function of the
autopilot had been interrupted for 59 seconds, whereas
　
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