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independence of the cross check was the crucial factor.
The repair organisation quality system required pursuant to JAR-145 had proved to be insufficient
in this case. In addition it has become obvious that in this case there are deficits in the accomplishment
of prescribed procedures and in the necessary system knowledge of the staff members.
2.3 Documentation
Since the reference number was mixed up when the complaint was copied from the TLB into the
GLB, the previous maintenance action could not be found initially in the “RELIABILITY DATA ON
DEMAND“ immediately following the occurrence. Even though this error is not directly related to
the cause of the confusion of the pairs of wires it indicates that the quality system did not work optimally.
A complicated and complex documentation system which thus is difficult to handle increases the
risk of mistakes. The 173 procedural instructions valid for the area concerned contain many cross
references making handling considerably more difficult. It was very time-consuming to find out
which procedural instructions were relevant to the tasks to be performed.
In the past, the maintenance organisation made great efforts to establish an internal documentation,
which exists parallel to the manufacturer’s documents and like them has always to be kept up
to date. Diversions from the manufacturer’s documents have in this case resulted in actual mistakes.
The aeroplane manufacturer classified the occurrence as a maintenance error, which will not lead
to changes in aeroplane design. The ambiguous instruction in the AMM was amended on the insistence
of the maintenance organisation immediately following the occurrence.
Towards the BFU the manufacturer justified the problem of the colour interchange red/blue -
blue/red between the side stick connector and the ELAC plug with the objective of obtaining a uniform
wiring of all fly by wire aeroplanes A 320, A 330 and A 340 which previously had differences.
This applies to a certain A 320 transition series, which includes the aeroplane concerned. This particularity
involves an increased risk of errors. In the opinion of the BFU, the manufacturer should
have more plainly and more emphatically pointed out this particularity.
2.4 Supervision by the LBA
The depth of supervision as could be achieved by the technical inspectors of the LBA led to a condition
in which deficiencies in the organisation and accomplishment of work and in the quality assurance
with the operator as well as with the maintenance organisation had not been recognized. It
does not seem to make sense that such a large organisation as in this case falls within the purview
of only one technical inspector of the LBA who is also responsible for several other organisations.
For reasons of capacity, the technical inspectors are not in a position to check the organisations
more thoroughly. Especially in the organisation concerned plenty of internal provisions had been
compiled in the course of the years, the contents of which were not sufficiently known to the technical
inspectors. Up to February 2001 only one technical inspector of the LBA was responsible for
the operator as well as the maintenance organisation, now this task is shared by two LBA staff
members, which, however, still seems to be insufficient.
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 26
2.5 Illustration of the causal chain
The investigation has revealed that numerous factors have contributed to this occurrence. The
causal chain was never interrupted. In order to illustrate this the Swiss Cheese Model according to
Reason was modified in to a chronological sequence.
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 27
3. Conclusions
3.1 Findings
• The maintenance organisation is certified by the LBA and has been working under JAR-
145 since 1993.
• The entering of the incident into the Ground Log Book and into the "Reliability-Data on
Demand" (ROD) under an incorrect reference number shows a lack of care.
• The complicated design of the damaged pin (6K) on the plug segment AE of the ELAC # 1
did not allow a repair in confined space.
• The decision to replace the whole plug was a consequence of the fact that a suitable spare
part was not on stock.
• The decision to reconnect the wires of the whole plug involved a high risk of errors.
• The decision which pages of the Aircraft Wiring Manual were applicable was very difficult
to make on the basis of the accomplishment or non-accomplishment of SBs on this aeroplane.
• The prescribed interchange of colours within the pairs of wires 0603 and 0597 between the
　
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