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3. Conclusions......................................................................................................................... 27
3.1 Findings ................................................................................................................................ 27
3.2 Causes ................................................................................................................................. 29
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 II
4. Safety Recommendations..................................................................................................... 30
4.1 Immediate Actions .................................................................................................................. 30
4.2 Actions during the investigation................................................................................................ 30
4.2.1 Internal actions by the maintenance organisation ....................................................................... 30
4.3 Safety recommendations following the completion of the investigation........................................ 31
5. Enclosures:.......................................................................................................................... 31
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 3
Abbreviations
AMM Aircraft Maintenance Manual
AOC Air Operator’s Certificate
AWL Aircraft Wiring List
AWM Aircraft Wiring Manual
BFU Bundesstelle für Flugunfalluntersuchung
BMVBW Bundesministerium für Verkehr, Bau- und Wohnungswesen
(Federal Ministry of Transport, Building and Housing)
CVR Cockpit Voice Recorder
ECAM Electronic Centralized Aircraft Monitoring
EFCS Electronic Flight Control System
ELAC Elevator Aileron Computer
FAC Flight Augmentation Computer
FZE Flugzeugelektroniker (Aircraft Electronic Technician)
GLB Ground Log Book
JAA Joint Aviation Authorities
JAR Joint Aviation Requirements
LBA Luftfahrt-Bundesamt (Federal Office of Civil Aeronautics)
MEL Minimum Equipment List
QM Qualitätsmanagement (Quality Management)
QMH Qualitätsmanagementhandbuch (Quality Management Handbook)
QS Qualitätssystem (Quality System)
ROD Reliability-Data on Demand
SB Service Bulletin
SEC Spoiler-Elevator Computer
SfB Sammelblatt für Beanstandungen (list of complaints)
SPM Standard Practices Manual
SSFDR Solid State Flight Data Recorder
TLB Technical Log Book
UTC Universal Time Coordinated
VA Verfahrensanweisung (Procedural Instruction)
WD Wiring Diagram
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 4
Synopsis
On 21 March 2001 at 18:10 hrs1, the Federal Bureau of Aircraft Accidents Investigation (hereafter
referred to as BFU) was informed of a serious incident at Frankfurt/Main airport.
An Airbus A 320 had departed at 11:00 hrs UTC from runway 18 for a flight to Paris. 115 passengers and
6 crew members were aboard the aeroplane. Immediately following the lift-off the aeroplane assumed a
slight bank angle to the left. The commander, who was the pilot flying, tried to correct the attitude by a
slight input on the left sidestick. However, the bank angle increased continuously up to approx. 22°. With
the commander’s call out :“I can’t do anything more“ the first officer took over the controls with the words
“I have control“ and pressed the TAKE OVER PUSH BUTTON. The First Officer had already beforehand
instinctively tried to counteract the rolling movement with his sidestick.
Controlled by the second autopilot the aeroplane climbed to flight level FL 120 where the crew cautiously
analysed the control system. With an input on the left sidestick the aeroplane - after a short shaking and a
brief bank angle corresponding to the input - suddenly reacted contrary. The right-hand sidestick
functioned normally.
The crew decided to not continue the flight but to return to Frankfurt. The First Officer took over the
controls and safely landed the aeroplane in Frankfurt. The aeroplane was than handed over to the
maintenance organisation.
Prior to this flight, the aeroplane had already been at the maintenance organisation for two days for repair
purposes. On several previously conducted flights had problems occured on one of the two elevator
aileron computers (ELAC), which control, among other things, the bank angle. When the computer was
replaced, a bent pin, which could not be repaired, was found on the plug of the ELAC no. 1. Therefore the
whole plug of the ELAC no. 1 was replaced and rewired. Two pairs of wires were connected inverted, the
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