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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
sidestick and the ELAC plug was not realized by the mechanics probably because of the
complicated documentation.
• The work of the late shift on the plug segment AB was inadmissibly entered into the same
field of the GLB in which already the work of the morning shift on the plug segments AA,
AD and AE had been copied, instead of being entered into a separate column.
• The malfunction “PITCH TRIM FAULT“ which had occurred during ground scanning after
completion of the work was not related to the confused wires.
• The technical personnel was adequately licensed to accomplish the work.
• The qualification of the B2 or the mechanic III personnel having attended a one day additional
training course to obtain the cross-check rating cannot be equated with the qualification
of an inspector of aeronautical products or of certifying staff under JAR-66.
• The cross checking staff member did not carry out an independent cross-check as he had
incorrectly used the documents of his colleague who had done the previous work.
• The measuring of the individual wires was considered unnecessary by Maintenance Support
and therefore omitted.
BFU German Federal Bureau of Aircraft Accidents Investigation
5X004-0/01 28
• The duplicate inspections, i.e. functional check pursuant to the AMM and control system
check pursuant to the Job Order was conducted incorrectly due to the fact that the provisions
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