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as far as possible that such an occurrence will happen again. A large number of medium and longterm
actions have mostly been realized already in the course of investigation. They shall contribute
to the creation of new working conditions and human relations as well as to the bulding up of a
more distinct sense of responsibility.
• As an immediate action an instruction has been issued that the functional and control system
checks on fly by wire aeroplanes must always be performed from both sidesticks. The
Standard Practices Manual (SPM) as well as the Job Cards have been amended accordingly.
Airbus Industrie have been requested to correspondingly amend unclear wordings in
the “AIRCRAFT MAINTENANCE MANUAL“. The staff members involved in this process
have received instruction.
• Within the scope of the short-term actions mainly internal processes, quality assurance
procedures and the rules for the documentation of maintenance actions have been
checked and modified. The continuation training of the staff members has been intensified.
• Within the scope of medium term actions an improved familiarization of newly employed
personnel with all necessary operational procedures has been achieved and accordingly
documented. The exchange of information should be improved. An anonymous reporting
system similar to that in flight operations has been installed, in order to allow staff members
to complain about inacceptable requirements or technical and other conditions without
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
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