Key Safety Issue(s)

Fuel Leak

  • An undetected, high rate, fuel leak.
  • Flight crews performing procedures from memory rather than following checklist

Automation

  • Highly automated airplane systems (ECAM, fuel transfer) that contributed to the delay in the crew recognizing the fuel leak.

Standard Operating Procedure Checks 

  • Standard Operating Procedural checks involving comparison of onboard fuel to predicted fuel at specified route waypoints were unable to detect large volume fuel leaks

Configuration Control

  • Configuration control of components prior to their installation for compatibility with the service bulletin configuration of the aircraft
  • Not properly completing and validating incorporation of non-mandatory service bulletins

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