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Old 15th March 2011 | 17:05
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IGh
 
Joined: May 2007
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From: Castlegar
Continued descent below MDA

A final rpt is available (pdf) on the web-site for Swiss AAIB, use the registration & date
BFU - BEAA - UIIA - AAIB
24.11.2001
6 km East Zurich Kloten, ZH
Switzerland HB-IXM

From Swiss AAIB report, pg 11:
At 21:05:21 UTC flight CRX 3597 reported on the aerodrome control frequency. When the aircraft reached the minimum descent altitude (MDA) of 2390 ft QNH at 21:06:10, the commander mentioned to the copilot that he had certain visual ground contact and continued the descent.

At 21:06:36 UTC the aircraft collided with treetops and subsequently crashed into the ground. The aircraft caught fire on impact. Twenty-one passengers and three crew members died from their injuries at the site of the accident; seven passengers and two crew members survived the accident.

Investigation
The AAIB set up an investigation team designated to investigate an aircraft accident ...
The Analysis Sections do address several of the "human factors" you questioned. Regarding the "ground contact" observed by the pilots, from pg 111:
"... the commander was provably used ... to descend below the minimum descent height, even when he had sight only of the ground and not of the runway. As the incident of December 1995 shows, the commander obviously believed he was capable of carrying out such a procedure even at night and under instrument conditions.
In view of the meteorological conditions, visual contact with the runway was highly improbable, since when it flew through the MDA the aircraft was still at an oblique distance of approximately 4.4 NM (8.1 km) from VOR/DME Kloten and 3.5 NM (6.5 km) from the runway threshold.
At 21:06:22 UTC a radar altitude of 500 ft RA was reached and the ground proximity warning system reported: “Five hundred”. This call-out may have caused the commander some displeasure ..."
From pg 120+ of the Swiss AAIB Investigation Report:
3 Conclusions
...
• The ground proximity warning system (GPWS) issued no warnings because throughout its flight path the aircraft was outside the envelopes of
mode 1 – excessive descent rate and
mode 2B – excessive terrain closure rate.
...
• The recordings of the CVR and the radio transcriptions prove that immediately before reaching the minimum descent altitude (MDA) the copilot was occupied by tasks.
• The operator’s procedures specified a clear division of tasks between pilot flying and pilot not flying for this flight phase. The flight crew did not comply with these specifications.
• The commander deliberately violated the minimum descent altitude (MDA) for the standard VOR/DME approach 28.
• The copilot made no attempt to prevent the continuation of the flight below the minimum descent altitude.
None of the crew members had visual contact with the runway or with the approach lights. Therefore the conditions for going below the minimum descent altitude (MDA) and continuing the final approach visually were not met.


Last edited by IGh; 15th March 2011 at 17:56.
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