Crossair Bassersdorf Report

[DCS99]

Don't know if someone has already posted.

It's a heavy report and breath-taking history of the skipper, amongst many other items in here.

RIP to all. Never forget.http://www.bfu.admin.ch/common/pdf/u1793_e

[Longtimer]

The range of hills with which the aircraft came into contact was entered in the
Swiss AIP. However, this obstacle was missing on approach chart 13-2 of the
Jeppesen route manual, which the flight crew were using.

[Wirraway]

Tues "The Australian" Late News

'Overtired' pilot in Swiss crash
By Naomi Koppel in Geneva
February 03, 2004

AN "overtired" pilot who flew too low was the cause of a plane crash that killed 24 people, Swiss investigators concluded today, as justice officials considered whether to prosecute officials of the Swiss national airline.

"The commander deliberately descended below the minimum descent altitude ... without having the required visual contact to the approach lights or the runway," the federal Air Accident Investigation Bureau said in its 161 page report on the November 24, 2001, crash of Crossair Flight CRX3597.

The scheduled flight from Berlin, arriving in rain and snow, crashed into woodland on the approach to Zurich Airport, killing 24 and injuring nine other people.

Among the dead were US singer Melanie Thornton, two of the three members of the pop group Passion Fruit and the dean of Israel's Hebrew University school of medicine. The pilot and co-pilot also died.

The report found that the pilot, who was not identified, had been working for more than 13 hours when the crash occurred, and had exceeded maximum duty times in the two days before the accident as well, meaning that he "would tend to be overtired".

It concluded that the pilot's "ability to concentrate and take appropriate decisions as well as his ability to analyse complex processes were adversely affected by fatigue".

The report also criticised the co-pilot for failing to step in.

Swiss International Air Lines - the new name of Crossair - said in a statement that it followed all national and international safety requirements.

"The highly experienced captain had all the qualifications required for the flight," the company said.

Hansjuerg Mark Wiedmer, spokesman for Switzerland's federal prosecutors office, confirmed that a criminal investigation has been opened, on suspicion of negligent homicide and grievous bodily harm by negligence.

Swiss made no comment except to say that it was "keen to have this case fully clarified."

Investigators concluded that over a long period airline officials "did not make correct assessments of the commander's flying performance. Where weaknesses were perceptible, they did not take the appropriate measures."

Other factors that contributed to the crash included the fact that there was no alarm system on Zurich's runway 28 to warn pilots if they went too low, and the system for measuring visibility at the airport was inappropriate for that runway.

A range of hills over which the plane flew were not marked on the chart the pilots were using, it said.

Swiss said that since the accident it has introduced a new flight safety program covering recruitment, training, checks, workflow and procedures throughout its operations.

Swiss said it has paid compensation to the families of the victims but was still facing lawsuits in Switzerland, Germany and Israel.

===========================================

[TopBunk]

It is interesting to note that there appears to be no recommendation to install an ILS onto 28, it may require a steep slope, or infringe obstacle limits, I don't know. At Stuttgart, prior to them lengthening the runway about 10 years ago, runway 08, as it was then, had an ILS promulgated as not for use, but it sure helped those NDB/DME approaches a lot. Surely something similar could and should be done at ZRH, especially as the late evening arrivals are on 28 as a matter of routine nowadays.

I believe that an ILS is being installed onto 34 now - about time, this place really does need sorting out, safety at ZRH really does appear to be a very poor second relation to the Zurich rich folks.

[finalschecks]

I am surprised that they would come up with the beforementioned "negligent homicide and grievous bodily harm by negligence" in respect to this accident an not the one before.

About a year before crossair had the saab 340 crash at Nassenwil, a case where the prosecution would have much stronger case.


Another question that comes up is the nicely worded but very bold statement:
Investigators concluded that over a long period airline officials "did not make correct assessments of the commander's flying performance. Where weaknesses were perceptible, they did not take the appropriate measures."Shouldn't we interprete that like "We knew he was a flunky but had him pass years and years of LPC/OPC's anyway" ?

Could this be the basis of the prosecutions case?

If this case gets people convicted, I wonder what will happen if the Nassenwil saab 340 crash ever makes it into a swiss courtroom.

[Spuds McKenzie]

To put it bluntly, it is shocking. :(

Re ILS 34/28, in April LOC 34 will be up and running, followed by GP in October.
ILS 28 will be installed next year.

BTW VOR/DME APP procedures are safe, as long as they are flown correctly...

[RASTAMIKE]

politically correct

In the report, I couldn't find a mention of why ILS 14 was closed. The vis was not good and aircraft were redirected to a non-precision approach (VOR/DME 28).

The reason is simple: it was late and the rich germans living on the Swiss border don't like overflying jets, even if they enjoy the facilities that Kloten offers. German authorities imposed a night ban overhead German territory: a contributing factor?

[TopBunk]

Rasta

I was of the impression that it was because the Swiss had over flown Germany about 4x the agreed no. of flights for the last n years? Am I wrong? Was the use of 28 not due to this reason? Why has ZRH not previously installed ILS onto 34? Was it not due to the fact that the approach path took aircraft over prestigious lakeside properties over Lake Zurich?

Please correct me if I'm wrong.

Spuds

All procedures are safe if flown correctly - on this occasion it was not. This raises the question as to what could be done to make it safer - the report would appear to ignore some opportunities - ie an ILS.

This report supresses the real issues re ZRH - the lack of decent instrument approaches to all runways at the expense of safety for the benefit of a a few rich ZRH inhabitants in the city, who for decades have abused the rights of their German neighbours.

[RRAAMJET]

Holy mackerel...I don't ever like to critique in the aftermath, but in this case I feel compelled.

This must stand as an example of why, if you ever fly with someone you feel to be completely at odds with SOP's or normal safe and prudent aviating, you MUST report it up the chain of command, or even to your Union if necessary. This commander had enough warning flags - nobody seems to have collated and prevented the incidents. You are doing your pax and fellow crew a favour, and perhaps helping out the struggling individual.

In this case I feel a very inexperienced FO was hoodwinked into not intervening. Descent below MDA when not visual is illegal as well as imprudent.

Failing the MD-80 course and having difficulty with the 146? Hmmm....more red flags. These are not, by any measure, difficult aircraft. (The MD-80 is simply archaic and chaotic, but not difficult).

Raising the gear on the ground as a demo in the real aircraft? WTF? That's what sim's are for, if you want to play. Good grief. VFR nav into the wrong country? Helloooo...
How many strikes do you get at Crossair? 3 and out? 4? What?
Now combine the above with fatigue....hello trees.

9 survivors are a testament to the incredible structural strength of the 146.:ok:

This is the first time I can be correctly accused of "Monday morning quarterbacking", but to you newcomers out there: don't ever, ever be afraid to query, question and refer those who would appear to be Gods. A policy of no foul should apply. Perhaps 24 souls would still be alive had it occurred here.

No wonder there's a lawsuit pending....:sad:

[Spuds McKenzie]

TopBunk,

There was never an agreement with Germany about a maximum number of flights, the agreement was to use RWY16/14 equally, which, as we know, was never complied with.

I agree that the Swiss authorities failed to recognise the demands of the German population in the South.

However, fact is that it wasn't the procedure as such which led to the crash, but non compliance with the procedures by the crew.
An ILS APP reduces the workload for pilots, but doesn't necessarily prevent them from making mistakes (ie the crash of Alitalia flight 404 in Nov. 1990 in ZRH).
This leads to the conclusion, that if you wanted to make flying fail safe you would have to eliminate the human factor, which, as we both (you as a pilot and me as an ATCO) know, is illusory.
The PiC left the minimum altitude without having sufficient visual ground contact, the Copilot failed to correct the PiC, human error, period.

[411A]

Have to agree with RRAAMJET.

First operated into ZRH in the mid-seventies in an old straight pipe 707, and the approach (as it was then) to 28 was not an easy one, especially with low ceiling/vis, and suspect it isn't any better now.

That ILS for 28 should have been installed long ago.

[694c]

Quote:

'All procedures are safe if flown correctly'

Trouble is non-precision approaches are often not flown correctly.
There's a long and sorry history of aircraft crashes from this kind of approach, and they will continue to happen until every runway has an ILS and every aircraft and airport has the necessary safety filters.

Two such systems could have saved Crossair 3597 from disaster:

Ground radar based automatic approach altitude deviation warning, which should have been installed on all runways at Kloten following the Alitalia crash but was not. It could have been replaced by human monitoring, but the responsible ATC controller had gone home early.

Enhanced GPWS, which had been fitted to most Swissair aircraft at the time of the accident but not to those of Crossair. I remember flying some trial approaches in an A320 simulator following the CRX profile. 'Terrain Terrain' came in about 30 seconds before impact and 'Whoop Whoop Pull Up' about 20 seconds before; enough time for even the mentally incompetent and physically exhausted Captain Lutz to abandon his criminally negligent attempt at a non-precision approach, and for the pathetically submissive First Officer Loehrer to intervene. They have paid the ultimate price for their foolishness, I hope that others who have been found responsible will be prosecuted to the full extent of the law.

[TopBunk]

Spuds

I don't disagree with you on much, just approaching it from a different angle - the pilots.

The fact is that at ZRH the local procedures require the VOR28 procedure to be used for political reasons whenever possible after 2000Z (?), in as in this case, often marginal weather conditions. This despite having a CAT3 ILS available. When you fly into ZRH with 28 in use (and a 20kt tailwind on the approach for a 3.7 deg slope) and request ILS 14 due safety, what do you think ATC will say to you? At most places they would accommodate you - not at ZRH - you accept the approach or divert - no choice.

The politicians must decide whether safety or votes come first.

Re the Alitalia crash: as I recall that was (in part) due to the glideslope receiver on the DC9 failing without any fail flags in the central (ie on glideslope) position - ie at least partly technical. Yes, crew procedures should have picked it up, but a bit of a fluke - I have never had a glideslope rxr fail - for it to happen (a) in low ceiling IMC, (b) at ZRH with the terrain, (c) with no fail flag is pretty bl**dy bad luck.

[Daysleeper]

694c

I would be very carefull about what you say about the dead pilots, I know they cannot sue you for slander but their estates may be able to. Nor have they been found so in a court. Should criminal proceedings be instigated against others your comments could be seen as predujical.
They have not been named elsewhere on this site I suggest you edit your post.

[270/55G75]

Aircrew should be able to fly a Vor/dme approach. As it is less precise tha a ILS it has higher minimas. ILS approaches can also become dangerous if you do not stick to the minima's !

Fact remains that noise and environment lobby forces you to fly a less favourable approach in marginal conditions.

[Capt H Peacock]

Interesting to note that despite adding all salient factors such as the position of the Sun etc, the report at no stage recognises altimeter temperature error despite ATIS giving ISA-12!

[Hostie from Hell]

(Mr Hell here btw)

Re FLT 404, A failed reciever had just been replaced on the aircraft with what turned out to be another failed unit.
Flight crew were an experienced training captain and a very junior f/o.
The ILS reciever failure gave "on glideslope "on the f/o's side and a fly down on the captains when in "split".
There was a cultural issue in play namely that the captain
a) ticked off the f/o for being high on the glide, b) selected from split to ILS 1(captains side.. fly down ... )to make the picure fit,
c) closed the power levers after the f/o initiated a go around after the GPWS kicked in.
From previous comments here in the light of the Crossair accident and indeed the Alitalia 404, the message has to be that if you are a first officer no matter how junior and don't like what you see.. SPEAK UP !!, if you are ignored speak up again, and if you are ignored call go-around.
Harder to do than say, but now consider the implications of not doing so.

[694c]

Sleeper:
No way will I edit my post.
The information I have given is freely available on the BFU accident report website and in the online editions of Swiss newspapers such as the NZZ.
Captain Lutz deliberately descended below MDA without having visual contact with the runway or its lighting systems, thereby breaking the law.
He also ignored the minimum rest and flight duty regulations.
I suggest that you edit your post for spelling: don't you mean prejudice?

[Spuds McKenzie]

694C,

I've read the BFU accident report and the pilots' names are not mentioned.
The Captains name has been mentioned in the newspapers, but I still don't think this should be done on Pprune!
And slagging someone off ("I suggest that you edit your post for spelling") who only wants to give you a well meant advice, is off topic and totally inappropriate. We're trying to have a factual discussion on here and comments like yours are utter c:mad: p!

:yuk:

[Col. Walter E. Kurtz]

I think this accident also draws into question the prudence in including low time and inexperienced FO's into transport category aircraft. (The A320 accident at Bahrain was another that comes to mind).

It is all well and good to encourage junior/inexperienced FO's to speak up, but what experience do they have to draw upon when they have to find the courage to challenge the Captain when things go wrong (that's if they can actually see the problems evolving)?

Experience means ALOT, especially when things start to go pear shaped.

[RRAAMJET]

Kurtz,

that one's sailing into the heart of darkness....

Stand by for indignant retorts from all the BA College grads, etc;)

[alf5071h]

The Swiss BFU report is a comprehensive, if somewhat Germanic, report of an accident that indicated failings at all levels of our industry. The BFU should be congratulated in their investigation of complex human factors issues, so often avoided by other authorities; although I suspect that the UK CAA and/or German BFU had some input here.

However in dealing with issues under the SHELL model it is surprising that two significant hazards of Software (non material parts of the system) did not warrant safety recommendations. Safety recommendations are normally issued for circumstances that when removed would have prevented the accident or would prevent another accident.

Surely the use of the precision ILS 14 instead of the forced choice of NPA VOR/DME 28 would have prevented this and future accidents. If a crew decides to use a NPA where an ILS is available and then has an accident / incident, they would be severely criticised. Why then, are the Government and National Authority not criticised for their ill-conceived implementing the noise ban. Is this restriction still in place, why?

Similarly, the geometric design of the VOR/DME procedure induces an unstable approach and invites bad practice, against industry wide recommendations for a continuous descent path. The approach is deemed unsuitable for larger aircraft yet these are probably the best equipped for flying a safer VNAV approach. The National Authority had published an alternative chart (13-3 STOL) which clearly avoids all obstacles but still introduces a destabilising discontinuity in the approach path. I also note that it is based on a 6 deg flight path, but the RJ 100 is only cleared to 5.5 deg. National Authority oversight, or oversight? Thus as above, if a crew had flown an unstable approach – criticism; if the National Authority produces a destabilising procedure … it’s still the crew’s fault?

Objective reporting is good but requires some equality.

[Daysleeper]

Based on how the FO learnt at the same flight school as the captain tought any idea as to whether they flew together there?

[Few Cloudy]

On another thread here, there is a discusssion on procedures, or SOPs as they are called in the UK.

The tendency on that thread is to condone "private procedures" it seems.

Well if ever there were an example of the results of busting procedures - company as well as legal - this accident is it. In my opinion rigid control is needed about sticking to the procedures. It needs a strong managerial level. It also needs a managerial level which will listen to complaints and inputs from the pilots and examine them thoroughly - very occasionally to incorporate new wordings or ideas in the procedures (only after thorough trial and not every month ...)

Another factor is that the FO did nothing to intervene. I understand that so well but we MUST now get these young folk to speak up when needed.

Too much hot air has been spent on CRM discussions - too little results are to be seen for it - just a tick on the board.

As for naming the names - the names are well known in Switzerland - quoted in all the papers and on TV, so they may as well come out on PPRune.

[Groundbased]

Daysleeper,

The report mentions that they flew two flights together in the training scenario. They didn't appear to think it significant in the conclusions.

GB

[694c]

Spud-

Facts on PPRuNe? You must be joking! Scroll down to the bottom of this page and read the warning that's printed in red. Actually, just for fun, as I recently finished reading 'Eats, Shoots & Leaves' by Lynne Truss, I'll slag off the punctuation and spelling of that warning message as well! She has written a great book and I can highly recommend it.
To return to the topic: everything I have written is true and without rumour or speculation.

Alf-

Yes there are still restrictions on approach paths into Kloten during the early morning, late evening, at weekends and on German public holidays. There are now two non-precision approach procedures: 28 and 34.
As for approach angles, I think you're confusing percentages with degrees (3.0deg=5.3%). The accident report mentions both.

Sleeper-

Lutz and Loehrer flew together twice on 28th April 2000 in a Horizon Swiss Flight Academy aircraft with Lutz as instrument rating flight instructor!

[vdive]

I don't think that inexperienced first officers are a real problem. Many airlines have demonstrated over years that one can produce highly capabale ab-initio pilots with a good structured training program being able to serve on a transport category aircraft.

But if they arrive into an airline cockpit with these hours, careful adaption training has to be given and not just a type rating and a few hours in a simulator. Unfortunately, most self sponsored pilots are not able to enjoy such a bridge training assisted by highly experienced commanders. Bridge trainings can eliminate many faults and are a great source of information.

Other point is, what support does a new first officer recieve from the company. Does the company encourage reports concerning flight safety and operation ? Do they offer a confidential reporting system, etc. How are SOP's enforced and violations handled ?

If the company structure is weak and uncoordinated, people start doing things "their own way". If these things aren't stopped or reported, it will continue upon fatal accident.

May the rest in peace and hopefully, the involved have learned from this accident :(

[Stu Bigzorst]

I'm surprised that not much is said of the training of ab-initio FOs. I came through this route and fairly quickly found my way onto the 737. I had top quality training all the way through and have never had significant problems in the technical nor practical side of flying an aeroplane....... except in ONE area that was completely untouched.....

How to deal effectively with the "flying gods". I have only ever encountered a couple of these guys, but one started to take me through MSA (still very IFR) when not on a procedure - "looking to go visual". I had to do some pretty fast learning, especially since I had about 250 hours total time at that moment.

It surely would be a useful part of the ab-initio training to actually simulate some of these situations and people you may encounter when on-line. Having done it before, it makes it a hell of a lot easier the second time, and if it's simulated the first time then there's a much greater chance that there will be a second time.

Just can't help but wonder if the Crossair FO would have behaved differently if he'd been trained this way.

[RRAAMJET]

VDive,

Pair-up an inexperienced FO with a Capt with wanton disregard for SOP's and you have a problem.

At all my other carriers, and my present one, when you reach MDA if nothing seen: "Minimums, go-around". This FO made no such clear call.

In transport jets no more bumbling along at MDA hoping to see something, 'cos you should be on an approximate normal descent path anyway. Flying level would make for an unstable final visual segment, so hence an automatic missed. As for descending below MDA when the runway or lights are not in sight - well, you see the result here.

Even more curiously: both these crew should have been familiar with ZRH as their home base, so missing terrain info on the Jepp is not really a factor, IMHO. You'd think you would know about a ridge short of the runway, especially if you intended to fly recklessly below MDA.

No, overall I'm fairly confident that an experienced FO would have commandingly intervened in this mess (especially one with prior transport command experience).

Stub Exhaust: you posted a fraction ahead of me - good post, good points.:ok:

[AN2 Driver]

Alph5071h,

<<Surely the use of the precision ILS 14 instead of the forced choice of NPA VOR/DME 28 would have prevented this and future accidents. If a crew decides to use a NPA where an ILS is available and then has an accident / incident, they would be severely criticised. Why then, are the Government and National Authority not criticised for their ill-conceived implementing the noise ban. Is this restriction still in place, why?>>

This, in my view, was the first link in the chain of events that lead to the crash.

Background:

ILS14 and 16 approaches both penetrate German territory which starts around 4 NM north of the airport. There was an agreement between Germany and Switzerland that basically regulated overflights as inevitable, they were accepted by the German government.

For reasons that are still unclear, some say they believe it had to do with Germany not caring for another hub in it's neighbourhood, some say some politicians desperate for profilation, the German government put the pressure on ZRH and threatened to simply close the airspace of the approach sector, thereby depriving ZRH of their 2 ILS's. In a not very nicely lead debate, Germany threatened the Swiss Minister of Transport in such a way, that he agreed to a contract, limiting overflights over German Territory in such a way, that in night hours and on weekends, the ILS's could not be used if the minima for the other approaches were given. Therefore, in a rushed ruling from above, the Runway 28 VORDME approach, designed to provide a legal approach in case of strong westerly winds, was pressed into service as a main landing approach. That is the only reason whatsoever that that plane was at this position at that night. There was NO reason whatsoever to use this approach other than political pressure from Germany. The contract was NOT ratified by the Swiss Government in the end, not least so as a result of the crash. As a result, Germany posted an unilateral ruling even more restrictive than the contract would have been.

While I agree with the report in all it's findings about the execution of the approach, the failures of the crew, the failures of the system e.t.c. I think it a shame that the real reason for the use of the VOR DME 28 approach are not thematized. Then again, the BFU's job is to analyze data, not to engage in politics.

It is correct that Zurich Airport did not have an ILS on 28 nor 34, something which now has to be done in an atmosphere close to civil unrest. Why? Well, for starters, 28 is not a landing runway, was never intended as one. With 2500 m lenght, it is not enough for most heavies, it has a problematic terrain as this accident proves, and it has a lot of people in the immediate approach path. 34 likewise, its approach leads over densely populated agglomeration area of Zurich, some 220'000 people live there. Under the approach path of 14/16, there are some 3000 people of which 270 are active in the noise movement that got the Germans to disregard ICAO rules and to castrate ZRH.

In my personal view, the political aspect of this accident is the primary reason for the crash for the very simple reason that this aircraft would NEVER have been on this approach in these weather conditions if the use of that approach had not been forced onto ZRH airport by the politicians.

At the moment, the situation is as follows:
The ILS 16 and 14 approaches are banned daily from 21'00 lt to 07'00 lt on weekdays and from 20'00 lt to 0900 lt on weekends and public holidays. In the event that the minima for the NPA's 28 or 34 are not met, a special permission must be sought by the airport authority from Germany, which is generally given.

So yes, the restrictions are still in use and no, they won't ever be lifted.

[alf5071h]

For the discussion on the qualities of the crew, I suggest that we look at our own operations first. With the luxury of hindsight, how would we or individuals in our organisation be seen after a fatal accident? We are all people, some have good days, some bad; if we have been lucky enough to earn a pilots licence then we have to live up to all that this demands, and that is very hard work. For those of us who struggle to achieve the highest standards then there must be some protection from error, be this additional checking or training, peer reviews, good operational procedures, or the safest option for an approach.

For those who discuss First Officer did not intervene; have you considered some of the practical aspects. Did the SOP require the pilot monitoring (PM) to remain head down, if so how could he determine if the Capt had seen the required visual references? The Capt had stated ‘ground contact’, words used in the SOP but not the intent of the SOP for the required visual reference, the call for which is ‘runway in sight’. Although the PM could have deduced that he should intervene, how many of us would do so after a call of ground contact. Furthermore how does the PM detect flight path excursions on a non-precision approach after MDA. Neither the chart or company SOP showed a table of range vs altitude, so monitoring was limited to speed, attitude, rad alt, etc, not an easy task for an inexperienced pilot. Thus, logically where the flight path is assessed relative to the approach lights / runway the PM should spend some time head-up, monitoring the ‘visual’ approach. But then again if the PM was head-up how could he be sure that he was seeing the same references as the Capt?

Human Factors are not easy, nor is drafting or interpreting SOPs; take care with both.

’All procedures are safe if flown correctly’, but the issue with NPAs is that a different operating technique is required from the ‘norm’ ILS approach. Crews are required to determine the approach path and control the aircraft in pitch to a visualised datum; whereas with an ILS the flight path is predetermined. For accuracy, the NPA requires stability both in configuration and speed, whereas during an ILS a decelerating approach with configuration change is acceptable. Where most approaches today are ILS, an NPA requires special thought and procedures; they are no longer routine, and some are hazardous.

Thus 649c I hope that the new procedure on 34 does not have the pitfalls of the NPA on 28. You appear to have missed my point on the procedure design. The standard 28 approach (13-2) had a 3.03 deg slope transitioning to 3.7 deg, but the STOL approach (13-3) requires a 5.65 deg (9.9% gradient) that transitions to 3.7 deg; both procedures are destabilising.

The new build Crossair RJ100’s had EGPWS fitted at the time if the accident; the accident aircraft was one of the last to leave the factory without EGPWS; I hope that all of the PPrune operators/readers fully appreciate the value of such equipment. Not only does it increase situation awareness, it also provides support for those of us who may be having a bad day.

[Airfix]

Interested in the "FOs must speak up" inputs.

What if (and this has happened to me with low time FOs.... they speak up in this way to say really dumb things ? or are just wrong ?

If this happens more than once or twice with a particular FO (and it has) there is a natural tendency, if under pressure, to disregard further inputs.

When they speak up they not only have to be right, but to have been right in the past .

[safetypee]

It’s interesting to see that FOCA agrees with the recommendation to set MDA on the Alt Sel. Previous PPrune threads discussed this topic; most, if not all manufacturers do not recommend setting MDA for NPA straight in landings. An altitude capture would make the approach unstable, as indicated by the simulator tests in the report. Setting MDA may apply to circling approaches.
How do the operators reconcile recommendations that oppose the industry’s efforts to maintain and improve safety?

[Spuds McKenzie]

AN2 Driver,

Your explanation of why we have to put up with today's shambles regarding the situation at ZRH airport leaves out a few key details which have to be considered as well:

It is a fact that the German population has been skated over from the very beginning, meaning already when RWY 14 was built. They were not considered persons affected and therefore were never involved in the planning process.
When they asked for their voice to be heard as well, they were too often treated as a nuicance (by the Zurich Canton Council, unique and Swissair), hindering ZRH airports development into a major hub. Unfortunately for them even the then German CDU government wouldn't act on their behalf. The only concession they would achieve was the equal use of RWY 14 and 16 (the so called "zipper procedure"). However this procedure was soon given up and the majority of flights was vectored for ILS 14.
With the SPD taking over in Germany things changed in favour of the Southern Germans and their demands were heard.
So Germany asked Switzerland to negotiate a State Contract to address the issues in question.
According to this contract, the regulations imposed would have been less restrictive than they are now (there are now also restrictions for departing aircraft in force: early left turn to MINGA/LOKTA/TGO only if passing German territory FL150 or above). Or 2200loc till 0600loc not below FL100 over Germany (in the contract) as opposed to 2000loc till 0700loc not below FL120 (now).
The most flabbergasting fact is though, that Unique and Swiss lobbied against the contract in Berne as if it was a matter of life and death, until the parlamentarians voted in their favour (surprising enough this fact is never being mentioned by Unique now, it is "the parliament which voted against the contract"). Arrogant as they are, they claimed that they would have good chances in court against the regulations imposed by Germany and they knew exactly what these restrictions would look like!
Now everyone is crying foul (one of the loudest are Unique and Swiss) over the Germans implementing such restrictive measures and, since there is no legally binding contract, that they can "tight the screw" as they like...
On a side note: Isn't it remarkable how much less delay there is for arrivals (RWY28) and departures (RWY32) in the evening compared to the TKOF34/LDG16 disaster (EAT's in the 40s) of previous times....?
And on top of that: with ILS's installed to all RWY's (forced upon them by Germany of course), maximum flexibility is achieved, and the Germans can be "blamed" for it!

[jetjackel]

I flew a season for CrossAir as a MD-80 contract Captain a few years back. Flew the VOR/DME approach to 28 many times while operating out of Zurich. Didn't take a rocket scientist to figure out it was being used for noise abatement. At best the apporach is demanding and its critical to stay on profile.

Had another opportunity to fly it last Oct., again in a MD80, during some serious wx, with moderate to heavy rain, serious turbulence and IMC until near minimums. Runway had a direct crosswind. Extremely demanding, especially after not having flown it for several years.

Noise abatement takes presidence over safety at Zurich, no question. ILS would have been much safer that evening. Somebody is cowtowing to the rich. Hope they enjoy the quiet evenings. Someone needs to answer some questions.

That is a very demanding approach in heavy wx, especially if not flown consistantly.

[320DRIVER]

One thing that is really outstanding is that oil indicator installed upside down. That is a sign of general slopiness and I cannot see how a professional crew can accept that.

[alf5071h]

AN2 Driver, Spuds McKenzie, thanks for the information and background.

Whilst the BFU should not have to play politics, it should at least engage them. The BFU’s job is to report on accidents and the primary objective of their report is ‘for accident/incident prevention’ as written on the front page.

There is no reason why the Swiss BFU should not have issued a safety recommendation to the German government requesting a review or even with-drawl of the noise restrictions; without this perhaps those who ought to review the situation may never know of the hazard – unless they read PPrune. The German BFU was party to the investigation, so they too should have added comment; or did they veto the issue…., now that would be politics.

If there were to be another accident where the use of a higher risk approach procedure when a lower risk option was available, or the use of an approach procedure where the design was contributory to the cause, then the lawyers would be queuing on the government and FOCA doorsteps. Perhaps they are already as a result of this accident.

In our industry we are expected to report safety risks, so too the BFU, FOCA, or government; the difficulty is identifying the persons responsible and who is to take action …, but that is politics.

How many operators have experienced and cited difficulty with the 28 approach (see previous threads)? How many Air Safety Reports have been filed? If we see a hazard we must report it and argue for change.

Which address do I write to?

[Spuds McKenzie]

Somebody is cowtowing to the rich

Well, not really. The rich live along the "Gold Coast", below the approach to RWY 34, in fact, they're not as rich anymore, since the values of their houses have declined considerably...

Besides, RWY28 is not only used for noise abatement (in favour of the Southern Germans, which, to my knowledge, are not overly rich either), but also during strong westerly winds.

[TopBunk]

Spuds

Maybe the fact that the (now not so) rich live under the approach to 34 is the reason that 34 has not historically had a precision approach, despite it being longer and more suitable (less terrain) than 28.

The report states that 28 is now used in conditions other than those of strong westerlies that are typically associated with higher cloud ceilings and good visibility, and now right down to limits, frequently in icing conditions with marked turbulence and with a not insignificant tailwind down a steep slope. These are not conditions that are 100% conducive to safe operations.

I believe the BFU were not fully discharging their full responsibilities 'for accident/incident prevention ' when they failed to make recommendations for ILS's for 28 and/or 34.

[jetjackel]

Well somthing isn't right. Why is that approach to 28 used for anything but a last resort when proceision apporaches are available and within safer tollerence. Maybe you don't have to be rich, just real "vocal" to squeeze the Swiss ATC at Zurich. Someone enlighten me.

[safetypee]

MJ ‘balance of judgment on setting MDA’. Yep, all flying is a balance of judgment, but levelling at MDA on 28 would, IMHO, exacerbate the problems of a poor approach procedure. All major industry safety initiatives caution against level flight at MDA. When approaching 28 any level flight after VDP rapidly increases the approach angle and encourages pilots to ‘press on’, often in marginal conditions. The two aircraft that landed preceding the accident flew appalling flight paths (6 deg ‘dunk’ in 2000m with snow and rain – were there GPWS alerts?), those crews should be chastised as much as the accident crew.

‘You shouldn't be descending below MDA unless the necessary visual criteria are met’, but did anyone investigate if the Capt could have mistook the lights of a town during his ground contact call, was there opportunity for confusion, hesitation? Industry encourages an immediate missed approach from MDA and that advice should have been followed. If the first two aircraft had also followed that advice then would ATC have switched runways back to 14, thus no accident?

I remind PPruners of further hazards of the standard 28 approach. The 13-2 chart is subtitled GPS – this implies that it can be flown with LNAV; and thus VNAV, as has been suggested. However there may still be some VNAV systems that construct a straight line path from the final fix (CF28 at 4000 ft 8nm) to the runway threshold (50 ft); the resultant flight path would be below that charted, with reduced terrain clearance; then that 40 ft temp correction would be significant. N.B. this is not an approved procedure.

A more sensible procedure on 28 for both manual and VNAV would be to construct a constant 3.7 deg descent from 4000ft 7nm (approx distance as I have not calculated the exact value). Terrain clearance would be assured, there is a constant flight path, MDA = 2390 ft, the aircraft is aligned with the visual guidance, and the MAP should be at or just after VDP (MAP 3 DME?). This principle would also apply to steeper flight paths (STOL 28), it eliminates the kink in the vertical approach – and may enable the azimuth to be aligned with the runway.

Hindsight is a wonderful thing.

[694c]

I think that all this talk of politics and bowing to the rich is irrelevant.

Don't forget that the accident was caused by a proven incompetent flying his aircraft in a criminally negligent manner.

Many airports impose approach direction limitations for whatever reason. I've flown the Canarsie 13 VOR approach at JFK when an ILS on the 22's would have been a more convenient option more times than I care to remember, or a VOR into Nice 05 from the South. I don't complain about it but get on with the job of flying a difficult manoeuvre as safely and elegantly as I can.

If it looks as though safety will be compromised I ask for a different approach and invariably get it, if I do meet with intransigence from ATC I bugg@r off somewhere else and boll@cks to anyone who criticises my decision. I always use the monitored approach procedure (Copilot flying, full use of autopilot) for NPA's. If only the Crossair crew had done the same...

The address of the Swiss CAA is:

Bundesamt fuer Zivilluftfahrt
Maulbeerstrasse 9
CH 3003 Berne

[AN2 Driver]

Hi Spuds,

surely there have been mistakes in the past. However, the way this thing has gone now is in my opinion unacceptable.

As far as I am concerned, on an international airport like ZRH, there should be ILS approaches onto all runways, no doubt. I see the fact that an ILS is finally installed on 28 and 34 as an additional safety feature for the airport which will finally do away with constant tailwind approaches and impossible regimes like the 16 landing/34 take off moronity of the past.

I guess what has happened was that all concerned went the way the considered the one of least resistance and also the way that they thought was the least damaging in terms of number of people affected. If you look at the map, it is pretty clear to me that the 14/16 approaches are overflying a significant lower number of people and at a greater altitude than at 28 and 34.

I am NOT convinced at all however that the German SPD/Grüne Government has acted simply on the behalf of the very few voters north of the border, who on top of that make their income from Swiss cross border shoppers, but with clear economic and political goals in mind. I would like to see one federal politician (unless he has a house there himself) who would risk this kind of international exposure (they were slammed into the ground by Flight International just for a starter) and the good relations with a neighbouring country just to satisfy an anti noise league of some 300 people.


The issue I have with the current situation tough is that this new regime was put in force totally uncoordinated and through an act of threats and force rather than in a way that 2 neigbouring states should deal with each other.

What Germany has done is against ICAO guidelines. On top, with the "fait accompli" at ZRH, it has made other border airports like LUX or SZG extremely vulnerable, as they have only got approaches over foreign territory due to terrain or border limitations.

Correcting something that is wrong by breaking international agreements and thereby putting in question the whole concept of ICAO is not the answer to solve political powerplays. Putting the lives of passengers and inhabitants alike at risk is unacceptable. Apart from that, I have a sneaking suspicion that the whole concept can backfire deadly on the Germans. I suspect that their anti noise leagues in FRA and their other airports are only waiting for the court cases to be ruled finally to demand equal treatment.
As the German airports can only have deps/arrs over German territory, that would mean a quite comprehensive night ban. Can you imagine Frankfurt reducing it's hours like that? With regard of Europe being one happy family now, I too was against this contract for this very reason, as it sets a precedent that could damage civil aviation in Europe beyond belief as those suffering from noise elsewhere would not sit on their behinds and see one airport being restricted without asking for the same.


The solution I would like to see is one in which ZRH has precision approaches on all directions which are then used according to a concept taking in account 1. safety, meaning wind, weather, conditions and so on 2. traffic flow and 3rd noise and convenience considerations. If you look at the weather conditions at ZRH you would get a pretty much fair distribution of noise which would not be pressed into a corset that is determined to spark the kind of unrest we have now.

Best regards

AN2 Driver

[Spuds McKenzie]

jetjackel,

Believe me, if it was up to ATC things would look a lot different.
Unfortunately however, as long as politics is (too much) involved (and there is a real lot of it involved), shambles remains a sad fact of life. And, of course, the politicians and certain airport authorities and airlines, who have been heavily involved in the creating of this shambles, deny and/or keep quiet about the role they played, and they don't have to fear to be held accountable.

The true extent of it all is a first rate scandal and I hope that the public will realise who is really to be blamed!

TopBunk,

Your assumption concerning 34 is probably not too far from the truth.
The BFU recommending ILS's for 28 and 34 would have been running in open doors. As I've mentioned previously, by April 34 will be equipped with a LOC, followed by a Glidepath in October, and 28 will see an ILS next year.

[alf5071h]

694c we tolerate many opinions in this forum, but I hope that you have a more open and considerate approach to the crews who you will fly with, than that you show to the accident crew.

We are not all aces in this profession, we are pilots with a range of skills and capabilities, but the operation, and governance of the industry is such that it can usually tolerate the poor pilot on a bad day. However, any pilot on his bad day may make further errors, some without consequence, others self mitigated, or caught by other people, but if these errors, or those of others are not detected then the hazard can overcome all safety devices.

This accident may just be one of those occasions. You argue that you would mitigate the threats to your flight and follow procedures, but on a bad day you will make errors in the same way that all of us will (or have done); and then if the system – those around you, the operator, the regulator, or the government have been less vigilant than expected, it could be you who is being chastised in this forum.

Edit: I credited 694c with being a professional pilot or member of our industry; this may not be correct, but then assumption is a primary human error.

[safetypee]

Good post and edit alf. A lesson in the importance of good CRM and the failure of threat and error management at all levels.

[694c]

Alf, you're absolutely correct, but...
Even if I was having a bad day I wouldn't descend below minimums without knowing where I was. That's a discipline that was hammered into my admittedly sometimes diffident brain 35 years ago and I haven't ignored it since.

[Chronic Snoozer]

694c

Whilst I appreciate where you are coming from, such a simplistic response is not merited. The collective body of airline instructors, ops managers, supervisors and so on must view this accident not only on that fateful night, but also in the preceding years. Sounds like many systemic failures in the supervisory chain leading to a latent accident looking for a place to happen.

Blame will not prevent a similar situation in the future.

The arguments against NPAs are somewhat weak. Proper training, airmanship and flying discipline should prepare pilots enough to fly any approach, any time as is demanded by the job. Yes, the ILS is better and easier but...

CS

[vdive]

RRAAMJET, i don't know why he didn't speak up. Probably not enough confidence blended by commanders experience, afraid of loosing his job afterwards, etc. ?

There are so many questions in this report. He might has lost situational awareness at all ?

I agree with your comment that his inexperience in this particular flight was contributing. Another factor might have been his previous IFR training with this Captain as a flight instructor while in flight school. He probably felt that he can't interfere with his former instructor sice he was the person training him earlier...:confused:

[Few Cloudy]

One point which has only been skated over on this thread, though well documented on the thread which was here just after the crash is that RW 28 had been used for years as a VOR APP. There was never a problem because it was only used when the Tailwind or Crosswind for the southern runways was out of limits.

You always had a beefy headwind so that that glidepath was never a problem to keep.

On the night in question the runway was being used on one of the first occasions since the concession to the Germans had been made and not only didn't it have a roaring Headwind, it didn't have any headwind at all - even, if memory serves a slight X/TW drift!

That makes this approach an entirely different animal and as one contributor wrote last time, it needs a LOT of planning and understanding. It actually needs a lot of thought at home, before you even get to the airport.

What happened here? Just look at the approach briefing... First time they briefed for an ILS approach and let the speed run away (here the FO caught it in time and spoke up) then, when they were unexpectedly given 28, tried to make a quicky briefing. I admit I have been guilty of this - but how fateful was it on this particular night - confident of Just Another 28 approach and then getting into an untried situation?

Now even the best among us would be hard tried here. What I hope is that at some point (there were a few possible "gates" on the way down) a decision to Go Around would be made, however.

The FO whispered "two four"as they went through that fateful altitude and the Captain said quietly to himself "Go Around?" a couple of seconds before he finally went for it and another second or so before they hit.

No matter whom we blame, let's learn from this and be rigid in our procedures and decisions at minimum altitude. It is after all your @#se too...

[golfyankeesierra]

One thing that is really outstanding is that oil indicator installed upside down. That is a sign of general slopiness and I cannot see how a professional crew can accept that
According to the Report last work was done on 6 nov, 18 days earlier! This was not the only crew that accepted it...... that makes it a safety-culture issue.

[alf5071h]

GYS Re incorrect instrument installation; not so much a safety-culture issue as another example of human error. First one of installation and second of crew perception.

But I only speak from experience; 4 sectors with st by instruments interchanged and I never noticed (nor did P2). Major investigation as to how such an installation error could occur, form, fit, wiring etc. My error? It’s the way that I am wired, like most pilots I hope.

I think therefore I am.
I think?

To err is human, I am human.
I think?

I think, I err.

[golfyankeesierra]

Alf, you're absolutely right. You, I , we all err.
That's why I will not criticise the accident crew for missing (not accepting!) the inverted oil indicator.
However, if the thing had been in the plane for eighteen days, chances are that at least some pilots must have seen it, and apparently didnot object. And that is more then an individual error.

[694c]

alf-
talking about inverted/standby instuments how about this one that I was recently confronted with?
http://www.airliners.net/open.file/191456/L/

[arcniz]

Few Cloudy's point is well taken - about 28 being used mostly as a relief approach during periodic high westerly winds at ZRH.

I can remember one occasion - quite a while back - when a DC-3 landed on 28 in such stiff winds that it could not lower the tailwheel into ground contact. It tarried on the runway, brakes on and tail still flying (with some stabilizing power) until a crew of wing-walkers (or tail sitters) could be gathered to give them a margin of safety for taxiing off the point of the gale.

In those days, short and medium-haul non-heavy jets used 28 extensively during daytime operations, taking advantage of the short taxi to the terminal. But the relatively shorter length of 28 and the close proximity of old Kloten village to the threshold was a point of sensitivity which moved usage more toward the north-south runways as volume grew.

[320DRIVER]

694c, I guess you've never flown an aircraft cos if you had looked closely all that was wrong in that case was that the gyro had just toppled and just needed caging to bring it back to the correct attitude... happens if the aircraft has been depowered for a while.

The slip indicator is correctly located at the bottom of the STBY ATT so this is not a case of bad installation.

[safetypee]

Few Cloudy
‘Why 28’: Good points, but also there was no thought of using a timed approach or pre calculating the required vertical speed; both of which require knowledge, thus awareness of groundspeed. Are we forgetting the basics due to ‘ILS’ laziness?

[694c]

320driver - don't worry, only a joke. Well spotted anyway. Actually there is something wrong: in the given configuration the warning flag should be visible on the standby horizon. Now back to the serious business...

Three things disappointed me in the accident report:

1/ The reference to the inverted No.1 oil instrument without any further investigation or explanation.

It's as though this was a piece of dirt thrown in to make one think "yeah, ****e maintenance, cr@p pilots, not at all Swiss-watchmaker-like to have clocks and gauges upside down". I guess it went something like this: the original failure was on the No.2 engine oil indication; the only spare was an older item. If you look at the illustration on page 157 of the report you can see that this was a different instrument, probably with different wiring connections, and it fouled the others on being slid into the recess, the only solution was to invert No.1 gauge. The scales for temperature and pressure have green arcs so it's easy to see at a glance if all is normal even when upside down; quantity might require a closer look but it's not an important parameter in the short term. I would consider this an acceptable fix until the correct spare part became available.

2/ The glib statement that 'The accident was only survivable by chance'.

I saw one of the survivors interviewed on television on the day of publication and he was deeply insulted by this remark. He'd moved aft from his originally assigned seat to avoid disturbance from an African-American pop singer (ex La Bouche) and her entourage and fortunately registered that the closest exits were now behind him. After impact he was hanging upside down amongst twisted metal and branches with an inferno in front. He managed to get out by the remains of the aft galley and then helped other passengers. I would say that the accident was survivable thanks to two important points: the strength of construction of the Avro RJ and the incredible initiative and willpower to survive shown by those passengers and crew who were not immediately incapacitated. This should have been recognised.

3/ The omission of a full cockpit voice recorder transcript.

Only edited highlights were presented, which gave one the impression that the investigators only released those parts that suited their conclusions. It's usual to provide a full transcript with timeline that includes all that was recorded, including coughs, whistles, rustling paper etc.. The recording from the Korean 747 at Guam (another NPA disaster) is fascinating in that it does just this; throughout the entire approach the Captain was adjusting his seat electrically - probably a nervous reaction - it provides an interesting insight into the atmosphere in the cockpit during those final minutes.

[jetjackel]

Thanks for the info Spuds, sounds like Zurich will finally upgrade to international standards.

If there is not politics envolved, why is the substandard apporach being used consistantly when better facillities are available, especially in lousy wx? Like I said before, something ain't right.

[TopBunk]

694c

Actually there is something wrong: in the given configuration the warning flag should be visible on the standby horizon.
Again you show a lack of knowledge, the fail/warning flag normally only appears if the power supply or instrument has failed.

In this case neither has happened, it just hasn't be preflighted and re-erected.

[Man Flex]

FOs speaking up

"Interested in the "FOs must speak up" inputs. What if (and this has happened to me with low time FOs.... they speak up in this way to say really dumb things ? or are just wrong ? If this happens more than once or twice with a particular FO (and it has) there is a natural tendency, if under pressure, to disregard further inputs. When they speak up they not only have to be right, but to have been right in the past ."

Did he actually write that?

So, the F/O should only speak up if

a) he isn't going to say something really dumb and

b) only if he is right and

c) has been right in the past!

I am lost for words...

[Spuds McKenzie]

jetjackel,

Sorry, I don't get your question. Just to reiterate: Politics is heavily involved, and the "substandard" approaches are not being used consistently, only during the times mentioned in one of my previous posts. Besides, the wind at 4000ft can be quite different from the surface wind, which can lead to the situation that pilots report strong tailwind on, let's say, ILS 14, but the surface wind is in fact 190/5 (happened recently, when for this very reason an A320 went around on 14, and landing RWY had to be changed to 28). Also, fog patches in the approach path on a VOR/DME APP can only be "detected" by pilots reports, leading to the situation that the first aircraft to perform such an approach has to execute a go around, because the RWY is not visible, although the ATIS states a visibility of 4500m or more. Only then ATC is aware, that in fact, a VOR/DME APP is not suitable. Now, in a "normal" environment, ILS approaches would be used if there's the slightest indication, that for a VOR/DME APP conditions could be too marginal.
However, since the German restrictions have to be strictly followed, and the exceptions are specifically defined (wx, emergencies and others), ATC in ZRH has to inform the German authorities about the reason, every time those restrictions can't be complied with.

[694c]

Yes topbunk you're probably right, I can't remember how it was, it's an old picture and since the accident at Halifax the aircraft have been fitted with brighter EFIS type standby instruments with different warnings.

[safetypee]

649c; ‘no full cockpit voice recorder transcript’ Yes, a full transcript may have given more insight to the crew’s behavior and interaction.

I note an interesting exchange between the crew re ‘air change over’; I assume APU air for air conditioning replacing engine air. However, from my understanding of the RJ100:
1. You are allowed to land with engine air on.
2. You cannot use APU air with airframe anti icing on, which presumably it should have been in the conditions at that time.

Thus for ‘2’ there would have been distracting alerts due to air low pressure, air conditioning, etc. What did the Capt imply by “air change over” – commander: “ Mache!” ‘leave it’, ignore them? If so then this may have been the first time that the P2 had encountered this situation and thus would be puzzling as to why alerts are ignored. Furthermore, this situation could reinforce the potential ‘Capt / Student’ interaction; the Capt knows so best – press-on.

Any RJ100 operators able to comment / confirm?

[AN2 Driver]

Safetypee,

((What did the Capt imply by “air change over” – commander: “ Mache!” ‘leave it’, ignore them?))

"Mache" is Swiss German for "Do it".

Best regards
AN2 Driver

[White Knight]

Been over a year since I flew it, but the air changeover isn't complicated really.

Something like airframe anti ice off, APU air on and engine air off. You can land with the engine air on but not if the engine anti-ice is also on - or something would flash at you, memory is a bit hazy though.

Whatever else, this guy shouldn;t have been let loose as a pilot by the sounds of it.....

[safetypee]

Thanks AN2 Driver, but then isn’t the point even more relevant? If the SOP required change air over (yet unnecessary) why should P2 query the procedure? Was he confused because anti icing was already on and changing over the air supply would be an incorrect selection? It has not been reported if airframe anti icing remained on or was selected off; with anti icing on then distracting alerts would be given and remain on, with anti icing off the P2 may have been concerned about continued flight in icing conditions. Or, was an alternative procedure expected when in icing conditions where air changeover was to be made on short finals? Whichever of these scenarios applies they add to crew workload, potential for confusion, and give another reason why P2 could have been out of the loop.

The front cover of their report states “Within 30 days after receipt of the investigation report, any person giving proof of a well-founded interest in the investigation result may request the report to be examined by the Review Board (Eidg. Flug-unfallkommission – EFUK) for completeness and conclusiveness.”
Thus for those who have concerns over this accident or the current situation at Zurich, then instead of writing to the Swiss CAA, e-mail this thread to the BFU [email protected].

There appears to be many ‘well-founded interests’ in this thread.

[Few Cloudy]

Man Flex,

I guess your post referred to that of Air Fix?

Well of course, there is only one answer - the guy MUST speak up.

Let me look back at some incidents in my past - Captain takes off in Lisbon without the checklist being complete - Captain lands looooooong in Johanneburg and nearly runs out of concrete - Captain takes over the RT and talks French to get a short approach in Nice, forgets to fly and I end up doing the flying, while he does the RT.

What did I say? I did nothing but think to myself and watch. Am I proud of that? You bet I am not. I am only here by luck on that showing! And I changed. I started saying too much - started annoying Captains by over inputting. That is much safer but leads to a tense cockpit atmosphere. After a while I hit the happy medium - fair but with definite limits.

Here is a young FO with a senior Captain. In many ways he is like me all those years ago. He has paid the price. This is a critical matter - probably the most important matter in the whole of CRM teaching. Both these guys had done the CRM course - heard the good words and nodded their heads. It takes two to get it working, however.

When I was in Japan I had a nice easy time as a Captain because there was very little criticism from the right hand seat. Nice and easy but not safe. Those of us foreigners there spent a lot of time opening doors and waiting for the FO to walk through and drinking beer with them so that when the chips were really down - those guys would speakup.

The pattern of dominance and submission must be broken. I don't want to write that rude word again but your's is at stake....

[jetjackel]

Didn't ask a question Spuds, just relating my experience, with Runway 28 when I was based out of Zurich with Crossair. Numerous occassions when I was forced to use 28 in "marginal" conditions with direct crosswinds. Also remember using the 28 approach to circle to land. Never did figure that one out.

[alf5071h]

An earlier post / theme suggested the need for more equality in investigating and reporting on accidents. Here is a further example within this accident; first I quote from Dr Rob Lee Former Director, Australian Bureau of Air Safety Investigation, BASI.
Human factors in an investigation must be subject to the same rules of evidence as all other elements of the investigation.In the Crossair accident when comparing the investigation into the aircraft with that of the crew there is an inequality in the evidence. For the aircraft, the evidence showed that it had not failed and that the particular airframe did not suffer more faults or failures than similar aircraft in the operator’s fleet (and no doubt all fleets).

However, whilst the evidence did indicate that the crew failed with respect to the standard of operations during the accident flight, there was no evidence on which to calibrate their behaviour with respect to other pilots in the same operation, or more generally against a wider range of pilots. There was historical evidence where previously individuals had exhibited failings and, which unlike an aircraft, had not been rectified. Yet how many of us in the industry have historical failings, or more seriously, residual weakness that when under strain may also fail?

Therefore, it is unfair criticise the crew without any comparison of their behaviour against known standards. Many contributors to this thread may have judged the crew against their own standards, their personal perceptions, those of others, or the expectations of the industry. Whereas in fact few people actually know what the standard pilot is, or how they as individuals relate to pilots in other operations, particularly when under the strain of complicated operations and surrounded by weak defences.

The nub of the problem is that while there are rules for the design, construction, and maintenance of aircraft, there are few if any that apply to humans, particularly pilots. Yes well done BFU to tackle human factors, but without the necessary tools or evidence, the conclusions on crew behaviour should have been presented with many caveats.

This crew have been found guilty in their absence. Actually it was the inaction of the aviation system in which they operated that condemned them by failing to trap error, support them, and provide the highest standards of infrastructure. The crew have paid for a costly mistake; their names should not suffer further as their last lesson still has to be learnt by us all. The lesson would be all the stronger and easier to learn with a balanced presentation of the evidence with respect to the industry at large.

Again from Rob Lee:
To achieve progress in air safety investigation, every accident and incident, no matter how minor, must be considered as a failure of the system and not simply as the failure of a person, or people, even though human errors or violations will almost certainly be involved in the occurrence.
Human error is inevitable… We have to accept this fact and design systems which are error tolerant. We have to manage errors and violations, abandon the ‘blame and train’ philosophy, create a just organizational culture where people are encouraged to report errors. A culture in which intentional malicious violations are not tolerated, but the reasons for routine violations are investigated and rectified.

[ettore]

Back to the sequence of events, as published by ASW less than three weeks after the crash. Item at 10:04 is pretty much telling... :bored:


Sequence of Events All times local

Time : 9:01 p.m.
Item: Crossair Flight 3597 departs Berlin's Tegel airport for Zurich. Captain was the pilot flying (PF)

Time : 9:42
Item: Aircraft cleared to descent to 16,000 ft. from 24,000 ft. Captain gives expected ILS approach briefing to Zurich's Runway 14.

Time : 9:48
Item: Control transferred to Zurich Arrival. Crew informed of VOR/DME approach to Runway 28 and instructed to hold at RILAX.

Time : 9:52
Item: Captain gives brief for VOR/DME approach, stating minimum descent altitude was 2,390 feet and radar altimeter would be set at 300 ft. above ground level.

Time : 9:54
Item: Crew crosschecks altimeters and they are set correctly.

Time : 9:58
Item: Flight 3597 cleared for approach to R28 and instructed to reduce speed to 180 knots.

Time : 10:03
Item: Aircraft transferred to Zurich Aerodrome Control. At this point, the aircraft was between 5,000 ft. and 4,000 ft., and descending in a right turn.

The minimum safe altitude on the approach chart is 5,000 feet, suggesting that the airplane may have been 1,000 feet lower than it should have been at this point. During about the turn the captain tells the first officer he has groun contact (see the ground).

Time : 10:04
Item: The pilot of Crossair Saab 2000 twin-turboprop immediately ahead of Flight 3597 reports to ATC that the runway was visible at 2.2 NM from the DME. The minimums on the approach chart are 2.0 NM from the DME and 1.1 NM from the runway threshold. Thus, visibility was only slightly above minimum.

Note, if the Saab pilot only had the runway in sight at 1.3 NM and was still at the required safe altitude above the ground of 974 feet, it would have required a rate of descent to land the aircraft of some 1,700 feet per minute to make a 50 ft. threshold crossing height. That's a real plummet.

Time : 10:05
Item: Flight 3597 reports established on VOR/DME for R28, although the aircraft clearly is slightly south of the radial after its right turn. As aircraft approaches minimum descent altitude, Capt. Lutz comments that he has some ground contact. At 500 ft., altitude alert sounds.

Time : 10:06
Item: Radar altimeter 300 ft. minimum alert sounds, indicating that the aircraft is 600 or more feet too low at this point. ATC issues clearance to land. Just after this transmission ends, Capt. Lutz calls for a go-around and sound of autopilot disconnect is recorded. First Officer Lohrer declares a go-around. One second later, sound of first impact on cockpit voice recorder.

Source: BFU for times, events. Some interpretive comments added to BFU timeline.

[fireflybob]

Interesting posting by ettore in relation to this accident on another thread:-

Track History (http://www.pprune.org/forums/showthread.php?s=&postid=1178789#post1178789post1178789)

[what_goes_up]

Nice posting Ettore

There is just one point not quite right.
The minimum safe altitude on the approach chart is 5,000 feet, suggesting that the airplane may have been 1,000 feet lower than it should have been at this point. During about the turn the captain tells the first officer he has groun contact (see the ground).
Intermediat approach altitude for the VOR/DME approach is 4000ft. You are allowed to leave 5000ft after passing OSDAN fix and that is where the right-turn starts.
Methinks the conclusion of the final part of this APP is clear enough in the report.

Cheers

[ramsrc]

Having read ettore's post one thing here springs to mind.

Note, if the Saab pilot only had the runway in sight at 1.3 NM and was still at the required safe altitude above the ground of 974 feet, it would have required a rate of descent to land the aircraft of some 1,700 feet per minute to make a 50 ft. threshold crossing height. That's a real plummet.

The question is did the pilot of the Saab descend at such a rapid rate?

Of course, we will never know but my point is how often are the written procedures deviated from based on "local knowledge", perceived passenger comfort or "It'll be alright - it has always worked before"?

It has been mentioned previously that descending below the minimum altitude is illegal - but surely, as long as nothing goes wrong it is very difficult to prove. Is it more common than we think and even endemic in some places/ on some approaches?

[safetypee]

The recent posts (ettore & what_goes_up) focused on altitude, but it’s the combination of both range and altitude that is important.

Although the autopilot was coupled to the VOR the Capt was displaying LNAV on the EFIS, thus the main instrument did not show DME range; instead it would have been distance to waypoint. If the 28 runway threshold had been selected as the ‘to’ waypoint then the captain could have been calculating the aircrafts progress with an error of nearly 1 nm (distance from 28 touchdown to KLO VOR). This could account for a low approach up to MDA and add to the Capt’s concern of not seeing the approach lights.

Are all LNAVs approved for approach use; the 146 / RJ has a mixture of equipment?

[AN2 Driver]

Safetypee,

sorry, I would not know any of what you ask me, I merely responded to your query about the Swiss German expression.

The impression I got from the report about this sequence is that they were in a checklist and the FO queried the item from the checklist and got the reply "Do it". If it was not a checklist item, then the FO had some reason to query it at this particular time, and got the answer in the affirmative.

All I can contribute to this.

Best regards
AN2 Driver

[Aviatrix69]

Safetypee,
as far as I know on our a/c of former Crossair we are not allowed to use the LNAV any further than IAF or MSA, whichever is lower. This means in the VOR DME 28 until ZUE (a bit later, as MSA is 4'8), then we have to switch to conventional nav. I also think that the confusion for height over distance has been a result of using a distance-to-waypoint such as threshold 28, which could have been used to anticipate the rate of decsent.

Stefan and I have started together at Crossair. He had the lovliest smile. I wish he had spoken up.

Av

[safetypee]

AN2 Driver and Aviatrix69, thanks for your inputs. There is something that is still not quite correct with the reporting of the approach.

Flight International reporting on the accident focused on the Captain’s ‘deliberate’ action of descending below MDA. I cannot find anything in the report that substantiates a deliberate action. The Captain my have been mistaken in his decision, he may not have realized where he was, or the circumstances were such that he just lost the plot, but not deliberately.

‘Flight’ also reports on the lack of obstacles marked on the approach chart as being a contributor to the accident. How? Obstacle information is usually associated with visual flight; IFR approaches guarantee obstacle clearance.

[Few Cloudy]

Safetypee,

Have you read the CVR transcript? The captain said at 21.06.10, "Two-Four - the Minimum - we have ground contact - we will carry on down for a moment..."

That is surely a deliberate act of going below minimum.

What he did not have in sight, were any of the prescribed visual clues (Threshold lights, approach lights etc. ) listed in the Crossair procedures.

[411A]

Lesson for all here.
During a non-precision approach, should you decide to continue below MDA without the required visual items clearly in sight...is not only illegal, but many times lethal, for you and the folks behind.

[safetypee]

Few Cloudy, but this is my point. The call was ‘ground contact’ but exactly what the Captain had seen is not known. Furthermore, there is a small subpara in JAR-OPS and the operator’s procedures that allows for a something other than the runway or approach lights to qualify as the required visual reference. I understand that the operator, with authority agreement, uses this alternative definition for approaches to at least one airport in their route structure. Hence there is room for ambiguity.

If the Captain had called ‘lights’ instead of ‘ground contact’ there would be little debate that the descent was continuing i.a.w. SOPs, but actually we still would not know what the Captain had seen; could the lights have been the village or a road?
Deliberation is a mental process, thus until we get a recorder for the brain, we are only guessing about judgment and decisions taken at a particular time. When adding fatigue, experiences, and personality it would be even more difficult to conclude with certainty that the Captain deliberately took a course of action.

[694c]

A Dose has resigned as CEO of Swiss. About time too as he and several other former Crossair managers are directly responsible for three of the worst kind of aviation accident: CFIT. (Nassenwil, Bassersdorf, and I include the Saab 2000 that wiped off its undercarriage near Berlin as CFIT). Hopefully they will now all be brought to justice.

Clap!

[finalschecks]

You reap what you sow, what goes around comes around, etc..etc...

[Robert Vesco]

Good riddance :ok:, although I doubt that they can keep the momentum going... :E

[Few Cloudy]

The reason Dose has officially given for his resignation is that the board has discerned that some legal action may be taken against him relating to just this crash. Up until now no charges have been levelled by the authorities but it seems to be expected.

The board feels that the stress would be detrimental to his continuing in the post and he agrees.

The big Dutchman now has two jobs until a new CEO is found...

[Danou_71]

Just heard last night on TV that, Andre dose gave his resignation as Swiss's CEO!
It seams to me that he was pushed to take this decision. Now is it good or bad for the company itself, this is the question!
-They still don't have their credit.
-They will face big problems soon due to the negotiations for a new CLA for its pilots.
-And there is a big problem for the trainning for the charter A320. For info the charter is to be flown by ex- Crossair pilots(with ex-CRX salaries...) but the trainning is done in-house by ex-Swissair instructors! See the point?;)

Any comment from the pilots involved would be great.

D-71

[Robert Vesco]

The accident report is just a tool. Behind the screens it's all politics. The 'coup d'etat' is is now complete. Soon (guess who the new CEO will be ;) ) Swissair/Aeropers will be in complete control of Crossair.

Let's hope that they can enjoy it before it goes bankrupt again! :p

[ettore]

Indeed, Robert, the Bassedorf crash is an excuse for Dose dismissal. The fact is that the famous credit facility he so often announced as being « almost undersigned » will not come. His credibility comes to zero not because security but because of the Swiss business going down the drain.

Swiss cannot achieve a turnaround alone. Since no money will come from the banks nor from the government, the only option left open is to have a foreign airline buying a stake and refinancing the business. And, I swear, this is going to happen.

Why ?

A. - SWISS is relatively fit for a takeover :
A1. -Swiss restructuring is not good enough for a turn-around but is doing well above budget, making Swiss cheaper to invest in,
A2. Loss making « Political routes » are now flown on ACMI by third parties a new Swiss could drop anytime,
A3. Code-sharing on other important routes, such as GVA-LDN, grants more flexibility as to a further restructuring,
A4. Always more internal services are being outsourced both to reduce fix-costs and gain more flexibility,
A5. Five Saab 2000 are also externalised to Crossair Europe (EQ), a full subsidiary of Swiss flying with a French AOC which could very well and easily be spun-off,
A6. financing for existing A/C orders is secured, leaving little room for bad surprises and encouraging builders and lessors to keep Swiss flying.

B. - SWISS has no other choice but to open its equity to another airline :
B1. As mentionned before, Swiss has nothing more left to garantee a new credit.
B2. As seen in January, existing share holders are not ready to invest a penny more,
B3. The Swiss governement said again it will not pay again for Swiss,
B4. Share holders (including the State, the main one) agreed not to sell their shares until August 31st. Among them, the private industries will drop their Swiss shares on Sept. 1st.
B5. The very result is that Swiss can and must open its capital to a foreign company/holder before.

C. - There are Majors out there interested in keeping Swiss flying :
C1. AA has invested so much management capacity and money in reaching and preserving through the Swissair grounding a very good code-share agreement with the former Swissir that it won’t let it go like that,
C2. BA made a very good deal with Swiss in granting it a 50m loan in exchange of 8 paires of slots in Heathrow and, a.o., the GVA-LDN route, that it would be foolish to leave this protected market share open to any rival.
C3. Star Alliance controls most of the East european market. Oneworld’s members AA and BA are interested in keeping a small hub as far East as possible to get their share of the cake.
C4. AF is too busy with KLM to undertake anything else and can only hope that Aeroflot will land, as expected, with SkyTeam. But Af and SkyTeam are certainly not unhappy if oneworld, together with Swiss, can contain Lufthansa and Star Alliance on an already highly competitive continental market.

Wishfull thinking ? I’m ready to bet a deal will be struck until August 31st.

[alf5071h]

Those who criticize the CEO should reflect that like he, they too are only human. Are you working in a blame free (a ‘just’ or tolerant) environment? Whilst at the workface we have CRM (cockpit/crew resource management), but at the management level CRM is corporate resource management. Would those in today’s operating ranks who aspire to become senior management have done any better? For those who criticize from within the airline or industry; what did you do to prevent the accident, what did you know of the underlying circumstances, what safety reports were filed, etc, etc. This was an ‘industry’ accident, the result of which identified many issues that we must all learn from.

New people in an organisation, airline, national authority, or government, would not necessarily provide an instant resolution to the problems, particularly if the core issues are systemic or cultural (organisation). It is the individuals within an airline / organisation that form the organisation, and they create and operate their system. If the CEOs departure was due to the accident, then what other resignations can we expect from the authority or the governments involved?

[TvB]

:mad:

Long overdue step!!! In good old days, where people took personal responsibility especially when people got killed, Dose and his gang were ready to step down already after the first CRX accident. His further continued regime and later becoming CEO of what was left of SWISSAIR was constantly built on lies, inside the company and to the public. History teaches: such people are dangerous, if they are in power! - Regardless if they are politicians or running safety sensitive businesses like an airline.

I know from many conversation I had in the past with ex-CRX pilots and staff that they constantly raised their concerns about the safety culture in the company. May I remind everybody here that there have been many, for my taste ‘too many’ pilots, who courageously formulated what was wrong among the company culture under Mr. Dose’s and Mr. Moritz Suter’s (sorry, you have to call it:) l’etat ce moi - rulings. These colleagues of yours did thereby practiced their responsibility for the lives of others, and let’s not forget the ones of their other crewmembers and other entrusted lives. – The very same people, - and I know quite some of them personally now for years -, who were responsible enough to speak out loud were heavily bashed by exactly this Mr. Dose and his 'praetorians' (strategically placed into all key positions of former CROSSAIR). They were threatened, de-ranked, suspended, killed at simulator-sessions, and fired. Remember that in nice and clean Swiss even a president of the union and his speaker can get fired, because they dare to speak out loud what everybody saw would sooner or later lead into a disaster, were you loose a perfectly fine airplane and a bunch of innocent people. Nevertheless they stood up, even in public when all other ways of communication did fail, and clearly spoke out their warnings about another imminent, hopefully not fatal, event. Two fatal accidents followed.

The sad thing is that Dose was a pilot himself and knows what it means to have at least human conditions while mastering a serious task on a day by day basis: safety.

The good thing is that he now might face for the first time a serious investigation and there is a chance the outcome might even lead to a conviction. Some more heads may hopefully roll in the wake of this.

The second sad thing is that we face similar discrepancies and other negative communalities with situations such as within old CROSSAIR and SWISSAIR with many other companies out there, and with too many its right 11’59’59. Everybody should watch out there, and specially if safety-culture is merely a synonym within the small print
of the corporate id.
:{

[Danou_71]

A.D.'s departure is more politically than a safety problem, as he was one last ex-CRX with some kind of power. He even tried to please Aeropers, but they wanted his head since the first day of Swiss. Actually Aeropers and Kapers started a while ago a petition to request the resignation of Dose, which was finally cancelled after a few days. But there was already plenty of signatures on it! The crash of the ARJ was just a good excuse at the right time. The failure rate of the charter A320 was brought to the media at the very same time. Once more politics!!! But those who play this game, should be carefull by not sawing off the branch they are sitting on!

D_71

[TvB]

Danou_71

I'm afraid there is not much left to sit on...
:) :E :cool:

[ettore]

Tim,
There are thousand grounds to be upset at the CRX management for the way they endangered the life of their staff and customers, not to mention people on the ground.

But Danou_71 is right: Andre Dose has been eventually fired on totally different issues. Sad to say, but he has not even been fired for the worse he did.

Interestingly, former CRX-President Moritz Suter remains out of reach of the Swiss justice, since (up to now) no causality link have been shown between his policy and the two fatal CRX-crashes in 2000 and 2001.

[TvB]

Ettore,

name it what you want. He was not fired. It is merely a coordinated "step down" in the light of what is happening. Of course Aeropers and others were trying to kick him out of this position. I'm well aware of this. But without this investigation he would be still on the throttles, though his qualifications for flying this bird are more than doubtful. Again, in good old days where moral and ethics were high among this industry and society in general he would have been out already, shortly after Nassenwiel

In regards to MS: well that's what I mean with "clean and nice Switzerland". But maybe if a prosecutor really gets his head into all the mess of 1999 - 2001, Moritz will be called in for questioning as well and depending how many powerful "buddies" of his may or may not protect him further, they might go for him as well.

Unfortunately the prosecution only focusses on the Bassersdorf accident, not on Nassenwiel (Saab 340). - For now... Let's see when they will have sorted it out.

On the other hand I doubt that anybody in CH will really dig out the s :yuk::yuk: t and go for the big shots, who tolerated the situation and are therefore as much responsible as others.

The Swiss have a problem with thruth, especially when it's not a nice one.

I'm aware of last Sonnatgszeitung and other articles, but already back in 2002 I lost my trust into the Swiss media, so what you may read there is only what the public should think. There are no knowledgable and independent investigative journalists in Heidiland, nor will they ever be printed.


:cool:

[ettore]

Let's hope that the FOCA will take a close look at Moritz Suter new project "Hello Airways" he is intending to start in Basel...

As a matter of improving control and supervision, FOCA will hire 60 more people. Just guess where they'll most probably come from... Its starts with an S and ends with an R :E Suter might be well inspired to ask for a French AOC :p

[scrotometer]

just remember all of you perfect pilots that are ex swissair that moritz suter was a product of your system and indeed of the swiss military machine. dose was a protege of suter's.
therefore have a good long hard think about critisizing everything and everyone to do with crossair.
if the swissair system was so fantastic and it's managers so squeaky clean and so good then the rest of the show wouldn't be on it's knees today.
i'm not a great fan of dose but he was given mission impossible to try to fix the situation when the rest of your perfect ex swissair employees were constantly working against him.
stop blaming the crossair people for your demise. switzerland cannot afford your existance. you simply do not make enough money as a company and are too expensive to run.
that is the bottom line my friends.

[middlepath]

why did the swiss ceo had to go alone for the cause of accident now only? can anyone shed light, why not the ops director,chief training pilot and so on whoever is directly linked to the cause.

[Airbubba]

Which accident?

[middlepath]

zrh rwy 28 accident.