Crossair Flight 850 accident, 10 July 2002

[Super VC-10]

Original thread is closed http://www.pprune.org/rumours-news/59336-swiss-makes-emergency-landing-germany.html

The BFU released their final report (in German) into the accident on 1 October 2010, over 8 years after the accident.

http://www.bfu-web.de/cln_005/nn_223970/DE/Publikationen/Untersuchungsberichte/2002/Bericht__02__AX002__Saab2000__Werneuchen,templateId=raw,prop erty=publicationFile.pdf/Bericht_02_AX002_Saab2000_Werneuchen.pdf

Crossair Flight 850 - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Crossair_Flight_850)

[hetfield]

Eight years only, ehrrm....

[40KTSOFFOG]

Link to accident report in english: -

http://www.bfu-web.de/cln_005/nn_226462/EN/Publications/Investigation_20Report/2002/Report__02__AX002__Saab2000__Werneuchen,templateId=raw,prope rty=publicationFile.pdf/Report_02_AX002_Saab2000_Werneuchen.pdf

[reverserunlocked]

An interesting read, and a true display of the holes in the cheese lining up.

[DCS99]

I'd be interested to hear the opinion of US posters - especially how the dispatcher system over there might have handled this one.

[BRE]

From reading the BFA report, I got the impression that the pilots were blissfully unaware both of the front as well as what airports were below them.

They were holding over Lübeck (which is serviced by Ryanair), and the whole area to the north and east of Hamburg is littered with aerodromes that can handle a regional airliner, but they decided to go south-west, towards the front. When that failed, it seems the only other major city they could think of was Berlin.

[Super VC-10]

40KTS, thanks for the English language report link. :ok:

[misd-agin]

DCS99 - Preflight we have links to worldwide weather. Sat, IR Sat, radar(if radar coverage), forecast hazardous wx areas, PIREPS, etc, etc.

Enroute - In ACARS coverage we can get current and forecast weather. Selecting 'area weather' for a specific airport gives us the current weather for several nearby airports.

Enroute - Dispatch has an automated system that sends SIGMETS/AIRMETS to aircraft in the same ATC center's airspace and the adjacent center's airspace. Eg. if you're in NYC Center you'll get warnings for Toronto, BOS, and Washington Center.

We have the capability to send text messages to dispatch while in ACARS coverage.

Dispatch will ususally send us updated information about the location of lines of weather or weather at destinations or alternates. Usually, but not guaranteed. Sometimes it takes a direct request for information to generate a response.

Based on the flight diverting, along with holding with significant weather in the area, our dispatch system would have been in contact with a flight in similar circumstances. Typically prior to the divert decision.

It's been my experience, and practice, to have early engagement with dispatch - "in the event we go around our plan is ABC. Do you agree?"(or similar type communication). Once the decision to divert is made the only contact dispatch would need to make is if the preplanned divert is no longer appropriate.

The workload is very high during a divert, especially in congested airspace. Having an agreed upon plan prior to the divert is important. However, sometimes circumstances require last minute, unplanned, diverts - "that's what you get the big bucks for" (US pilot phrase) :ok:

[EDDNHopper]

BRE,

this is, for me, indeed one of the crucial aspects (or holes in the Swiss cheese):

"After the aborted approach to Hamburg and their entry into the LUB Lübeck holding pattern, the next task was to reach a decision upon how the flight should continue. If there could be no landing at the original declared destination, a diversion to a predetermined alternate airport is a standard operating procedure. Because Bremen was behind the weather front and the crew was not prepared to penetrate the front or fly around the frontal area, the decision to divert to the second alternate – Hannover, which by that time was also behind the cold front – is not understandable." (BFU, p. 39)

After this initial and maybe flawed decision (and I use "flawed" with extreme caution here as I am not in a position whatsoever to make judgements), and once on their way to Berlin, we have to consider this:

"At this time, their weather radar indicated that the Berlin area seen in their screen was as yet unaffected by the approaching front, and requested an approach to Berlin-Tegel. At this time, no further options were discussed. The controller gave clearance for the flight to Berlin-Tegel.
At 2015 hrs the crew monitored the ATIS broadcast for Berlin Tegel; this supported their decision of two minutes earlier to divert to Berlin Tegel. Information Delta timed at 1950 hrs gave the impression that the prevailing weather at the airport was very good (CAVOK). The NOSIG Trend suggested that the weather conditions were stable. The BFU holds the view that the crew’s estimate was understandable." (p. 37)

I find that last remark crucial. Once they had made the decision to head for Berlin they were supported in their view that this was the right, and appropriate, choice, rather than look for, quote BRE, littered "aerodromes that can handle a regional airliner". Understandable. (?)

[Iron Duck]

They were in a holding pattern over Lübeck, which is quite close to Hamburg. I haven't seen mention of the weather at Lübeck at the time - was an approach and landing there feasible?

If so, why did the controller not suggest a landing at Lübeck?, It's not clear from the report that the crew were aware that they were dealing with a front rather than isolated convection, but the controller should have been, and should have known that both Bremen and Hannover were behind the front.

[EDDNHopper]

Iron Duck,

the report has this on p. 16:

Lübeck Regional Airport
Until 1950 hrs the cloud cover was 7-7 oktas cumulonimbus without thunder activity, with the base at about 5,000 ft AGL. The front did not reach the airport until between 2010 hrs and 2020 hrs. There was heavy rain with gusts reaching nearly 50 kt.
The METAR reports read:
EDHL 101750Z(19:50 Uhr) 30015KT 9999 SCT019 SCT035C BKN050 19/16 Q1005 ATIS Z=
EDHL 101820Z(20:20 Uhr) 26032G48KT 3000 9999 +TSSHRA BKN009CB 13/12 Q1007 ATIS A=

May we interpret what I highlighted in green as BFU asking the same question as you: Why didn't they land there or why were they not advised to do so?

[misd-agin]

Why is diverting to an airport on the other side of the front "not understandable"?

It's a great option IF you can get through the front. That's the judgement call - are there gaps or is the line solid?

[Doors to Automatic]

In the English version of the report there is a map of their position with the radar image superimposed. At that point they were almost in the clear behind the front, so I wonder what made them fly East back through the front to be just ahead of it in the Berlin area as it arrived!

[misd-agin]

Doors - perhaps they were trying to get through the front to approach Hamburg from the 'dry' side? (pdf page 17)

The second weather image seems to indicate that Luebeck might have been in the clear. Also based on that weather image I wonder if the weather was better if they had turned north towards Copenhagen?

[threemiles]

They wanted to go to a place where ground service facilities endorsed by Crossair were available. That ruled out everything else than Hamburg, Hannover and Berlin. Narrow view.

[EDDNHopper]

Doors,

just to clarify: they were not flying back east. The image shows their position when radar vectoring began, initial approach to Hamburg, not after missed approach.

[Speedwinner]

2500hrs total time and a captain. also chief ground instructor. Maybe a little lack of experience??:ugh:

[HeadingSouth]

having read the report and your comments shows that there wasn't an easy way out of the situation they were in.
there are several opinions of all of you who have read the report. I would have done this, I would have done that.
This alone shows that there were different possibilities, Werneuchen maybe not the ideal one. The real problem IMHO lies more in the CRM when they have been informed about the earth wall, the captain on the other hand tells the FO to "land wherever he wants".
To err around in the skies is one issue, to ignore the messages from the controller is another one. The second one could have been disastrous, the first one probably not.

Over to you more experienced guys...

[PT6A]

Going back to a point made in this thread, in Europe their is no requirement for a dispatcher. It would be interesting to see what the effect would of been of the OCC tracking their flights with almost live weather data. Seeing the bigger picture and providing this to the crew.

ACARS or a company radio network are a great help at times like this.

On a side note Lufthansa are just about to hook up their EFB's to the Internet so they will have live weather information.

All of these things would help, but at the end of the day the PIC had to make a decision - he just needs the right information to do it.

PT6A

[PT6A]

Heading, what I took from the report was that neither ATC or the flight crew understood that this earth wall was there. In fact ATC thought the airport owner were talking about the airport having two runways.

I think the first time anyone in the incident knew about the wall other than the airport owner was when the aircraft hit it.

The factors leasing up o the accident aside, that wall being there along with the markings / lack of hazard warnings and the published charts... Is pretty bad IMO.. I'm sup prised it was the first time it was hit... The pictures from the police helicopter show it was hard to pick out.

PT6A

[Wilton Shagpile]

I don't really get why they piled earth walls up across the runway? They could have just made sure the white crosses were visible and left it at that. Then, they can declare their runway closed but still have it available in an emergency if somebody was in desperate need of it.

[PT6A]

I have a feeling the wall was put their to comply with some local planning ordinance, clearly the implications of such were not very well thought out.

PT6A

[Denti]

The walls were put there to prevent illegal car races that were very common and often lead to injuries and deaths. Mostly done during the night by the local youths. The runway in itself is not closed, it is just shortened considerable.

Remember, there are highways close by without any speed restriction, however there is continuous traffic and races are not possible in that way, especially improvised drag or drift races.

However the airport didn't comply with the required notification about those walls, there was no NOTAM or DFS VFR bulletin about it as far as i know and therefore the ATCO wasn't aware of them.

[Less Hair]

And the runway markings hadn't been changed properly to indicate the displaced threshold. When they were over the numbers they could not see the low wall. However ending up with a fuel emergency like that was the trigger of all the troubles.

[RatherBeFlying]

I can imagine that 2500m of paved runway in an out of the way place is a big temptation to bootleg racers. Doubtless the locals would be more annoyed by tires squealing and engines revving up at 2 am. than by a few a/c movements during the day.

Our glider club is attractive to off road racers as well even though all surfaces are grass -- and vulnerable to getting gouged by energetic maneuvers:mad: We are dependent upon our neighbors to keep an eye and ear out and phone the police when needed.

Likely the insurance company will be looking for recovery of the hull loss and I can see the lawyers for the several implicated parties pointing fingers at everybody else:}

Now if the pilots had had access to the radar picture in the report, I suspect they would have agreed that flying parallel to a CB front in the hope that they would get to an alternate before a CB did is simply a recipe for painting yourself into a corner as your fuel is used up -- and would have looked E or NE for an airport safely well away from the front.

[AN2 Driver]

Actually, reading the report, the person in charge of the Airfield told the ATC guys about the wall and advised them to tell the pilot to be careful, but ATC misunderstood or misinterpreted the phone conversation. The words "displaced threshold" never were used (and technically it isn't displaced but the runway shortened) neither did ATC tell the pilots off the wall but just to "use the eastern part of the runway" which did not make much sense to them in the twilight.

There were also pilots on the ground who watched the approach and tried to call the Crossair plane, but as they had never been given the AFIS Frequency, they never heard them. They certainly would have told them.

Anyhow, putting obstacles like that even on a shortened runway is asking for trouble. What if someone had landed on the opposite end and overrun? Same problem, even if he had known about it. To put an obstacle there, for whatever reason, was not a clever thing.

[Hussar 54]

And it needed 8 ( eight !! ) years for this report ????

Significant as its conclusions may be on the future careers of the crew ( and I wonder whatever happened to these two poor guys ) is it just me who finds it incredible that the BFU took ( I won't say needed ) 8 years.....

Heaven forbid they are required to investigate something like the BA 777 at Heathrow - the crew would have retired to their pensions and all 777's would be either beer cans or gun running in Africa before they'd finished.....

But then again, some Lufty crews I met a few months ago, at the time actually said that the BFU's main purpose in life seems to be to destroy the myth of German efficiency.....

[Misterredmist]

Well at least everybody's skin was saved........ it just goes to show
that a nice clear weather report handed to the crew prior to lift-off
can lead them into a whole load of trouble......

[Lonewolf_50]

Denti:
However the airport didn't comply with the required notification about those walls, there was no NOTAM or DFS VFR bulletin about it as far as i know and therefore the ATCO wasn't aware of them.
Less Hair:

And the runway markings hadn't been changed properly to indicate the displaced threshold. When they were over the numbers they could not see the low wall. However ending up with a fuel emergency like that was the trigger of all the troubles.
Who is accountable for such omissions? The facility, or the agencies who publish charts and terminal information?

I hope that this incident is encapsulated into training program for pilots world wide. It is an extraordinary example of both the Swiss Cheese model, and the "operations at an unfamiliar field" issue that can rise up to smite one.

I've a contact who still does pilot training for the Navy. I'll send him a link to this report. I think it worthy of inclusion in the pilot training / safety programs, specifically the instrument flight training/flight planning, cross country training modules.

This sort of thing could happen to any pilot, flying any kind of mission, when the weather goes sour and getting into the alternate changes from "planned" to "reality."

[BRE]

Repeating that the runway had not been remarked here won't make it truer: according to the BFÜ report, the old markings had been painted over (presumably black), x-markings on the disused part and new markings on the remaining part had been applied. However, the paint had partially worn off to the point where with rain and the poor remaining daylight, from the approach path, the old markings were more visible than the new ones.

On inspection a few months earlier, the local regulator (state, not federal) did not object to the quality of the markings, which was a mistake. Also, using an earth wall rather than a wooden barrier was also not a very bright idea.

The aerodrome chart reproduced in the report looked pretty clear to me as a non-expert. It may not have been drawn according to standards, but with a bit of common sense applied, it was clear enough that onle the last 2/3 of the runway were actually in use.

[krohmie]

The controller in Tegel did not have this (VFR) Aerodrome chart and the crew had the chart not on board or in their FMS.

[krohmie]

However the airport didn't comply with the required notification about those walls, there was no NOTAM or DFS VFR bulletin about it as far as i know and therefore the ATCO wasn't aware of them.This is not an airport. It is a "Sonderlandeplatz" where Prior Permission is Required (PPR).

The runway with the new threshold was published in the german AIP VFR (not availabel in electronic form). The tower in Tegel had no AIP VFR.