Go Back  PPRuNe Forums > Flight Deck Forums > Rumours & News
Reload this Page >

Crossair Bassersdorf Report

Rumours & News Reporting Points that may affect our jobs or lives as professional pilots. Also, items that may be of interest to professional pilots.

Crossair Bassersdorf Report

Old 4th Feb 2004, 21:56
  #21 (permalink)  
 
Join Date: Apr 2000
Location: FL, USA
Posts: 357
Likes: 0
Received 0 Likes on 0 Posts
Angel

Kurtz,

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

Stand by for indignant retorts from all the BA College grads, etc
RRAAMJET is offline  
Old 4th Feb 2004, 23:40
  #22 (permalink)  
 
Join Date: Jul 2003
Location: An Island Province
Posts: 1,252
Likes: 0
Received 0 Likes on 0 Posts
Objective reporting requires equality.

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.
alf5071h is offline  
Old 5th Feb 2004, 00:16
  #23 (permalink)  
 
Join Date: Oct 2003
Location: n/a
Posts: 1,425
Likes: 0
Received 0 Likes on 0 Posts
Based on how the FO learnt at the same flight school as the captain tought any idea as to whether they flew together there?
Daysleeper is offline  
Old 5th Feb 2004, 00:24
  #24 (permalink)  

ex-Tanker
 
Join Date: Apr 2000
Location: Luton Beds UK
Posts: 907
Likes: 0
Received 0 Likes on 0 Posts
Procedures

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.
Few Cloudy is offline  
Old 5th Feb 2004, 00:39
  #25 (permalink)  
 
Join Date: Apr 2002
Location: In the circuit
Posts: 177
Likes: 0
Received 0 Likes on 0 Posts
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
Groundbased is offline  
Old 5th Feb 2004, 00:57
  #26 (permalink)  
 
Join Date: Mar 2003
Location: hamble
Posts: 28
Likes: 0
Received 0 Likes on 0 Posts
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!

Last edited by 694c; 5th Feb 2004 at 01:09.
694c is offline  
Old 5th Feb 2004, 05:19
  #27 (permalink)  
 
Join Date: Aug 2003
Location: Europe
Posts: 49
Likes: 0
Received 0 Likes on 0 Posts
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
vdive is offline  
Old 5th Feb 2004, 22:34
  #28 (permalink)  
 
Join Date: Dec 1999
Location: England
Posts: 144
Likes: 0
Received 0 Likes on 0 Posts
Inexperienced FO's

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.
Stu Bigzorst is offline  
Old 5th Feb 2004, 22:35
  #29 (permalink)  
 
Join Date: Apr 2000
Location: FL, USA
Posts: 357
Likes: 0
Received 0 Likes on 0 Posts
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.
RRAAMJET is offline  
Old 5th Feb 2004, 23:51
  #30 (permalink)  
 
Join Date: Nov 2003
Location: ZRH
Age: 61
Posts: 574
Received 1 Like on 1 Post
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.
AN2 Driver is offline  
Old 6th Feb 2004, 00:06
  #31 (permalink)  
 
Join Date: Jul 2003
Location: An Island Province
Posts: 1,252
Likes: 0
Received 0 Likes on 0 Posts
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.
alf5071h is offline  
Old 6th Feb 2004, 00:26
  #32 (permalink)  
 
Join Date: Aug 2003
Location: UK
Posts: 1
Likes: 0
Received 0 Likes on 0 Posts
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 .
Airfix is offline  
Old 6th Feb 2004, 00:52
  #33 (permalink)  
 
Join Date: Dec 2002
Location: UK
Posts: 2,445
Likes: 0
Received 8 Likes on 4 Posts
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?
safetypee is offline  
Old 6th Feb 2004, 02:48
  #34 (permalink)  

The Original Party Animal
 
Join Date: Dec 2000
Location: Around the corner
Posts: 375
Likes: 0
Received 0 Likes on 0 Posts
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!
Spuds McKenzie is offline  
Old 6th Feb 2004, 03:46
  #35 (permalink)  
 
Join Date: Apr 2000
Location: Zurich Switzerland-not
Posts: 156
Likes: 0
Received 0 Likes on 0 Posts
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.
jetjackel is offline  
Old 6th Feb 2004, 03:48
  #36 (permalink)  
 
Join Date: Jan 1999
Location: Europe
Posts: 341
Likes: 0
Received 0 Likes on 0 Posts
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.
320DRIVER is offline  
Old 6th Feb 2004, 03:50
  #37 (permalink)  
 
Join Date: Jul 2003
Location: An Island Province
Posts: 1,252
Likes: 0
Received 0 Likes on 0 Posts
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?

Last edited by alf5071h; 6th Feb 2004 at 04:35.
alf5071h is offline  
Old 6th Feb 2004, 04:16
  #38 (permalink)  

The Original Party Animal
 
Join Date: Dec 2000
Location: Around the corner
Posts: 375
Likes: 0
Received 0 Likes on 0 Posts
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.
Spuds McKenzie is offline  
Old 6th Feb 2004, 05:13
  #39 (permalink)  
 
Join Date: Dec 2000
Location: on the golf course (Covid permitting)
Posts: 2,130
Likes: 0
Received 0 Likes on 0 Posts
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.
TopBunk is offline  
Old 6th Feb 2004, 05:30
  #40 (permalink)  
 
Join Date: Apr 2000
Location: Zurich Switzerland-not
Posts: 156
Likes: 0
Received 0 Likes on 0 Posts
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.
jetjackel is offline  

Thread Tools
Search this Thread

Contact Us - Archive - Advertising - Cookie Policy - Privacy Statement - Terms of Service

Copyright © 2024 MH Sub I, LLC dba Internet Brands. All rights reserved. Use of this site indicates your consent to the Terms of Use.