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Crossair Bassersdorf Report

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Crossair Bassersdorf Report

Old 6th Feb 2004, 05:38
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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.
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Old 6th Feb 2004, 05:58
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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
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Old 6th Feb 2004, 06:07
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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
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Old 6th Feb 2004, 06:16
  #44 (permalink)  

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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.
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Old 6th Feb 2004, 06:30
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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.

Last edited by alf5071h; 6th Feb 2004 at 17:29.
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Old 6th Feb 2004, 17:43
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Good post and edit alf. A lesson in the importance of good CRM and the failure of threat and error management at all levels.
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Old 6th Feb 2004, 19:21
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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.
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Old 6th Feb 2004, 20:44
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Reason

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
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Old 6th Feb 2004, 21:40
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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...
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Old 7th Feb 2004, 02:12
  #50 (permalink)  

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Exclamation Why 28?

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...
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Old 7th Feb 2004, 04:06
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Re oil indicator

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.
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Old 7th Feb 2004, 04:39
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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.
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Old 7th Feb 2004, 07:08
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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.
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Old 7th Feb 2004, 07:27
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alf-
talking about inverted/standby instuments how about this one that I was recently confronted with?
http://www.airliners.net/open.file/191456/L/
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Old 7th Feb 2004, 17:41
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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.
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Old 7th Feb 2004, 18:47
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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.
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Old 7th Feb 2004, 21:46
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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?
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Old 7th Feb 2004, 23:24
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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.
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Old 7th Feb 2004, 23:40
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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.
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Old 7th Feb 2004, 23:40
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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.
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