Crossair Bassersdorf Report
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FOs speaking up
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...
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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.
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.
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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.
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?
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?
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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.....
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.....
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.
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.
ex-Tanker
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Speaking Up
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....
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....
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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.
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.
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:
Human factors in an investigation must be subject to the same rules of evidence as all other elements of the investigation.
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.
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.
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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... 
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.
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.
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Nice posting Ettore
There is just one point not quite right.
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
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).
Methinks the conclusion of the final part of this APP is clear enough in the report.
Cheers
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Having read ettore's post one thing here springs to mind.
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?
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.
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?
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?
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?
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
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
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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
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
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.
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.
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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.
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.
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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.
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.