Crossair Bassersdorf Report
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Crossair Bassersdorf Report
Don't know if someone has already posted.
It's a heavy report and breath-taking history of the skipper, amongst many other items in here.
RIP to all. Never forget.http://www.bfu.admin.ch/common/pdf/u1793_e
It's a heavy report and breath-taking history of the skipper, amongst many other items in here.
RIP to all. Never forget.http://www.bfu.admin.ch/common/pdf/u1793_e
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From the report
The range of hills with which the aircraft came into contact was entered in the
Swiss AIP. However, this obstacle was missing on approach chart 13-2 of the
Jeppesen route manual, which the flight crew were using.
Swiss AIP. However, this obstacle was missing on approach chart 13-2 of the
Jeppesen route manual, which the flight crew were using.
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Tues "The Australian" Late News
'Overtired' pilot in Swiss crash
By Naomi Koppel in Geneva
February 03, 2004
AN "overtired" pilot who flew too low was the cause of a plane crash that killed 24 people, Swiss investigators concluded today, as justice officials considered whether to prosecute officials of the Swiss national airline.
"The commander deliberately descended below the minimum descent altitude ... without having the required visual contact to the approach lights or the runway," the federal Air Accident Investigation Bureau said in its 161 page report on the November 24, 2001, crash of Crossair Flight CRX3597.
The scheduled flight from Berlin, arriving in rain and snow, crashed into woodland on the approach to Zurich Airport, killing 24 and injuring nine other people.
Among the dead were US singer Melanie Thornton, two of the three members of the pop group Passion Fruit and the dean of Israel's Hebrew University school of medicine. The pilot and co-pilot also died.
The report found that the pilot, who was not identified, had been working for more than 13 hours when the crash occurred, and had exceeded maximum duty times in the two days before the accident as well, meaning that he "would tend to be overtired".
It concluded that the pilot's "ability to concentrate and take appropriate decisions as well as his ability to analyse complex processes were adversely affected by fatigue".
The report also criticised the co-pilot for failing to step in.
Swiss International Air Lines - the new name of Crossair - said in a statement that it followed all national and international safety requirements.
"The highly experienced captain had all the qualifications required for the flight," the company said.
Hansjuerg Mark Wiedmer, spokesman for Switzerland's federal prosecutors office, confirmed that a criminal investigation has been opened, on suspicion of negligent homicide and grievous bodily harm by negligence.
Swiss made no comment except to say that it was "keen to have this case fully clarified."
Investigators concluded that over a long period airline officials "did not make correct assessments of the commander's flying performance. Where weaknesses were perceptible, they did not take the appropriate measures."
Other factors that contributed to the crash included the fact that there was no alarm system on Zurich's runway 28 to warn pilots if they went too low, and the system for measuring visibility at the airport was inappropriate for that runway.
A range of hills over which the plane flew were not marked on the chart the pilots were using, it said.
Swiss said that since the accident it has introduced a new flight safety program covering recruitment, training, checks, workflow and procedures throughout its operations.
Swiss said it has paid compensation to the families of the victims but was still facing lawsuits in Switzerland, Germany and Israel.
===========================================
'Overtired' pilot in Swiss crash
By Naomi Koppel in Geneva
February 03, 2004
AN "overtired" pilot who flew too low was the cause of a plane crash that killed 24 people, Swiss investigators concluded today, as justice officials considered whether to prosecute officials of the Swiss national airline.
"The commander deliberately descended below the minimum descent altitude ... without having the required visual contact to the approach lights or the runway," the federal Air Accident Investigation Bureau said in its 161 page report on the November 24, 2001, crash of Crossair Flight CRX3597.
The scheduled flight from Berlin, arriving in rain and snow, crashed into woodland on the approach to Zurich Airport, killing 24 and injuring nine other people.
Among the dead were US singer Melanie Thornton, two of the three members of the pop group Passion Fruit and the dean of Israel's Hebrew University school of medicine. The pilot and co-pilot also died.
The report found that the pilot, who was not identified, had been working for more than 13 hours when the crash occurred, and had exceeded maximum duty times in the two days before the accident as well, meaning that he "would tend to be overtired".
It concluded that the pilot's "ability to concentrate and take appropriate decisions as well as his ability to analyse complex processes were adversely affected by fatigue".
The report also criticised the co-pilot for failing to step in.
Swiss International Air Lines - the new name of Crossair - said in a statement that it followed all national and international safety requirements.
"The highly experienced captain had all the qualifications required for the flight," the company said.
Hansjuerg Mark Wiedmer, spokesman for Switzerland's federal prosecutors office, confirmed that a criminal investigation has been opened, on suspicion of negligent homicide and grievous bodily harm by negligence.
Swiss made no comment except to say that it was "keen to have this case fully clarified."
Investigators concluded that over a long period airline officials "did not make correct assessments of the commander's flying performance. Where weaknesses were perceptible, they did not take the appropriate measures."
Other factors that contributed to the crash included the fact that there was no alarm system on Zurich's runway 28 to warn pilots if they went too low, and the system for measuring visibility at the airport was inappropriate for that runway.
A range of hills over which the plane flew were not marked on the chart the pilots were using, it said.
Swiss said that since the accident it has introduced a new flight safety program covering recruitment, training, checks, workflow and procedures throughout its operations.
Swiss said it has paid compensation to the families of the victims but was still facing lawsuits in Switzerland, Germany and Israel.
===========================================
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It is interesting to note that there appears to be no recommendation to install an ILS onto 28, it may require a steep slope, or infringe obstacle limits, I don't know. At Stuttgart, prior to them lengthening the runway about 10 years ago, runway 08, as it was then, had an ILS promulgated as not for use, but it sure helped those NDB/DME approaches a lot. Surely something similar could and should be done at ZRH, especially as the late evening arrivals are on 28 as a matter of routine nowadays.
I believe that an ILS is being installed onto 34 now - about time, this place really does need sorting out, safety at ZRH really does appear to be a very poor second relation to the Zurich rich folks.
I believe that an ILS is being installed onto 34 now - about time, this place really does need sorting out, safety at ZRH really does appear to be a very poor second relation to the Zurich rich folks.
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Why Bassersdorf and not Nassenwil
I am surprised that they would come up with the beforementioned "negligent homicide and grievous bodily harm by negligence" in respect to this accident an not the one before.
About a year before crossair had the saab 340 crash at Nassenwil, a case where the prosecution would have much stronger case.
Another question that comes up is the nicely worded but very bold statement:
Shouldn't we interprete that like "We knew he was a flunky but had him pass years and years of LPC/OPC's anyway" ?
Could this be the basis of the prosecutions case?
If this case gets people convicted, I wonder what will happen if the Nassenwil saab 340 crash ever makes it into a swiss courtroom.
About a year before crossair had the saab 340 crash at Nassenwil, a case where the prosecution would have much stronger case.
Another question that comes up is the nicely worded but very bold statement:
Investigators concluded that over a long period airline officials "did not make correct assessments of the commander's flying performance. Where weaknesses were perceptible, they did not take the appropriate measures."
Could this be the basis of the prosecutions case?
If this case gets people convicted, I wonder what will happen if the Nassenwil saab 340 crash ever makes it into a swiss courtroom.
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To put it bluntly, it is shocking. 
Re ILS 34/28, in April LOC 34 will be up and running, followed by GP in October.
ILS 28 will be installed next year.
BTW VOR/DME APP procedures are safe, as long as they are flown correctly...
Re ILS 34/28, in April LOC 34 will be up and running, followed by GP in October.
ILS 28 will be installed next year.
BTW VOR/DME APP procedures are safe, as long as they are flown correctly...
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politically correct
In the report, I couldn't find a mention of why ILS 14 was closed. The vis was not good and aircraft were redirected to a non-precision approach (VOR/DME 28).
The reason is simple: it was late and the rich germans living on the Swiss border don't like overflying jets, even if they enjoy the facilities that Kloten offers. German authorities imposed a night ban overhead German territory: a contributing factor?
In the report, I couldn't find a mention of why ILS 14 was closed. The vis was not good and aircraft were redirected to a non-precision approach (VOR/DME 28).
The reason is simple: it was late and the rich germans living on the Swiss border don't like overflying jets, even if they enjoy the facilities that Kloten offers. German authorities imposed a night ban overhead German territory: a contributing factor?
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Rasta
I was of the impression that it was because the Swiss had over flown Germany about 4x the agreed no. of flights for the last n years? Am I wrong? Was the use of 28 not due to this reason? Why has ZRH not previously installed ILS onto 34? Was it not due to the fact that the approach path took aircraft over prestigious lakeside properties over Lake Zurich?
Please correct me if I'm wrong.
Spuds
All procedures are safe if flown correctly - on this occasion it was not. This raises the question as to what could be done to make it safer - the report would appear to ignore some opportunities - ie an ILS.
This report supresses the real issues re ZRH - the lack of decent instrument approaches to all runways at the expense of safety for the benefit of a a few rich ZRH inhabitants in the city, who for decades have abused the rights of their German neighbours.
I was of the impression that it was because the Swiss had over flown Germany about 4x the agreed no. of flights for the last n years? Am I wrong? Was the use of 28 not due to this reason? Why has ZRH not previously installed ILS onto 34? Was it not due to the fact that the approach path took aircraft over prestigious lakeside properties over Lake Zurich?
Please correct me if I'm wrong.
Spuds
All procedures are safe if flown correctly - on this occasion it was not. This raises the question as to what could be done to make it safer - the report would appear to ignore some opportunities - ie an ILS.
This report supresses the real issues re ZRH - the lack of decent instrument approaches to all runways at the expense of safety for the benefit of a a few rich ZRH inhabitants in the city, who for decades have abused the rights of their German neighbours.
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Holy mackerel...I don't ever like to critique in the aftermath, but in this case I feel compelled.
This must stand as an example of why, if you ever fly with someone you feel to be completely at odds with SOP's or normal safe and prudent aviating, you MUST report it up the chain of command, or even to your Union if necessary. This commander had enough warning flags - nobody seems to have collated and prevented the incidents. You are doing your pax and fellow crew a favour, and perhaps helping out the struggling individual.
In this case I feel a very inexperienced FO was hoodwinked into not intervening. Descent below MDA when not visual is illegal as well as imprudent.
Failing the MD-80 course and having difficulty with the 146? Hmmm....more red flags. These are not, by any measure, difficult aircraft. (The MD-80 is simply archaic and chaotic, but not difficult).
Raising the gear on the ground as a demo in the real aircraft? WTF? That's what sim's are for, if you want to play. Good grief. VFR nav into the wrong country? Helloooo...
How many strikes do you get at Crossair? 3 and out? 4? What?
Now combine the above with fatigue....hello trees.
9 survivors are a testament to the incredible structural strength of the 146.
This is the first time I can be correctly accused of "Monday morning quarterbacking", but to you newcomers out there: don't ever, ever be afraid to query, question and refer those who would appear to be Gods. A policy of no foul should apply. Perhaps 24 souls would still be alive had it occurred here.
No wonder there's a lawsuit pending....
This must stand as an example of why, if you ever fly with someone you feel to be completely at odds with SOP's or normal safe and prudent aviating, you MUST report it up the chain of command, or even to your Union if necessary. This commander had enough warning flags - nobody seems to have collated and prevented the incidents. You are doing your pax and fellow crew a favour, and perhaps helping out the struggling individual.
In this case I feel a very inexperienced FO was hoodwinked into not intervening. Descent below MDA when not visual is illegal as well as imprudent.
Failing the MD-80 course and having difficulty with the 146? Hmmm....more red flags. These are not, by any measure, difficult aircraft. (The MD-80 is simply archaic and chaotic, but not difficult).
Raising the gear on the ground as a demo in the real aircraft? WTF? That's what sim's are for, if you want to play. Good grief. VFR nav into the wrong country? Helloooo...
How many strikes do you get at Crossair? 3 and out? 4? What?
Now combine the above with fatigue....hello trees.
9 survivors are a testament to the incredible structural strength of the 146.
This is the first time I can be correctly accused of "Monday morning quarterbacking", but to you newcomers out there: don't ever, ever be afraid to query, question and refer those who would appear to be Gods. A policy of no foul should apply. Perhaps 24 souls would still be alive had it occurred here.
No wonder there's a lawsuit pending....
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TopBunk,
There was never an agreement with Germany about a maximum number of flights, the agreement was to use RWY16/14 equally, which, as we know, was never complied with.
I agree that the Swiss authorities failed to recognise the demands of the German population in the South.
However, fact is that it wasn't the procedure as such which led to the crash, but non compliance with the procedures by the crew.
An ILS APP reduces the workload for pilots, but doesn't necessarily prevent them from making mistakes (ie the crash of Alitalia flight 404 in Nov. 1990 in ZRH).
This leads to the conclusion, that if you wanted to make flying fail safe you would have to eliminate the human factor, which, as we both (you as a pilot and me as an ATCO) know, is illusory.
The PiC left the minimum altitude without having sufficient visual ground contact, the Copilot failed to correct the PiC, human error, period.
There was never an agreement with Germany about a maximum number of flights, the agreement was to use RWY16/14 equally, which, as we know, was never complied with.
I agree that the Swiss authorities failed to recognise the demands of the German population in the South.
However, fact is that it wasn't the procedure as such which led to the crash, but non compliance with the procedures by the crew.
An ILS APP reduces the workload for pilots, but doesn't necessarily prevent them from making mistakes (ie the crash of Alitalia flight 404 in Nov. 1990 in ZRH).
This leads to the conclusion, that if you wanted to make flying fail safe you would have to eliminate the human factor, which, as we both (you as a pilot and me as an ATCO) know, is illusory.
The PiC left the minimum altitude without having sufficient visual ground contact, the Copilot failed to correct the PiC, human error, period.
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Have to agree with RRAAMJET.
First operated into ZRH in the mid-seventies in an old straight pipe 707, and the approach (as it was then) to 28 was not an easy one, especially with low ceiling/vis, and suspect it isn't any better now.
That ILS for 28 should have been installed long ago.
First operated into ZRH in the mid-seventies in an old straight pipe 707, and the approach (as it was then) to 28 was not an easy one, especially with low ceiling/vis, and suspect it isn't any better now.
That ILS for 28 should have been installed long ago.
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Quote:
'All procedures are safe if flown correctly'
Trouble is non-precision approaches are often not flown correctly.
There's a long and sorry history of aircraft crashes from this kind of approach, and they will continue to happen until every runway has an ILS and every aircraft and airport has the necessary safety filters.
Two such systems could have saved Crossair 3597 from disaster:
Ground radar based automatic approach altitude deviation warning, which should have been installed on all runways at Kloten following the Alitalia crash but was not. It could have been replaced by human monitoring, but the responsible ATC controller had gone home early.
Enhanced GPWS, which had been fitted to most Swissair aircraft at the time of the accident but not to those of Crossair. I remember flying some trial approaches in an A320 simulator following the CRX profile. 'Terrain Terrain' came in about 30 seconds before impact and 'Whoop Whoop Pull Up' about 20 seconds before; enough time for even the mentally incompetent and physically exhausted Captain Lutz to abandon his criminally negligent attempt at a non-precision approach, and for the pathetically submissive First Officer Loehrer to intervene. They have paid the ultimate price for their foolishness, I hope that others who have been found responsible will be prosecuted to the full extent of the law.
'All procedures are safe if flown correctly'
Trouble is non-precision approaches are often not flown correctly.
There's a long and sorry history of aircraft crashes from this kind of approach, and they will continue to happen until every runway has an ILS and every aircraft and airport has the necessary safety filters.
Two such systems could have saved Crossair 3597 from disaster:
Ground radar based automatic approach altitude deviation warning, which should have been installed on all runways at Kloten following the Alitalia crash but was not. It could have been replaced by human monitoring, but the responsible ATC controller had gone home early.
Enhanced GPWS, which had been fitted to most Swissair aircraft at the time of the accident but not to those of Crossair. I remember flying some trial approaches in an A320 simulator following the CRX profile. 'Terrain Terrain' came in about 30 seconds before impact and 'Whoop Whoop Pull Up' about 20 seconds before; enough time for even the mentally incompetent and physically exhausted Captain Lutz to abandon his criminally negligent attempt at a non-precision approach, and for the pathetically submissive First Officer Loehrer to intervene. They have paid the ultimate price for their foolishness, I hope that others who have been found responsible will be prosecuted to the full extent of the law.
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Spuds
I don't disagree with you on much, just approaching it from a different angle - the pilots.
The fact is that at ZRH the local procedures require the VOR28 procedure to be used for political reasons whenever possible after 2000Z (?), in as in this case, often marginal weather conditions. This despite having a CAT3 ILS available. When you fly into ZRH with 28 in use (and a 20kt tailwind on the approach for a 3.7 deg slope) and request ILS 14 due safety, what do you think ATC will say to you? At most places they would accommodate you - not at ZRH - you accept the approach or divert - no choice.
The politicians must decide whether safety or votes come first.
Re the Alitalia crash: as I recall that was (in part) due to the glideslope receiver on the DC9 failing without any fail flags in the central (ie on glideslope) position - ie at least partly technical. Yes, crew procedures should have picked it up, but a bit of a fluke - I have never had a glideslope rxr fail - for it to happen (a) in low ceiling IMC, (b) at ZRH with the terrain, (c) with no fail flag is pretty bl**dy bad luck.
I don't disagree with you on much, just approaching it from a different angle - the pilots.
The fact is that at ZRH the local procedures require the VOR28 procedure to be used for political reasons whenever possible after 2000Z (?), in as in this case, often marginal weather conditions. This despite having a CAT3 ILS available. When you fly into ZRH with 28 in use (and a 20kt tailwind on the approach for a 3.7 deg slope) and request ILS 14 due safety, what do you think ATC will say to you? At most places they would accommodate you - not at ZRH - you accept the approach or divert - no choice.
The politicians must decide whether safety or votes come first.
Re the Alitalia crash: as I recall that was (in part) due to the glideslope receiver on the DC9 failing without any fail flags in the central (ie on glideslope) position - ie at least partly technical. Yes, crew procedures should have picked it up, but a bit of a fluke - I have never had a glideslope rxr fail - for it to happen (a) in low ceiling IMC, (b) at ZRH with the terrain, (c) with no fail flag is pretty bl**dy bad luck.
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694c
I would be very carefull about what you say about the dead pilots, I know they cannot sue you for slander but their estates may be able to. Nor have they been found so in a court. Should criminal proceedings be instigated against others your comments could be seen as predujical.
They have not been named elsewhere on this site I suggest you edit your post.
I would be very carefull about what you say about the dead pilots, I know they cannot sue you for slander but their estates may be able to. Nor have they been found so in a court. Should criminal proceedings be instigated against others your comments could be seen as predujical.
They have not been named elsewhere on this site I suggest you edit your post.
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Aircrew should be able to fly a Vor/dme approach. As it is less precise tha a ILS it has higher minimas. ILS approaches can also become dangerous if you do not stick to the minima's !
Fact remains that noise and environment lobby forces you to fly a less favourable approach in marginal conditions.
Fact remains that noise and environment lobby forces you to fly a less favourable approach in marginal conditions.
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Interesting to note that despite adding all salient factors such as the position of the Sun etc, the report at no stage recognises altimeter temperature error despite ATIS giving ISA-12!
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Topbunk
(Mr Hell here btw)
Re FLT 404, A failed reciever had just been replaced on the aircraft with what turned out to be another failed unit.
Flight crew were an experienced training captain and a very junior f/o.
The ILS reciever failure gave "on glideslope "on the f/o's side and a fly down on the captains when in "split".
There was a cultural issue in play namely that the captain
a) ticked off the f/o for being high on the glide, b) selected from split to ILS 1(captains side.. fly down ... )to make the picure fit,
c) closed the power levers after the f/o initiated a go around after the GPWS kicked in.
From previous comments here in the light of the Crossair accident and indeed the Alitalia 404, the message has to be that if you are a first officer no matter how junior and don't like what you see.. SPEAK UP !!, if you are ignored speak up again, and if you are ignored call go-around.
Harder to do than say, but now consider the implications of not doing so.
Re FLT 404, A failed reciever had just been replaced on the aircraft with what turned out to be another failed unit.
Flight crew were an experienced training captain and a very junior f/o.
The ILS reciever failure gave "on glideslope "on the f/o's side and a fly down on the captains when in "split".
There was a cultural issue in play namely that the captain
a) ticked off the f/o for being high on the glide, b) selected from split to ILS 1(captains side.. fly down ... )to make the picure fit,
c) closed the power levers after the f/o initiated a go around after the GPWS kicked in.
From previous comments here in the light of the Crossair accident and indeed the Alitalia 404, the message has to be that if you are a first officer no matter how junior and don't like what you see.. SPEAK UP !!, if you are ignored speak up again, and if you are ignored call go-around.
Harder to do than say, but now consider the implications of not doing so.
Last edited by Hostie from Hell; 4th Feb 2004 at 17:52.
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Sleeper:
No way will I edit my post.
The information I have given is freely available on the BFU accident report website and in the online editions of Swiss newspapers such as the NZZ.
Captain Lutz deliberately descended below MDA without having visual contact with the runway or its lighting systems, thereby breaking the law.
He also ignored the minimum rest and flight duty regulations.
I suggest that you edit your post for spelling: don't you mean prejudice?
No way will I edit my post.
The information I have given is freely available on the BFU accident report website and in the online editions of Swiss newspapers such as the NZZ.
Captain Lutz deliberately descended below MDA without having visual contact with the runway or its lighting systems, thereby breaking the law.
He also ignored the minimum rest and flight duty regulations.
I suggest that you edit your post for spelling: don't you mean prejudice?
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694C,
I've read the BFU accident report and the pilots' names are not mentioned.
The Captains name has been mentioned in the newspapers, but I still don't think this should be done on Pprune!
And slagging someone off ("I suggest that you edit your post for spelling") who only wants to give you a well meant advice, is off topic and totally inappropriate. We're trying to have a factual discussion on here and comments like yours are utter c
p!
I've read the BFU accident report and the pilots' names are not mentioned.
The Captains name has been mentioned in the newspapers, but I still don't think this should be done on Pprune!
And slagging someone off ("I suggest that you edit your post for spelling") who only wants to give you a well meant advice, is off topic and totally inappropriate. We're trying to have a factual discussion on here and comments like yours are utter c
p!
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I think this accident also draws into question the prudence in including low time and inexperienced FO's into transport category aircraft. (The A320 accident at Bahrain was another that comes to mind).
It is all well and good to encourage junior/inexperienced FO's to speak up, but what experience do they have to draw upon when they have to find the courage to challenge the Captain when things go wrong (that's if they can actually see the problems evolving)?
Experience means ALOT, especially when things start to go pear shaped.
It is all well and good to encourage junior/inexperienced FO's to speak up, but what experience do they have to draw upon when they have to find the courage to challenge the Captain when things go wrong (that's if they can actually see the problems evolving)?
Experience means ALOT, especially when things start to go pear shaped.