Crossair flight 3597

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Crossair flight 3597
Crossair HB-IXM.jpg

The plane involved in the accident in April 2001 at Frankfurt Airport
Accident summary
Accident type Controlled flight into terrain
place near Bassersdorf in the canton of Zurich
date November 24, 2001
Fatalities 24
Survivors 9
Injured 5
Aircraft
Aircraft type Avro RJ100
operator Crossair
Mark HB-IXM
Departure airport Berlin Tegel Airport
Destination airport Zurich
Passengers 28
crew 5
Lists of aviation accidents

The Crossair flight 3597 (CRX 3597) was a scheduled passenger flight from Berlin-Tegel to Zurich . The aircraft of the type Avro RJ100 with the aircraft registration HB-IXM crashed on November 24, 2001 about five kilometers before reaching runway 28 after touching trees near Bassersdorf , Canton of Zurich . According to the Swiss Aircraft Accident Investigation Bureau (BFU), the main cause of the accident is falling below the minimum descent altitude . Of the 33 inmates, 24 died, including the captain, the copilot, the singer Melanie Thornton and two of the three singers of the pop group Passion Fruit .

Aircraft

The aircraft, an Avro RJ100 with registration HB-IXM and production number E.3291, made its maiden flight on August 16, 1996 and was used by Crossair from August 22, 1996 . The aircraft had completed 13,194 flight hours during 11,518 flights. On the day of flight CRX 3597, the aircraft had a relatively low load factor with 33 of a maximum of 82 passengers.

crew

A total of two pilots (commander and co-pilot) and three flight attendants were on board on flight CRX 3597. The co-pilot had sufficient rest time before the flight. The commander, Hans Lutz, was a Swiss citizen (born in 1944) and was assigned to this flight as a flying pilot (PF). The commander's flying and school career showed considerable deficits overall. He did not finish the district school (preparatory school for high school in the canton of Aargau) and began training as a locksmith. At the age of 17 he failed the entrance exam for the pre-flight training of the Swiss Air Force. Further applications for approval were rejected because of a lack of academic performance. During his professional training and activity, he then undertook private training as a glider instructor and as a private pilot for single-engine machines. In 1967 he acquired a commercial pilot's license. After that he also became a flight instructor and stunt pilot. His training in instrument flight began in 1966, and approval could only be granted in 1969 because practical and theoretical exams were repeatedly failed. Experts criticized the insufficient overview and incorrect use of the navigation systems. The exam grade was average . His further activity was on-demand flying on Cessnas and flight instructor, especially for instrument flight. "The periodic checks in instrument flight between 1969 and 1979 were generally passed with the grade average ." Experts occasionally criticized the fact that checklists were not applied consistently, procedures were not adhered to and the navigation devices were not used appropriately. These findings also concerned the work as a flight instructor.

On January 28, 1979, the captain applied to Crossair as a pilot. There he was retrained on the Fairchild Metroliner and then on the Saab 340 , both fan guns. From June 1979 he was a part-time and then a full-time pilot at Crossair until May 31, 1982. At Crossair, at the end of his contract, he had an excellent reputation and was deputy chief pilot. He then had freelance contracts with Crossair from June 1, 1982 to May 31, 1991 , but also worked for other companies. From autumn 1982 he worked as a flight instructor at the Horizon Swiss Flight Academy flight school. In 1983/1984 he was to be retrained on the McDonnell Douglas MD-80 jet aircraft - it is not clear whether with Crossair or another airline. He did not pass this retraining despite repeated retraining, gaps in the overview and coordination were found. Then he was trained back on the Saab 340. From 1991 to 1993 he had a part-time contract with Crossair, from 1994 he was full-time with Crossair. He was still doing his job as a flight instructor at Horizon.

At Crossair he was initially used again on the Saab 340 fan gun in 1991, until he was retrained in 1996 on the McDonnell Douglas MD-80 jet engine . Again he struggled to perform as required. He had big problems with the Digital Flight Guidance System (DFGS) of the MD-80. Despite various additional exercises and training, the exam was not passed. The inadequacies concerned, among other things, the manual control of the aircraft, an inadequate systematics with regard to the use of the flight guidance system and a limited ability to analyze and make timely decisions. On May 6, 2001, the commander began retraining on the Avro RJ85 . He successfully completed this retraining, and there were no faults whatsoever. There have been dangerous incidents before during his service:

  1. February 21, 1990: While working as an instructor on a Saab 340, he retracted the landing gear while the machine was on the ground, so that the plane fell on the ground. He wanted to demonstrate to a trainee that the landing gear would not retract on the ground, but he was wrong. The aircraft HB-AHA suffered a total loss.
  2. June 25, 1991: A route check was aborted due to a mistake as a commander, which led to a dangerous situation. An expert judged the commander's overview to be insufficient.
  3. End of 1991: The pilot was released from his job as a training captain because his performance was insufficient.
  4. December 1995: Almost unsuccessful landing approach in Lugano. The incident only became known after the Bassersdorf accident.
  5. March 21, 1999: Navigation error during a private sightseeing flight with a Saab 340. When the weather was good, he headed for the runway in Aosta instead of Sion - 50 km south, beyond the main Alpine ridge. Interventions by the copilot due to his navigation were disregarded. When the aircraft occupants recognized that they were in Italy from the town signs on the approach, the commander took off the plane and flew over the Great St. Bernhard into the Rhone Valley , where the landing in Sion took place. The airline concerned only found out about it after the Bassersdorf accident.

Colleagues testified that the captain's team and leadership behavior was not always correct. He is said to have not consistently integrated the co-pilots into the operating and decision-making processes. In total, he had a flying experience of 19,555 hours.

The co-pilot Stephan Löhrer, who was assigned as a non-flying pilot on this flight, was also a Swiss citizen (born in 1976). He began training as a commercial pilot at the Horizon Swiss Flight Academy in January 1999. On July 9, 2000, he applied to Crossair as a co-pilot. On January 8, 2001, he was retrained to the Avro RJ85. He successfully completed the retraining with only positive comments. His colleagues said they were positive about the copilot's service after the accident. The co-pilot had a flying experience of around 490 hours.

The three Swiss flight attendants were all trained by Crossair about the emergency procedure.

Passengers

On board the machine were 28 passengers, 21 of whom were killed in the accident, including ten Germans , one each from Canada , the USA , Ghana , Sweden , Spain and the Netherlands , two Swiss and three Israelis . Among the dead were two of the three singers from the Passion Fruit pop group , who were on their way to a performance in Lipperswil in the canton of Thurgau . Only Deborah St. Maarten survived, seriously injured. According to Crossair, the then Vice Mayor of Jerusalem was among the Israelis . The pop singer Melanie Thornton also died in the accident, she was on the way to an appearance for her single Wonderful Dream (Holidays Are Coming) in the final show of the series Die Bar on TV3 - this show was then canceled.

The later Swiss National Councilor Jacqueline Badran and her business partner Peter Hogenkamp, ​​who were also on board this plane, survived the accident only slightly injured thanks to fortunate circumstances. They had gone to the back of the plane during the flight.

Weather

The last METAR weather report for Zurich Airport before the accident was as follows:

METAR 242050 16002KT 3500 –SN FEW006 BKN015 OVC022 00 / M00 Q1024 8829 // 99 TEMPO 5000

That means in plain language: On the 24th day of the current month at 8:50 p.m. world time (around 20 minutes before the accident) the wind was blowing from the direction of 160 ° with a wind force of two knots. The visibility on the ground was about 3500 meters with light snowfall. There were a few clouds with a cloud base at 600 feet (180 m) above the ground, broken clouds at 1,500 feet and overcast skies at 2,200 feet. The air temperature at the time of publication was 0 ° C with a dew point of 0 ° C. The QNH was 1024 hPa. All of the airport's runways were wet or covered with puddles of water on more than 50 percent of their surface; no reliable information on the estimated braking effect was possible. Visibility should temporarily improve to 5000 meters, but no more than an hour.

The weather conditions in the approach sector of runway 28 were actually worse. The crew of an aircraft flying ahead could only see the runway threshold from a distance of around 2400 meters (see sequence below). Weak precipitation was observed in the accident area - snowfall mixed with rain. When other BAe-146 pilots were interviewed, it was found that landing would still have been possible under these visual conditions.

procedure

Before the flight

Before the scheduled flight to Zurich, the aircraft was used for the scheduled flight from Zurich to Berlin-Tegel. After landing at 19:25 UTC , i.e. 20:25 local time, it reached Gate A11 of the airport five minutes later. The passengers left the aircraft and shortly afterwards the cleaning of the machine was initiated. The “Jumbolino” was not refueled because the remaining fuel was sufficient for the return flight to Zurich. Between 7:40 p.m. and 7:45 p.m., passengers boarded the plane. There were no special incidents.

Flight 3597

At 19:48, the commander requested clearance to start the engines and clearance to taxi to the runway. These were given and the aircraft was pushed to the taxiway ten minutes after the scheduled time . Shortly thereafter, the Avro RJ100 rolled to the runway , whereupon it took off at 8:01 p.m. The climb was initiated and after reaching cruising altitude the flight proceeded as before without any problems.

At 8:40 p.m. the descent to an altitude of FL 240 (around 24,000 feet) was initiated. The two pilots then carried out the approach briefing (including the discussion of the approach procedure) for an instrument landing approach on runway 14. The copilot noticed that the speed was too high, which he then reported to the captain. During the descent, the air traffic controller handed the Crossair over to the eastern approach control (Zurich Arrival East Sector) . At this point in time, the pilots were briefly informed by the air traffic controllers that they should expect runway 28 to land. The aircraft was put into a holding loop above the RILAX waypoint , where the pilots prepared the approach to runway 28 using the VOR / DME approach procedure. At 20:57 hrs, the clearance for a further descent to 6000 feet QNH was given . A few seconds later, the aircraft received permission for a VOR / DME approach to runway 28, during which time the aircraft was already between 4000 and 5000 feet QNH. The pilots turned to the right in order to reach the final approach course 275 ° inbound KLO VOR. During the right turn, the commander mentioned that he had a view of the ground.

At 9:03 p.m., an Embraer 145 landed on runway 28 and at 9:04 p.m. transmitted the following message to the control tower : "Just for information, the weather for runway 28 is pretty minimum, so we had runway in sight about 2.2 DME distance away." (German: «For information only, the weather for runway 28 is pretty much [at] the minimum - so we could only see the runway from about 2.2 DME away.»). In this case, 2.2 DME correspond to approx. 2400 meters in front of the runway threshold. The Embraer was the first aircraft to make the VOR / DME approach to Zurich Airport that evening. The responsible air traffic controller did not forward this weather information. However, as the tower frequency was already set in the cockpit of the Crossair aircraft, the information was perceived by the pilots.

The BFU report contains slightly different versions of the radio message from the crew of the Embraer. For example, in the second paragraph on page 19, a quotation is made using colloquial language « NM », while the same radio message is mentioned in the first paragraph on page 137 and in the cockpit recording from 21:04:31 on page 155 without the slang elements and with «DME »Is reproduced. Since in the last paragraph on page 119 when looking at the relationship between flight crew and procedures, a distance of “2.2 NM to the VOR / DME” - which corresponds to a display of 2.2 on the DME - is indicated, this variant is assumed here . The video documentation from the Mayday - Alarm im Cockpit series shows an additional version of this radio message at 27:18: “Just for your information, visibility approaching 28 was borderline. We could only see the runway from 1.3 miles out. " The source for this version remains unclear. The mentioned distance corresponds to about 2 kilometers.

At 21:04 hrs, Crossair flight 3597 left the flight altitude of 4000 feet QNH, the speed was 160 knots . At 21:05 h the machine reported to the control tower for clearance for landing. At this point the aircraft was at 3240 feet QNH. The crew completed the checklist for the final approach (“final check”) in preparation for landing.

At 21:05:55 h the commander mentioned that he had a "certain view of the ground" while the aircraft was passing the minimum descent altitude of 2390 feet QNH. The descent continued unchanged; at 21:06:22 the Ground Proximity Warning System (GPWS) sounded that 500 feet above ground had been reached. A few seconds later, the commander incorrectly stated that they had reached 2000 feet ( 1024 according to QNH ). Immediately afterwards the message "MINIMUMS" generated by the GPWS sounded, which means for this approach that the distance to the ground measured by the radar altimeter was still 300 feet (around 91 m).

At 9:06:32 p.m., the tower cleared the landing for Runway 28. During the radio message, the commander said: "Go around?" - shortly after he ordered a go-around ( go-around ), after the autopilot was turned off. The recordings registered the increase in the thrust, a second later the recorder recognized the signs of an impact. A short time later, the recordings broke off.

When the site manager gave clearance to land, the Crossair 3597 was still on the screens. Since he did not receive an answer to the clearance to land, the air traffic controller assumed that the pilots were busy and therefore could not answer immediately. He was busy with some other work after the radio transmission before he could turn back to Crossair. He found that the machine could no longer be seen on the screens and searched for the whereabouts of the aircraft together with the ground control officer.

Place of Disaster, a few meters from the scene of the accident (June 2003)

Accident process

Before first touching the ground, the engine was traveling at 118 knots and on a heading of 274 °. The aircraft's bank angle was almost zero. By initiating the go - around procedure, the pitch changed from −2 ° to + 5 °. The landing gear and the landing flaps were extended at this time. The authorities assume that kerosene leaked before the ground hit the tree for the first time . The plane hit other trees and hit the ground after about 200 meters. According to statements from passengers, the right wing broke off and the aircraft caught fire, whereupon a fireball shot through the cabin. The impact and the intense fire that followed destroyed the cockpit, front and middle sections of the fuselage, and a large part of the aircraft's wings. Only the torn off rear part of the fuselage remained largely intact. There was considerable damage to the forest, and the site has now been renatured.

Rescue and recovery measures after the accident

Injuries crew Passengers
fatal 3 21st
heavy 1 4th
easy / not 1 3
Memorial stone near Bassersdorf for the 24 fatally injured. In the alphabetical list three names with Hebrew transcription.

Almost four minutes after the landing permit, after the aircraft went off on the radar screen, the traffic controller triggered the highest level of alert at 9:10 p.m. ( UTC , i.e. 10:10 p.m. local time, at night). A first police officer arrived at the scene of the accident at 9:16 p.m. after a witness had seen what was happening and instructed him. A few minutes later a police patrol drove near the scene of the accident. Some survivors then ran to the police car, guided by the flashing lights. Shortly afterwards, at 9:22 p.m., the first vehicles from the professional fire brigade of Zurich Airport and medical rescue services arrived almost simultaneously; care for the injured has now started. As a fire broke out, additional units from the Nürensdorf , Bassersdorf and Kloten fire brigade were called in . The fire was extinguished at 9:39 p.m. The canton police initiated a large-scale search operation; however, no other survivors could be found.

Cause of the accident

The main cause of the aircraft accident was the fact that the pilots did not descend below the minimum descent altitude during the approach, without being in visual contact with the approach lights or the runway itself. The two pilots did not react immediately to the two warnings issued by the aircraft, but instead acted wait and see while they continued the descent. This resulted in a classic CFIT ( Controlled flight into terrain ). The Aircraft Accident Investigation Bureau also criticized the controller in the tower, as she did not monitor the aircraft for a short time after the landing permit and therefore did not ask for confirmation of the landing permit. The accident could possibly have been prevented if the commander had carried out the go-around procedure earlier after the first or both warnings; the much younger co-pilot did not take any measures, despite the warning displays, to carry out the go - around earlier , but adhered exclusively to the commander. According to the final report of the accident, the chances of survival were low, as the passengers were surprised by the emergency and no emergency landing was announced.

The final report also states that the commander's ability to concentrate and make decisions, as well as his ability to analyze complex processes, were impaired due to fatigue, as he had fallen slightly below the prescribed rest time on the day of the flight and significantly exceeded the maximum operational times on the previous days.

The approach chart used by the pilots was a version printed in November 2000. No obstacles in front of runway 28 were shown on this map. In AIP Switzerland, however, two hills are mentioned. The machine collided with the northern hill. If the two obstacles had been mentioned on the approach chart, the accident could possibly have been prevented.

At the time of the accident, only one approach (approach) controller and two air traffic controllers were responsible for the tower. According to the sector occupancy plan of the Swiss air traffic control system Skyguide , four controllers are required in the approach sector and four in the tower sector. The responsible service manager left his workplace at 9:03 p.m. and made his way home a few minutes later. He handed over the service manager function to a ground traffic controller who did not have the necessary training to exercise his functions. According to the occupancy plan, the previous service manager should be present until 10 p.m. This requirement was not met.

Legal consequences

The then CEO André Dosé , the Crossair founder Moritz Suter and four other employees had to answer for negligent homicide in 24 cases and negligent bodily harm in nine cases before the Federal Criminal Court in Bellinzona since May 5, 2008 . The charge of bodily harm was dropped, however, as the federal prosecutor Carlo Bulletti was unable to submit a list of the injured in due time.

Suter was accused of not allowing any criticism due to a dictatorial hierarchy. This corporate policy resulted in employees deliberately disregarding regulations. Suter invited newly hired co-pilots to dinner, where he explained to them that good pilots would fall below the minimum approach altitude in bad weather in order to be able to land. Another point of criticism from the court is the expansion policy at the time, which was paramount to flight safety. Aircraft in need of maintenance continued to be used in flight operations and the lack of staff forced employees to fly longer than the regulations permitted. If they didn't, they were threatened with firing.

The CEO Dosé was accused of having done nothing despite known problems in the company. The pilot of the Bassersdorf accident had already attracted negative attention several times before and was still not suspended from active flight duty. In addition, safety recommendations from the authorities after the Saab 340 crash in Nassenwil in 2000 ( Crossair flight 498 ) were not implemented within the company.

The trial lasted two weeks and the verdict was opened on May 16, 2008. 25 witnesses were summoned by the court, including former employees of Crossair, experts and ex- FOCA boss André Auer.

On May 16, 2008, the Federal Criminal Court obtained an acquittal for all of the accused because the court did not have sufficient evidence for many of the allegations. The court also found that there was no causal connection with the accident in the accusation of "aggressive expansion policy" Suter. The defendants received a total of 851,000 Swiss francs (of which 836,000 CHF defense costs) as compensation .

The negotiations on compensation for the victims and their surviving dependents were also concluded on May 11, 2008 by Swiss , Crossair's successor company.

See also

Web links

Individual evidence

  1. ↑ Aircraft Accident Investigation Bureau (BFU): Information on the aircraft (p. 34) (PDF; 3.3 MB)
  2. ↑ BFU: Information on the commander (p. 23) (PDF; 3.3 MB)
  3. ↑ BFU: Information on the commander (p. 21) (PDF; 3.3 MB)
  4. ↑ Route check: Review of a pilot for the purpose of determining his knowledge of the route flown, in particular the terrain overflown, the minimum altitude to be observed, the seasonal meteorological phenomena, the radio and air traffic control procedures, the search and rescue procedures as well as the route-specific navigation aids and their practical implementation. Such a route check (sometimes also called “en route check”) is typically carried out annually with a so-called check captain flying in the cockpit.
  5. ↑ BFU: Information on the commander (p. 21) (PDF; 3.3 MB)
  6. ↑ BFU: Information on the copilot (p. 27) (PDF; 3.3 MB)
  7. ↑ Crossair: Passenger list of flight LX 3597 released. ( Memento from July 14, 2014 in the Internet Archive ) In: presseportal.de , November 26, 2001
  8. ↑ A misfortune rarely comes alone, Jacqueline Badran and her experiences in the snow. In: Neue Zürcher Zeitung , February 9, 2009.
  9. ^ Investigation report CRX 3597, November 24, 2001: The flight from Berlin-Tegel to Zurich. In: Vereinigung Cockpit , VCInfo 08/07. From 2007 or 2008. - On November 24th, 2016 contribution no longer available.
  10. ↑ BFU: Security deficit (p. 137, section 4.1.5.1) (PDF; 3.3 MB)
  11. ↑ BFU: BFU report (PDF; 3.3 MB)
  12. ↑ National Geographic : Mayday - Alarm in the cockpit - Crash over Zurich - CRX3597 , meanwhile (status November 24, 2016) the video is marked as private and no longer generally available
  13. ↑ BFU: Flight 3597 (p. 16–20) (PDF; 3.3 MB)
  14. ↑ BFU: Accident procedure (p. 76) (PDF; 3.3 MB)
  15. ↑ BFU: Alerting and Rescue (p. 76) (PDF; 3.3 MB)
  16. ↑ BFU: Causes of the accident (p. 130) (PDF; 3.3 MB)
  17. ↑ The Commander, Medical Aspects - p. 112 f. (PDF; 3.3 MB)
  18. ↑ Allocation of employees - p. 67 f. (PDF; 3.3 MB)
  19. ↑ Ex-Bazl boss supports Crossair. In: espace.ch , May 9, 2008. - Article on November 24, 2016 no longer available. - Note FOCA = Federal Office for Civil Aviation.
  20. ↑ a b Ex Crossair head before criminal court. In: swissinfo.ch , April 28, 2008. Retrieved November 24, 2016.
  21. ^ Federal Criminal Court : Dates for hearing
  22. ↑ Was the accident pilot qualified enough? In: espace.ch , May 7, 2008. - Article on November 24, 2016 no longer available.
  23. ↑ Consistently acquittals in the Crossair trial. In: NZZ Online , May 16, 2008
  24. ↑ Crossair: The court lacked evidence ( Memento from May 19, 2008 in the Internet Archive ) In: Tages-Anzeiger , May 16, 2008
  25. ↑ Crossair crash: settlement with victims and bereaved. In: Basler Zeitung , May 11, 2008
This version was added to the list of articles worth reading on May 25, 2008 .

Coordinates: 47 ° 27 '15 "  N , 8 ° 37' 24"  E ; CH1903:  six hundred and eighty-nine thousand three hundred and thirty-nine  /  two hundred and fifty-six thousand six hundred and five