Pilot error blamed in Swiss Citation crash

Aviation International News » May 2005
November 1, 2006, 7:17 AM

A Cessna 560 Citation V, registered HB-VLV and operated by Eagle Air of Bern, Switzerland, crashed on takeoff at Zurich Airport on Dec. 20, 2001, on a freezing cold night. The aircraft burned and both pilots–the only occupants–were killed. In its final report published on March 17, the Swiss Air Accident Investigation Bureau (BFU) lists pilot error as the main cause, but also points to other factors that contributed to the accident.

The report describes the captain, 35, as personable but not a strong leader. He joined Eagle Air in late 2000 after he was downgraded to first officer when flying as a captain for Crossair, for an error without consequences. He was trained on the Citation V at FlightSafety in the U.S. and had logged a total of 4,738 flight hours.

The 37-year-old first officer was a latecomer to aviation, having first studied law. He had obtained a private pilot license at age 29 and had 1,110 flight hours. The BFU notes some deficiencies in his training syllabus. There was no known personality clash between the two pilots.

On the day of the accident, the pilots had dropped eight passengers at Zurich Airport after a flight from East Midlands, UK. They had landed at 8:31 p.m. local time and were preparing to ferry the aircraft to their base at Bern Airport. Both had nine hours and 17 minutes of duty time on arrival at Zurich. They had filed a flight plan for Bern (about 80 miles from Zurich) and obtained clearance for approximately 9:30 p.m. local time.

Pilots under Pressure

The pilots were anxious to take off on time since there is a 10 p.m. curfew at Bern Airport, but ATC delayed their departure because of increasingly bad weather. After the Eagle Air owner obtained permission for a landing 30 minutes after the curfew in Bern, HB-VLV finally taxied onto Runway 34 at 10:05:54 local time.

The BFU noted that the company’s tight financial situation intensified the pressure on the pilots. For the flight from East Midlands to Zurich, the pilots had taken sufficient fuel aboard for the flight to Zurich, plus the leg to Bern, to benefit from tax-free fuel. This had raised the takeoff weight of the aircraft to 16,926 pounds, well over the certified mtow of 16,300 pounds.

To correct the problem, the pilots had eliminated fictitiously one passenger from the flight plan, but in fact all eight passengers had remained aboard. In Zurich, the crew had de-iced the aircraft themselves with sprays and scratch pads. The pilots also felt pressure from the company’s owner, who wanted to avoid hotel and parking costs in Zurich.

In their eagerness to get to Bern quickly, the pilots made a rolling start on Runway 34. During the takeoff roll, the aircraft veered up to 10 degrees to the right, due to asymmetric thrust. They regained control after a nosewheel correction and thrust reduction of the left engine, and the aircraft took off normally.

The BFU notes that European JAR-OPS 1 rules require a stop before takeoff to stabilize engine thrust, but HB-VLV was operating under the old Swiss VBR 1, which did not require that procedure. In fact, Eagle Air, which changed its name to Swiss Eagle in 2002, started operating under JAR-OPS 1 only in May last year.

HB-VLV entered dense fog immediately after takeoff, and the pilots lost all visual references outside the aircraft. The BFU presumes that the first officer was the pilot flying during takeoff, as it was an informal standard at Eagle Air when there were no passengers aboard. Investigative authorities could not confirm this because the cockpit voice recorder had been out of order for 20 months when the crash occurred.

BFU Implicates Instrumentation

The flight data recorder was recovered and contained all the data before the crash. The aircraft went into a shallow dive as soon as it had entered fog–the BFU assumes because of the pilot’s loss of spatial orientation. The old-fashioned mechanical attitude indicator installed on the right side of the flight deck, less precise than a modern EADI, may have contributed to the flying pilot’s lack of awareness about the airplane’s dangerous attitude. Also, the flaps were retracted unusually early. The aircraft was in a slight nose-up attitude when it hit the ground, which indicates that the pilots were trying to regain altitude. At impact, HB-VLV had been airborne for only 20 seconds.

The BFU cites as the cause of the accident the pilot’s loss of spatial orientation and unintentional loss of altitude after takeoff. It identified as contributing factors the fact that the first officer’s basic training in instrument flying did not include night instrument takeoffs; the crew’s performance was adversely affected by pressure; the rolling takeoff was not appropriate for prevailing weather conditions; the aircraft had no GPWS (not required by Swiss rules, but required by JAR-OPS 1); and the instrumentation on the right side of the flight deck was not optimal.

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