Pilot blamed in Crossair crash; others implicated

Aviation International News » March 2004
March 16, 2007, 10:46 AM

Switzerland’s Federal Bureau of Air Accident Investigation, known as the BFU, identified pilot error as the cause of a Crossair Avro RJ100 accident on Nov. 24, 2001, near Bassersdorf, Switzerland, during an approach to Zurich Airport. However, investigators also pointed to external deficiencies at other levels.

According to the BFU, the approach to Runway 28 had not been equipped with a ground-based altitude-alert system despite earlier recommendations, and the hill that the aircraft hit had not been reported to Jeppesen and thus was not depicted on the approach charts. Additionally, the investigators said minimal sight limits in effect at the time of the accident were not appropriate; meteorological conditions from the airport weather service were not representative of actual conditions encountered by the crew during descent; and Crossair management failed to react appropriately to the captain’s errors during his tenure at Crossair.

The BFU emphasized that the goal of its report is not to apportion guilt. However, the Swiss federal attorney general has started a preliminary inquiry, which might lead to prosecution against parties that possibly contributed to the crash.

The 57-year-old captain was an experienced pilot and had logged 19,555 hours TT, mostly in piston aircraft and regional turboprops, including the Swearingen SA-226 Metro II and Metro III, as well as the Saab 340. He joined Crossair in 1979 and left on his own initiative in 1982, but continued working as a freelance pilot for the airline. He joined Crossair again as a full-time pilot in 1994 while simultaneously retaining a part-time job as an instrument flight instructor at a private flying school in Zurich.

He had several black marks in his piloting career, including a landing gear-retraction incident in a Saab 340 while on the ground, excessive speed during a route check and an excessive descent rate during an approach to Lugano, all of which
led to his termination as a training captain at Crossair. The list further includes an interrupted attempt to upgrade to MD-80 in January 1996, and another attempt in June of the same year, which ended with a failed type rating check in August. Instructors noted that he proved unable to make proper use of the MD-80’s digital flight-guidance system and cited a limited capability for analysis and timely decisions under pressure.

Despite these weaknesses, the pilot was retrained in the Saab 340 and served again as a captain from Sept. 1, 1996, in that capacity. In 1999 he privately chartered a Saab 340 from Crossair for a sightseeing flight over the Alps with paying passengers aboard. The program included a landing at Sion in southwestern Switzerland before returning to Zurich. After initial radio contact with Sion, the copilot–who was the pilot not flying (PNF)–announced he had lost communication with the airport controller. The captain proceeded nonetheless with the approach, but shortly before landing realized from road signs that he was actually about to land at Italy’s Aosta Airport, situated in an alpine valley parallel to Sion. He aborted that approach and subsequently landed at Sion. The incident was not reported to Crossair.

After the airline’s decision to phase out the Saab 340, the pilot was trained for the Avro RJ85/100, an aircraft considered relatively simple to fly by Crossair instructors. He successfully passed the type rating check on June 22, 2001. At the time of the accident he had logged 287 hours in the Avro RJ85/100.

The 25-year-old first officer had logged 490 hours TT, of which 348 were in the Avro RJ85/100. He was described as personable but not assertive.

The Accident Flight
Flight CRX 3597 took off at 20:01 UTC on Nov. 24, 2001, at Berlin Tegel Airport destined for Zurich Airport. After an uneventful flight, the crew expected to land as per ATIS information Kilo on ILS-equipped Runway 14 at Zurich Airport. But at 20:40:10 information Lima announced that Runway 28 was now the landing runway. ATC told the crew at 20:48:30 that they would be flying the VOR/DME approach to Runway 28, which had no ILS. The captain reacted with disappointment, as this meant a longer flight. He had reported for duty at Crossair in the afternoon, but had conducted IFR instruction with a student pilot in the morning after arriving at 7:30 a.m. at Zurich Airport.

Weather at the time of the accident was poor, with intermittent snowfall and a Crossair Embraer ERJ-145 crew, having landed immediately before CRX 3597, reported visibility to be close to the limit for the VOR approach to Runway 28.

At 21:05:21, the Avro captain contacted the tower to announce he was established on the approach, and shortly after told his copilot that he could see enough of the ground to continue the descent. Crossair procedures at the time obliged the pilot flying a nonprecision approach to monitor his instruments continuously and to leave the search for outside visual reference points to the PNF.

But the captain continued peering out of the windshield and neglected to monitor the aircraft’s altitude closely, according to the accident report. The radar plot of flight CRX 3597 shows that the aircraft went distinctly below the normal glide path soon after the right turn to final approach. When the captain announced he was established, the aircraft was at 3,240 feet msl instead of 3,360 feet. At 21:06:10, the aircraft reached the minimum descent altitude (MDA) of 2,400 feet msl. Twelve seconds later the radar altimeter called out “500” feet agl while the aircraft was at 2,150 feet msl. At 21:06:32, the radar altimeter called out “minimums” and at 21:06:33/34 the captain decided to go around for lack of visibility. But two seconds later the radar altimeter called out “100” just as the aircraft hit tree tops. The regional jet then broke apart and caught fire. Three crewmembers, including both pilots, and 21 passengers died, while seven passengers and two flight attendants survived.

The main cause for the crash as determined by the BFU is that the captain, as the PF, allowed the aircraft to descend below MDA without having the prescribed visibility, and the copilot did nothing to prevent continuation of the flight below MDA.

Former Crossair managers, ATC, and the Swiss Federal Office of Civil Aviation have been accused by the BFU of having potentially contributed to the accident. They reacted to these accusations by stating that procedures were appropriate at the time or have since been improved.

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