Crossair Flight 3597
A similar Avro RJ100 registered HB-IXT.
|Date||24 November 2001|
|Summary||Controlled flight into terrain, pilot error, lack of pilot training and crew experience|
|Aircraft type||Avro RJ100 Regional Jet|
|Flight origin||Berlin Tegel Airport
Crossair Flight LX 3597 was a scheduled flight from Berlin, Germany to Zurich, Switzerland. On 24 November 2001, the Crossair Avro RJ100 operating the route, registered HB-IXM, crashed into a wooded range of hills near Bassersdorf and exploded, killing 24 of the 33 people on board.
The flight departed Berlin Tegel Airport at 21:01 CET with 28 passengers, three flight attendants, and the cockpit crew of Captain Hans Ulrich Lutz (57) and First Officer Stefan Loehrer (25). Lutz was an extremely experienced pilot with more than 19,500 flight hours - approximately 19,300 of which were as pilot in command. Loehrer, in contrast, was inexperienced with just 490 total flight hours.
Upon arrival in Zurich about an hour later, it was cleared to approach runway 28 in poor visibility conditions due to low clouds; the cockpit voice recorder captured the transmission of a previously landing Crossair flight informing the tower that they could not see the runway until 2.2 nautical miles (4.1 km; 2.5 mi) away. At 22:07 CET, the airplane crashed into a wooded range of hills near the small town of Bassersdorf, around 4 km (2.5 miles) short of the runway, where it broke apart and went up in flames. 24 people died (including the cockpit crew and a flight attendant), while 9 (7 passengers and 2 flight attendants) survived.
The German pop group Passion Fruit was aboard flight 3597; singers Nathaly(i.e.) van het Ende and Maria Serrano Serrano were killed, while singer Debby St. Maarten and the band's manager survived with injuries. St. Maarten's injuries were classified as "severe".
Peter Hogenkamp, founder and CEO of Swiss commercial blog service company Blogwerk AG, and his wife Jacqueline Badran were originally seated one row behind the pair of rows taken up by the trio of Passion Fruit and their manager, but moved to the rear of the plane in-flight in order to rest in a more quiet area in the sparsely-populated cabin. One of the portions of the fuselage that broke open as a result of the crash did so almost directly in front of them, and they were able to escape the plane largely unharmed. During an interview for the Canadian Discovery Channel show Mayday (known as Air Emergency in the US) entitled "Cockpit Failure", Hogenkamp says that his and his wife's survival were largely due to "good luck", but also hypothesized that their original desire for rest drove them to change seats and sides of the plane to get away from the rambunctious behavior of the members of Passion Fruit, "so the Passion Fruits may have saved our lives."
While Captain Lutz was an experienced pilot, his competency would come under close scrutiny during the course of the investigation, which concluded that the accident was a controlled flight into terrain (CFIT) caused by a series of pilot errors and navigation mistakes that led the plane off-course. This course deviation caused the plane to crash into a hilltop, 4.05 kilometres (2.52 mi) short of and 150 metres (490 ft) north of its assigned landing strip, runway 28.
Flight 3597 had originally been scheduled to land on runway 14, the main landing runway at Zurich, a runway equipped with an Instrument Landing System (ILS) that provides vertical and lateral guidance to the runway. The CVR records Lutz and Loehrer discussing "the 14 approach" as well as Lutz's request that Loehrer call out the height when the plane reaches 100 feet above DA (Decision Altitude - The altitude at which an immediate decision to land or initiate a missed approach must be made). However, Flight 3597 was behind schedule and would not reach Zurich until after 2200 CET. This delay forced Flight 3597 to change its landing plan. Zurich Air Traffic Control Tower, in order to comply with a new Swiss law designed to reduce airport noise from approaching aircraft over southern Germany in the late evening hours, must redirect all flights on final approach to switch from the ILS-equipped runway 14 to the less-accurate VHF Omnidirectional Range (VOR)/Distance Measuring Equipment (DME)-equipped runway 28. This runway change forced Captain Lutz to abandon his planned ILS approach and required First Officer Loehrer to consult the Jeppesen charts for runway 28. The charts included a new set of approach parameters, of which the higher MDA (Minimum Descent Altitude) was the most crucial piece of information.
The MDA states the minimum altitude in MSL to safely fly above any obstructions or terrain in the final approach flight-path before visual contact with the runway is made. Unlike a DA in a Precision Approach, an MDA requires that after crossing the Final Approach Fix, the pilot is to descend and maintain MDA until the non-flying pilot reports that the runway is in sight, allowing the pilot to safely complete the landing visually. In contrast to the ILS approach, which displays lateral and vertical position, the VOR/DME approach only shows the lateral position of the aircraft and its range to the runway. Due to increased azimuth error associated with the use of VORs and lack of vertical guidance (Glide Slope), the MDA is therefore much higher than a DA (Decision Altitude) for an ILS.
Although both pilots were based in Zurich and the CVR picks up Lutz's query to Loehrer about Loehrer's familiarity with "the 28 approach", which Loehrer confirmed he had, Lutz put the plane into an overly-steep descent that brought flight 3597 to MDA far too soon. When Loehrer reported the plane reaching 100 feet above MDA, the CVR records Lutz asking Loehrer, "Do we have ground contact?" Loehrer hesitated before replying "Yes". However, flight simulators programmed with the time of day, terrain, and weather Lutz was facing at that time allowed investigators to determine that the only ground Lutz or Loehrer could see was the ground of the hilly terrain over which the plane was flying. Upon reaching MDA of 2,400 feet (730 m), Lutz declared that he had "ground contact" and would continue on, then deliberately descended the plane below the minimum descent altitude (MDA) without having the required visual contact with either the approach lights or the runway, a major piloting error that ultimately led directly to the crash. The fact that Loehrer made no attempt to prevent the continuation of the flight below the minimum descent altitude also directly contributed to the crash. Lutz made an additional error by not monitoring his Distance Measuring Equipment (DME) as he made his approach; the CVR recorded Lutz's running narrative on nearly every move he made in the cockpit, but did not record any readout of the DME after a check, verified by Loehrer, at 6 nautical miles (11 km; 6.9 mi) from runway 28. Moments before the crash, Lutz's running commentary indicated to investigators that Lutz must have thought he was at or near 2.2 nautical miles (4.1 km; 2.5 mi) from runway 28 because he said "Someone said he saw the runway late here". instead, Lutz was over 4 nautical miles (7.4 km; 4.6 mi) from the runway, and could not possibly have seen the runway due to the presence of a hill, below the MDA of 2,400 feet (730 m), that would have obscured his view. It was into this hill that flight 3597 eventually crashed. Just before the crash, the synthetic voice of the ground proximity warning system (GPWS) announced the radio altimeter reading 500 feet above ground. Immediately thereafter Lutz exclaimed "*****, two miles he said, he sees the runway". A few seconds later Lutz said “Two thousand” and then one second later the synthetic voice gave the “minimums” GPWS message, which was triggered by the radio altimeter reading at 300 feet. Even though Lutz finally realized that his inability to see the runway meant he needed to initiate a missed approach maneuver (called a "Go-around"), his call for the go-around came too late; the plane's engines were not able to spool up fast enough to generate lift sufficient to climb above the hill that had been obstructing his view, and it crashed into the hilltop at 22:06 CET.
The report revealed that the pilot had failed to perform correct navigation and landing procedures on previous occasions, but no action had been taken by the airline to remove him from transporting passengers. A series of accidents and incidents had occurred during Lutz's career as a training captain with Crossair, including multiple failures to upgrade his flight certifications to higher-complexity aircraft such as the MD-80 due to insufficient comprehension of computerized navigational systems. The report also documented Lutz's role in causing the total loss of a Crossair Saab 340 by retracting its landing gear while it was still on the tarmac, which led to Crossair relieving him of his training captain duties in 1991.
In spite of those demonstrated deficiencies, however, Crossair continued to allow Lutz to fly passengers (reportedly due to a shortage of qualified Crossair pilots), and Lutz continued to demonstrate his overall deficiencies as a line pilot. These included a near-miss incident on final approach to Lugano Airport where Lutz came within 300 feet (91 m) of colliding with the shore of a lake during his final descent and a navigational error during a sightseeing tour over the Alps that took the flight far off its course to Sion, Switzerland. In this particular incident, Lutz missed his approach into Sion and circled over what he thought was Sion's airport for several minutes before passengers spotted road signs in Italian; the navigation error had taken them over the St. Bernard Pass through the Alps, and the airport they had been circling was in fact located near Aosta, Italy.
The BFU's Final Report states that other factors also contributed to the accident:
- The range of hills the plane crashed into was not marked in the Jeppesen approach chart used by the crew.
- Despite the hilly terrain surrounding it, the approach to runway 28 was not equipped with a Minimum Safe Altitude Warning (MSAW) system, which triggers an alarm if a minimum safe altitude is violated.
- The airport's means of determining visibility were inadequate for runway 28.
- The visual minimums at the time of the accident were actually inappropriate for using the standard approach to runway 28.
The story of the disaster was featured as the first episode of the tenth season of Canadian Discovery Channel show Mayday (known as Air Emergency in the US). The episode is entitled "Cockpit Failure".
- Final Report No. 1793 by the Aircraft Accident Investigation Bureau concerning the accident to the aircraft AVRO 146-RJ100, HB-IXM, operated by Crossair under flight number CRX 3597, on 24 November 2001 near Bassersdorf/ZH pg. 12
- "Liste der tödlich Verunglückten". Neue Zürcher Zeitung (in German). 27 November 2001. Retrieved 11 December 2009.
- "Cockpit Failure", episode of Mayday, Season 10, episode 1
- Final Report No. 1793 by the Aircraft Accident Investigation Bureau concerning the accident to the aircraft AVRO 146-RJ100, HB-IXM, operated by Crossair under flight number CRX 3597, on 24 November 2001 near Bassersdorf/ZH pg. 11
- Final Report No. 1793 by the Aircraft Accident Investigation Bureau concerning the accident to the aircraft AVRO 146-RJ100, HB-IXM, operated by Crossair under flight number CRX 3597, on 24 November 2001 near Bassersdorf/ZH pg. 23
- Final Report No. 1793 by the Aircraft Accident Investigation Bureau concerning the accident to the aircraft AVRO 146-RJ100, HB-IXM, operated by Crossair under flight number CRX 3597, on 24 November 2001 near Bassersdorf/ZH pg. 25
- Final Report No. 1793 by the Aircraft Accident Investigation Bureau concerning the accident to the aircraft AVRO 146-RJ100, HB-IXM, operated by Crossair under flight number CRX 3597, on 24 November 2001 near Bassersdorf/ZH pg. 26
- Final Report No. 1793 by the Aircraft Accident Investigation Bureau concerning the accident to the aircraft AVRO 146-RJ100, HB-IXM, operated by Crossair under flight number CRX 3597, on 24 November 2001 near Bassersdorf/ZH pg. 27
- Final Report No. 1793 by the Aircraft Accident Investigation Bureau concerning the accident to the aircraft AVRO 146-RJ100, HB-IXM, operated by Crossair under flight number CRX 3597, on 24 November 2001 near Bassersdorf/ZH pg. 13
- Final report on the crash (Archive) - Aircraft Accident Investigation Bureau
- Crossair Status of the Accident Investigation