Crossair Flight 3597
HB-IXM, the aircraft involved, three months prior to the disaster.
|Date||24 November 2001|
|Summary||Controlled flight into terrain due to navigational error and pilot error|
|Site||Bassersdorf, Switzerland |
|Aircraft type||Avro RJ100|
|Flight origin||Berlin Tegel Airport, Germany|
|Destination||Zürich Airport, Switzerland|
Crossair Flight 3597 was a scheduled flight from Berlin Tegel Airport, in Germany, to Zürich Airport, in Switzerland. On 24 November 2001, the Crossair Avro RJ100 operating the route, registration HB-IXM, crashed into a wooded range of hills near Bassersdorf and caught fire, killing 24 of the 33 people on board.:12
The accident aircraft, a British-made Avro 146-RJ100, registration HB-IXM, was manufactured in 1996 and logged more than 13,000 hours and 11,500 cycles in total before the crash. The aircraft was powered by four Lycoming LF507-1F turbofan engines.:12
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 Löhrer (25). Lutz was an extremely experienced pilot with more than 19,500 flight hours – approximately 19,300 of which were as pilot in command. Löhrer, in contrast, was inexperienced with just 490 total flight hours.
Upon arrival in Zürich about an hour after takeoff, the pilots were cleared for an ILS approach runway 14, but were switched to a VOR/DME approach runway 28 because of a noise law past 10:00 PM. There were poor visibility conditions due to low clouds, and 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. Twenty-four people died (including the cockpit crew and a flight attendant), while nine (seven passengers and two flight attendants) survived.
|Nationality||Passengers (dead)||Crew (dead)||Total (dead)|
| United Kingdom
| United States
The ill-fated flight was carrying a total of 33 people, 5 crew members and 28 passengers were onboard.
The Eurodance group Passion Fruit was among those who were onboard flight 3597; singers Nathaly(ie) 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 business partner Jacqueline Badran survived the accident.
While Captain Lutz was an experienced pilot, his competence came 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.[failed verification] This course deviation caused the plane to crash into a hilltop, 4.05 kilometres (2.52 mi; 2.19 nmi) short of and 150 metres (490 ft) north of its assigned landing strip, runway 28.:12
Flight 3597 had originally been scheduled to land on runway 14, the main landing runway at Zürich, a runway equipped with an Instrument Landing System (ILS) that provides vertical and lateral guidance to the runway. The CVR records Lutz and Löhrer discussing "the 14 approach" as well as Lutz's request that Löhrer 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 Zürich until after 22:00 CET. This delay forced Flight 3597 to change its landing plan. Zürich 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 Löhrer 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 Zürich and the CVR picks up Lutz's query to Löhrer about Löhrer's familiarity with "the 28 approach", which Löhrer confirmed he had, Lutz put the plane into an overly-steep descent that brought flight 3597 to MDA far too soon. When Löhrer reported the plane reaching 100 feet above MDA, the CVR records Lutz asking Löhrer, "Do we have ground contact?" Löhrer 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 Löhrer 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 Löhrer 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 Löhrer, 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 sufficient thrust to climb above the hill that had been obstructing his view, and the plane 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. Lutz had twice failed to upgrade his flight certifications to the more complex MD-80 due to insufficient comprehension of its computerized navigational systems.:23 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 apron,:25 which led to Crossair relieving him of his training captain duties in 1991.:26
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:26 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.:27
The final report of the Aircraft Accident Investigation Bureau (AAIB, German acronym BFU) 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.:13
- 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.:13
- The airport's means of determining visibility were inadequate for runway 28.:13
- The visual minimums at the time of the accident were actually inappropriate for using the standard approach to runway 28.:13
- Korean Air Flight 801
- Asiana Airlines Flight 733
- Air China Flight 129
- Crossair Flight 498
- Henan Airlines Flight 8387
- TransAsia Airways Flight 222
- Alitalia Flight 404, another CFIT accident near Zurich
- American Airlines Flight 965
- "Swiss Aircraft Registry (HB-IXM)". Federal Office of Civil Aviation.
- "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" (PDF). Aircraft Accident Investigation Bureau.
- "Media release November 26, 2001 Passenger list published for flight LX 3597 Monday, November 26, 17:00." Crossair.
- "Liste der tödlich Verunglückten" [List of fatally injured]. Neue Zürcher Zeitung (in German). 27 November 2001. Archived from the original on 15 January 2013. Retrieved 11 December 2009.
- "Cockpit Failure", episode of Mayday, Season 10, episode 1
- "Cockpit Failure". Mayday. Season 10. 2011. Discovery Channel Canada / National Geographic Channel.