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INVESTIGATION4242

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Date 24 November 2001

Summary Controlled flight into terrain due to navigational


and pilot error

Site Bassersdorf, near Zürich Airport, Switzerland


47°27′14″N 8°37′24″E

Aircraft

Aircraft type Avro RJ100

Operator Crossair

IATA flight No. LX3597

ICAO flight No. CRX3597

Call sign CROSSAIR 3597

Registration HB-IXM

Flight origin Berlin Tegel Airport, Germany

Destination Zürich Airport, Switzerland

Occupants 33

Passengers 28

Crew 5

Fatalities 24

Injuries 9

Survivors 9

\
WHAT HAPPENED

Flight 3597 departed Berlin Tegel Airport at 21:01 CET with 28


passengers, three flight attendants, and the cockpit crew
consisting of Captain Hans Ulrich Lutz (57) and First Officer
Stefan Löhrer (25). Lutz was a highly 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.

The pilots were cleared for an instrument landing system (ILS)


approach to runway 14 when they entered Zürich airspace,
approximately an hour after takeoff. However, because of a
noise abatement statute after 10:00 p.m., they were forced to
switch to a VOR/DME (VHF Omnidirectional Range/Distance
Measuring Equipment) approach to runway 28. Low clouds
made visibility poor. A previously landing Crossair flight's
transmission to air traffic control (ATC) stated that they could
not see the runway until 2.2 nautical miles (4.1 km; 2.5 mi)
away.[2] At 22:07 CET, Flight 3597 crashed into a forested
range of hills close to the small town of Bassersdorf, about 4
km (2.5 mi) short of the runway, where it broke apart and
burst.
WHY IT HAPPENED

Lutz had previously failed to execute proper landing and navigation


procedures, but Crossair had not taken any action to remove him from
passenger transportation. Due to his inadequate understanding of the
MD-83's computerized navigational systems, Lutz had twice failed to
upgrade his flight certifications to the more complex model. 23 The
report also detailed Lutz's involvement in the complete loss of a Crossair
Saab 340 by retracting its landing gear while it was still on the apron
which resulted in Crossair relieving him of his flight instructing duties in
1991.
Despite Lutz's evident shortcomings, Crossair persisted in
permitting him to transport passengers (ostensibly because of a
lack of certified pilots), and he persisted in exhibiting his
general shortcomings as a line pilot. These included a near-miss
incident on final approach to Lugano Airport where Lutz made a
risky 4,000 feet (1,200 m) per minute descent and a
navigational error during a sightseeing tour over the Alps that
caused the aircraft to veer significantly off course to Sion. In
one instance, Lutz misjudged his approach into Sion and spent
many minutes circling above what he believed to be the airport
before onlookers noticed road signs in Italian; the navigational
blunder had taken them over the Great St Bernard Pass, and
the airport they had been circling was in fact Aosta Valley
Airport in Italy.

WHAT IT CABE DONE?


One of the mistake is an inexperienced air traffic controller was
alone in the control tower. A more experienced controller might
have allowed the flight to land on runway 14 because of the
poor weather conditions.
Communication skills is important to have a Clear directions to
pilots and the coordination of aircraft movements depend on
effective communication. Years of experience have given
seasoned controllers excellent communication skills, which
allow them to deliver information clearly and effectively even in
hectic or stressful circumstances.

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