Final Report Of The Aircraft Accident Investigation Bureau
Federal Department of the Environment,Transport, Energy and CommunicationsNo. 1781Final Reportof the Aircraft AccidentInvestigation Bureauon the accidentto the Saab 340B aircraft, registration HB-AKKof Crossair flight CRX 498on 10 January 2000near Nassenwil/ZHThis report has been prepared for the purpose of accident prevention. The legal assessment of accidentcauses and circumstances is no concern of the accident investigation (art. 24 of the air navigation law).This report is a translation of the German language.The valid formulations for this report exist in the German language.According to art. 22 – 24 of the Ordinance relating to the Investigation of Aircraft Accidents and Serious Incidents (VFU), the investigation report dated October 21, 2002 of the Aircraft Accident Investigation Bureau was submitted forexamination by the Federal Aircraft Accident Review Board (Review Board).The Review Board declared the investigation report as the final report.Bundeshaus Nord, CH-3003 Berne
Final Report CRX 498Ve 15.04.04AcknowledgementsThe Aircraft Accident Investigation Bureau (AAIB) thanks the following representatives of authorities and organizations for the support given to it in the course of the investigation:Aeroflot Russian Airlines, RussiaAirport police of ZurichBureau Enquête Accidents de FranceCantonal police of ZurichCEFA Aviation FranceChipworks Ltd.Civil Aviation Academy, St. Petersburg, RussiaCrossair AGEMPA - Federal Materials Testing and Research InstituteFederal Office for Civil AviationFederal Office of Communications (OFCOM)Fire-fighting department of the airport of Zurich-Kloten and the municipality of Nassenwil,NiederhasliFlightscape Inc.Flughafen Zurich AGHoneywell Aerospace ElectronicsInstitute for Forensic Medicine of Zurich UniversityInstitute for Geodesy and Photogrammetry of the ETH ZurichInterstate Aviation Committee, RussiaInstitute of aviation medicine of the Swiss Air ForceMeteo Schweiz AGMoldavian AirlinesMoldavian Civil Aviation AuthorityNational Transportation Safety Board, USARockwell-Collins Inc.RUAG AerospaceRussian Civil Aviation AuthoritySaab Aircraft ABScandinavian Airlines System (SAS) Flight AcademyScientific Department of the Zurich city policeSeismology Department of the ETH ZurichSextant AvionicsSlovakian Civil Aviation AuthoritySpecial Duties Section of the Federal Department for the Environment, Transport, Energy andCommunications (DETEC – Umwelt, Verkehr, Energie und Kommunikation – UVEK)SR Technics Ltd.Swissair Ltd.Swisscom AGSwisscontrol AGTechnical Department of the News sub-group of the Federal Department for Defense, Civil Protection and Sport (Verteidigung, Bevölkerungsschutz und Sport – VBS)Transportation Safety Board of CanadaUljanovsk Aviation School, RussiaUniversal Avionics Inc.Aircraft Accident Investigation Bureaupage 2/117
Final Report CRX 498Ve 15.04.04Synopsis 9Brief presentation 9Investigation 91Factual information 111.1 Prior history and history of the flight 111.1.1 Prior history for the last 24 hours1.1.1.1The aircraft1.1.1.2Flight crew1.1.2 History of the flight111111111.2 Injuries to persons 141.3 Damage to the aircraft 141.4 Other damage 141.5 Personnel information 141.5.1 Commander1.5.2 First officer1.5.3 Cabin attendant1.5.4 Air traffic controller (TWR)1.5.5 Air traffic controller (DEP)1.5.6 Training, examinations and certification1.5.6.1Pilot training in the former Soviet Union at the Krementschug flying school1.5.6.2Training of the crew of flight CRX 4981.5.6.2.1 Commander1.5.6.2.2 First officer141516161617171818201.6 Aircraft information 231.6.1 Aircraft HB-AKK1.6.1.1General1.6.1.2Left engine1.6.1.3Right engine1.6.1.4Left propeller1.6.1.5Right .2 Mass and centre of gravity1.6.3 Flight controls1.6.3.1Control and control forces1.6.3.1.1 Background information1.6.3.1.2 Findings on the aircraft involved in the accident1.6.3.2Flap system1.6.3.3Control blockage1.6.3.4Gust lock warning1.6.3.5Disconnect handle1.6.4 Engines and propellers1.6.4.1Left-hand engine1.6.4.2Right-hand engine1.6.4.3Propellers1.6.4.4Summary1.6.5 Cockpit configuration1.6.5.1General1.6.6 Flight guidance systems1.6.6.1Electronic flight instrument system (EFIS)1.6.6.1.1 Electronic instrument displays1.6.6.1.2 Description of the system1.6.6.1.3 EFIS failure after switching on the logo lightsAircraft Accident Investigation 29293030303031page 3/117
Final Report CRX 498Ve 15.04.041.6.6.2Automatic flight system (AFS)1.6.6.2.1 Description of the system1.6.6.2.2 Presentation of the flight director1.6.6.2.3 Investigation of the mode select panel1.6.6.2.4 Use of the automatic flight system1.6.6.3Flight management system (FMS)1.6.6.3.1 Description of the system1.6.6.3.2 Installation1.6.6.3.3 Certification1.6.6.3.4 Training1.6.6.3.5 Operating experience1.6.6.3.6 Maintenance1.6.6.3.7 Navigation database1.6.6.3.8 Misleading navigation1.6.6.3.9 Use of the FMS1.6.6.4Other navigation equipment1.6.6.4.1 VOR displays1.6.6.4.2 Air data system1.6.7 Bank angle warning system1.6.8 Ground proximity warning system1.6.9 Performance of the aircraft1.6.10Maintenance of the aircraft1.6.10.1 Maintenance records1.6.10.2 Procedures in the metalwork shop1.6.11Examination of the fuel 43431.7 Meteorological information 441.7.1 General weather situation1.7.2 Weather at Zurich airport1.7.3 Weather in the region of the accident1.7.4 Pilots' .4.4Precipitation1.7.4.5Temperature on the ground1.7.4.6Observations on icing1.7.5 Icing1.7.5.1Air temperature1.7.5.2Atmospheric humidity1.7.5.3Liquid water content of the cloud1.7.5.4Drop size distribution1.7.5.5Upwind speed1.7.5.6Icing in clouds with precipitation1.7.6 Turbulence4445454646464646464646474747474748481.8 Aids to navigation 481.8.11.8.21.8.3Relevant navigation systems 48Constellation of the GPS satellites 48Radar equipment and radar displays 491.9 Communications 491.9.11.9.21.9.31.10ATC involved 49Recordings of conversations 49Communications equipment 49Aerodrome information 491.10.11.10.21.10.3General 49Runway equipment 50Rescue and fire-fighting services 50Aircraft Accident Investigation Bureaupage 4/117
Final Report CRX 4981.11Ve 15.04.04Flight recorders 501.11.1Digital flight data recorder (DFDR)1.11.1.1 Technical description1.11.1.2 Specific parameters1.11.1.3 Maintenance and monitoring1.11.1.4 Position recording of the right-hand aileron1.11.2Cockpit voice recorder (CVR)1.11.2.1 Technical description1.11.2.2 Maintenance1.11.3Reading the flight data recorders1.11.4CVR communication1.12Wreckage and impact information 531.12.11.12.21.12.31.12.41.13ImpactInitial findings at the site of the accidentDebris fieldSalvage operations53535353Medical and pathological information 541.13.1Commander1.13.1.1 History and medical findings1.13.1.2 Medical forensic findings1.13.2First officer1.145050505151525252525354545457Fire 571.14.11.14.2Investigation of traces of fire among the aircraft wreckage 57Results of interrogation of eye witnesses 571.15Survival aspects 571.16Tests and research 571.16.1Investigations related to electromagnetic interference (EMI)1.16.2Investigation of the flaps1.16.3Comparison flights1.16.4Ergonomics and crew workload1.16.5Intercultural aspects1.16.5.1 Aircraft instrumentation1.16.5.1.1 Artificial horizon1.16.5.1.2 Compass1.16.5.1.3 Bank angle warning1.16.5.2 Cockpit procedures1.16.5.3 Crew resource management (CRM)1.16.5.4 l and management information 641.17.1Operator1.17.1.1 General1.17.1.2 Structure1.17.1.2.1 Pilot selection1.17.1.2.2 Selection procedure for direct entry commanders1.17.1.2.3 Selection procedure for first officers1.17.1.3 Terms of employment1.17.1.4 Working climate1.17.1.5 Rolls Royce Germany audit1.17.1.6 Maintenance quality system1.17.1.7 Reporting system1.17.1.7.1 AMOS1.17.1.7.2 Occurrence report1.17.1.7.3 Reliability reporting1.17.1.7.4 Special reporting1.17.2Regulatory authority1.17.2.1 General1.17.2.2 StructureAircraft Accident Investigation Bureau646464646464656666676767676768686868page 5/117
Final Report CRX 498Ve 15.04.041.17.2.3 Re-organization 681.17.3Crossair's relations with the regulatory authority 691.18Additional information 691.18.1Training equipment1.18.1.1 Overview1.18.1.2 Flight simulator1.18.1.2.1 Certification1.18.1.2.2 Installation of the FMS1.18.1.3 FMS trainer1.18.2Artificial horizons in the former eastern block1.18.3Program for retraining pilots for deployment on international routes with western aircraft1.1926969696970707071New investigation techniques 71Analysis 732.1 Technical aspects 732.1.1 Flight guidance system2.1.1.1Electronic flight instrument system (EFIS)2.1.1.1.1 Reliability2.1.1.1.2 Availability during flight CRX 4982.1.1.2Auto flight system (AFS)2.1.1.2.1 Reliability2.1.1.2.2 Availability during flight CRX 4982.1.1.3Flight management system (FMS)2.1.1.3.1 Reliability2.1.1.3.2 Availability during flight CRX 4982.1.2 Other avionics equipment2.1.2.1Air data system2.1.2.1.1 Reliability2.1.2.1.2 Availability during flight CRX 4982.1.2.2Ground proximity warning system (GPWS)2.1.3 Flight controls2.1.3.1Flaps system2.1.4 Engines and propellers2.1.5 Maintenance2.1.6 Electromagnetic interference (EMI)2.1.7 878782.2 Human and organizational aspects 782.2.1 Flight crew2.2.1.1Commander2.2.1.1.1 Career2.2.1.1.2 Pilot training and training specific to his profession2.2.1.1.3 Training2.2.1.1.4 Language knowledge2.2.1.1.5 Social background2.2.1.1.6 Psychological aspects2.2.1.1.7 Medical aspects2.2.1.2First officer2.2.1.2.1 Pilot training and training specific to his profession2.2.1.2.2 Social background2.2.1.2.3 Psychological aspects2.2.1.2.4 Medical aspects2.2.2 The flight crew environment2.2.2.1Social environment2.2.2.2General pilots’ environment2.2.2.2.1 Procedures2.2.2.2.2 Times of flying duty2.2.2.2.3 Language and communication2.2.3 The Crossair airlineAircraft Accident Investigation ge 6/117
Final Report CRX 498Ve tion procedure for leased direct entry commanders2.2.3.4Selection procedure for first officers2.2.3.5Working climate2.2.4 Regulatory authority8787878787882.3 Operational aspects 882.3.1 History and analysis of the flight 882.3.2 Division of tasks 972.3.3 Analysis of actions 982.3.4 Error management 992.3.5 Crew resource management (CRM) 1002.3.6 Cockpit configuration 1012.3.6.1Ergonomics 1012.3.6.2Control and control forces 1012.3.6.3Electronic instrument displays 1022.3.6.4Flight director 1022.3.7 Cockpit procedures 1022.3.7.1General 1022.3.7.2Unusual attitudes 1022.3.8 Air traffic services 1033Conclusions 1043.1 Findings 1043.2 Causes 1074Safety recommendations and safety actions taken 1084.1 Safety recommendations relating to technical and operational aspects 1084.1.1 Operation of the flight management systems (FMS) 1084.1.1.1Safety deficiency 1084.1.1.2Findings 1084.1.1.3Analysis 1084.1.1.4Safety recommendation 1084.1.1.5Opinion of the Federal Office for Civil Aviation (FOCA) (Bundesamt für Zivilluftfahrt – BAZL) 1084.1.2 Procedure for programming the flight management system (FMS) 1094.1.2.1Safety deficiency 1094.1.2.2Findings 1094.1.2.3Analysis 1094.1.2.4Safety recommendation 1094.1.2.5Opinion of the Federal Office for Civil Aviation 1094.1.3 Use of the autopilot 1094.1.3.1Safety deficiency 1094.1.3.2Findings 1094.1.3.3Analysis 1104.1.3.4Safety recommendation 1104.1.3.5Opinion of the Federal Office for Civil Aviation 1104.1.4 Harmonization of departure procedures with Saab 340B operating procedures 1104.1.4.1Safety deficiency 1104.1.4.2Findings 1104.1.4.3Analysis 1104.1.4.4Safety recommendation 1114.1.4.5Opinion of the Federal Office for Civil Aviation 1114.2 Safety recommendations regarding human and organizational aspects 1114.2.1 Transfer of foreign pilots’ licences4.2.1.1Safety recommendation4.2.1.2Opinion of the Federal Office for Civil Aviation4.2.2 Validation of licences which were not issued under JAR-FCL4.2.2.1Safety recommendationAircraft Accident Investigation Bureau111111111111111page 7/117
Final Report CRX 498Ve 15.04.044.2.2.2Opinion of the Federal Office for Civil Aviation4.2.3 Validation of foreign medical certificates4.2.3.1Safety recommendation4.2.3.2Opinion of the Federal Office for Civil Aviation4.2.4 Employment of foreign pilots with validated licences4.2.4.1Safety recommendation4.2.4.2Opinion of the Federal Office for Civil Aviation4.2.5 Clarification of aptitude for crew members4.2.5.1Safety recommendation4.2.5.2Opinion of the Federal Office for Civil Aviation4.2.6 Training and crew pairing4.2.6.1Safety recommendation4.2.6.2Opinion of the Federal Office for Civil Aviation4.2.7 Training and induction of direct entry commanders4.2.7.1Safety recommendation4.2.7.2Opinion of the Federal Office for Civil 1141144.3 Safety actions taken 114Glossary 115Annexes 1-9Aircraft Accident Investigation Bureaupage 8/117
Final Report CRX 498Ve 15.04.04Final ReportOperator:Crossair Limited Company for Regional EuropeanAir Transport, CH-4002 BasleAircraft type and version:Saab r:Cinderella Aviation LLC, Isle of Man, U.K.Place of the accident:Au, community of Nassenwil ZHSwiss co-ordinates:677 850/258 250Latitude:N 47 28’ 12”Longitude:E 08 28’ 17”Elevation:424.25 m/M1392 ft AMSLDate and time:10 January 2000 at 16:56:27.2 UTCSynopsisBrief presentationOn 10 January 2000, at 16:54:10 UTC, in darkness, on runway 28 of Zurich airport, the Saab340B aircraft of the Crossair airline company, registered HB-AKK, began its scheduled flightCRX 498 to Dresden. Two minutes and 17 seconds later, after a right-hand spiral dive, the aircraft crashed on an open field near Au, Nassenwil ZH.The ten occupants (three crew members and seven passengers) were fatally injured by the impact. The aircraft was destroyed. A fire broke out and there was damage to farmland.InvestigationThe accident occurred at 16:56:27.2 UTC. The Swiss air rescue service (REGA) alerted the dutyservice of the Swiss Aircraft Accident Investigation Bureau (AAIB) (Büro für Flugunfalluntersuchungen – BFU) at 17:05 UTC. The investigation was opened on 10 January 2000 at 20:15UTC in cooperation with the Zurich cantonal police.The Swiss AAIB set up an investigation group to investigate air accidents of a catastrophic nature involving large aircraft.Aircraft Accident Investigation Bureaupage 9/117
Final Report CRX 498Ve 15.04.04According to Annex 13 to the Convention on International Civil Aviation (ICAO Annex 13) theStates of Manufacture of the aircraft have the option of delegating accredited representatives tothe investigation. Both Sweden as the State of Manufacture of the aircraft and the United Statesof America as the Country of Manufacture of the eng
Interstate Aviation Committee, Russia Institute of aviation medicine of the Swiss Air Force Meteo Schweiz AG Moldavian Airlines Moldavian Civil Aviation Authority National Transportation Safety Board, USA Rockwell-Collins Inc. RUAG Aerospace Russian Civil Aviation Authority Saab Airc
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