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Investigation Report of the Aircraft Accident Investigation Bureau

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Investigation Report of the Aircraft Accident Investigation Bureau Federal Department of Environment, Transport Energy and Communications No. u1793 Investigation Report of the Aircraft Accident Investigation Bureau on the accident to aircraft AVRO 146-RJ100, HB-IXM, operated by Crossair under flight number CRX 3597, on 24 November 2001 near Bassersdorf/ZH This report has been prepared for the purpose of accident/incident prevention. The le- gal assessment of accident/incident causes and circumstances is no subject of the ac- cident investigation (Art. 24 Air Navigation Law). The language of the valid formulation of this report is German. Within 30 days after receipt of the investigation report, any person giving proof of a well-founded interest in the investigation result may request the report to be examinated by the Review Board (Eidg. Flug- unfallkommission – EFUK) for completeness and conclusiveness. Bundeshaus Nord, CH-3003 Berne Investigation report CRX 3597 Ve 23.01.04 Table of contents Brief presentation........................................................................................................10 Investigation ...............................................................................................................11 1 Factual information ..........................................................................13 1.1 Prior history and history of the flight ..........................................................13 1.1.1 Prior history...................................................................................................................13 1.1.1.1 Aircraft .....................................................................................................................13 1.1.1.2 Flight crew ................................................................................................................14 1.1.1.2.1 Commander ........................................................................................................................ 14 1.1.1.2.2 Copilot ................................................................................................................................ 14 1.1.2 History of the flight ........................................................................................................14 1.1.2.1 Flight preparation ......................................................................................................14 1.1.2.2 The flight from Berlin-Tegel to Zurich ..........................................................................15 1.2 Injuries to persons.......................................................................................19 1.3 Damage to the aircraft.................................................................................19 1.4 Other damage ..............................................................................................19 1.5 Personnel information .................................................................................19 1.5.1 Commander...................................................................................................................19 1.5.1.1 Professional training...................................................................................................20 1.5.1.2 Pilot training and activity ............................................................................................20 1.5.1.2.1 First conversion course to aircraft type MD 80 ....................................................................... 22 1.5.1.2.2 Second conversion course to aircraft type MD 80................................................................... 22 1.5.1.2.3 Conversion course to aircraft type Avro RJ 85/100................................................................. 22 1.5.1.3 Activity as flight instructor ..........................................................................................24 1.5.1.4 Particular incidents during his professional career .........................................................24 1.5.1.4.1 General............................................................................................................................... 24 1.5.1.4.2 Unintentional retraction of the landing gear on the ground..................................................... 24 1.5.1.4.3 Aborted route check ............................................................................................................ 25 1.5.1.4.4 Cessation of activity as training captain................................................................................. 25 1.5.1.4.5 Night-time instrument approach to Lugano ........................................................................... 25 1.5.1.4.6 Navigation error during a private sight-seeing flight............................................................... 25 1.5.1.5 Working and management behaviour ..........................................................................26 1.5.2 Copilot ..........................................................................................................................27 1.5.2.1 Professional training...................................................................................................28 1.5.2.2 Pilot training..............................................................................................................28 1.5.2.3 Selection of the copilot by the Crossair operator ...........................................................28 1.5.2.4 Conversion course to aircraft type Avro RJ 85/100........................................................28 1.5.2.5 Particular incidents during his professional career .........................................................29 1.5.3 Cabin attendant A ..........................................................................................................29 1.5.4 Cabin attendant B ..........................................................................................................29 1.5.5 Cabin attendant C ..........................................................................................................30 1.5.6 Air traffic control officer A ...............................................................................................30 1.5.7 Air traffic control officer B ...............................................................................................30 1.5.8 Air traffic control officer C ...............................................................................................31 1.5.9 Air traffic control officer D...............................................................................................31 1.5.10 Air traffic control officer E ...............................................................................................31 1.6 Aircraft information .....................................................................................31 1.6.1 Aircraft HB-IXM..............................................................................................................31 1.6.1.1 General.....................................................................................................................31 1.6.1.2 Engine number 1 .......................................................................................................32 1.6.1.3 Engine number 2 .......................................................................................................32 1.6.1.4 Engine number 3 .......................................................................................................33 1.6.1.5 Engine number 4 .......................................................................................................33 Aircraft Accident Investigation Bureau Page 2/145 Investigation report CRX 3597 Ve 23.01.04 1.6.1.6 Auxiliary power unit ...................................................................................................33 1.6.1.7 Navigation equipment ................................................................................................33 1.6.1.8 Communications equipment........................................................................................34 1.6.2 Mass and centre of gravity..............................................................................................34 1.6.3 Aircraft control...............................................................................................................34 1.6.3.1 Primary aircraft control...............................................................................................34 1.6.3.2 Secondary aircraft control...........................................................................................35 1.6.4 Engines.........................................................................................................................35 1.6.4.1 Visual inspection........................................................................................................35 1.6.4.2 Analysis of the digital flight data recorder and engine life computer data ........................35 1.6.4.3 Oil indicator installation ..............................................................................................35 1.6.5 Auxiliary power unit........................................................................................................35 1.6.5.1 Visual inspection........................................................................................................35 1.6.5.2 Maintenance documentation .......................................................................................36 1.6.6 Ice detection system ......................................................................................................36
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