Büro für Flugunfalluntersuchungen Bureau d’enquête sur les accidents d’aviation Ufficio d’inchiesta sugli infortuni aeronautici Uffizi d'investigaziun per accidents d'aviatica Aircraft accident investigation bureau 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 Bundeshaus Nord, CH-3003 Berne Final Report HB-IXM (CRX 3597) General remarks to this report In accordance with the agreement on International Civil Aviation (ICAO Annex 13) the sole objec- tive of the investigation of an accident or incident shall be the prevention of accidents and inci- dents. It is not the purpose of this activity to apportion blame or liability. According to art. 24 of the Swiss Air Navigation Law the legal assessment of accident/incident causes and circumstances is no concern of the investigation. The masculine form is used exclusively in this report regardless of gender for reasons of data pro- tection. If not otherwise stated, all times in this report are indicated in universal time coordinated (UTC). At the time of the accident, the Central European Time (CET) was valid for the area of Switzerland. This CET was equal to the local time (LT). The relation between LT, CET and UTC is: LT = CET = UTC + 1 h. The german-language version of this report is authoritative. The Aircraft Accident Investigation Bureau (AAIB) of Switzerland would like to thank the authori- ties and other organizations for the given support throughout the investigation Aircraft Accident Investigation Bureau Page 2 of 146 Final Report HB-IXM (CRX 3597) Table of contents Brief presentation........................................................................................................11 Investigation ...............................................................................................................12 1 Factual information ..........................................................................14 1.1 Prior history and history of the flight ..........................................................14 1.1.1 Prior history...................................................................................................................14 1.1.1.1 Aircraft .....................................................................................................................14 1.1.1.2 Flight crew ................................................................................................................15 1.1.1.2.1 Commander ........................................................................................................................ 15 1.1.1.2.2 Copilot ................................................................................................................................ 15 1.1.2 History of the flight ........................................................................................................15 1.1.2.1 Flight preparation ......................................................................................................15 1.1.2.2 The flight from Berlin-Tegel to Zurich ..........................................................................16 1.2 Injuries to persons.......................................................................................20 1.3 Damage to the aircraft.................................................................................20 1.4 Other damage ..............................................................................................20 1.5 Personnel information .................................................................................20 1.5.1 Commander...................................................................................................................20 1.5.1.1 Professional training...................................................................................................21 1.5.1.2 Pilot training and activity ............................................................................................21 1.5.1.2.1 First conversion course to aircraft type MD 80 ....................................................................... 23 1.5.1.2.2 Second conversion course to aircraft type MD 80................................................................... 23 1.5.1.2.3 Conversion course to aircraft type Avro RJ 85/100................................................................. 23 1.5.1.3 Activity as flight instructor ..........................................................................................25 1.5.1.4 Particular incidents during his professional career .........................................................25 1.5.1.4.1 General............................................................................................................................... 25 1.5.1.4.2 Unintentional retraction of the landing gear on the ground..................................................... 25 1.5.1.4.3 Aborted route check ............................................................................................................ 26 1.5.1.4.4 Cessation of activity as training captain................................................................................. 26 1.5.1.4.5 Night-time instrument approach to Lugano ........................................................................... 26 1.5.1.4.6 Navigation error during a private sight-seeing flight............................................................... 26 1.5.1.5 Working and management behaviour ..........................................................................27 1.5.2 Copilot ..........................................................................................................................28 1.5.2.1 Professional training...................................................................................................29 1.5.2.2 Pilot training..............................................................................................................29 1.5.2.3 Selection of the copilot by the Crossair operator ...........................................................29 1.5.2.4 Conversion course to aircraft type Avro RJ 85/100........................................................29 1.5.2.5 Particular incidents during his professional career .........................................................30 1.5.3 Cabin attendant A ..........................................................................................................30 1.5.4 Cabin attendant B ..........................................................................................................30 1.5.5 Cabin attendant C ..........................................................................................................31 1.5.6 Air traffic control officer A ...............................................................................................31 1.5.7 Air traffic control officer B ...............................................................................................31 1.5.8 Air traffic control officer C ...............................................................................................32 1.5.9 Air traffic control officer D...............................................................................................32 1.5.10 Air traffic control officer E ...............................................................................................32 1.6 Aircraft information .....................................................................................32 1.6.1 Aircraft HB-IXM..............................................................................................................32 1.6.1.1 General.....................................................................................................................32 1.6.1.2 Engine number 1 .......................................................................................................33 1.6.1.3 Engine number 2 .......................................................................................................33 1.6.1.4 Engine number 3 .......................................................................................................34 1.6.1.5 Engine number 4 .......................................................................................................34 Aircraft Accident Investigation Bureau Page 3 of 146 Final Report HB-IXM (CRX 3597) 1.6.1.6 Auxiliary power unit ...................................................................................................34 1.6.1.7 Navigation equipment ................................................................................................34 1.6.1.8 Communications equipment........................................................................................35 1.6.2 Mass and centre of gravity..............................................................................................35 1.6.3 Aircraft control...............................................................................................................35 1.6.3.1 Primary aircraft control...............................................................................................35 1.6.3.2 Secondary aircraft control...........................................................................................36 1.6.4 Engines.........................................................................................................................36 1.6.4.1 Visual inspection........................................................................................................36