Summary:
On November 24, 2001, as winter weather conditions worsened, the pilots of Crossair Flight 3597 struggled to visually locate the airport runway on final approach to Zurich. And when faced with a crucial decision to continue or abandon the approach, the captain chooses to keep going. In our latest episode of Take to the Sky: The Air Disaster Podcast, join Shelly as we explore if the captain made the right call and how what happened on Flight 3597 became a microcosm for larger problems within the global regional carrier industry.Listen, Review, and Subscribe on:
Read the Story!
Expand the text below to read more about this episode.On November 24, 2001, Crossair Flight 3597, with 33 people onboard crash landed in the hills outside of Zurich International Airport. In episode 111 of Take to the Sky: the Air Disaster Podcast, we discuss how the captain of the flight, Hans Ulrich Lutz, while preparing for a non-precision approach to runway 28, put the plane into a steeper descent than was laid out on the approach chart for the runway and incorrectly assumed the aircraft was closer to the airport than it actually was. His assumption was based on a previous report by pilots of another Crossair jet that landed just before Flight 3597. Based on that radio communication from that flight crew, Captain Lutz mistakenly thought his aircraft was closer to the runway than it was. Ultimately, Lutz realized his mistake and tried to perform a go-around, but because of the steep descent he had put the aircraft into, it was too late. Flight 3597 crashed into the hills, killing all but 9 of the people onboard. The Swiss AAIB investigation uncovered a long history of pilot errors on the part of Captain Lutz, proving that regional carriers like Crossair had felt compelled to keep pilots like Lutz on staff to keep up with consumer demand despite the danger that such pilots posed to passengers. Following the crash, pilot hiring practices across regional carriers improved, and runway 28 at the airport in Zurich was upgraded with an ILS.
Crossair Flight 3597 Heads Back to Zurich One Last Time on November 24, 2011
On the night of November 24, 2001, Crossair Flight 3597 makes yet another journey from Zurich International Airport to Berlin. This route between the two cities is one of the most popular for Crossair, and the flight crews who command these flights often find themselves traversing back and forth several times a day.
This happens to also be true for the flight crew on this day. While passengers will disembark the aircraft for Berlin, and new passengers will board the plane now headed back to Zurich, so, too, will this same flight crew. The commander is Captain Hans Ulrich Lutz, and he will be flying the aircraft this leg. He has been with Crossair for over 20 years, both as a pilot and instructor, with almost 20,000 flight hours. His first officer is 25-year-old Stefan Löhrer, who was hired right out of flight school by Crossair and who has less than 500 total hours. As the first officer is the non-flying pilot, he will be responsible for, among other things, radio communications with air traffic control throughout the flight. The captain and first officer are also joined by three flight attendants. Their aircraft is an AVRO 146 RJ 100 jet, which is a British-made aircraft and one that is popular with regional airlines.
Soon, twenty-eight passengers and 23 pieces of luggage are checked in for Flight 3597. Though 49 passengers were expected to board, a group of 21 travelers never made it to the plane. The remaining 28 passengers boarded the aircraft and found they had many empty rows to themselves. These passengers included American pop singer Melanie Thornton and the Eurodance group Passion Fruit, who had been touring and were on their way to a show in Zürich.
Twenty minutes later, Flight 3597 took off into darkness toward Zurich for one last time, and soon reaches its cruising altitude of 27,000 feet (or 8200 m) over the airspace in Germany. For most of the 90-minute flight, things were completely standard, and thankfully, very uneventful.
Crossair 3597 Preapres to Make Non-Precision Approach into Zurich on Runway 28
When Flight 3597 is about 30 minutes from landing at Zurich, air traffic control (or ATC) clears them to descend toward 16,000 feet (or 4900 m), and the flight crew prepares for landing by going over the approach briefing, which will be an ILS approach to runway 14. As we know, when a plane makes an ILS (or instrument landing system) approach, it means the pilots will be guided to the runway by radio signals and much of their workload will be carried out by the plane.
But, there is a unique factor that will change their approach into Zurich. About a month previously, authorities in Switzerland and Germany signed an agreement to address the concerns of residents in southern Germany who had complained about the noise of airliners landing in Zürich late at night. Consequently, the approaches to runways 14 and 16 — the two main runways at Zürich Airport — both passed over German villages at relatively low altitude, so the two countries agreed that between 10:00 p.m. and 6:00 a.m., all airplanes landing in Zürich would use runway 28, which would route planes over Swiss territory. This change was purely for political reasons and not in any way for operational decisions. In fact, before this rule change, runway 28 was rarely used for landings.
The pilots know they are landing between those designated timeframes when this rule would apply, so First Officer Löhrer confirms with ATC they are landing at runway 28 and not 14, which ATC confirms.
Here is another aspect that will impact their approach. Runway 14, which was typically where they would land, has an ILS, but runway 28 has a VOR/DME system. On a VOR , or non-precision approach, pilots must manage their descent and altitude manually. This is because the VOR sends a signal to the plane about where the plane is relative to the runway but does not offer guidance around descent or altitude minimums along the flight path. For this guidance, pilots will gradually descend along a series of minimum published altitudes on an approach chart. Then, as a plane approaches its final segment of the approach, it will reach what is known as its MDA (or minimum descent altitude). Obviously, as we can all imagine, one of the biggest downsides to a non-precision approach is that it places more work on the pilots.
And to make things worse for the workload of the pilots flying Flight 3597, at Zurich, snow is getting worse, and visibility is decreasing. The flight crew begins to focus on preparing for the non-precision approach to runway 28 and go over every step they will take.
Crossair 3597 Pilots Struggle to Find Runway Lights in Nighttime Weather
Captain Lutz makes the final turn to line up with the runway, and this places the aircraft further into the thickness of the heavy weather surrounding Zurich. But Flight 3597 is not alone in the skies that night, nor is it the only plane making a non-precision approach to runway 28. In fact, right before them is another Crossair jet that has just landed. The flight crew of that plane reported that while they had landed successfully, the weather conditions were near the minimum visibility thresholds, and the pilots only saw the runway from 1.3 miles (2.09 km) out. The crew of 3597 can hear this broadcast, too, and this information gives them a data point for what they could expect on their approach.
Captain Lutz puts the plane into a final and steep descent toward the airport, a rate of descent equal to about 1200 feet (or 365 m) per minute. Based on where the pilots of the other Crossair jet reported being able to see the runway, Captain Lutz expects to see the runway lights at any moment. But the lights haven’t come into view yet, which frustrates and puzzles the captain.
Crossair 3597 Passes Through its MDA and Captain Decides to Continue with Approach
Minutes later, as they continue to descend, Flight 3597 reaches its minimum decision altitude (or MDA), which was 2400 feet (or 730 m) above sea level and 1000 feet (or 304 m) above ground. This altitude is the minimum height they can descend to before a pilot would need to decide whether they can see the runway and continue with the approach or perform a go-around.
Captain Lutz confirms they have reached their minimum decision altitude and tells the first officer, “I have ground contact, we’re continuing at the moment…we have ground contact, we’re continuing on.” This remark means that the captain is continuing with the approach as planned, even though the airport is not in sight.
As the runway fails to come into view, Captain Lutz continues to get even more frustrated. Ten seconds after deciding to continue past the MDA, he says, “Scheisse, two miles he said, he sees the runway!” First Officer Löhrer continues to call out their altitude, which is decreasing rapidly due to the plane’s steep descent.
Moments later, the ground proximity warning system informs the pilots them that they have reached their pre-set minimum radio height of 300 feet (or 91 m) above the ground. And yet, still no runway in sight. Things were going very, very wrong.
At last, Captain Lutz seemed to finally understand what needed to be done when he said, “Make a go around?” Two seconds later, he made his decision. “Go around,” both pilots said in unison. The captain pushed the throttles to go-around power and pulled up to abandon the approach. Little did he know it was already too late. There was simply not enough time for the engines to get to full power and get above what was now streaming right toward their aircraft: a forest.
Crossair 3597 Crashes into Hillside Miles from Zurich Airport, Killing All But 9 People
There are accounts of what happened next. On the ground below, Franz Brunner was out walking his dog when he noticed that the plane looked lower than usual. And then he watched in disbelief as it clipped the tops of trees along the forest’s edge before disappearing further into the darkness.
Here is what we know happened onboard. Two seconds after applying go-around power, just as the plane began to level off, flight 3597 smashed into a tree-covered ridge that stuck up into the clouds. Tree trunks ripped through the right wing, causing its engines to fail. Upon impacting the trees, the fuel tank burst, and a stream of fuel erupted into a ball of fire as the plane continued to rip through the forest.
The plane skidded another 656 feet (or 200 m), and as it did, the two right side engines and the right-hand wing hit the ground. With this first impact with the ground, the entire airframe kicked up and rolled. In the process, the aircraft broke into several parts with the tail section left mostly intact, and most of the middle section of the plane burst into fire.
But let’s go back to the tail section for a moment because this is where we have the only bright spot in our story: this is where the survivors made it out alive. In the final report, some of the survivors’ words have been captured, and they describe what happened during the crash sequence.
Crossair 3597 Survivors Share Accounts of Sudden Crash and Escape from Fire
A passenger in seat 16F said, “Suddenly there was a thud...On the right side I noticed a fireball outside the aircraft. Up to that moment I thought everything was going normally. Then it rumbled and jolted like a roller coaster. Suddenly, it went quiet”. A passenger in seat 10A said, “Then there was a sudden crash, and a fireball came at us at great speed from the nose”. A passenger in seat 14B said, “...suddenly a loud crashing noise could be heard, and the aircraft shook violently. I immediately looked forward and saw through the open cockpit door and the cockpit windscreens that outside the aircraft a real shower of sparks was rising. Next moment there was a massive impact…”.
Passenger Peter Hogenkamp has since gone on to do many interviews in the press about his experience on Flight 3597. When he first boarded the plane, he wasn’t sitting near the back. He and his partner Jacqueline Badran only moved further back into the cabin once the band Passion Fruit became so noisy that they wanted to get away from it. It was a decision that saved their lives.
Myriam Wettstein was one of the lucky handful who also made her way out of the burning aircraft. As the plane was crashing down, Myrian put her head into her knees. Once the plane stopped, the only escape route was through a hole in the back of the plane. Of that moment, she recounted, “I had no time to be scared. I was just very cold. I thought, ‘I have to get out of here, the plane can explode.” Wettstein told of a harrowing effort to get out of the burning plane amid her fellow passengers’ screams, many of whom could not escape the fiery crash.
Peter Hogenkamp’s partner, Jacqueline Badran, said that when the plane hit the ground, she immediately undid her safety belt. In front of her, everything was burning. Then she turned and realized the only way out was through the back of the tail section, where she saw the ground and jumped out.
Nine survivors in total made it out alive. 24 of the 33 people onboard Flight 3597 did not. Among the victims were both Captain Lutz and First Officer Löhrer and one flight attendant, along with American pop singer Melanie Thornton and two of the three members of the Eurodance group Passion Fruit, who had been on their way to a gig in Zürich. Several of those who survived also suffered serious injuries, including Passion Fruit singer Debby St. Maarten, who still required weekly medical care more than a decade after the crash — effectively ending her music career.
Swiss AAIB Rules Out Several Contributors of Crossair 3597 Crash
Before morning, members of Switzerland’s AAIB investigative team is onsite to begin its investigation. Based on the location of the crash, and the fact that the plane had been flying so low to the ground so far away from the airport, investigators believe there may have been a problem encountered while on approach to the airport.
Over the next several months, the AAIB rules out several key contributors:
The pilots’ approach chart did not show the hill that the plane collided with. However, because both pilots had flown this route many times before, investigators did not believe this exclusion on the chart contributed to the crash.
An oil gage was installed upside down but was still readable. While the fact that the instrument was installed incorrectly was concerning, investigators said it did not confuse the pilots.
Engine failure is ruled out as well as mechanical failure.
Factors involving ATC are also ruled out, though investigators did find ATC was understaffed that night with only one controller left to guide in Flight 3597. They also found that had the controller shut down runway 28 after hearing from the first Crossair jet that they could only see the runway 28 from 1.3 miles out, the disaster likely would have been avoided. But her supervisor had left, and this controller did not have the experience or confidence to shut that runway down.
After ruling out so many contributors, investigators are left with a central question: why did Captain Lutz keep going with the approach if he also had the same information as the controller?
AAIB Determines Crossair 3597 Captain Thought Runway Closer Than it Was
Listening to the cockpit voice recorder (or CVR), investigators gain a full picture of what was happening during the approach. First, they hear that the crew were looking for the runway and not able to see it. Second, they can hear the crew calling out the aircraft’s distance from the runway as they got closer and closer, but then the pilots stop calling out distance after a certain point.
When Captain Lutz thought he had reached the point where the previous flight said they saw the runway — that is, 1.3 miles out, they were actually 4.8 miles (7.7 km) from the runway. This is because their excessive rate of descent led them to reach the minimum descent altitude (or MDA) earlier in the approach than Captain Lutz had anticipated.
And here is what is at the heart of the error: the captain did not check his distance measuring equipment (or DME) to confirm how far out they were. The pilots were so focused on trying to find the airport, that they were no longer paying attention to how far from the airport they actually were. If the captain had checked the DME, he would have known he was further away from the airport than he thought he was.
AAIB Finds Crossair 3597 Captain Put Plane into Too Steep of a Descent
Third, as the plane approached the airport, Captain Lutz put the plane into a steep descent. But his approach was not aligned with the recommended step downs laid out in the approach chart, which called for pilots to make a steady and gradual descent toward runway 28. Following this chart would have ensured that the plane only descended to 2400 feet (decision height) after it cleared the steep hills. At that point, they would level off until they see the runway. When investigators compare the approach by the captain and the one laid out in the chart, they find the captain’s steep descent put them at 2400 feet well before they ever cleared the hills. The captain failed to follow a key rule of flying: aircraft making non-precision approaches are supposed to level off at a minimum safe height until they have the runway in view. Instead, he didn’t even pause at 2400 feet, and instead, put the plane into a descent.
And lastly, when Captain Lutz says he has “ground contact”, it should have meant that he could see the airport, but the only thing he could see were the lights from the villages below. The captain should have abandoned the approach and asked for another way into the airport due to low visibility.
The AAIB also noticed that the first officer never spoke up against the captain when the captain began to break the minim descent rule. Investigators believe that the first officer was either too intimidated by the captain or too trusting of the captain.
AAIB Investigation Uncovers History of Pilot Errors on the Part of Crossair 3597 Captain
The captain’s flying record is examined to see if anything in his historical performance would have indicated he could make these kinds of mistakes. The AAIB finds a series of professional issues throughout his career, including failing proficiency checks, having inadequate comprehension of procedure and flight performance, and incorrect usage of navigational systems. And very specifically, he had a history of coming in too steeply and quickly during night landings.
One of the worst or egregious ones was during a sightseeing flight in 1999 on its way to Sion, Switzerland, when he flew into Italy by mistake and only noticed his error when the passengers began to see street signs in Italian and notified the crew. Some of these incidents were never reported by the copilots of those flights until they had been interviewed because of the fatal accident of Flight 3597.
But Crossair did know about several incidents, including a mistake that cost the airline millions. In one of those, Captain Lutz inadvertently retracted the landing gear while the aircraft was still on the tarmac. He was instructing his copilot on the procedure for remedying a landing gear retraction fault. The captain thought that on the ground, with the landing gear under load, the retraction mechanism would not work, as is the case, for example, with smaller aircraft. However, it did. The captain pressed the down lock release button, which overrode the safety device, and the copilot brought the landing gear lever to the retract position. The aircraft completely collapsed and impacted on the ground and was a total loss. The captain suffered a head injury while several others who were in and around the aircraft were uninjured. The incident was investigated by the airline, which led to them firing him as an instructor, but they kept him on as a flying pilot.
The AAIB concluded that because Crossair grew too fast for its own good, this made them keep on pilots that perhaps should not have been kept on – they were desperate to keep their pilots staffed so they could keep up with consumer demand.
After Crossair 3597 Crash, Changes Made to Pilot Hiring Practices and Zurich Runway Safety
Following the accident, many changes were made. Crossair was required to hire additional staff to oversee and assess the performance of pilots. Crossair eventually declared bankruptcy in 2002 and was absorbed by Swiss International Air Lines, which absorbed Crossair’s assets after the filing. Despite the airline’s eventual fate, many experts believe that because of this fatal accident, pilot hiring practices were absolutely improved across many European regional airlines.
And the notorious runway 28 at Zurich airport was upgraded with an ILS and automated warnings that tell a pilot when a plane’s approach is too low. Flight 3597 was the last crash on that runway.
Perhaps the biggest takeaway from the crash of Flight 3597 is that for a system like commercial air travel to work, there must be consumer confidence in airlines to put the right person in the cockpit. And while there have been few accidents with regional carriers in the last 10 years, a story like that of Crossair 3597 reminds us again that in those worst-case scenarios from the past, passengers have paid with their lives when airlines don’t take measures to ensure the right person is flying us to our next destination. And that is a lesson we don’t want to learn again.
And THAT is the frustrating story of the unnecessary crash of Crossair Flight 3597.
Show Notes:
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Credits:
Written and produced by: Shelly Price and Stephanie HubkaDirected and engineered at: Snow Monster Studios
Sound editor: Podcast Engineers
Producer: Adam Hubka
Music by: Mike Dunn