Incident Overview

Date: Monday 10 January 2000
Aircraft Type: Saab 340B
Owner/operator: Crossair
Registration Number: HB-AKK
Location: near Nassenwil, 1.5 km W of Zrich-Kloten Airport – ÿ Switzerland
Phase of Flight: En route
Status: Destroyed, written off
Casualties: Fatalities: 10 / Occupants: 10
Component Affected: Flight Management System (FMS) ? specifically the command execution and monitoring of the SID ZUE 1Y command.Flight Management System (FMS) ? specifically the command execution and monitoring of the SID ZUE 1Y command.
Investigating Agency: BFU Switz.BFU Switz.
Category: Accident
At 17:00, a Saab 340 HB-AKK, departing Zurich, landed at Dresden, Germany, following a flight from Guernsey. The aircraft was cleared for a standard instrument departure SID ZUE 1Y, which involved a climb straight ahead heading 280 and a left turn to cross overhead the airport at the KLO VOR, followed by a heading of 054ø onto airway R234 to the Zurich East (ZUE) beacon. The crew, upon receiving the SID ZUE 1Y clearance, executed a standard climb, then a left turn to intercept the KLO VOR, and then continued to the ZUE beacon. However, during the climb, the pilot initiated a command to ZUE, which was not properly monitored or checked by the captain. The command was subsequently performed by the pilot alone, without proper oversight. Subsequently, the captain initiated a right turn, a standard action for Flight Director commands. The aircraft entered a cloud layer, experiencing a right roll, reaching a right bank angle of 65.8ø. The pilot advised a left turn, which the Zurich departure controller noted, prompting a re-clear. The aircraft subsequently descended rapidly, entered a high-rate spiral descent, and crashed in an open field. The incident was attributed to a collision with the ground, resulting from a loss of control by the flight crew, triggered by the inappropriate handling of the departure clearance and a failure to properly monitor the command.At 17:00, a Saab 340 HB-AKK, departing Zurich, landed at Dresden, Germany, following a flight from Guernsey. The aircraft was cleared for a standard instrument departure SID ZUE 1Y, which involved a climb straight ahead heading 280 and a left turn to cross overhead the airport at the KLO VOR, followed by a heading of 054ø onto airway R234 to the Zurich East (ZUE) beacon. The crew, upon receiving the SID ZUE 1Y clearance, executed a standard climb, then a left turn to intercept the KLO VOR, and then continued to the ZUE beacon. However, during the climb, the pilot initiated a command to ZUE, which was not properly monitored or checked by the captain. The command was subsequently performed by the pilot alone, without proper oversight. Subsequently, the captain initiated a right turn, a standard action for Flight Director commands. The aircraft entered a cloud layer, experiencing a right roll, reaching a right bank angle of 65.8ø. The pilot advised a left turn, which the Zurich departure controller noted, prompting a re-clear. The aircraft subsequently descended rapidly, entered a high-rate spiral descent, and crashed in an open field. The incident was attributed to a collision with the ground, resulting from a loss of control by the flight crew, triggered by the inappropriate handling of the departure clearance and a failure to properly monitor the command.

Description

At 17:00 Saab 340 HB-AKK arrived at Zurich, Switzerland following a flight from Guernsey. The aircraft was then prepared for Crossair flight 498 to Dresden. Germany. Taxi clearance was given at 17:50 and the crew taxied to runway 28. The crew expected to be cleared for a standard instrument departure SID ZUE 1Y. This procedure calls for the aircraft to climb straight ahead heading 280 and then make a left turn to cross overhead the airport at the KLO VOR and then assume a heading of 054ø onto airway R234 to the Zurich East (ZUE) beacon. At 17:54 the aircraft was cleared for takeoff. Takeoff and climb were conducted with flaps at 0 degrees, which is normal for a Saab 340 departing from runway 28. The aircraft climbed normally at 136 knots IAS. After retracting the gear the Flight Director was switched on. While climbing through 2500 feet QNH the crew switched to Zurich Departure Control and were recleared to climb to FL110. At 17:55 the crew were cleared to make a left turn to intercept airway R234. A left turn was initiated, during which the first officer entered a command in the Flight Management System (FMS) to ZUE. The command “direct to (DTO) – left – ZUE” however was programmed only as “direct to – ZUE”. The programming was performed by the first officer alone, without the prescribed monitoring and checking by the captain. The latter was absorbed in manually flying the aircraft. After having turned left for 7 seconds the captain started a right turn, consistent with Flight Director commands generated by the FMS for a ‘direct to ZUE’ as the right hand turn was the shortest. In clouds the aircraft continued a right roll, which at 17:56:14 reached a right bank angle of 65.8ø. The first officer advised the captain that the aircraft should actually turn to the left. This was also noted by the Zurich departure controller at 17:56:20, who asked the crew about the direction of the turn. The first officer replied: “Moment please, stand by”. Upon which the Departure controller recleared the flight to continue the right turn direct to ZUE. By then the pitch had also decreased rapidly, accompanied by a marked speed increase and the Saab entered a high speed high-rate spiral descent. At 17:56:28 the aircraft crashed in an open field. Weather reported included temperature 2deg C; dew point 1deg C; 1032 mB wind WNW/3 knots and light drizzle. CAUSES: “The accident is attributable to a collision with the ground, after the flight crew had lost control of the aircraft for the following reasons: – The flight crew reacted inappropriately to the change in departure clearance SID ZUE 1Y by ATC. – The co-pilot made an entry in the FMS, without being instructed to do so by the commander, which related to the change to the SID ZUE 1 standard instrument departure. In doing so, he omitted to select a turn direction. – The commander dispensed with use of the autopilot under instrument flight conditions and during the work-intensive climb phase of the flight. – The commander took the aircraft into a spiral dive to the right because, with a probability bordering on certainty, he had lost spatial orientation. – The first officer took only inadequate measures to prevent or recover from the spiral dive. The following factors may have contributed to the accident: – The commander remained unilaterally firm in perceptions which suggested a left turn direction to him. – When interpreting the attitude display instruments under stress, the commander resorted to a reaction pattern (heuristics) which he had learned earlier. – The commander’s capacity for analysis and critical assessment of the situation were possibly limited as a result of the effects of medication. – After the change to standard instrument departure SID ZUE 1Y the crew set inappropriate priorities for their tasks and their concentration remained one-sided. – The commander was not systematically acquainted by Crossair with the specific features of western systems and cockpit procedures.”

Source of Information

http://www.skybrary.aero/index.php/SF34,_vicinity_Zurich_Switzerland,_2000http://www.skybrary.aero/index.php/SF34,_vicinity_Zurich_Switzerland,_2000

Primary Cause

Inappropriate handling of departure clearance, specifically the failure to properly monitor and check the pilot’s command to ZUE, leading to a lack of oversight and a single-pilot execution of a command without proper coordination.Inappropriate handling of departure clearance, specifically the failure to properly monitor and check the pilot’s command to ZUE, leading to a lack of oversight and a single-pilot execution of a command without proper coordination.

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