Flight 3597 Plunges Into A Hillside | Cockpit Failure | FULL EPISODE | Mayday: Air Disaster

[Music] cross air flight 3597 is cruising at 27 000 feet above germany as the autopilot flies the plane the crew begins reviewing procedures for their landing according to the report the apron and taxiways are wet breaking action is not specified so the friction report is missing uh indeed that usually means they haven't been out to check lately indeed [Music] it's the last flight of the day on this busy european route the 660 kilometer journey from berlin south to zurich takes only an hour and a half there are many empty seats on board a group of 21 passengers never showed up for the flight internet entrepreneur peter hogenkamp is returning from a business trip in germany with his partner jacqueline badran on that day we wanted to take the train but we had to be in zurich for that opening ceremony of that trade show so we decided okay so we need to go by by plane we have got to get some sleep it had been a very busy day so we were very tired when we arrived at the airport among the passengers is the girl band passion fruit germany's answer to the spice girls they're on their way to perform the last show of a concert tour i was shocked when suddenly all the passion fruits all the three of them were coming over and they were sitting right in front of us just what i needed flight 3597 is an avro 146 airliner it's a british-made jet popular with regional airlines like crossair captain hans ulrich lutz is in command he's been with the airline for more than 22 years having served as a pilot and as an instructor so tell me about the runway and the conditions uh overcast with light snowfall visibility first officer stefan lehrer is a newcomer to the airline he's had his pilot's license for just a year and a half he was hired by cross air right out of flight school the passion fruits were being quite noisy they were excited i think they went from one gig to the other so they were still in their stage clothes i said oh my god do i really need this can i just sleep [Music] it's probably okay to move we decided to move back a few rows and and change the side where we were sitting so we were in a very quiet area then the flight is slightly behind schedule it's due to land in zurich in less than half an hour according to the latest information we'll be using runway 14. what kind of approach uh uh ils approach okay an ils or instrument landing system approach means the pilots will be guided to the runway by radio signals beamed from the airport and a decision altitude of 1600 feet call me a hundred above minimums okay i'll call 100 above minimums the plane's sophisticated computers will do most of the work getting them down at zurich airport the weather is getting worse it's snowing and visibility is dropping cross air 3191 turn left heading 150. in the tower controllers have started a nightly routine a supervisor sends out a message notifying crews that runway 14 is being taken out of service because of a controversial new law planes landing on runway 14 must fly over germany on their approach but people in germany have long complained about the noise because of the political issue airplanes had to fly over switzerland in their final descent to the airport of zurich for noise reasons [Applause] there was no other operational or weather reasons whatsoever it was purely political switzerland has agreed to shut down runway 14 after 10 pm to keep landing planes out of german airspace and use runway 28 instead the crew hasn't received this information yet but first officer lehrer is familiar with the new rule should i ask if it's still runway 14 it it's almost 10 o'clock yes i'm pretty sure it's still 14. zurich approach crosshair 3597 please confirm the approach in use is the ils 14. crosshair 3597 you're identified it will be a v-o-r-d-m-e approach runway 2-8 for you hell what next okay fine unlike runway 14 with its sophisticated instrument landing system runway 28 is not equipped for ils landings instead it has a less accurate navigational system it's called vor dme a radio beacon sends information to an aircraft about its distance from the runway and whether it's left or right of it it provides no guidance on the plane's altitude pilots would rather not make vor approaches because they place a greater workload on the flight crew he would always prefer an eyeless approach because he gets guidance on the approach slope and he can also use his autopilot to guide him down literally on ground to the runway because of its less precise technology runway 28 was rarely used for landings before the new noise law okay then rebriefing for runway 28 that will be chart 13-2 now captain lutz abandons the ils approach he was planning and prepares his first officer for the new non-precision approach are you familiar with the 28 approach yes i've done it a couple of times the crew goes over every detail of how they will approach zurich airport zurich east 6000 feet there are only a few planes left to land tonight including flight 3597 and two other cross air flights just ahead of it as the aircraft approach the runway controllers need to keep them apart crosshair 3597 reduce speed to 180 or less speed 180 or last crosshair 3597 captain lutz makes the final turn to line his jet up with the runway 160 knots the plane is now in the thick of the heavy weather surrounding zurich at the airport the second last crosshair flight touches down on runway 28. now with only flight 3597 to land the supervisor decides to head home early the controller handling the aircraft is the only controller left in the tower crosshair 3597 continue speed reduction to final approach speed she gets a report from the plane that just landed visibility approaching 28 was borderline we could only see the runway from 1.3 miles out but captain lutz knows zurich airport well he continues towards the runway gear down the plane begins the final stage of its approach cabin crew prepare for landing captain lutz begins slowing the jet and puts it into a steep descent miles is checked yes flaps three three flaps three three selected final check final check confirmed three greens is checked 116 knots the descent gets even steeper full flaps set check flight 3597 is about three minutes from the runway captain lutz it to come into view any second now uh 100 above do we have ground contact yes passengers prepare themselves for landing we were pretty close to the airport so you think okay this is going smoothly but it was dark and it was snowing so we couldn't see anything in the tower the controller monitors the flight to make sure it's lined up with the runway air 3597 cleared to land runway two eight two four the minimum two four the flight has hit decision height 2400 feet above sea level 1000 feet above the ground near zurich decision height is the minimum height you can descend before you need to decide whether you can see the runway and continue the approach visually or you have to make a decision to go around i have ground contact we're continuing on still can't see the runway lights but knows that the flight ahead of him had the same problem damn he said he's other runway 1.3 miles they should almost be on top of the runway by now but for some reason they still can't see it they could go around crosshair 3597 the crew decides to abort the landing go around go around and pushes the plane to its limits in an effort to get it to climb captain lutz throttles up his planes four jet engines as he aborts his landing at zurich airport but it's too late there's not enough time for the engines to get to full power and clear a tree covered hills suddenly looming dead ahead residents of a nearby village witnessed flight 3597's final moments i was walking down with my dog all of a sudden i saw that aircraft coming from behind the forest the little hill and i thought oh it's very it's very low and it's not on the same route as aircrafts normally are coming to land at the airport of surrey the jet clips the treetops suddenly it was it was shaking very hard what's happening something is wrong moments later the aircraft plunges into the hillside crosshair 3597 this is zurich tower do you copy crosstail 3597 this is zurich tower do you copy all of a sudden the whole sky in the west was getting really orange like a big fire like an explosion the impact tears the aircraft apart the wings broke off and the fuel is in the wings so the flames really sort of shot inside the plane this is zurich tower do you copy this is eric tower we have a possible emergency and approach sector east i repeat approach sector east cross air flight 3597 has crashed near the village of bassersdorf northeast of zurich some people have survived the accident including peter hogan camp and jacqueline badran i don't have any any memory of how we really walked out because the the bag was cut off and and we were just able to to walk out there one member of passionfruit also survives but her two bandmates seated just one row ahead of her have been killed i i thought you know when they give you these instructions in the beginning when you get on the plane how come they never tell you how far you have to run away from a burning plane because they never tell you get away from here so we thought i don't know 100 meters within minutes emergency workers get to the crash site [Music] 24 of the 33 people on board flight 3597 are dead including captain lutz and first officer stefan lehrer daniel connect an investigator from switzerland's aircraft accident investigation bureau arrives at the scene i got the call from our rescue service about half past 10 in the evening half an hour later i was on the accident side the rear part of the fuselage was quite intact it was also the region where most of the survivors step out without injury for peter hogenkamp and his partner it appears that moving to the rear of the plane saved their lives i think it was just good luck i think it would have been a whole different story if we wouldn't have changed seeds so the passion fruits may have saved our lives while rescuers care for the survivors connect and his team survey the crash site the location of the wreckage far from the airport is of interest to the investigators four kilometers and 50 meters the aircraft was not where he was intended to be he collided with a hill east of of runway 28 so obviously he was too low and the first question was why was this aircraft too low the black box flight recorders are found in the wreckage they're in good condition [Music] investigators are well aware that this is the worst aviation disaster on swiss territory in over a decade they're under pressure to find answers fast while work continues at the crash a command post is established nearby jean overnight heads the swiss investigation bureau he takes charge of the cross air file the public was very anxious about this crash the media were raising many questions so we naturally had to open a more in-depth investigation [Music] the accident happened at the end of a long day for captain lutz but given his background investigators must consider other causes we knew that the captain was very experienced he had about 17 000 flight hours during his old career flight instructor flight examiner within the company for more than 20 years the flight recorders are sent to a lab in paris to extract their data at the same time investigators have begun retrieving fragments of wreckage from the crash site they look for telltale signs of trouble the position of switches is very important also if you have some indication panels for example with bulbs in it you can after a crash you can analyze the different wires in the bulbs and then you can determine which for example indications or even warnings were active at the moment of the impact an investigator comes across an intriguing piece of wreckage oil gauges provide information about the oil flowing to the plane's four turbofan engines curiously one of them is installed upside down this raised a lot of questions for us and for the media everyone wanted to know how you could fly a plane with an instrument installed upside down it wasn't a very important instrument you could still read it even if it was installed upside down but if this obvious problem was never fixed what else could be wrong with the plane obviously there were maintenance issues here we looked at how the company was doing the maintenance of the planes while this review is being launched investigators study the plane's engines to determine if they were running at the time of the crash soil tree branches and other debris lodged inside the engines suggest they were we checked them out visually and we saw that the four engines were turning in the moment of the accident authorities need to be sure they will have to check their findings against data from the flight recorders in the meantime the location of the crash suggests something may have tragically misled the crew on their descent towards zurich airport connect focuses on the flight charts they use to plan their approach is the problem with the approach or is the problem with the aircraft this kind of question was dominant when we started the investigation are you familiar with the 28 approach yes i've done it a couple of times the approach chart provides pilots with directions to the runway details about radio frequencies as well as altitudes and speed for various stages of the landing when investigators study an approach chart like the one the crew used they make a shocking discovery the chart does not show the hill that the plane hit an approach chart is a very important thing because an indication which is not correct on this approach chart could mislead a crew and so easily make them do something wrong so tell me about the runway and the conditions uh overcast with light snowfall a faulty chart would certainly have been a danger to a crew unfamiliar with zurich airport but lutz had flown in and out of zurich countless times he and his first officer were both based in the city the commander was flying out of zurich i think for the last 15 to 20 years so he was really used to this airport investigators conclude that the approach chart while faulty could have tripped up some crews but not this one some definitive news finally arrives the engine data from the black box confirms the observations at the crash site we could see quite easily that the engines worked absolutely normally another potential cause of the accident is eliminated from the list mechanical failure investigators now consider a different possibility i was covering the approach west position on the night of the accident could air traffic control have somehow mishandled the plane investigators study records from the night of the accident and make a disconcerting find zurich airport's control tower was understaffed at the time of the accident he left before his shift ended the supervisor in the tower went home early leaving a lone controller to guide flight 3597 in for its landing she was relatively young and let's say she didn't have that much experience investigators now study transcripts of conversations between that air traffic controller and the flight crew looking for signs she made a mistake crosshair 3597 you're identified crosshair three feet speed one eight zero four left two eight free right there three times approach they find no indication the controller gave the crew faulty instructions but they do come across the radio call by the pilot of the crosshair flight that landed minutes earlier this is crosshair 3891 visibility approaching 28 was borderline we could only see the runway from 1.3 miles out that pilot warned of poor conditions on the approach to runway 28. she had options they wonder why the controller didn't shut the runway down because of poor visibility she could have reopened runway 14 in spite of the noise bylaw this would have allowed the crews to make an instrument approach but she didn't do that thank you crosshair 3891 have a good evening it would have been much easier to fly alice approaches in this kind of vet regardless of this political issue it's suspected that without her supervisor present the controller lacked the experience to make such an important call so it's clear that to make the decision not to allow an approach on runway 28 and instead make it on runway 14 demanded a certain kind of confidence a certain kind of courage a certain determination however captain lutz also heard the same warning was borderline we could only see the runway from 1.3 miles out gear down he kept going in spite of it investigators are now certain that the controller was in no way responsible the pilot can always say no he can always recheck the clearance if he thinks that landing is probably not possible he is free to reject and approach clearance and ask for a different one jean overnight can't understand why captain lutz didn't do exactly that he should have known that he didn't have to make a non-precision approach in bad weather when we saw the mistake the pilot had made we immediately asked ourselves well how's it possible because for an experienced pilot who was an instructor this was a really basic mistake overnigh is beginning to wonder if something in lutz's long career is hiding clues about his behavior on the night of the accident one by one investigators are ruling out the possible causes of the crash of cross air flight 3597 they hope the answer lies in the cockpit voice recorder or cvr of the doomed jet after waiting many days for its data to be sent back from france final check they now pour over it carefully listening for any clues that might explain why the plane was flying so close to the ground so far from the airport authorities get more than they expected not only is the cvr complete but captain lutz offers a running commentary on everything he does and on inbound track 275 speed is checked flaps 18. it's practically a road map to understanding what went on in the cockpit that's not usual that the pilot flying is uh talking so much about what he is doing or what he is seeing and for the investigation this helped a lot 100 above do we have ground contact uh yes investigators learned that the crew of flight 3597 was looking for the runway and believed it would soon come into view from the cvr we saw that the commander and also his co-pilot were not feeling some fear or feeling that something was not going as they planned but what they didn't know was that the plane was actually four miles shy of its target damn he said he saw the runway 1.3 miles 300. captain lutz obviously thought his jet was closer to the runway than it was investigators consider the possibility he was misled by his distance measuring equipment or dme it's supposed to tell pilots how far they are from the airport the enemy indication would have given this distance and then he would have detected immediately damn that he was below the approach class perhaps the dme from flight 3597 was faulty it's been recovered from the wreckage but it's impossible to tell what information it gave the pilots however there is another way to check whether the instrument was functioning or not the dme distance is not recorded on the fdr but on two occasions the pilots mentioned the distance six miles is checked yes but was captain lutz really six miles out from the runway when he made that report investigators compare the time lutz checked his dme with radar data on the aircraft's location at that exact same time they can see that when lutz's instruments were telling him he was six miles out that's precisely where he was so we knew that the pilots had an indication for the distance available at that time an instrument problem can now be crossed off the list as a factor in the crash which only heightens the mystery i have ground contact we're continuing on if the instrument was working why did lutz think he was closer to the runway than he actually was the answer lies not in what investigators hear on the cockpit voice recorder but what they don't hear i don't see anything after six months do we have ground contact neither pilot read out a dme check after the six mile reading yes it tells investigators that lutz wasn't monitoring his vital instrument during the final minutes of his approach instead he was preoccupied with spotting the lights of the runway that's not what pilots are supposed to do the pilot flying is supposed to keep his eyes on the instruments because all the information he needs is there he only switches to flying by sight when the non-flying pilot says run away in sight only then can the captain take his eyes off the instruments and fly by sight because the landing is performed visually if lutz had checked his instruments he would have known how far from the runway he actually was but how had he ended up such a long distance from it confirmed three greens 400 is checked 116 further analysis of the black box data reveals that lutz put his plane into a steep descent as it began its final approach to zurich airport but it's readily apparent his approach profile was out of sync with the trajectory laid out in his chart the approach profile for runway 28 calls for pilots to make a gradual and steady descent which would bring them to 2400 feet after they've cleared the hills around zurich then pilots have to level off until they spot the runway when investigators compare the approach lutz made with the approach profile he was supposed to follow they find that his overly steep descent brought him to 2400 feet well before he cleared the hills then he continued to descend until he hit the ground it's beginning to look like lutz had violated one of the cardinal rules of flying aircraft making non-precision approaches are supposed to level off at minimum descent altitude or safe height until they have the runway in view this safe height is intended to keep the aircraft above any potential hazards it's really a basic error every pilot is trained to respect such minimums not only with vor dme approaches but also with ils approaches but captain lutz kept his aircraft in a steep descent without even pausing at 2400 feet the logical next question for investigators could he see the runway or not i have ground contact we're continuing on what does he mean by ground contact they need to know if it was even possible for lutz to see the runway when he reported ground contact they retrace his steps in a simulator programmed with the weather he was facing that night [Music] six miles from runway altitude 3300 feet 4.8 miles 2400 feet still no runway in sight no he couldn't see the runway because there was a hill between him and the runway and at that altitude there's no way he could see it the conclusion captain lutz had clearly violated his minimum descent altitude whether there is flat terrain or hills minimums are are are set accordingly and in no way you can just bust the minimums whether there's hills or not this discovery raises questions not just about lutz's actions but his young first officers as well 2-4 the minimum 2-4 we're continuing on a first officer should not let his captain reach minimum descent altitudes the co-pilot could have said no stop we can't see the runway we're not descending he considered his captain an old pilot with a lot of experience not making any mistakes most probably he was trusting him too much and also by being a submissive maybe he wouldn't speak up on time just to keep harmony in the cockpit there were no mechanical failures or instrument problems with the plane nor was the air traffic controller negligent in any way but it is now clear that captain lutz made a series of catastrophic piloting errors that doomed flight 3597 and claimed the lives of 24 people investigators dig deeper into captain hans ulrich lutz's flying record to see if there's anything in his long background that could explain why he crashed flight 3597 [Music] what they discover is truly alarming lutz applied to flight school when he was 17 years old he was rejected three times because of his lack of education he finally got his license at the age of 20 but continually failed exams to upgrade due to his inadequate comprehension of navigation systems captain lutz may have had a long career but it was not a stellar one years of flying and flying hours don't say anything about competence for some reason though his record as a below average pilot didn't prevent cross air from hiring him in 1979 there was a red line through his career where several incidents happened before and he had missed several checks well he had some limits but what's hard to understand for me is that they were identified and decision was made made to keep him flying captain lutz's limited abilities continued in his new job while commanding a sightseeing tour of the swiss alps he made a navigation error and ended up in italy he only realized his mistake when his passengers spotted road signs in italian in another incident he wrecked a one and a half million dollar aircraft after inadvertently retracting the landing gear while the plane was still on the tarmac lutz's failures forced cross air to fire him as an instructor but they allowed him to continue flying passenger planes i personally do pilot assessments and he would never have gone through my assessment with a positive recommendation okay approach course one three investigators wonder why crosshair allowed lutz to stay on as a pilot if he was not entirely competent the answer appears to be they may have had little choice investigators first glimpse into the problems at crossair came after they found the upside down gauge at the crash site [Music] we had to check if the employees had received the proper training if they had the qualifications required for this kind of work no glaring maintenance issues were found but a closer look at crosstail's hiring practices explains why captain lutz was allowed to keep flying the airline may have grown too fast throughout the 80s and 90s the company expanded very rapidly and with that success it's clear that you have to quickly increase the staff office workers mechanics that's one thing but pilots you have to go out and find them in those days they were desperate for pilots and somehow no decision was made to lay him off because of his questionable performance during his career captain looks his failings caught up with him on november the 24th 2001. they can go around go around 24 people paid with their lives after the accident report was issued sweeping changes were made swiss aviation authorities had cross air increase the number of employees overseeing pilots they also scrutinized other airlines to determine if there were other substandard performers like lutz [Music] one thing is for sure that selection process has improved considerably and of course awareness of people's performance during their career was increased considerably cross air went out of existence in 2002 it was folded into the swiss national carrier as the crosstalk became swiss they adopted the previous research selection process and i can say today which is already nine years since that safety has improved considerably and also quality of of the pilots that are hired by companies like swiss since the crash of flight 3597 zurich's runway 28 has been upgraded with both an instrument landing system and an automatic warning that alerts controllers when a plane's approach is too low there has never been another accident involving that runway but the crosshair tragedy and the circumstances that spawned it isn't an isolated case regional airlines have boomed worldwide since the 1980s particularly in the united states where they account for half of all flights and carry 100 million passengers a year in the rush to fulfill consumer demand for cheap air travel these airlines often hire less experienced pilots and pay them far lower salaries than their counterparts at major carriers some even neglect to test their pilots for basic skills there is no such thing as a compulsory pilot assessment before they get hired does not exist in february of 2009 one of its planes crashed in buffalo new york killing 50 people the accident was blamed on the actions of an inexperienced crew an eerie reminder of the cross air disaster it underlined the urgency of improving oversight of smaller carriers there's if you're making a product for a large company and you make a mistake you may lose part of the market you may lose some clients but an airline company can lose a plane its crew and passengers the stakes are very different [Music] you

Channel: Mayday: Air Disaster

Views: 113,225

Keywords: Mayday Air Disaster, Mayday Air Disaster YouTube Channel, Mayday Air Disaster TV Series, Plane Crashes documentary, where to watch air crash investigation, where to watch plane crashes, boeing crash, mayday air disaster streaming, where can i see mayday, mayday full episodes, worst plane crashes, Mayday season 10 episode 1, Mayday season 10 episode 1 cockpit failure, flight 3597 crash, what caused flight 3597 to crash?, crossair flight 3597 air crash investigation

Id: CRXeS-rQyY4

Length: 43min 42sec (2622 seconds)

Published: Fri Sep 03 2021