La "storia aviatoria" del pilota (estratto del report svizzero sull'incidente)
Pilot training and activity
At age 17, the commander applied for preliminary pilot training (Fliegerische Vorschulung
– FVS). He failed the first entry exam. An application for renewed permission to
take the 1963 entry examinations and two applications in 1965 were rejected by the
institute of aviation medicine of the Swiss Air Force with reference to a lack of educational
qualifications.
During professional training, the commander began training on gliders and singleengine
aircraft. The pilot’s licence for gliders was issued by the Federal Aviation Office
on 17 August 1963, and the licence for private pilots on 19 February 1964. The commander
then participated in a theory course for instrument rating and the professional
pilot’s licence. After the corresponding training, on 12 April 1966 he obtained the extension
for aerobatics and on 16 August 1966 the professional pilot’s licence.
In spring 1966 the commander passed the aptitude test for piston engine flight instructor
and after the corresponding course and practical experience of about six months
duration, on 31 January 1967 he was promoted with the authorisation to train private
pilots.
Between 1967 and 1970 the commander worked intensively as a VFR flight instructor
for private pilots. During this time he increased his visual flight rules flying experience
from about 200 to more than 2000 flight hours.
From 1965 to 1970 he converted successfully to six other aircraft types; five of these
aircraft types were used predominantly for visual flying.
Instrument flight training commenced in 1966, but the special instrument rating was
not granted until 10 July 1969, because the complementary theoretical examinations
and the practical examination were failed several times between 1967 and 1969. The
experts from the Federal Aviation Office complained in particular about inadequate
comprehension and incorrect use of navigation systems. The examination to acquire
the instrument rating was passed with the grading “average”.
From then until 1979 the commander regularly flew charter flights on Cessna 337 and
Cessna 414 aircraft types for various operators. In autumn 1972 the commander was
allowed to participate in a Federal Aviation Office IFR flight instructor’s course. Subsequently
he regularly trained students outside of Crossair in instrument flying up to the
time of the accident.
The periodic instrument flying checks between 1969 and 1979 were generally passed
with the gradings “average”. The respective experts occasionally criticised the fact that
checklists were not used consequently, that procedures were not complied with and
that navigation instruments were not used appropriately. These assessments also related
to his work as a flight instructor.
On 28 January 1979 the commander applied for the position of pilot with Crossair. No
documentation on checking of his aptitude is available. In spring 1979 the commander
undertook a conversion course at Flight Safety International to the SA 226 TC Metroliner
II used by Crossair at that time. On 5 April 1979, with a total flying experience of
4490 flying hours, he passed the type rating examination with the grading “below average
– average”.
From 15 June 1979 to 31 August 1979 the commander worked as a freelance pilot in
addition to his regular duties, and between 1 September 1979 and 31 May 1982 he
was employed full-time by Crossair. In spring 1981 the commander converted from aircraft
type SA 226 TC Metroliner II to the SA 227 AC Metroliner III. He was employed
as commander, flight instructor, route check pilot and expert. Furthermore he was
deputy chief pilot for the company. During the same time he was still registered in the
flight operations manual (FOM) of three airlines as a flight instructor and pilot. At his
own request he left Crossair on 31 May 1982. The commander’s flying performance
was assessed by Crossair as above average.
From 1 June 1982 to 31 May 1991 the commander worked under seven freelance contracts
for Crossair. On 12 August 1987 the commander obtained the type rating for the
Saab 340. From 1 June 1991 to 31 December 1993 he was employed on an 83% parttime
basis by the airline. From 1 January 1994 up to the time of the accident, the
commander was working 100% for Crossair. Since 11 September 1981 he also had a
part-time employment contract with the Horizon Swiss Flight Academy flying school as
a flight instructor.
First conversion course to aircraft type MD 80
In 1993 and 1994 the commander was assessed three times for conversion to the aircraft
British Aerospace 146 “Jumbolino”. For various reasons he was not referred for
conversion and the commander continued to fly the Saab 340.
In the course of 1995 the commander was designated for conversion to the MD 80 aircraft
type. No selection procedure or aptitude check took place. The conversion course
began on 2 January 1996 and shortly after the beginning of simulator training the
commander experienced problems reaching the required performance levels. Two additional
simulator sessions were therefore offered to him. Even after these training sessions
there remained gaps in comprehension and coordination. Since his learning progress
was too slow, it was decided to abort the conversion course and to allow the
commander to make another attempt to convert to the MD 80 aircraft type after a few
months.
A deeper analysis of the reasons for failing the conversion course did not take place.
The commander was subsequently requalified on the Saab 340 aircraft type and employed
on scheduled traffic.
Second conversion course to aircraft type MD 80
On 24 June 1996 the commander was able to begin a second conversion course to the
MD 80. Before this course, no aptitude check took place. In the second simulator session
it became apparent that the commander was having major problems with the MD
80’s digital flight guidance system (DFGS) and this had a major impact on his overall
performance. When the difficulties became even greater after the fourth simulator session,
an additional simulator exercise was carried out. One additional exercise was
planned after the following regular simulator session and after the eighth training respectively.
On 15 August 1996 the commander failed the type rating check at the end of the conversion
course. The inadequacies concerned, among other things, the manual control
of the aircraft and a deficient systematic approach to the use of the flight guidance
system; a limited ability to analyse and to take decisions at the appropriate time was
also noted.
Afterwards, the commander was once again requalified on the Saab 340 and from 1
September 1996 was again employed on scheduled services. No performance check
and no more detailed examination of the reasons for the repeated failure of the conversion
course took place.
Conversion course to aircraft type Avro RJ 85/100
As early as 1993 and 1994 the commander was discussed for conversion to the Avro
RJ 85/100 aircraft type. This conversion did not take place, for various reasons. After
the failed attempts to convert to the MD 80, the commander continued to be employed
was being envisaged and Crossair attempted to find another aircraft type which the
commander could fly in the future. The commander, who wished to fly until aged 65,
again applied for the MD 80. Since at that time there was no need of pilots for the MD
80 aircraft type, conversion to this type was out of the question. It was decided to
convert the commander to the Avro RJ 85/100. The relative simplicity of this aircraft
type was cited by the responsibles of the airline as a reason for this decision.
Prior to the conversion to the Avro RJ 85/100, the commander was not subject to any
aptitude checks. The chief flight instructor of the Avro RJ 85/100 indicated that he was
not aware that the commander had already had two unsuccessful attempts at conversion
to another jet aircraft.
On 6 May 2001 the commander began conversion to the Avro RJ 85/100 aircraft type.
On 28 May 2001 a first part of the proficiency check was carried out. Because of a
simulator failure, the rest of the check had to be completed on 4 June 2001 on another
simulator. Route introduction under supervision ended on 22 June 2001 with a line
check after 20 sectors. On 24 October 2001 the commander passed the last semi annual
recurrent check as a proficiency check. On the corresponding checkforms, only
positive comments from the experts are to be found concerning the commander’s performance.
During the proficiency and line check as well as during the line-introduction
under supervision, no mistakes were pointed out and no items were mentioned that
the commander could have improved.
During assignment to the Avro RJ 85/100 aircraft type, the following exercises in relation
with non-precision approaches were carried out in the cockpit procedure mockup
(CPM), in simulator training (SIM) and during the subsequent checks.
Date Training Number and type of approaches
26.04.2001 CPM lesson 5 2 non-precision approaches
04.05.2001 CPM lesson 8 1 non-precision approach
12.05.2001 SIM lesson 1 1 VOR approach Zurich
13.05.2001 SIM lesson 2 1 VOR approach Geneva
14.05.2001 SIM lesson 3 2 NDB approach Stuttgart
20.05.2001 SIM lesson 5 1 LOC/DME circling approach
1 VOR approach Milan-Linate
25.05.2001 SIM lesson 9 2 NDB approaches Basel
28.05.2001 proficiency check 1 VOR approach Zurich
10.07.2001 CDR type rating line check 1 standard VOR/DME approach 28 Zurich
29.10.2001 Semi annual recurrent check 1 LOC/DME approach Zurich
on the Saab 340. In the course of the year 2000, decommissioning of the Saab 340
During route training under supervision, no non-precision approaches were flown. During
his training on the Avro RJ 85/100 aircraft type, therefore, the commander carried
out 14 non-precision approaches as pilot flying. Among those was one standard
VOR/DME approach 28 in Zurich in the simulator and one approach in the aircraft.
Activity as flight instructor
The commander was employed as flight instructor by the Horizon Swiss Flight Academy
for over 20 years. He was mainly assigned as an instructor for future professional pilots
seeking for instrument rating. At his request, he carried out the training almost exclusively
on aircraft and hardly ever used the simulator.
On 22 September 1992 the commander was designated by the Federal Office for Civil
Aviation as an expert for the acceptance of flying examinations for achieving instrument
rating. Four years later, on 13 August 1996 the commander additionally received
authorisation for flying examinations according to visual flight rules.
From 1990 to 1993 he was employed as an instructor on FOCA courses for the training
of instrument flight instructors.
In autumn 1998 the commander took part in the FOCA’s VFR piston engine flight instructor
refresher course for two weeks in order to obtain his teaching authorisation for
visual flight rules, which had expired on 15 December 1986.
Since the introduction of JAR-FCL 1 between 1999 and 2002, flight instructors have to
pass periodically a proficiency check in order to get certain ratings renewed. Each flight
instructor at the Horizon Swiss Flight Academy had to undergo a proficiency check for
multi-engined aircraft with piston engines on the school’s own simulator. As, according
to several statements, the commander did not hold simulators in particularly high esteem,
this proficiency check was carried out on the aircraft instead.
On 28 April 2000 the commander made two training flights as flight instructor with the
copilot of the aircraft involved in the accident. At this time the copilot was in the process
of acquiring his professional pilot’s licence with instrument rating.
As shown on the flight activity records, the commander occasionally made training
flights in the morning and then flew several sectors on the same day as an air transport
pilot. On 13 November 2001, for example, between 06:00 UTC and 13:00 UTC the
commander made four flights with two student pilots. He then flew two sectors with
Crossair and went off duty after 13 hours and 34 minutes. Neither the Crossair airline
nor the Horizon Swiss Flight Academy carried out any supervision of flying time and
rest time across different companies.
Particular incidents during his professional career
General
As the investigation showed, various incidents occurred during the commander’s professional
career between 1967 and the time of the accident. Only the most important
events are dealt with below; they occurred during his employment with the Crossair
company and some of them became known only after the accident.
Unintentional retraction of the landing gear on the ground
On 21 February 1990 the commander, as instructor, carried out a system training on
the Saab 340 aircraft type with a copilot onboard the aircraft HB-AHA. The discussion
turned to the procedure for remedying a landing gear retraction fault. The commander
was of the opinion that on the ground, with the landing gear under load, the function
of the retraction mechanism was interrupted, as is the case, for example, with smaller
aircraft. Actually, however, the corresponding safety device of the Saab 340 only prevented
operation of the landing gear lever. The commander pressed the down lock release
button, which overrode the safety device and the copilot brought the landing
gear lever to the retract position. Contrary to the commander’s assumption, the hy
draulic pumps began to work and the retraction process could not be interrupted. The
aircraft impacted on the ground and was a whole loss. The commander suffered a
head injury whilst the other persons who were in and around the aircraft were uninjured.
The incident was investigated by the airline and the commander was subsequently no
longer employed as an instructor. This event had no further effects on the commander’s
career.
Aborted route check
On 25 June 1991 the commander was taking a route check during which he did not
comply with a speed instruction from air traffic control for several minutes. This led to
a situation where the aircraft flew into the wake turbulence of a Boeing 747 during the
final approach. The check for approach and the final check had been forgotten and on
landing the cabin attendant was still standing in the passenger cabin corridor. The expert
assessed the commander’s comprehension as inadequate and aborted the route
check, which had to be repeated subsequently
Cessation of activity as training captain
At the end of 1991 the commander was relieved of activity as a line training captain,
because his performance was inadequate.
Night-time instrument approach to Lugano
According to the statement of the copilot involved, in December 1995 the commander
was carrying out an approach to Lugano airport as pilot flying, at night and under instrument
flight conditions. Shortly before the Saab 340 reached the PINIK waypoint at
an altitude of 7000 ft QNH, the aircraft was configured for the landing, i.e. the landing
gear was lowered and a landing flap setting of 35° was selected. For the descent, the
commander used the autopilot’s vertical speed mode and selected a rate of descent of
4000 ft/min. Since rates of descent of less than 2000 ft/min are usually used for this
approach, the copilot asked for the reason for the increased rate of descent. The
commander explained that one could implement the procedure in this way. During the
descent, which continued unchanged to a radar altitude of 300 ft RA above the lake,
the speed of the aircraft increased from 135 to more than 200 KIAS. When the aircraft
changed over to horizontal flight at 300 ft RA, part of the lake shore and the mountainside
could be seen. The aircraft then flew at this altitude in the direction of Lugano
aerodrome until the runway finally came into view and the aircraft was able to land.
The overspeed warning and the ground proximity warning system (GPWS) had been
deactivated before the descent.
The incident became known only after the accident. Reconstruction flights in the Simulator
showed that it is possible to fly the approach in the described way.
Navigation error during a private sight-seeing flight
The Crossair airline offered its employees the possibility to charter commercial aircraft
for private flights. The way such sight-seeing flights were carried out, usually according
On 21 March 1999, together with a copilot and a cabin attendant, the commander
made a private flight with 30 passengers onboard Saab 340 HB-AKI. The plan was to
execute an alpine sight seeing flight from Zurich with an intermediate landing in Sion
and then a return flight to Zurich.
In Zurich the sky was nearly overcast, whilst the weather conditions in the Alpine region
were fine.
On the outward flight to Sion, Crossair flight number CRX 4718, the commander was
pilot flying. The departure from Zurich took place under instrument flight rules. Above
the clouds the flight continued towards the Bernese Alps under visual flight rules.
Witnesses’ statements and a film document prove that the commander issued extended
explanations of the flight path and that the passengers were allowed to visit
the cockpit.
When the aircraft was at an altitude of about 12 000 ft QNH above the Savoy Alps, the
copilot made radio contact with Sion aerodrome control. Shortly afterwards, the commander
realised that the planned flight time to Sion had more or less expired. He immediately
initiated a descent in the direction of an aerodrome which he had in sight.
This was Aosta (I) aerodrome, which is located approximately 50 km to the south of
Sion in a valley which runs along the other side of the main ridge of the Alps. No discussion
on the approach took place and the most important checklist points were covered
intuitively and in an undefined order. The copilot tried several times to make contact
again with Sion aerodrome control, which he was unable to do because of the topographical
conditions. The commander did not react to interventions from the copilot.
Several descending turns were made above Aosta aerodrome and the approach was
continued without radio contact. When the aircraft was making its final approach, the
passengers could see from road signs that they were in Italy. The commander then initiated
a go around and flew over the St. Bernhard pass into the Rhone valley, where
the landing in Sion took place.
The navigation error was explained to the passengers. The airline was not informed of
the incident and learned of it only after the accident. There is no indication that the
health of the crew was adversely affected.
Working and management behaviour
According to several copilots’ statements, the commander occasionally operated the
aircraft alone as pilot flying (one-man operation) and did not always integrate copilots
consequently in the operating procedures and decision-making process. It is also
documented that he placed a value on being able to land punctually, especially on the
final flight sector of a day’s duty.
From the conversion course documentation and from witness statements, it is apparent
that the commander had a distinctly defensive behaviour in relation to more complex
technical systems and frequently exhibited difficulty with their operation.
The commander’s behaviour was unanimously described as very quiet and tending toward
the remote. Copilots occasionally felt a perceptible drop in their authority during
cooperation, which they attributed predominantly to the commander’s vastly higher
experience.
to visual flight rules, was regulated in the operations manual. In principle, the same
standards were applied as for scheduled flights. The commander made many Alpine
sight-seeing flights in a chartered Saab 340; the passengers in each case were organized
by the crew
