Crossair - Avro RJ100
Zurich, Switzerland
24th November, 2001

Zurich, Switzerland On 24 November 2001 at 20:01 UTC the aircraft AVRO 146 RJ 100, registered as HB-IXM of the Crossair airline company took off in darkness from runway 26L at Berlin-Tegel airport as scheduled flight CRX 3597 to Zurich. At 20:58:50 UTC, after an uneventful flight, the aircraft received the clearance for a standard VOR/DME approach 28 at Zurich airport. Ahead of the aircraft involved in the accident, an Embraer EMB 145, flight CRX 3891, landed on runway 28 at Zurich airport. The crew informed the control tower that the weather was close to the minimum for this runway.
br> At 21:05:21 UTC flight CRX 3597 reported on the aerodrome control frequency. When the aircraft reached the minimum descent altitude (MDA) of 2390 ft QNH at 21:06:10, the commander mentioned to the copilot that he had certain visual ground contact and continued the descent. At 21:06:36 UTC the aircraft collided with treetops and subsequently crashed into the ground. The aircraft caught fire on impact. Twenty-one passengers and three crew members died from their injuries at the site of the accident; seven passengers and two crew members survived the accident.

The investigation has determined the following causal factors in relation to the accident:

The commander deliberately descended below the minimum descent altitude (MDA) of the standard VOR/DME approach 28 without having the required visual contact to the approach lights or the runway.
The copilot made no attempt to prevent the continuation of the flight below the minimum descent altitude.

The following factors contributed to the accident:

In the approach sector of runway 28 at Zurich airport there was no system available which triggers an alarm if a minimum safe altitude is violated (minimum safe altitude warning – MSAW).
Over a long period of time, the responsible persons of the airline did not make correct assessments of the commander’s flying performance. Where weaknesses were perceptable, they did not take appropriate measures.
The commander’s ability to concentrate and take appropriate decisions as well as his ability to analyse complex processes were adversely affected by fatigue.
Task-sharing between the flight crew during the approach was not appropriate and did not correspond to the required procedures by the airline.
The range of hills which the aircraft came into contact with was not marked on the approach chart used by the flight crew.
The means of determining the meteorological visibility at the airport was not representative for the approach sector runway 28, because it did not correspond to the actual visibility.
The valid visual minimums at the time of the accident were inappropriate for a decision to use the standard VOR/DME approach 28.