When invited to Germany to speak at the Baden-Baden CPPP, I took a
pilgrimage to the site of the fatal Cirrus accident at Zurich Airport. It wasn't a planned trip. But it was an impactful one.
Coming almost half-way around the world for this CPPP
motivated me to spend some extra time here. And Baden-Baden features the Black Forest, southwestern
France and Switzerland, all ready for day trips. Today the Autobahn beckoned and I drove (fast) south to Basel and thought
about going futher.
As I drove, I recalled that Zurich Airport was the location
of a Cirrus fatal accident. I've
done this a couple of times before, gone out in a car to visit locations of
Cirrus accidents. Never a planned
trip, but occasionally something draws me to them. Given my penchant for studying accident reports, the
opportunity to survey the area adds a three-dimensional perspective while
contemplating the tragedy helps me appreciate what challenges faced the accident
In the Zurich accident, the pilot experienced a system failure and diverted to Zurich.
The plane crashed short of the runway as it was apparently maneuvering
in low clouds to get lined up for landing. My files bulged with photos culled from various news
reports, so I expected to find some key landmarks to locate the crash site.
As I drove closer, I followed the highway signs for the
airport and then pulled over and got out my laptop to research where the crash
occurred. From the news photos, I recalled the wide open space surrounding the
wreckage, with no terminal buildings in sight, and that the photographer had an
unobstructed view of the runway safety zone where the wreckage lay.
News photo of the crash site at Zurich airport, Oct 22, 2008
Using the portable navigator in my rental car, I set off to
find a good vantage point. While
driving around the back roads near the airport, getting closer to the area
under the approach to runway 14, a rain squall blew through. What a reminiscence of the low clouds
and poor visibility that the accident pilot must have experienced.
Standing in the mist and rain from the same spot as the
photographer eleven months later, no visible evidence of the crash
remained. But powerful imagery and
feelings arose. Imagine the frustration
and confusion of the pilot attempting to maneuver onto one of these two long,
almost parallel runways. So close,
yet not able to land. Concern
rising as the normal systems operated differently. The pressure mounting to deliver his family safely.
Panorama photo of Zurich airport, with runway 14 at the left edge going to the center, runway 16 at center right going straight away from the camera, and the Met Office building behind the red/white pole; terminal buildings barely visible two miles away in the center over the lady in the red coat; note low clouds with a rain squall behind me coming towards the airport, Sept 14, 2008
The scale of the accident site surprised me. Zurich Airport stretches from urban
highways, office buildings, terminals and parking garages out to a pastoral
valley several miles long. One end
bustles, the other end wafts in the mist.
Planes emerge from the low clouds and whine all the way onto the runway.
My photo of a bizjet landing on runway 14 almost precisely over the crash site, Sept 14, 2009
Runways 14 and 16 lay in a shallow bowl with sloping
sides. Even with a lid of low
clouds, you realize that nothing much would get in your way. Yet, the Cirrus dropped out of the sky
and fell short of the runway by several hundred metres.
Seeing the space around the airport, feeling the low clouds
and rain, imagining the stress, all contributed to some clarity about accidents
in general, and this one in particular.
Honor those who perish in Cirrus accidents by learning from
Recall that investigators describe the pilot causes of
accidents as failures rather than errors.
Failure to maintain altitude, to maintain airspeed, to maintain control,
to execute a procedure, to perform a remedial action, to plan for weather, etc.
Failures you can learn to avoid.
Very powerful and a compelling argument for better emergency procedures planning by all of us, now matter what airplanes we fly.
A good reminder for us, thanks for posting
Thanks a lot for your work on Cirrus accidentology and all the lessons we've learnt from you.
Despite that we don't have the final report, we can learn a lot from this tragedy : the complete ATC recording helps us to understand this accident.
- as often the first cause to be given to explain the accident has an engine failure. In fact a problem with English phraseology...
- first event leading to the accident was an alternator failure. It seems that the redundancy of our electric system worked fine in that case because neither transponder or communication failure occurred until the last seconds of the flight. Though the pilot unlikely lost the ILS. He decided to divert which is right in that case but failed to declare an emergency
- real cause of the accident was the inability to follow the glide slope (likely due to attention dispersion not ILS failure), then not performing a go around when advised by ATC that he was above the glide slope. On the contrary the pilot tried to reach the runway in marginal conditions, doing maneuvers over the threshold to reach the right runway. No room for CAPS in that situation...
- pilot voice was calm and professional : probably a trained, experienced, English proficient pilot.
My conclusions are :
- I am not immune from the same mistakes
- Always declare an emergency when uncountering an electrical failure, which means to begin all ATC conversation by ""Mayday, mayday, mayday Cirrus N842CD ....".
- We must be prepared to benign failures because our plane is complex. Electric problems are frequent in Cirrus, electric system is complex, we have to anticipate these traps.
- We must improve our English phraseology, specially to deal with unusual situation
- Full ILS deflection = go around.
The Swiss Accident Investigation Board has released their probable cause report. See this thread on COPA:
Cirrus fatal #42 probable cause report for SR22 N467BD at Zurich, Switzerland [22 Oct 2008]
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