Pilgimage to the Zurich Airport location of Cirrus fatal accident #42 - Pull early, pull often! - Safety and Training Programs - Cirrus Owners and Pilots Association

Pilgimage to the Zurich Airport location of Cirrus fatal accident #42

Pilgimage to the Zurich Airport location of Cirrus fatal accident #42

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.

A Day Trip to Switzerland

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 pilot.

Cirrus Fatal Accident #42

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.

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.

Imagining

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

Realizing

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.

Insights

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.

  • When in trouble, get help from people on the ground.  Declare an emergency.  Ask for help.  Use it when you get it.
  • Maneuver if you must, but do it skillfully.  Keep the airplane flying.  Yanking and banking low to the ground must pose greater risk.  Move smoothly and deliberately.  And have a Plan B if things don't work out.
  • Avoid giving up altitude.  You may need it for CAPS.  When stuck in the clouds with an emergency, think of CAPS as your safe landing card.  Sure there are risks, but crashing is worse.
  • Commercial airports are really big!  A CAPS pull over one has lots of advantages - open space, few obstructions, emergency response within a mile.  Ask for help and the controllers know exactly where to send you.  Great place to drop in, so to speak.
  • Don't worry about shutting down airport operations.  If you parachute in, you can tell them you are okay.  If you crash, they will take longer to secure the wreckage.

Powerful Motivation

Honor those who perish in Cirrus accidents by learning from their mistakes. 

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.

 

Cheers
Rick

Comments
  • 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

  • Rick,

    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.

    Cheers.

  • 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]

    www.cirruspilots.org/.../131178.aspx

    Cheers

    Rick

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