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Crossair Safety Practices Under Microscope

Wed May 10, 2000 7:06 am

I found this rather intersting article. It is true, there have been a rather large ammount of Crossair incidenrs recently! Here it goes:

May. 08, 2000 (Air Safety Week, Vol. 14, No. 19 via COMTEX) -- Pilot proficiency, pilot pairing and pilot pushing are just some of the safety issues swirling around Swiss regional carrier Crossair since the fatal crash of a Saab 340B twin-turboprop aircraft last January.

The carrier's overall practices have been under intense scrutiny by the European media since. Aggressive reporting of every operational error and assiduous digging into company documents, aided by confidential and not-so- confidential complaints by company employees, has placed the airline's safety under a dark shadow. The carrier is engaged in a contract dispute with its pilots union, which may be contributing to the level of discontent visible to the public. The European Cockpit Association (ECU), representing Crossair and other European pilot unions, complained in an April 19 letter to Crossair CEO Moritz Suter of "the possible consequences of this dispute on safety standards."

"Company behavior is having an impact on Crew Resource Management," the letter declared, a reference to punitive actions taken against pilots for their trade union activities. The letter intimated that the company's tendency to purge outspoken pilots has eroded mutual trust needed in the cockpit.

The most recent operational error involved an April 27 runway incursion by a Crossair MD-80 at Saloniki, Greece. The Crossair jet taxied without clearance onto an active runway as an Alitalia MD-80 was on its takeoff run. The Crossair captain was immediately suspended.

Crossair is Europe's third largest carrier, in terms of the number of daily flights. It was less than two months short of 25 fatality-free flying years since its March 1975 founding when Flight 498 crashed January 10 shortly after takeoff from Zurich on a flight to Munich. The two pilots, the flight attendant, and all seven passengers were killed (see ASW, Jan. 17).

An interim accident report issued March 28 by the Buro fuer Flugunfalluntersuchung (BFU), the Swiss Bureau for Flight Accident Investigation, points strongly to crew error. The 41-year-old pilot, Capt. Pavel Gruzin, was a Moldavian flying on contract with Crossair. The 35-year old first officer from Slovenia, Ratislav Kolesar, was another contract pilot. While both pilots had flown the Saab 340B in their native countries, the aircraft in Slovenia were not equipped with the Universal 1 C Flight Management System (FMS) technology installed in the Crossair 340B.

After a routine 5:54 p.m. takeoff from Zurich International Airport's runway 28, with Gruzin flying the aircraft, the crew was cleared to execute a left turn to intersect the outbound radial. During this left turn, First Officer Kolisar entered commands into the FMS consistent with "direct to ZUE," to intersect the Zurich east VOR (ZUE). The immediate result, according to the BFU report, was a right turn to ZUE, as it was the shortest distance to fly. During this turn reversal, the commander asked if ZUE was selected, and the first officer said it was.

The right turn progressed with a steady increase in bank angle to some 42?. Although a transcript of the cockpit voice recorder (CVR) has not been released, the first officer is reportedly heard urging the pilot flying, "Left, left, left."

After this so-called "stable" phase, roll rate increased significantly due to aileron movement. Since the flight director would not likely command an extreme bank angle, the aileron input may have resulted from the actions of the pilot flying. If, flying in darkness through broken clouds, the pilot flying did not keep his eyes on primary instruments, could he have inadvertently rolled the airplane while focusing his attention on the flight management system mounted on the center console? Recalling the old aphorism, "Fly, navigate, communicate," was there a failure in the first instance while dealing with the second? This scenario raises significant questions about basic airmanship and crew resource management. In a period of 30 seconds or less control was lost in a routine climb during unexceptional European winter weather.

Crossair's vice president of flight operations, Andre Dose, said the turn reversal does not explain the extreme attitude. Interviewed recently by ASW European contributor Ian Goold, Dose said the cockpit voice and flight data recorder information does not indicate a problem with engines or flight controls. The navigation system, he added, "always takes the shortest route, but that does not explain the dramatic bank angles."

At 5:54 Zurich control authorized the airplane to "continue right turn to ZUE." At this point the aircraft had already entered a high-speed spiral descent which ended a few seconds later with ground impact. In the grim aftermath of the accident, Swissair CEO Phillipe Bruggisser and Crossair CEO Moritz Suter commissioned a panel of three experts to conduct an independent review of the airline's safety practices (see ASW, Jan. 24). Crossair is a member of parent company SAir Group. That report is expected shortly.

In the meantime, the company's reputation has been rocked by a growing list of embarrassing disclosures:

Too eager to grow? According to the March 24 issue of CASH, a Swiss weekly business magazine, psychologists identified the copilot of the accident airplane as a risk factor at the time of his hiring in August 1999. Shortcomings in "oversight under stress" were cited in the psychologists' report. Kolesar nevertheless was hired to meet the need of a company faced with finding enough pilots to support a flight schedule that had increased 100 percent in five years. Crossair's Dose conceded to CASH that Kolesar had some problems in the psychological assessment but, overall, he showed "an average result."

Other Crossair pilots interviewed by CASH who had flown with Kolesar and with Gruzin described both as seemingly introverted, possibly resulting from their documented hesitancy with the English language. One Swiss copilot described Gruzin as an arrogant commander with whom he never wanted to fly again.

Another account has a Crossair check captain submitting a report the month before the accident strongly recommending that the accident aircrew not be paired for future flights. And, on the day of the accident, yet another report indicates the first officer requested that he not be paired with the Moldavian captain in future flight schedules.

Not the least of the media reports casting company practices in a bad light was the disclosure that First Officer Kolesar's records could not be found for about six weeks after the accident. They were only belatedly supplied to the BFU after the media reported the curious "disappearance" of the late pilot's records.

CASH also reported that two senior flight instructors resigned recently from Crossair, complaining of the pressure to qualify marginal contract pilots.

Lack of confidence in foreign pilots. More recently FACTS, a Swiss newsweekly magazine, reported the March 17 dismissal of a flight attendant for "refusing to fly." The flight attendant had served on a December 1999 Crossair operated flight for Swissair from Stuttgart to Zurich, and reported that the Latvian captain could barely speak English. The airplane landed with no announcement from the cockpit, and the cabin had not been reported secure by the senior flight attendant, as required by standard procedure. After the airplane parked, the captain cut all electric power, forcing the flight attendant to switch on the emergency lights for the passengers to disembark.

The cabin staff refused to continue the flight under the Latvian captain, leading to subsequent discussions between management and the chief flight attendant. The flight attendant who submitted this report was fearful about flying after the Jan. 10 crash at Zurich and was dismissed when a company doctor, who had not seen her, declared her fit to fly and she persisted in her refusal. Another company specialist, whom she had seen, declared her unfit to fly.

Draconian duty hours. Crossair pilots have reported to this publication that they feel pressured by an excessively demanding duty schedule. Some speculated that the runway incursion at Saloniki might have stemmed from crew fatigue. After post-flight duties, transport to hotel, etc., are factored in, crews often receive as little as 2-3 hours rest at Saloniki, according to one account. It is reliably reported to this publication that the captain of the Crossair jet involved in the incident at Saloniki had gotten about one and a half hours sleep the night before.

In August 1999 an ACARS (aircraft communications addressing and reporting system) message to the crew of a Crossair MD-80 directed a schedule that would take the Swissair code share flight crew above the 14-hour flight-duty time limit. Indeed, the extended duty time was approved by Crossair safety pilot Manfred Schmid prior to takeoff from the airplane's home base at Zurich. After the schedule was completed, the copilot logged 16.5 hours of flight duty time.

An October 1999 e-mail sent anonymously by a Crossair pilot dissatisfied with the carrier's practices to his fellow pilots complained that various ploys by management to squeeze more efficiency out of the schedule was compromising safety. This pilot, since identified as Timothy O'Brien and since dismissed by the carrier as a malcontent, charged that safety was being eroded by physical exhaustion, anger, mental burnout and the loss of experienced pilots resigning in disgust. O'Brien is now flying for U.S. cargo carrier Gemini.

A spate of incidents. The recent runway incursion at Saloniki is one of a number of incidents over the past five years, possibly indicating systemic problems. On March 26 a Crossair MD-80 took off from Cairo on a flight to Basel with a warning light illuminated indicating that the rear cargo door was not properly secured. The airplane made an emergency landing at Crete. Many of Crossair's own pilots regard the fatal Jan. 10 crash, not as the unfortunate aberration of an otherwise solid safety program, but as the tragic culmination of a long period of luck that finally ran out. (Note: Although offered an opportunity to do so, Crossair did not provide comments on this story by our press time)

Harbingers of Disaster

Significant Safety Related Events at Crossair A sampling, 1995 to present:

* July 1995: Zurich airport management writes Crossair Chief Pilot Fredi Luginbuhl, complaining of flight deviations and navigation errors. "On the basis of statistical evaluations, Crossair stands at the top of our complaints." Should navigation mistakes continue, stricter measures would be considered, the airport authorities warned.

* Dec. 1996: A stockholder group expresses its concern about flight safety.

* Oct. 1996: MD-80 departs runway at Pristina, Serbia, closing the airport for a week. A week after the airport was re-opened, another Crossair MD- 80 damaged the landing lights. The Serbs submitted a $2,700 bill for repair of the lights.

* Jan. 1997: A Crossair MD-82 wet-leased to South American carrier Dinar damages its landing gear on landing at Buenos Aires. The left main undercarriage departed the concrete of the runway.

* Aug. 1998: On a high and fast approach to Zurich's Kloten airport, the ground proximity warning system called out "Sink rate" and then "Pull up" according to the co-pilot's incident report to the company, submitted after his call for a go-around was ignored.


Jeremiah Teahan

Goodbye SR-LX MD-11 / 6th of March 1991 to the 31st of October 2004

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