What happened
On the evening of 24 November 2001, an Avro 146 RJ 100, registered as HB-IXM, departed from Berlin-Tegel airport for a scheduled flight to Zurich. Following a routine flight, the aircraft was cleared for a standard VOR/DME approach to runway 28 at Zurich. Prior to this arrival, an Embraer EMB 145 had landed on the same runway, with the crew noting that weather conditions were near the minimums for the field.
As the aircraft reached the minimum descent altitude of 2,390 feet, the pilot informed the co-pilot that they had visual contact with the ground and proceeded with the descent. Shortly thereafter, the aircraft struck treetops and crashed into the earth, resulting in a post-impact fire. The wreckage was located in the Geissbühl forest, approximately 4,050 meters from the threshold of runway 28. The accident resulted in 24 fatalities (comprising 21 passengers and 3 crew) and left 9 survivors (7 passengers and 2 crew).
Findings
The investigation concluded that the crash was a case of controlled flight into terrain. The primary cause was that the flight crew deliberately continued the descent below the minimum descent altitude without meeting the necessary visual requirements for the approach.
Several contributing factors were identified:
- The pilot's decision to descend below the MDA without sufficient visual contact with runway lights or the runway itself.
- A lack of intervention by the co-pilot during the unauthorized descent.
- The absence of a minimum safe altitude warning (MSAW) system for the approach sector at Zurich airport.
- Inadequate oversight by the airline regarding the commander's flying performance and decision-making.
- Fatigue, which impaired the commander's concentration and analytical abilities.
- Poorly managed task-sharing between the crew members during the final approach phase.
- Approach charts that failed to mark the specific hills encountered by the aircraft.
- Inaccurate meteorological visibility readings that did not reflect the actual conditions in the approach sector.