Original subtitles

NARRATOR: Zurich airport, November, 2001.

Crossair flight 3597 is one of the few planes left to land.

The commander was flying out of Zurich

for the last 20 years.

So he was really used to this airport.

Crossair, three--

NARRATOR: The lone controller in the tower tracks the approach.

Approach runway 28 for you.

I have ground contact, we're continuing on.

Crossair 3597, continue speed reduction

to final approach speed.

NARRATOR: But for some reason, the crew can't find the runway.

Damn.

He said he saw the runway 1.3 miles.

NARRATOR: And the flight ends in disaster.

Crossair 3597, this is Zurich tower.

Do you copy?

We have a possible emergency and a--

He collided with the hill, so obviously he was too low.

NARRATOR: A terrible mistake sent

a passenger jet dangerously off course, killing 24 people.

The clues will lead investigators

to a trained professional, with an astonishing past.

WOMAN: Ladies and gentlemen, we are starting our approach.

MAN: We lost both engines.

WOMAN: Put the mask over your nose, emergency descent.

MAN: Mayday, Mayday.

WOMAN: Brace for impact.

MAN: This is the last one.

[interposing voices]

MAN: It's going to crash.

NARRATOR: Crossair flight 3597 is cruising

at 27,000 feet above Germany.

As the autopilot flies the plane,

the crew begins reviewing procedures for their landing.

According to the report, the apron and taxiways are wet.

Braking actions not specified.

So the friction report is missing?

Indeed.

That usually means they haven't

been out to check lately.

Indeed.

NARRATOR: It's the last flight of the day

on this busy European route.

The 410 mile journey from Berlin South to Zurich

takes only an hour and a half.

There are many empty seats on board.

A group of 21 passengers never showed up for the flight.

Internet entrepreneur Peter Hogenkamp

is returning from a business trip in Germany

with his partner, Jaqueline Badran.

On that day, we wanted to take the train.

But we had to be in Zurich for that opening

ceremony of that trade show, so we said,

OK, so we need to go by plane.

Yes.

We have got to get some sleep.

It had been a very busy day, so we were very tired

when we arrived at the airport.

How are you?

NARRATOR: Among the passengers is the girl band Passion Fruit,

Germany's answer to the Spice Girls.

They're on their way to perform the last show of a concert

tour.

Yes.

I was shocked when suddenly all the Passion Fruits, all

the three of them are coming over,

and they were sitting right in front of us.

Just what I needed.

[laughter]

NARRATOR: Flight 3597 is an Avro 146 airliner.

It's a British made jet, popular with regional airlines,

like Crossair.

Captain Hans Ulrich Lutz is in command.

He's been with the airline for more than 22 years,

having served as a pilot and an instructor.

So, tell me about the runway and the conditions.

Overcast with light snowfall, visibility 3,000 meters.

NARRATOR: First officer Stephan Lohrer

is a newcomer to the airline.

He's had his pilot's license for just a year and a half.

He was hired by Crossair right out of flight school.

Hello.

[laughter]

The Passion Fruits were being quite noisy.

They were excited, I think, they went from one gig to the other.

So, they were still in their stage clothes.

I said, oh, my God, do I really need this?

Can I just sleep?

[laughter]

It's probably OK to move.

We decided to move back a few rows,

and change the side where we were sitting,

so we were in a very quiet area then.

WOMAN: Oh, my goodness.

Yes, oh, my gosh.

AIR TRAFFIC CONTROLLER: Crossair 3597,

clear to flight level 160.

NARRATOR: The flight is slightly behind schedule.

It's due to land in Zurich in less than half an hour.

According to the latest information,

we'll be using runway 14.

What kind of approach?

ILS approach.

OK.

NARRATOR: An ILS, or instrument landing system approach,

means the pilots will be guided to the runway

by radio signals beamed from the airport.

And a decision altitude of 1602 feet.

Call me 100 above minimums.

OK.

I'll call 100 above minimums.

NARRATOR: The plane's sophisticated computers

will do most of the work getting them down.

At Zurich airport, the weather is getting worse.

It's snowing, and visibility is dropping.

Crossair 3191, turn left, heading 150.

NARRATOR: In the tower, controllers

have started a nightly routine.

A supervisor sends out a message, notifying crews

that runway 14 is being taken out of service,

because of a controversial new law.

Planes landing on runway 14 must fly

over Germany on their approach.

But people in Germany have long complained about the noise.

Because of the political issue,

airplanes had to fly over Switzerland

in their final descent to the airport of Zurich,

for noise reasons.

There was no other operational, or weather reasons, whatsoever.

It was purely political.

NARRATOR: Switzerland has agreed to shut down

runway 14 after 10:00 PM, to keep

landing planes out of German airspace,

and use runway two instead.

The crew hasn't received this information yet.

But first officer Lohrer is familiar with the new rule.

Should I ask if it's still runway 14?

It's almost 10:00.

Yes, I'm pretty sure it's still 14.

Zurich approach, Crossair 3597,

please confirm the approach in use is the ILS 14.

Crossair 3597, you're identified.

It will be a VOR/DME, approach runway 28 for you.

Oh, hell.

What next?

OK, fine.

NARRATOR: Unlike runway 14, with its sophisticated instrument

landing system, runway 28 is not equipped for ILS landings.

Instead, it has a less accurate navigational system.

It's called VOR/DME.

A radio beacon sends information to the aircraft

about its distance from the runway, and whether it's left

or right of it.

It provides no guidance on the plane's altitude.

Pilots would rather not make VOR approaches,

because they place a greater workload on the flight crew.

He would always prefer an ILS approach, because he gets

guidance on the approach slope.

And he can also use his autopilot

to guide him down, literally on the ground to the runway.

NARRATOR: Because of its less precise technology,

runway 28 was rarely used for landings

before the new noise law.

OK, then, re briefing for runway 28.

That would be chart 13-2.

NARRATOR: Now, captain Lutz abandons the ILS approach

he was planning, and prepares his first officer for

the new non precision approach.

Are you familiar with the 28 approach?

Yes, I've done it a couple of times.

NARRATOR: The crew goes over every detail of how they

will approach Zurich airport.

Drazadingen Zurich, east, 6,000 feet.

NARRATOR: There are only a few planes left to land tonight.

3597.

NARRATOR: Including flight 3597, and two other Crossair

flights just ahead of it.

As the aircraft approached the runway,

controllers need to keep them apart.

Crossair 3597, reduce speed to 180 or less.

Speed 180 or less, Crossair 3597.

NARRATOR: Captain Lutz makes the final turn to line

his jet up with the runway.

160 knots.

NARRATOR: The plane is now in the thick of the heavy weather

surrounding Zurich.

At the airport, the second to last Crossair

flight touches down on runway 28.

Now, with only flight 3597 to land,

the supervisor decides to head home early.

The controller handling the aircraft

is the only controller left in the tower.

Crossair 3597, continue speed reduction

to final approach speed.

PILOT: Zurich tower, this is Crossair 3891.

NARRATOR: She gets a report from one

of the planes that just landed.

PILOT: Visibility approaching 28 was borderline.

We could only see the runway from 1.3 miles out.

NARRATOR: But Captain Lutz knows Zurich airport well.

He continues toward the runway.

Gear down.

NARRATOR: The plane begins the final stage of its approach.

Cabin crew, prepare for landing.

NARRATOR: Captain Lutz begins slowing the jet,

and puts it into a steep descent.

Six miles is checked.

Yes.

Flaps 33.

Flaps 33 selected.

Final check.

Final check, confirmed three greens.

Is checked.

116 knots.

NARRATOR: The descent gets even steeper.

Full flaps set.

Checked.

Captain Lutz expects it to come into view any second now.

100 above.

Do we have ground contact?

Yes.

NARRATOR: Passengers prepare themselves for landing.

We were pretty close to the airport,

so you think, OK, this is going smoothly.

But it was dark, and it was snowing,

so we couldn't see anything.

NARRATOR: In the tower, the controller

monitors the flight to make sure it's lined up with the runway.

Crossair 3597, cleared to land, runway 28.

24, the minimum.

24.

NARRATOR: The flight has hit minimum descent altitude,

2,400 feet above sea level, 1,000 feet

above the ground near Zurich.

Minimum descent altitude is the minimum height you can descend,

before you need to decide whether you can see the runway,

and continue the approach visually,

or you have to make a decision to go around.

I have ground contact, we're continuing on.

RECORDED FEMALE VOICE: 500, 500.

NARRATOR: Captain Lutz still can't see the runway lights,

but knows that the flight ahead of him has the same problem.

Damn.

He said he saw the runway 1.3 miles.

NARRATOR: They should almost be on top of the runway by now.

But for some reason, they still can't see it.

Make a go around?

Yeah.

Crossair 3597, cleared to land.

NARRATOR: The crew decides to abort the landing.

Go around.

Go around.

NARRATOR: And pushes the plane to its limits,

in an effort to get it to climb.

Captain Lutz throttles up his plane's four jet engines,

as he aborts his landing at the Zurich airport.

But it's too late.

There's not enough time for the engines to get to full power,

and clear a tree covered hill suddenly looming dead ahead.

Residents of a nearby village witnessed flight's

3597's final moments.

I was walking down with my dog.

All of a sudden, I saw that aircraft

coming from behind the forest, the little hill.

And I thought, oh, it's very low,

and it's not on the same route as aircrafts

normally are coming to land at the airport of Zurich.

NARRATOR: The jet clips the treetops.

[screams]

Suddenly, it was shaking very hard.

What's happening?

Something is wrong.

[screams]

NARRATOR: Moments later, the aircraft

plunges into the hillside.

Ah!

Crossair 3597, this is Zurich tower.

Do you copy?

Crossair 3597, this is Zurich tower, do you copy?

All of a sudden, the whole sky in the West

was getting really orange, like a big fire.

Like an explosion.

NARRATOR: The impact tears the aircraft apart.

The wings broke off, and the fuel is in the wings.

So the flames really sort of shot inside the plane.

Crossair 3597, this is Zurich tower.

Do you copy?

This is Zurich tower.

We have a possible emergency in approach sector East.

I repeat, approach sector East.

NARRATOR: Crossair 3597 has crashed

near the village of Basserdorf, Northeast of Zurich.

Some people have survived the accident,

including Peter Hogenkamp and Jacqueline Badran.

I don't have any memory of how we really walked out,

because the back was cut off.

And we were just able to walk out there.

NARRATOR: One member of Passion Fruit

also survives, but her two bandmates seated just one row

ahead of her have been killed.

Within minutes, emergency workers get to the crash site.

Hey, over here.

Over here!

Over here!

NARRATOR: 24 of the 33 people on board Flight 3597

are dead, including Captain Lutz and first officer Stephan

Lohrer.

Daniel Knecht, an investigator from Switzerland's

Aircraft Accident Investigation Bureau arrives on the scene.

DANIEL KNECHT: I got the call from our rescue service,

about half past ten in the evening.

Half an hour later, I was on the accident site.

The rear part of the fuselage was quite intact.

It was also the region where most of the survivors

stepped out without injury.

NARRATOR: For Peter Hogenkamp and his partner,

it appears moving to the rear of the plane saved their lives.

I think it was just good luck.

I think it would have been a whole different story if we

wouldn't have changed seats.

So, the Passion Fruits may have saved our lives.

NARRATOR: While rescuers care for the survivors,

Knecht and his team survey the crash site.

The location of the wreckage, far from the airport,

is of interest to the investigators.

Four kilometers and 50 meters from the runway.

The aircraft was not where he was intended to be.

He collided with a hill East of runway 28,

so obviously he was too low.

And the first question was, why was this aircraft too low?

NARRATOR: The black box flight recorders

are found in the wreckage.

They're in good condition.

is the worst aviation disaster on Swiss territory

in over a decade.

They're under pressure to find answers fast.

While work continues at the crash,

a command post is established nearby.

Jean Overney heads the Swiss Investigation Bureau.

He takes charge of the Crossair file.

[speaking french]

The public was very anxious about this crash.

The media were raising many questions,

so we naturally had to open a more in-depth investigation.

[speaking french]

NARRATOR: The accident happened at the end

of a long day for Captain Lutz.

But given his background, investigators

must consider other causes.

We knew that the captain was very experienced.

He had about 17,000 flight hours during his whole career, flight

instructor, flight examiner, within the company,

for more than 20 years.

NARRATOR: The flight recorders are sent to a lab in Paris

to extract their data.

At the same time, investigators have

begun retrieving fragments of wreckage from the crash site.

They look for telltale signs of trouble.

DANIEL KNECHT: The position of switches is very important.

Also, if you have some indication panels, for example,

with bulbs in it, you can, after a crash,

you can analyze the different wires in the bulbs.

And then you can determine which, for example,

indications, or even warnings, were active at the moment

of the impact.

NARRATOR: An investigator comes across an intriguing piece

of wreckage.

Oil gauges provide information about the oil

flowing to the plane's four turbofan engines.

Curiously, one of them is installed upside down.

This raised a lot of questions for us, and for the media.

Everyone wanted to know how you could

fly a plane with an instrument installed upside down.

[speaking french]

It wasn't a very important instrument.

You could still read it, even if it was installed upside down.

[speaking french]

NARRATOR: But if this obvious problem was never fixed,

what else could be wrong with the plane?

Obviously, there were maintenance issues here.

We looked at how the company was doing

the maintenance of the planes.

[speaking french]

NARRATOR: While this review is being launched,

investigators study the plane's engines

to determine if they were running

at the time of the crash.

Soil, tree branches, and other debris lodged inside the engine

suggest they were.

We checked them out visually, and we

saw that the four engines were turning

at the moment of the accident.

NARRATOR: Authorities need to be sure.

They will have to check their findings against data

from the flight recorders.

In the meantime, the location of the crash

suggests something may have tragically

misled the crew on their descent toward Zurich airport.

Knecht focuses on the flight charts they

use to plan their approach.

Is the problem with the approach,

or is the problem with the aircraft?

This kind of question was dominant when

we started the investigation.

Are you familiar with the 28 approach?

Yes, I've done it a couple of times.

NARRATOR: The approach chart provides pilots

with directions to the runway.

Trazadingen Zurich.

NARRATOR: Details about radio frequencies,

as well as altitudes and speed for various stages

of the landing.

When investigators study an approach

chart like the one the crew used,

they make a shocking discovery.

The chart does not show the hill the plane hit.

An approach chart is a very important thing,

because an indication which is not correct on this approach

chart could mislead a crew.

And so, easily make them do something wrong.

So, tell me about the runway and the conditions.

Overcast with light snowfall.

NARRATOR: A faulty chart would certainly have been a danger

to a crew unfamiliar with Zurich airport,

but Lutz had flown in and out of Zurich countless times.

He and his first officer were both based in the city.

The commander was flying out of Zurich, I think,

for the last 15 to 20 years.

So he was really used to this airport.

NARRATOR: Investigators conclude that the approach chart,

while faulty, could have tripped up

some crews, but not this one.

Some definitive news finally arrives.

The engine data from the black box

confirms the observations at the crash site.

We could see, quite easily, that the engines

worked absolutely normally.

NARRATOR: Another potential cause of the accident

is eliminated from the list, mechanical failure.

Investigators now consider a different possibility.

I was covering the approach West position

on the night of the accident.

NARRATOR: Could air traffic control have

somehow mishandled the plane?

Investigators study records from the night of the accident,

and make a disconcerting find.

Zurich airport's control tower was understaffed

at the time of the accident.

He left before his shift ended.

NARRATOR: The supervisor in the tower

went home early, leaving a lone controller to guide

flight 3597 in for its landing.

She was relatively young, and let's say she didn't

have that much experience.

NARRATOR: Investigators now study transcripts

of conversations between that air traffic

controller and the flight crew.

Crossair 3597.

Cleared to land.

NARRATOR: They find no indication the controller gave

the crew faulty instructions, but they

do come across the radio call by the pilot

of the Crossair flight that landed minutes earlier.

PILOT: Crossair 3891.

Visibility approaching 28 was borderline.

We could only see the runway from 1.3 miles out.

NARRATOR: That pilot warned of poor conditions on the approach

to runway 28.

She had options.

NARRATOR: They wonder why the controller

didn't shut the runway down.

Because of poor visibility, she could

have reopened runway four, in spite of the noise by law.

This would have allowed the crews

to make an instrument approach.

But she didn't do that.

Thank you, Crossair 3891.

Have a good evening.

It would have been much easier to fly ILS

approaches in this kind of area, regardless

of this political issue.

NARRATOR: It's suspected that without her supervisor present,

the controller lacked the experience

to make such an important call.

[speaking french]

So it's clear that to make the decision

not to allow an approach on runway 28,

and instead make it on runway 14,

demanded a certain kind of confidence,

a certain kind of courage.

[speaking french]

NARRATOR: However, captain Lutz also heard the same warning.

PILOT: Was borderline.

We could only see the runway from 1.3 miles out.

Gear down.

NARRATOR: He kept going in spite of it.

Investigators are now certain that the controller

was in no way responsible.

A pilot can always say no.

He can always recheck the clearance.

If he thinks that landing is probably not possible,

he is free to retract an approach clearance,

and ask for a different one.

NARRATOR: Jean Overney can't understand why Captain

Lutz didn't do exactly that.

He should have known that he didn't

have to make a non precision approach in bad weather.

[speaking french]

When we saw the mistake the pilot had made,

we immediately asked ourselves, well, how is it possible?

Because for an experienced pilot, who was an instructor,

this was a really basic mistake.

[speaking french]

NARRATOR: Overney is beginning to wonder if something

in Lutz's long career is hiding clues about his behavior

on the night of the accident.

out the possible causes of the crash of Crossair flight 3597.

They hope the answer lies in the cockpit voice recorder,

or CVR, of the doomed jet.

After waiting many days for its data to be sent back

from France, they now pore over it carefully,

listening for any clues that might explain why

the plane was flying so close to the ground, so far

from the airport.

HANS LUTZ: 16 knots.

LNAV is engaged.

NARRATOR: Authorities get more than they expected.

Not only is the CVR complete, but

Captain Lutz offers a running commentary

on everything he does.

And on inbound track 275.

Speed is checked, flaps 18.

NARRATOR: It's practically a roadmap to understanding

what went on in the cockpit.

HANS LUTZ: Flaps 33.

That's not usual, that the pilot flying

is talking so much about what he is doing, or what he is seeing.

And for the investigation, this helped a lot.

100 above.

Do we have ground contact?

STEPHEN LOHRER (BY CVR): Yes.

NARRATOR: Investigators learned that the crew of flight 3597

was looking for the runway, and believed

it would soon come into view.

From the CVR, we saw that the commander,

and also his co-pilot, were not feeling some fear,

or feeling that something was not going as they planned.

NARRATOR: But what they didn't know

was that the plane was actually four miles shy of its target.

Damn.

He said he saw the runway 1.3 miles.

RECORDED FEMALE VOICE: 300.

NARRATOR: Captain Lutz obviously thought his jet was closer

to the runway than it was.

Investigators consider the possibility

he was misled by his distance measuring equipment, or DME.

It's supposed to tell pilots how far they are from the airport.

The DME indication would have given this distance,

and then he would have detected immediately--

Damn.

--that he was below the approach pass.

NARRATOR: Perhaps the DME from flight 3597 was faulty.

It's been recovered from the wreckage,

but it's impossible to tell what information it gave the pilots.

However, there is another way to check whether the instrument

was functioning or not.

The DME distance is not recorded on the FDR,

but on two occasions, the pilots mentioned the distance.

Six miles is checked.

Yes.

NARRATOR: Investigators compare the time Lutz checked his DME

with radar data on the aircraft's location,

at that exact same time.

They can see that when Lutz's instruments were telling him

he was six miles out, that's precisely where he was.

So, we knew that the pilots had

an indication for the distance available at that time.

NARRATOR: An instrument problem can now be crossed off

the list as a factor in the crash, which

only heightens the mystery.

I have ground contact, we're continuing on.

NARRATOR: If the instrument was working,

why did Lutz think he was closer to the runway

than he actually was?

The answer lies not in what investigators

hear on the cockpit voice recorder,

but what they don't hear.

I don't see anything after six miles.

Do we have ground contact?

NARRATOR: Neither pilot read out a DME check

after the six mile reading.

Yes.

NARRATOR: It tells investigators that Lutz wasn't monitoring

his vital instruments during the final minutes of his approach.

Instead, he was preoccupied with spotting

the lights of the runway.

That's not what pilots are supposed to do.

[speaking french]

The pilot flying is supposed to keep his eyes

on the instruments, because all the information he needs

is there.

He only switches to flying by sight when the non flying

pilot says runway in sight.

Only then can the captain take his eyes off the instruments,

and fly by sight, because the landing is performed visually.

[speaking french]

NARRATOR: If Lutz had checked his instruments,

he would have known how far from the runway he actually was.

RECORDED FEMALE VOICE: 500.

NARRATOR: But how had he ended up

such a long distance from it?

RECORDED FEMALE VOICE: 400.

Confirmed, three greens.

RECORDED FEMALE VOICE: 400.

Is checked.

116 knots.

NARRATOR: Further analysis of the black box data

reveals that Lutz put his plane into a steep descent,

as it began its final approach to Zurich airport.

But it's readily apparent his approach

profile was out of sync with the trajectory

laid out in his chart.

The approach profile for runway 28

calls for pilots to make a gradual and steady descent,

which would bring them to 2,400 feet,

after they've cleared the hills around Zurich.

Then, pilots have to level off until they spot the runway.

When investigators compare the approach Lutz made,

with the approach profile he was supposed to follow,

they find that his overly steep descent

brought him to 2,400 feet well before he cleared the hills.

Then, he continued to descend until he hit the ground.

It's beginning to look like Lutz had

violated one of the cardinal rules of flying.

Aircraft making non precision approaches

are supposed to level off at minimum descent

altitude, or safe height, until they have the runway in view.

This safe height is intended to keep the aircraft

above any potential hazards.

DANIEL KNECHT: It's really a basic error.

Every pilot is trained to respect such minimums.

Not only with VOR/DME approaches,

but also with ILS approaches.

NARRATOR: But Captain Lutz kept his aircraft

in a steep descent, without even pausing at 2,400 feet.

The logical next question for investigators,

could he see the runway or not?

I have ground contact.

We're continuing on.

What does he mean by ground contact?

NARRATOR: They need to know if it was even

possible for Lutz to see the runway

when he reported ground contact.

They retrace his steps in a simulator,

programmed with the weather he was facing that night.

Six miles from runway, altitude 3,300 feet.

4.8 miles, 2,400 feet.

Still no runway in sight.

No, he couldn't see the runway,

because there was a hill between him and the runway.

And at that altitude, there is no way he could see it.

[speaking french]

NARRATOR: The conclusion, captain

Lutz had clearly violated his minimum descent altitude.

Whether there is flat terrain or hills,

minimums are set accordingly.

And in no way you can just pass the minimums,

whether there is hills or not.

NARRATOR: This discovery raises questions,

not just about Lutz's actions, but his young first officers

as well.

24, the minimum.

24.

We're continuing on.

NARRATOR: A first officer should not let his captain breach

minimum descent altitudes.

[speaking french]

NARRATOR: The co-pilot could have said no, stop.

We can't see the runway.

We're not descending.

[screams]

He considered his captain an old pilot

with a lot of experience, not making any mistakes.

Most probably, he was trusting him too much.

And also, by being submissive, maybe he

wouldn't speak up on time, just to keep harmony in the cockpit.

NARRATOR: There were no mechanical failures,

or instrument problems with the plane.

Nor was the air traffic controller negligent

in any way.

But it is now clear that Captain Lutz made a series

of catastrophic piloting errors that doomed flight 3597,

and claimed the lives of 24 people.

flying record, to see if there's anything in his long background

that could explain why he crashed flight 3597.

What they discover is truly alarming.

Lutz applied to flight school when he was 17 years old.

He was rejected three times, because

of his lack of education.

He finally got his license at the age of 20,

but continually failed exams to upgrade,

due to his inadequate comprehension

of navigation systems.

Captain Lutz may have had a long career,

but it was not a stellar one.

Years of flying, and flying hours

don't say anything about competence.

NARRATOR: For some reason, though,

his record as a below average pilot

didn't prevent Crossair from hiring him in 1979.

There was a red line through his career,

where several incidents happened before,

and he had missed several checks.

Well, he had some limits.

But what's hard to understand for me,

is that they were identified, and the decision

was made to keep him flying.

NARRATOR: Captain Lutz's limited abilities

continued in his new job.

While commanding a sightseeing tour of the Swiss Alps,

he made a navigation error, and ended up in Italy.

He only realized his mistake when his passengers

spotted road signs in Italian.

In another incident, he wrecked a one and a half million

dollar aircraft, after inadvertently

retracting the landing gear, while the plane

was still on the tarmac.

Lutz's failures forced Crossair to fire him as an instructor,

but they allowed him to continue flying passenger planes.

I personally do pilot assessments.

And he would never have gone through my assessment

with a positive recommendation.

OK.

Approach course 137.

NARRATOR: Investigators wonder why Crossair

allowed Lutz to stay on as a pilot, if he

was not entirely competent.

The answer appears to be, they may have had little choice.

Investigators' first glimpse into the problems at Crossair

came after they found the upside down gauge at the crash site.

[speaking french]

We had to check if the employees had received

the proper training, if they had the qualifications

required for this kind of work.

NARRATOR: No glaring maintenance issues were found.

But a closer look at Crossair's hiring practices

explains why Captain Lutz was allowed to keep flying.

The airline may have grown too fast

throughout the 80s and 90s.

[speaking french]

The company expanded very rapidly.

And with that success, it's clear that you have

to quickly increase the staff.

Office workers, mechanics, that's one thing.

But pilots, you have to go out and find them.

[speaking french]

In those days, they were desperate for pilots.

And somehow, no decision was made

to lay him off because of his questionable performance

during his career.

NARRATOR: Captain Lutz's failings caught up

with him on November 24, 2001.

Make a go around?

Go around.

NARRATOR: 24 people paid with their lives.

After the accident report was issued,

sweeping changes were made.

Swiss aviation authorities had Crossair increase the number

of employees overseeing pilots.

They also scrutinized other airlines,

to determine if there were other substandard performers

like Lutz.

One thing is for sure, that the selection process

has improved considerably.

And, of course, awareness of people's

performance during their career was increased considerably.

NARRATOR: Crossair went out of existence in 2002.

It was folded into the Swiss national carrier.

As Crossair became Swiss, they adopted the previous Swissair

selection process.

And I can say today, which is already nine years since,

that safety has improved considerably,

and also quality of the pilots that are

hired by companies like Swiss.

NARRATOR: Since the crash of Flight 3597,

Zurich's runway 28 has been upgraded

with both an instrument landing system,

and an automatic warning, that alerts controllers when

a plane's approach is too low.

There has never been another accident involving that runway.

But the Crossair tragedy, and the circumstances that spawned

it, isn't an isolated case.

Regional airlines have boomed worldwide since the 1980s,

particularly in the United States, where they account

for half of all flights, and carry

100 million passengers a year.

In the rush to fulfill consumer demand for cheap air travel,

these airlines often hire less experienced pilots,

and pay them far lower salaries than their counterparts

at major carriers.

Some even neglect to test their pilots for basic skills.

There is no such thing as a compulsory pilot assessment

before they get hired, does not exist.

NARRATOR: In February of 2009, one of Colgan air's planes

crashed in Buffalo, New York, killing 50 people.

The accident was blamed on the actions

of an inexperienced crew, an eerie reminder

of the Crossair disaster.

It underlined the urgency of improving

oversight of smaller carriers.

[speaking french]

If you're making a product for a large company,

and you make a mistake, you may lose part of the market.

You may lose some clients.

But an airline company can lose a plane,

its crew, and passengers.

The stakes are very different.

[speaking french]