Figure: Radar plot, from Swiss Final Report 1793, appendix 4, page 1.

Eddie Sez:

There are a lot of problems with this mishap:

  • The approach had been improperly designed and it would have been nearly impossible to spot the runway from the MDA at the PAPI angle given the weather, which was well above the published minimums.

  • The captain had a history of undisciplined flying and poor cockpit resource management skills.

  • This airline's culture, at the time, discouraged first officers from correcting their captains.

But all of that could have been overcome had the captain simply stayed at the non-precision approach's MDA until a good visual descent point or when on the PAPI glide slope. The captain decided to begin his descent upon first sight of the ground; it does not appear that he saw the runway, which was obscured by a patchy layer of clouds.

The mishap would have been prevented had the crew properly flown the approach. They would have been aided in this effort had they computed a visual descent point. More about this: Flight Lessons / Visual Descent Point. An even better technique is available today: Normal Procedures & Techniques / Continuous Descent Final Approach (CFDA). Though this mishap was in 2001, the aircraft and crew had all they needed to fly a CFDA back then.

What follows are quotes from the relevant regulatory documents, listed below, as well as my comments in blue.


Accident Report


Narrative

[Swiss Final Report 1793, page 11.]

[Swiss Final Report 1793, page 19.]