Report: 'High-risk
piloting' caused fatal JU-52 accident, Switzerland
Status: Final
Date: Saturday 4 August 2018
Time: 16:56
Type: Junkers Ju-52/3mg4e
Operator: Ju-Air
Registration: HB-HOT
C/n / msn: 6595
First flight: 1939
Total airframe
hrs: 10189
Cycles: 8783
Engines: 3 BMW 132A3
Crew: Fatalities: 3 / Occupants: 3
Passengers: Fatalities: 17 / Occupants: 17
Total: Fatalities: 20 / Occupants: 20
Aircraft damage: Destroyed
Aircraft fate: Written off (damaged beyond repair)
Location: 1,2 km (0.8 mls) SW of Piz Segnas
( Switzerland)
Crash site
elevation: 2540 m (8333 feet) amsl
Phase: En route (ENR)
Nature: Domestic Non Scheduled Passenger
Departure airport: Locarno Air Base (LSMO), Switzerland
Destination
airport: Dübendorf Air Base
(LSMD), Switzerland
Narrative:
A Junkers Ju-52/3m
aircraft, operated by Ju-Air, was destroyed in an accident in a mountainous
area in Switzerland. The aircraft crashed into the western slope of Piz
Segnas at an elevation of 2540 m. All 17 passengers and three crew members
were killed.
The aircraft had
departed Locarno, Switzerland, at 16:10 on a flight to it's home base at
Dübendorf.
The aircraft flew
on a northeasterly course into the basin southwest of Piz Segnas. Towards
the north end of the basin, it began a left turn, which developed into a
descending spiral trajectory. A short time later, the aircraft collided
with the ground almost vertically and at high speed.
Following the crash,
all Swiss Junkers Ju-52 aircraft were grounded. Ju-Air was allowed to
restart operations on August 17 with the two remaining aircraft of the same
type. Since there were no indications of general technical defects at this
time, the FOCA had approved the resumption of flight operations in
compliance with precautionary measures.
On November 20,
the Swiss TSB published an interim report. There was still no evidence that
a serious technical problem led to the accident. The investigation of the
wreck, however, revealed severe structural damage in the form of cracks and
corrosion on the main spar, the supporting element of the aircraft wing,
and other parts of the aircraft. This damage was hidden during normal
inspections and maintenance and could only be determined from the debris.
Since the two
Ju-52 HB-HOP and HB-HOS stationed in Dübendorf correspond in age as well as
in hours of operation to the crashed aircraft, the Swiss authorities
temporarily grounded both aircraft for inspections.
Probable Cause:
Direct cause:
The accident is
attributable to the fact that after losing control of the aircraft there
was insufficient space to regain control, thus the aircraft collided with
the terrain.
The investigation
identified the following direct causal factors of the accident:
- The flight crew
piloted the aircraft in a very high-risk manner by navigating it into a
narrow valley at low altitude and with no possibility of an alternative
flight path.
- The flight crew
chose a dangerously low airspeed as regard to the flight path.
Both factors meant
that the turbulence which was to be expected in such circumstances was able
to lead not only to a short-term stall with loss of control but also to an
unrectifiable situation.
Directly
contributory factors
The investigation
identified the following factors as directly contributing to the accident:
- The flight crew
was accustomed to not complying with recognised rules for safe flight
operations and taking high risks.
- The aircraft
involved in the accident was operated with a centre of gravity position
that was beyond the rear limit. This situation facilitated the loss of
control.
Systemic cause
The investigation
identified the following systemic cause of the accident:
- The requirements
for operating the aircraft in commercial air transport operations with
regard to the legal basis applicable at the time of the accident were not
met.
Systemically
contributory factors
The investigation
identified the following factors as systemically contributing to the
accident:
- Due to the air
operator’s inadequate working equipment, it was not possible to calculate
the accurate mass and centre of gravity of its Ju 52 aircraft.
- In particular,
the air operator’s flight crews who were trained as Air Force pilots seemed
to be accustomed to systematically failing to comply with generally
recognised aviation rules and to taking high risks when flying Ju 52
aircraft.
- The air operator
failed to identify or prevent both the deficits and risks which occurred
during operations and the frequent violation of rules by its flight crews.
- Numerous
incidents, including several serious incidents, were not reported to the
competent bodies and authorities. This meant that they were unable to take
measures to improve safety
- The supervisory
authority failed to some extent to identify the numerous operational
shortcomings and risks or to take effective, corrective action.
Accident
investigation:
cover
Investigating
agency: STSB Switzerland
Status: Investigation completed
Duration: 2 years and 6 months
Accident number: Np. 2370
Download report: Final report
https://aviation-safety.net/database/record.php?id=20180804-0
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