Aviation Investigation Report Out Boeing 737-210C Controlled flight into terrain
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Aviation Investigation Report Out Boeing 737-210C Controlled flight into terrain
Aviation Investigation Report A11H0002 (today)
Controlled flight into terrain
Bradley Air Services Limited (First Air)
Boeing 737-210C, C-GNWN
Resolute Bay, Nunavut
20 August 2011
Summary
On 20 August 2011, the Boeing 737-210C combi aircraft (registration C-GNWN, serial number 21067), operated by Bradley Air Services Limited under its business name First Air, was being flown as First Air charter flight 6560 from Yellowknife, Northwest Territories, to Resolute Bay, Nunavut. At 1642 Coordinated Universal Time (1142 Central Daylight Time), during the approach to Runway 35T, First Air flight 6560 struck a hill about 1 nautical mile east of the runway. The aircraft was destroyed by impact forces and an ensuing post-crash fire. Eight passengers and all 4 crew members sustained fatal injuries. The remaining 3 passengers sustained serious injuries and were rescued by Canadian military personnel, who were in Resolute Bay as part of a military exercise. The accident occurred during daylight hours. No emergency locator transmitter signal was emitted by the aircraft.
http://www.tsb.gc.ca/eng/rapports-re...2/a11h0002.pdf
Transportation Safety Board of Canada - Aviation Investigation Report A11H0002
Captain way off localizer with FO telling this to captain several times.
Controlled flight into terrain
Bradley Air Services Limited (First Air)
Boeing 737-210C, C-GNWN
Resolute Bay, Nunavut
20 August 2011
Summary
On 20 August 2011, the Boeing 737-210C combi aircraft (registration C-GNWN, serial number 21067), operated by Bradley Air Services Limited under its business name First Air, was being flown as First Air charter flight 6560 from Yellowknife, Northwest Territories, to Resolute Bay, Nunavut. At 1642 Coordinated Universal Time (1142 Central Daylight Time), during the approach to Runway 35T, First Air flight 6560 struck a hill about 1 nautical mile east of the runway. The aircraft was destroyed by impact forces and an ensuing post-crash fire. Eight passengers and all 4 crew members sustained fatal injuries. The remaining 3 passengers sustained serious injuries and were rescued by Canadian military personnel, who were in Resolute Bay as part of a military exercise. The accident occurred during daylight hours. No emergency locator transmitter signal was emitted by the aircraft.
http://www.tsb.gc.ca/eng/rapports-re...2/a11h0002.pdf
Transportation Safety Board of Canada - Aviation Investigation Report A11H0002
Captain way off localizer with FO telling this to captain several times.
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The Canadian Military and Nav Canada got of lightly on this one, the extreame intercept angle and total lack of any real IFR operating knowledge, along with totally non standard procedures were in fact the first link in this train of events. There have been other recent incidents due to the the military trying to usurp Nav Canada/ ATC authority at mixed use airports, in this case not helped by an old aircraft with numerous avionics updates, lets hope this does not happen again.
As above - slack Canadian TAWS requirement.
1998 US proposes TAWS requirement.
2001 US mandates the system.
2003 ICAO recommends TAWS, Annex 6 required TAWS after Jan 2007.
2008 EU mandates TAWS.
1995 Canadian TSB recommends TAWS after Sandy Bay accident.
2000 Canadian Aviation Regulation Advisory Council (CARAC) Recommends TAWS.
2011 Transport Canada Civil Aviation (TCCA) proposes regulations.
Canada finally mandated TAWS in July 2012 (no deviation from ICAO found), to be implemented by retrofit by July 2014.
A very tardy response, particularly when hosting ICAO headquarters.
1998 US proposes TAWS requirement.
2001 US mandates the system.
2003 ICAO recommends TAWS, Annex 6 required TAWS after Jan 2007.
2008 EU mandates TAWS.
1995 Canadian TSB recommends TAWS after Sandy Bay accident.
2000 Canadian Aviation Regulation Advisory Council (CARAC) Recommends TAWS.
2011 Transport Canada Civil Aviation (TCCA) proposes regulations.
Canada finally mandated TAWS in July 2012 (no deviation from ICAO found), to be implemented by retrofit by July 2014.
A very tardy response, particularly when hosting ICAO headquarters.
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The Canadian Military and Nav Canada got of lightly on this one, the extreame intercept angle and total lack of any real IFR operating knowledge, along with totally non standard procedures were in fact the first link in this train of events. There have been other recent incidents due to the the military trying to usurp Nav Canada/ ATC authority at mixed use airports, in this case not helped by an old aircraft with numerous avionics updates, lets hope this does not happen again.
It doesn't take a brain surgeon of a captain to figure out that if the localizer is showing full deflection on one or both of the instruments during the ILS and the FO is repeatedly saying that you are off course toward high terrain that it is time to go-around no matter what airport you are at. That is regardless of the stuff that happened earlier in the flight. There is always an excuse, but there is responsibility that comes with being PIC. Can't handle the obvious then don't take up the position.
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This is quite common in some companies, so let me explain my story on a future accident.
Last year I had to give line trainning to a captain fresh from sim on a new aircraft, 15.000 hours and had flown many different aircrafts. On the first days I noticed that something was going wrong with him. Another trainning captain took him over and had the same problems.
On my return with him I found out that he had no idea how to IFR, and I mean no idea!!! I don´t know how he passed sim at CAE. Further more asking other pilots they already new that, even OPS manager, but company didn´t care.
But that was not enough, he didn´t know how to read a METAR, avoid a thunderstorm or basic stuff like calculating fuel, etc.
We recommended to ground him and go back to basic flight school. What happened? company had him on trainning with a TRE for 10 months non-stop but still has no idea, fired us and let him fly...
Last year I had to give line trainning to a captain fresh from sim on a new aircraft, 15.000 hours and had flown many different aircrafts. On the first days I noticed that something was going wrong with him. Another trainning captain took him over and had the same problems.
On my return with him I found out that he had no idea how to IFR, and I mean no idea!!! I don´t know how he passed sim at CAE. Further more asking other pilots they already new that, even OPS manager, but company didn´t care.
But that was not enough, he didn´t know how to read a METAR, avoid a thunderstorm or basic stuff like calculating fuel, etc.
We recommended to ground him and go back to basic flight school. What happened? company had him on trainning with a TRE for 10 months non-stop but still has no idea, fired us and let him fly...
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After a quick skim through......
Copilot lacked assertiveness......he was aware of the danger , yet allowed himself to be browbeaten into accepting something he knew was wrong.
The Captain was complacent, lacking in humility and CRM.
IMO, As Commander, it was his duty to heed crew warnings and ask himself why Crew, GPS and Navaids all disagreed with the location he "thought" the Autopilot had them at.
I fail to see the relevance of the Military...they weren't flying the aircraft.
A very sad and sorry tale.."get there-itis?"
Copilot lacked assertiveness......he was aware of the danger , yet allowed himself to be browbeaten into accepting something he knew was wrong.
The Captain was complacent, lacking in humility and CRM.
IMO, As Commander, it was his duty to heed crew warnings and ask himself why Crew, GPS and Navaids all disagreed with the location he "thought" the Autopilot had them at.
I fail to see the relevance of the Military...they weren't flying the aircraft.
A very sad and sorry tale.."get there-itis?"
One of the finest air accident reports I have ever read in my over sixty years in the industry. A must read, especially for airline first officers whether brand new MPL's or highly experienced. It is a most comprehensive report and it is a dedicated pilot who will stick with it to the end. But it is gold standard.
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A quote from the report.
Are SOPS considered as guidance for wise men and for the obedience of fools?
In 2012, there were 24.4 million departures for a worldwide fleet of civil-operated, commercial, western-built jet airplanes heavier than 60 000 pounds maximum gross weight. 67 An article in AeroSafety World 68 stated that, while only 3.5% to 4% of approaches are unstable, 97% of unstable approaches are continued to a landing, with only 3% resulting in a go-around.
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Alioth, like PEI372, I have spent a fair chunk of my life sitting around the edge, or sitting in, smoking holes in the ground trying not to puke and do my job, so forgive me if I find your assesment of this crash to be a little simplistic. I for one cannot find any reference to reading "needle impact traces" on the Captains HSI as to what his side of the office was in fact indicating, its maybe in there, but I havnt been able to find it as yet. The placing of a "lash up" military ATC l system using uncalerbrated equipment and personell was in fact the first link in this chain of events, this doesnt change the fact that the crew were in a state of obvious overload and confusion in the last seconds of flight, but it certainly played a part and deserves more than a passing mention in the report, if one adds in the highly modified state of the avionics on these older aircraft, with set ups which have many traps and pitfalls its suprising there are not more CFIT incidents. The post by PE1372 should be mandatory reading for all in Nav Canada and Transport Canada.
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How many times you have been to a crash site means nothing and does not add anything to your argument.
There are many reasons why an aircraft can be off course. If your FO says to you multiple times things such as he is showing off course and full scale localizer deflection and that the GPS is also showing off course, reminds you about a hill that is on the off course track, suggests going around to figure things out and then you ignore him, continue and hit the hill, you are not going to look like a very professional pilot.
There are first links in the potential chain of events on every flight.
There are many reasons why an aircraft can be off course. If your FO says to you multiple times things such as he is showing off course and full scale localizer deflection and that the GPS is also showing off course, reminds you about a hill that is on the off course track, suggests going around to figure things out and then you ignore him, continue and hit the hill, you are not going to look like a very professional pilot.
There are first links in the potential chain of events on every flight.
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When asked whether a go-around was required with full-scale deflection of the localizer, all pilots interviewed stated that this condition required a go-around. However, all pilots interviewed agreed that an FO could not command a go-around, and could not see an FO taking control from the captain. They stated that the FO would likely make a suggestion or negotiate with the captain regarding the need for action.
Hope they think differently now
Hope they think differently now
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Alioth, I wish crash investigating was as simple as you seem to think it is, yes the aircraft was of track, yes the F/O stated this fact, but I can demostrate to you in the simulator how it is fairly easy to overlaod a pilot to the point that the computer between his/her ears just doesnt recieve or process what going into those ears, as for time spent at crash sites, Ive often thought that all pilots should do at least one "on site" investigation visit, it might make some pay more attention to to the little things which so often lead to such tragic events.
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Incompetent first officers?
It is difficult to understand how any captain, no matter how bone headed could ignore such concern from a first officer. Have any of the captains here ever had a first officer express such discomfort with an approach, and continue it, being certain in your own mind that he was wrong? Not having flown commercially, I have no knowledge of the range of communication/mis-communication in professional pilots cockpits.
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Peterwelch, the Captain was not a "bonehead", nor was he one to generate an atmosphere of intimidation in the flight deck, he was most likely in total overload and task saturation and/or task fixation, as I pointed out in a previous post we can replicate such conditions in the simulator with multipe distractions/mechanical failures. The final factor which doomed this flight was an EXPERIENCED non -asertive F/O, just the final factor in this sad affair, note I said "experienced" F/O, the USA has just increased the hours required to be in the right seat in a scheduled airline, Canada has just gone the other direction and introduced the "Multi Crew Lic",I can see problems with crewmembers ignoring an F/O who isnt allowed fly an aircraft solo and has less than a hundred hours of flight time, but that another discusion altogether.
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I agree an excellent report, much to be preferred to the often anodyne reports that offer few lessons prevent future occurrences.
In some ways reminiscent of another excellent report into a CFIT incident to an American 757 at Cali, Columbia in 1995.
The report of the Columbian investigation is here:
Cali Accident Report
but one pertinent extract is:
The Cali investigators also commented on peoples reluctance to change a decision, once made, even in the face of new and conflicting information.
The Canadian report does not say how many times the Captain had operated
into Resolute Bay, but mentions that he had previously made several successful approaches in similarly difficult conditions and that he knew that another pilot had experienced a similar anomaly on that approach.
It seems that, 16 years on, we are still not recognising the dangers of Recognition Primed Decision Making. Nor are instrument approach charts graphically representing terrain near airports or flight paths as recommended in the Cali report
In some ways reminiscent of another excellent report into a CFIT incident to an American 757 at Cali, Columbia in 1995.
The report of the Columbian investigation is here:
Cali Accident Report
but one pertinent extract is:
Researchers studying decision making in dynamic situations [22] have suggested that experienced persons can quickly make decisions based on cues that they match with those from previous experiences encountered in similar situations. A referenced text refers to this characteristic as Recognition Primed Decision Making, in which a decision maker's rapid assessment of the situation is almost immediately followed by the selection of an outcome. It states:
"Our research has shown that recognitional decision making is more likely when the decision maker is experienced, when time pressure is greater, and when conditions are less stable." [23]
22] Klein, G., (1993), Naturalistic Decision Making: Implications for Design. Wright-Patterson Air Force Base, Ohio: Crew System Ergonomics Information Analysis Center.
[23] Klein, G., (1993), A recognition primed decision (RPD) model of rapid decision making. In Klein, G. A., Orasanu, J., Calderwood, R., and Zsambok, C. E., (Eds.), Decision Making in Action: Models and Methods. Norwood, New Jersey, Ablex, p. 146.
"Our research has shown that recognitional decision making is more likely when the decision maker is experienced, when time pressure is greater, and when conditions are less stable." [23]
22] Klein, G., (1993), Naturalistic Decision Making: Implications for Design. Wright-Patterson Air Force Base, Ohio: Crew System Ergonomics Information Analysis Center.
[23] Klein, G., (1993), A recognition primed decision (RPD) model of rapid decision making. In Klein, G. A., Orasanu, J., Calderwood, R., and Zsambok, C. E., (Eds.), Decision Making in Action: Models and Methods. Norwood, New Jersey, Ablex, p. 146.
The Cali investigators also commented on peoples reluctance to change a decision, once made, even in the face of new and conflicting information.
The Canadian report does not say how many times the Captain had operated
into Resolute Bay, but mentions that he had previously made several successful approaches in similarly difficult conditions and that he knew that another pilot had experienced a similar anomaly on that approach.
It seems that, 16 years on, we are still not recognising the dangers of Recognition Primed Decision Making. Nor are instrument approach charts graphically representing terrain near airports or flight paths as recommended in the Cali report
Last edited by DLT1939; 26th Mar 2014 at 23:04.
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While company SOP go into detail on what the PNF should do when an approach become dangerously unstable and requiring a go-around, it does not give specific advice - purely the correct warm and fuzzy words to say like please captain we are too high I suggest we go-around. As numerous accident reports have testified captains have ignored the official calls and the aircraft has crashed.
That point is well covered in the Canadian Boeing 737-200 accident report.
For some reason it is placed in to too hard tray and the PNF is left to use his own judgement on how to physically take control from an aggressive captain intent on pressing on regardless. The result of two pilots fighting each other to keep or take control at low altitude is bound to finish in tragedy.
One airline in Australia years ago, took the initiative and advised first officers that if their SOP calls for a go-around were deliberately disregarded by the captain, they should call once more for a go-around and if disregarded, they should select the landing gear to up. It was assumed that no captain would then deliberately land wheels up just to make a point and he would be forced to go-around.
While it was conceded that this action could place the aircraft in a dangerous position if close to landing, the alternative of a crash into terrain was infinitely worse. It was stressed that selecting the gear lever to up to force a go-around was essentially a last ditch action to prevent a certain CFIT. If that SOP had been used in most of the crashes known to have followed seriously unstable approaches - including the Canadian 737 accident - then these tragedies would likely to have been avoided.
That point is well covered in the Canadian Boeing 737-200 accident report.
For some reason it is placed in to too hard tray and the PNF is left to use his own judgement on how to physically take control from an aggressive captain intent on pressing on regardless. The result of two pilots fighting each other to keep or take control at low altitude is bound to finish in tragedy.
One airline in Australia years ago, took the initiative and advised first officers that if their SOP calls for a go-around were deliberately disregarded by the captain, they should call once more for a go-around and if disregarded, they should select the landing gear to up. It was assumed that no captain would then deliberately land wheels up just to make a point and he would be forced to go-around.
While it was conceded that this action could place the aircraft in a dangerous position if close to landing, the alternative of a crash into terrain was infinitely worse. It was stressed that selecting the gear lever to up to force a go-around was essentially a last ditch action to prevent a certain CFIT. If that SOP had been used in most of the crashes known to have followed seriously unstable approaches - including the Canadian 737 accident - then these tragedies would likely to have been avoided.
I completely understand the Canadian reasoning regarding protecting of the CVR, but I do feel this is one of those cases where a proper transcript of the words the crew used would have been immensely illuminating.
As one in the right seat, what one would do if a Captain refused calls to Go Around is high in the mind. I am aware of an incident in gusty conditions a few years back where the crew received a hard windshear warning on final approach and the Captain continued to land the aircraft with the FO shouting "GO AROUND". The FO considered any attempt to take control from the Captain was too dangerous.
As one in the right seat, what one would do if a Captain refused calls to Go Around is high in the mind. I am aware of an incident in gusty conditions a few years back where the crew received a hard windshear warning on final approach and the Captain continued to land the aircraft with the FO shouting "GO AROUND". The FO considered any attempt to take control from the Captain was too dangerous.
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CRM training thirty odd years ago emphasised the use of an airline specific emergency language by the FO and was incorporated in the Ops manual. Qantas was 'Captain you must listen to me'. If this was said then it was a mandatory incident report.
Different airlines and different cultures used different phrases. My favourite was Lufthansa -their response was to call the Captain by his christian name.
Different airlines and different cultures used different phrases. My favourite was Lufthansa -their response was to call the Captain by his christian name.