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:
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.
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