Air Creebec near CFIT in Val-d’Or

[FurHat]

https://www.tsb.gc.ca/eng/rapports-repo ... q0143.html

Pretty wild, 400ft AGL in IMC with the gear and flaps up. Almost a really tragic accident.

[Dias]

The aircraft did not have a navigation screen showing the aircraft’s position on a map, which would be another tool available to help the flight crew build their situational awareness of the aircraft’s position.

The worst part about flying a Dash 8.

[Eric Janson]

The aircraft did not have a navigation screen showing the aircraft’s position on a map, which would be another tool available to help the flight crew build their situational awareness of the aircraft’s position.

The worst part about flying a Dash 8.

I've seen plenty of cases where the moving map had a position shift and was not giving correct information. Happened to me a few months ago.

Knowing how to use the equipment in your aircraft correctly is critical - as is cross checking with raw data.

Data entered into any kind of Flight Management Computer needs to be checked by both Pilots.

Continuing descent when not established on the final approach track is a bad idea. This could easily have been another First Air 6560.

A bad approach happens to all of us at some point - Go-around to a safe altitude and location and start again.

Airbus Golden Rules

-Fly, navigate and communicate - in that order with the appropriate tasksharing.
- Use the appropriate level of automation at all times
- Understand the FMA at all times
- Take action if things do not go as expected.

[Canoehead]

I've seen plenty of cases where the moving map had a position shift and was not giving correct information. Happened to me a few months ago.

Knowing how to use the equipment in your aircraft correctly is critical - as is cross checking with raw data.

Data entered into any kind of Flight Management Computer needs to be checked by both Pilots.

Continuing descent when not established on the final approach track is a bad idea. This could easily have been another First Air 6560.

A bad approach happens to all of us at some point - Go-around to a safe altitude and location and start again.

Agreed. This was a close call. The Dash 8 with the UNS and electromechanical instruments isn't the most user-friendly interface, but you gotta know your machine. I'm surprised at the Captain's progression at Cree though... roughly 14 years as an FO (almost certainly all on the DH8 given time on type). Is that how long upgrades were/are taking there?

[pelmet]

Only part way through the report but they are well below a thousand feet and close to 200 knots on approach from a holding pattern with the gear and flaps still up, in an aircraft commanded by a captain that has loads of time on type.

Button-pushing screw-ups happen but the question is: What do you do about it when things are obviously messed up during the approach?

You don’t spend over 30 seconds in discussion with ATC trying to get a clearance for a missed approach(while continuing to descend). You were already given the approval to do a missed approach by simply getting the clearance for the approach.

[Canoehead]

Exactly. This is wrong on so many levels... The TSB report is short on the HF breakdown and concentrates too much on the FMS/programming confusion. Both are important. I'm more concerned with why a 10,000 pilot, a "Captain", thought that descending while off course was ok.

[dustyroads]

Exactly. This is wrong on so many levels... The TSB report is short on the HF breakdown and concentrates too much on the FMS/programming confusion. Both are important. I'm more concerned with why a 10,000 pilot, a "Captain", thought that descending while off course was ok.

Situational awareness at all levels was poor. Holding at a waypoint with no approach loaded following the holding waypoint is unbelievable. Asking Center for missed approach approval is also unbelievable when it’s been approved when cleared for approach. This is basic stuff. Comes back to flawed hiring processes. Asking applicants what would you do if you need to do a missed approach is more relevant than asking someone why do you want to work for company etc.

[Jean-Pierre]

Yes 14 year as FO is a HR mistake.

[‘Bob’]

You can’t really screen people that effectively when so many line pilots don’t even know the rules.

The number of times I hear Radio say the preferred runway only for the PM to just repeat it back as if it was an ATC instruction without being aware they actually chose it. Or “I have the field in sight, I’d like to cancel IFR” as if those two things have anything to do with each other. Lots of companies ‘never’ go missed so it’s easy to see the confusion.

Also there’s any number of reasons why a pilot won’t move up to a spot. Surely all of the “forever FOs” at the airlines can appreciate that. Lifestyle can certainly include not having to study for an upgrade or have a position of responsibility.. something that has successfully kept me out of management for most of my career.

As for descending off course. Didn’t Swoop do that not once but twice coming into Abbotsford a few years ago when they were cleared direct an IF and figured the STAR altitudes were still safe? Not saying it’s good, just saying it’s not isolated to one pilot in a tiny turbo prop operator in Que.

[pelmet]

You can’t really screen people that effectively when so many line pilots don’t even know the rules.

Maybe so many line pilots don't know the rules because they don't screen effectively. I had an interviewer ask me who the CEO is.
Who cares.

I was on layoff at the time at another company where I had been for many years that had had multiple CEO's and went for quite a while without knowing who it was for the company I was working for. Did quite a few successful missed approaches though.

[pelmet]

Still reading through the report. They held at what is the published IAWP for ten minutes prior to being cleared for the approach. The IAWP is also the published MAWP which has a published hold. As the report states, they selected the MAWP in the FMC for holding instead of creating a hold at the IAWP. This meant that the FMC flightplan route had now passed(or bypassed) all the waypoints of the approach.

Mistakes like this can happen but the question is......what do you do while in the hold for 11 minutes. I did something similar with a Universal FMC once and was holding because the visibility went down to a reported value of zero(only ever seen that once). Therefore, I was in the same situation and guess what.....I had the DFO in the jumpseat. Fortunately, while holding, I decided to review the approach and noticed an issue and all was corrected for the approach when things got better. It would appear that this crew did not do this.

Meanwhile, they are holding north of the airport by about ten minutes and the airport has a Mandatory frequency. This would be a good time to contact them and give/receive the appropriate information. According to the report, the crew did not contact the Val d'Or FSS(or make any broadcast on the MF frequency for the entire first approach and missed approach, despite having plenty of time. They were advised to by ATC after being cleared for the first approach but things obviously got busy. Why not contact early and get this out of the way. Sometimes, there can be a bunch of information such as notams, traffic, and/or runway conditions to discuss.

[pelmet]

I finished the report and got further info on the reluctance to do a missed approach. The aircraft was about one mile right of course for runway 18. The previous arrival had done a missed approach and was holding somewhere to the west. The captain was worried about a potential conflict. I think a little over-paranoid. Plus, they likely had TCAS.

With regard to the failure to transition from the hold to the approach, the hold is at an angle to the approach at about 40 degrees(due to a blasting area to the north). The captain selected Proceed on the FMS and expected the aircraft to intercept final approach. When it did not, he started working on the FMC to correct the situation. It is possible that he did not have full situational awareness about the angle of the hold to the final approach track but that is not discussed. Assuming that he was aware of the 40 degree left turn that was required, and understanding that error in programming(or glitches happen - I have seen it in the sim), when the aircraft does not intercept final approach, simply go to heading select and turn the aircraft to an appropriate heading to get onto final(or disconnect the autopilot and manually fly to an appropriate heading) and then once settled down, re-program. All this assumes that one has the time to do so. They were already quite high during the hold to start with and when asked by ATC if they wanted to go around in the hold again, chose not to. Then they went further off course while re-programming the FMC and did nothing to slow down and configure. The F/O was flying. I think he made things worse with poor technique.

Screw-ups happen. The big mistake was continuing to descend below 1000' when totally unstable. One gets the feeling that the captain became too focussed on the button pushing and the go-around and not thinking about that actual position of the aircraft and being........close to 80 knots too fast on approach at one point.

[bobcaygeon]

Yes 14 year as FO is a HR mistake.

I've seen many FOs, even at small airlines, remain as FO's if they don't need the money or the "glory", and prefer getting the schedule and time off they want even though the Company wants to upgrade them.