First Air Crash Resolute Bay August 20 2011

[126.75]

F*cking brutal. That captain essentially killed his FO and the passengers and FAs in the back. The FO was being fairly deliberate in his wording to no avail. Short of grabbing the thrust levers himself by the sounds of it he made several recommendations to go around. Absolutely tragic, further more that we still have captains with such an inflated ego can't listen to an FOs recommendation when things are starting to go sideways, this is not the 1960s anymore. Absolutely tragic.

[arcticheliwrench]

As someone who flies on First Air regularly, I dismissed any concerns about continuing to fly with them as I was fairly certain that the crash had nothing significant to do with the boys in the cockpit or the guys in the hangar. I too agreed with the speculation of serious outside meddling by the military or a serious flaw with navigation instrumentation.

The transcript of the cockpit conversation as well as the bumping of the column knocking off the AP, and more-so the failure to realize it, speak for themselves. I am questioning my choice in northern airlines.

[halfmilevis]

Frustrating to see that from the transcripts alone, the FO clearly has a better picture in his head compared to the PIC, and speaks confidently about the situation to no avail... It’s sad to see the captains failure to recognize that he has lost the overall picture of the approach and instead of confiding in the trained personnel next to him he continues to press on a bad situation, Instead of breaking off and trying again on a stabilized approach.

A sad situation indeed!

[Eric Janson]

A very sad read - a simple go-around earlier in the sequence would have prevented this.

Just for comparison - at my company:-

"A clearance for an approach is also a clearance for a go-around" - emphasised repeatedly during initial groundschool. Also bold text in the SOPs

Either Pilot may call for a go-around at any time during the approach. A go-around is mandatory when either Pilot calls for one. The procedure is to perform the go-around and get the aircraft stabilised at a safe altitude and only then discuss the go-around.

We have a no fault go-around policy.

[CFR]

Too bad a missed approach is treated as an occurrence and gets you an entry in CADORS. There are currently over 5500 entries for missed approaches.

[flyinthebug]

Like most others, I am surprised by the findings in this report. There have been too many with this final outcome (Capt thinks all is well, and FO tries in vain to advise there is a major problem). What I really cant understand is what took the Captain so long to finally accept he was wrong! Once the approach became unstable, get outta there and regroup. Had they initiated the go around even on the FO`s third request, they would all still be here. Very sad and tragic.

My heart really goes out to all the families involved, and the FO`s family in particular. He knew things were going south fast and I just wish he would have "insisted" they go around, rather than do what so many before him did... with the same outcome for all of them. He was previously a Capt on a large turbo prop, so I really wonder why he wasn't more insistent on initiating the go around much sooner? Either way, its just a very sad.

RIP to all lost in the very preventable accident.

FTB

[DBC]

That was a depressing one to read

[Zapp Brannigan]

Too bad a missed approach is treated as an occurrence and gets you an entry in CADORS. There are currently over 5500 entries for missed approaches.

Agreed. A CADOR should not be issued for a missed approach. It sets the framework out for some approaches to be pushed. Anything that is perceived by a less experienced pilot of requiring paperwork will put doubt in his/her mind to do that action.

[ditar]

I really disagree. CADORs are records of occurrences, not just violations. All manner of things get reported in CADORs, from missed approaches to moose on the airport. "Getting CADORed" is in itself meaningless and should not be cause for any trepidation unless you actually committed a violation. I've been logged as having done missed approaches many times and I couldn't care less. Nothing ever became of it and I was questioned by nobody afterwards.

[C-FABH]

Too bad a missed approach is treated as an occurrence and gets you an entry in CADORS. There are currently over 5500 entries for missed approaches.

Agree with ditar. They're hardly indicative of a violation, and there's plenty of meaningless ones which get filed.
Source: I review every single one for my employer.

Our plane got tagged in a CADOR because it was delayed five minutes due to grass cutting equipment near the runway. Who cares.

[Mr. North]

How much force is required to "bump" the AP off? I find it odd you can do it accidentally and not notice.

[CFR]

I really disagree. CADORs are records of occurrences, not just violations. All manner of things get reported in CADORs, from missed approaches to moose on the airport. "Getting CADORed" is in itself meaningless and should not be cause for any trepidation unless you actually committed a violation. I've been logged as having done missed approaches many times and I couldn't care less. Nothing ever became of it and I was questioned by nobody afterwards.

I somewhat agree except that so many of the missed approach entries also include "Further Action Required - Yes". I suspect that most of the follow-ups result in simple explanations (unstable approach, previous aircraft slow to depart/leave runway, aircraft configuration, etc).

On the other hand there are few entries that describe situations where an unstable approach was continued to a landing. Had the Resolute Bay incident result in fighter like manoeuvring to a successful if not somewhat rough landing, it would likely not be entered. To prevent accidents you need to report and investigate incidents.

On another point, did you notice how hard the reporters tried to get the TSB members to state that it was "pilot error" and how hard they worked to dispel that term?

[Jim la Jungle]

Mr. North,
To partly answer your question. The A/P didn't click off. It changed mode. From the report:

"A low detent force (4 pounds in the roll axis and 5 pounds in the pitch axis) is required to move the control wheel out of the centre (detent) position. This force is comparable to the force required during manual flight. After overcoming this resistance, the command to pitch or roll is at a rate proportional to control-wheel or column force.

High detent force (8 pounds in the roll axis and approximately 18 pounds in the pitch axis) is provided to prevent inadvertent disengagement of various submodes. The force required to move the control wheel or column out of the detent position is increased. If reversion to CWS inputs only (no automatic heading, course, radio, or pitch commands) is desired, it may be accomplished by exerting a force greater than high detent level."

Also, the report at 2.8.2.2 "Crew mental models" points out a very interesting concept in situation like these where workload and discrepancies occur.

[MrWings]

I think the withholding of the actual transcript is a disservace to the flying public and aviation community. It may provide some stronger insight on the professionalism and mindset of the pilots. The perception is that something is being hidden.

[boxcut]

Not surprised at all by Transport's verdict. I've met a lot of "cowboys" flying in the North, it's unfortunate that in this case it led to a disaster.

There are some great pilots up north, and great airlines that understand safety comes before ego or 'experience'. Hopefully the lawsuits and Transport will reign in the mavericks and mustangs that put people's lives in jeopardy when flying across some of the most inhospitable terrain on earth.

Also Kudos to the military for acting so bravely to rescue those they could from the disaster.

[whipline]

I don't know why it took so long to come out. I was told what happened almost two years ago. From what I heard there's a reason why the cvr transcripts haven't been released. Poor pax and FO RIP.

[boxcut]

From what I heard there's a reason why the cvr transcripts haven't been released.

My guess is to allow 7F the time to hire really good lawyers and prep for the lawsuits.

[CFR]

... From what I heard there's a reason why the cvr transcripts haven't been released ...

Because the law governing the Transportation Safety Board does not allow it except for certain circumstances - the current situation is not one of them.
Same law prevents investigators from being compelled to give testimony.

[MrWings]

I was told what happened almost two years ago. From what I heard there's a reason why the cvr transcripts haven't been released.

And if they aren't going to tell us then rumour and speculation will become fact. Perhaps that is better than what the conclusions would be drawn if the transcript was released.

[YYZSaabGuy]

I was told what happened almost two years ago. From what I heard there's a reason why the cvr transcripts haven't been released.

And if they aren't going to tell us then rumour and speculation will become fact. Perhaps that is better than what the conclusions would be drawn if the transcript was released.

I'm really not sure how you get to that conclusion. The TSB's comments on this subject are found on P. 9 of the report and as CFR indicated, it's an ICAO regulatory compliance issue. I'm not sure why there would be any further rumour and speculation - the TSB's report seems pretty thorough - and I'm not sure why you feel any different conclusions would be reached if the transcript was released. Unless of course you're hinting that you work for the TSB and you're aware of a cover-up of some kind, which I frankly doubt.

[digits_]

I get it that something obviously went wrong. But if you look at the (limited) transcript, there are basically 2 people having different opinions.

Captain says all is OK. FO says there is something wrong.

In the end, it turns out the FO was right. But why is this considered a total breakdown of CRM ? What do you usually do in such a situation in a multi-crew environment ? They discussed it, and couldn't reach an agreement, so the FO went along with the captains plan. I guess that happens every now and then, albeit with less drastic consequences.

Also note that the captain did initiate a go-around when the FO asked for it the first time.

//edit: weird, on the animation here it says the FO did ask for a go-around 3 times: http://www.tsb.gc.ca/eng/medias-media/v ... /index.asp
Why would that be left out of the transcript summary in the report ? Isn't that an extremely important nuance ?

[Illya Kuryakin]

Sad indeed.
Illya

[matrix]

I get it that something obviously went wrong. But if you look at the (limited) transcript, there are basically 2 people having different opinions.

Captain says all is OK. FO says there is something wrong.

In the end, it turns out the FO was right. But why is this considered a total breakdown of CRM ? What do you usually do in such a situation in a multi-crew environment ? They discussed it, and couldn't reach an agreement, so the FO went along with the captains plan. I guess that happens every now and then, albeit with less drastic consequences.

Also note that the captain did initiate a go-around when the FO asked for it the first time.

//edit: weird, on the animation here it says the FO did ask for a go-around 3 times: http://www.tsb.gc.ca/eng/medias-media/v ... /index.asp
Why would that be left out of the transcript summary in the report ? Isn't that an extremely important nuance ?

If only there were something like instruments to back up the FO's "opinion". Oh wait there was! Full scale deflection of both the localizer and glideslope.

The FO's opinion was based on facts. The Captains was based on nothing.

He only started the go around when the GPWS started going off.

[CFR]

Here's a question for someone in the know. If the Military Terminal Control unit had been in operation might they have spotted the error and waved them off?

[midwingcrisis]

Great question CFR, I will refrain because I am not in the know. Questions I have is 1. Why is TSB withholding the CVR and "ATC" tapes? 2. Why the extended amount of time for the finality of the report? Looking for thoughts or answers from those that are in the know. I will hang up and listen