First Air Crash Resolute Bay August 20 2011

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Illya Kuryakin
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Re: First Air Crash Resolute Bay August 20 2011

Post by Illya Kuryakin »

Donald wrote:The Mayday video is fictional or incorrect in many places, if you truly wish to learn about this accident I suggest you read the TSB report.
p
Have to suggest here Donald, that the TSB report comes from a group, after spending two years ( or more ) studying what the crew had two minutes to figure out?
Not having a FIRM policy on who can, and when to "change the game plan" was, along with getting into that position in the first place was the lesson here. Scary stuff. Let's learn from this.
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Donald
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Re: First Air Crash Resolute Bay August 20 2011

Post by Donald »

Couldn't agree more Ilya.

As someone introduced to the show Mayday in flight school, and somewhat of a fan ever since, I have to say I'm really disappointed in it.

No commentary on company culture, SOP's, the interviews with FO's after the accident.

Completely incorrect display of the MCP as they would've used it, and no mention of the fact the company condones incorrect mode use for flying ILS approaches.

Incorrect comment that the crew got a "Terrain" warning just prior to impact. Not possible with that TAWS unit.

No mention that NWN was the only non-EGPWS aircraft in the fleet.

Characterizing the fo as inexperienced, which in my biased opinion is incorrect. Inexperienced on the 737, but not the area, company, or flying.

No mention of the unstable approach, late configuration.
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55+
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Re: First Air Crash Resolute Bay August 20 2011

Post by 55+ »

The aircraft was well outside the final approach design trapezoid for obstacle clearance, yet continued down while there was ample indications things were not aligned to an unfortunate sad ending.

http://www.tsb.gc.ca/eng/medias-media/v ... /index.asp
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Sidebar
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Re: First Air Crash Resolute Bay August 20 2011

Post by Sidebar »

Trematode wrote:Am I alone in not understanding why descent was continued or even initiated in the first place despite not ever being established on the LOC?

See appendix O from the TSB report showing the vertical profile relative to the glideslope.
Picture3.jpg
Picture3.jpg (29.93 KiB) Viewed 2307 times
The first officer called glideslope alive at 1638:25 as they began the turn onto final approach about 600 feet above the ILS glideslope (MUSAT on the chart). Therefore, the glideslope indicator was likely showing close to full deflection high. Except for about one minute as it passed abeam the FAF (OTNEL on the chart), the flight remained above the glideslope throughout the approach. At 1641:28, the first officer stated the glideslope was full deflection. The chart shows they were well above the glideslope at that time.

I think they were entirely focussed on the lateral deviation from the localizer. If the captain was thinking about altitude, he likely erroneously concluded they had adequate vertical clearance from terrain because he could see they were above the glideslope.
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Trematode
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Re: First Air Crash Resolute Bay August 20 2011

Post by Trematode »

I think they were entirely focussed on the lateral deviation from the localizer. If the captain was thinking about altitude, he likely erroneously concluded they had adequate vertical clearance from terrain because he could see they were above the glideslope.
This is exactly what I'm having trouble with -- if he was so focused on the lateral deviation from the localizer then he should have been acutely aware that his minimum IFR altitude MUST still have been MSA (or perhaps an appropriate proc turn altitude). The glideslope indication is irrelevant if you're not on the LOC! Allowing for any descent below your IFR minimums is the one overriding rule you're not supposed to break! It is hard for me to understand how an experienced crew could have let that happen, and I am surprised this fundamental error was not the focus of the report.

I can only speak from my own experience, but nobody is perfect and overshooting turns to final on an instrument approach happens to us all. No big deal -- but you reintercept your final approach course BEFORE you initiate your descent, not during or after.
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Alberta_x51
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Re: First Air Crash Resolute Bay August 20 2011

Post by Alberta_x51 »

The youtube video is for a non-aviation audience but it gives the substance of the causes of the accident.
The report takes a lot of reading but again, the same substance leaps out that any comment on
would probably not be appreciated on this forum.


I'd like to pose the question of in this particular flight,
what are various transitions that could be used, and what would be the most correct transition from GPS to ILS.

I notice the report refers to the MUSCAT position that does not appear on the ILS chart but
appears on the RNAV (GNSS) RWY 35 TRUE chart.

The report seems to allude that one can use the two approach charts at the same time?
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hamstandard
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Re: First Air Crash Resolute Bay August 20 2011

Post by hamstandard »

URC wrote:The TSB totally ignores the Captain's past training record and performance. Contrast this to the United States and the NTSB report on the UPS Birmingham crash.

Not sure why the TSB would choose to ignore these issues ? Perhaps it's something we can't handle being in politically correct Canada ?
Do you know something that we don't?
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URC
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Re: First Air Crash Resolute Bay August 20 2011

Post by URC »

Do you know something that we don't?
No. Because the PC TSB won't investigate it. Read an NTSB report or Public Docket to see what a REAL accident investigation looks like.

Here's a hint ....

http://dms.ntsb.gov/pubdms/search/hitli ... XTSEARCHT=
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hamstandard
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Re: First Air Crash Resolute Bay August 20 2011

Post by hamstandard »

URC wrote:
Do you know something that we don't?
No. Because the PC TSB won't investigate it. Read an NTSB report or Public Docket to see what a REAL accident investigation looks like.

Here's a hint ....

http://dms.ntsb.gov/pubdms/search/hitli ... XTSEARCHT=
Well, if you don't know anything, then I'm not quite sure what you are talking about. The link shows a whole bunch of further links.
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Sidebar
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Re: First Air Crash Resolute Bay August 20 2011

Post by Sidebar »

55+ wrote:The aircraft was well outside the final approach design trapezoid for obstacle clearance
I agree completely. The first officer's statements indicate he was likely aware of this, or at least aware that things were going bad quickly and they needed to bug out. On the other side of the cockpit, the captain's statements and actions indicate he likely was not aware they were outside the obstacle clearance area.

Trematode wrote:... if he was so focused on the lateral deviation from the localizer then he should have been acutely aware that his minimum IFR altitude MUST still have been MSA (or perhaps an appropriate proc turn altitude).
The key words in your analysis are "he should have been." Yes, he should have been, but was he?

Let's assume for a moment the captain was indeed aware that his min IFR altitude was MSA. In that case, one can expect that he would do a go-around and climb. However, the reality is that he did not respond in this expected way, despite prompts from the first officer. Why not? The fact that the captain continued the approach suggests to me that he likely wasn't thinking about the obstacle clearance trapezoid or MSA, but was instead determined to find the runway and land.


From the TSB report:
Section 2.8.2.2
The captain's mental model was likely that the autopilot would re-intercept the localizer from the right and a landing would follow.

Section 2.8.7
The captain's statement at 1640:54.3 that he could not go left occurred between his calls for flaps 25 and flaps 30. At this time, his attention was likely becoming focused on aircraft configuration and airspeed control, to the detriment of other parameters. As indicated by the rate of descent change and ballooning above the glideslope, his attention to flying the ILS approach was negatively affected. This situation is a strong indication that the captain was affected by attentional narrowing.

Section 2.11.3
The communications between the 2 pilots were ineffective. The captain was task-saturated and was likely influenced by plan continuation bias. Despite the FO’s communication efforts, concerns about FAB6560’s flight path were not incorporated into the captain’s decision-making process.

Section 2.11.5
... the FO’s mental model was that a go-around was necessary, while the captain’s mental model was that the approach could be salvaged and a landing could be made.

Findings as to causes and contributing factors
14.Due to attentional narrowing and task saturation, the captain likely did not have a high-level overview of the situation. This lack of overview compromised his ability to identify and manage risk.
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Sidebar
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Re: First Air Crash Resolute Bay August 20 2011

Post by Sidebar »

Alberta_x51 wrote:... what are various transitions that could be used, and what would be the most correct transition from GPS to ILS.
There are lots of legal transitions. In my view, the simplest one is just what the crew of flight 6560 likely planned. I would load the GPS with the RNAV 35 approach, and then go direct to MUSAT while descending to 100 nm MSA and then sector MSA once inside 25 miles. I'd have the ILS tuned and ready, and at about 10 miles before MUSAT I'd switch the autopilot and flight director to ILS from GPS. The aircraft should then intercept the localizer and I could capture the glideslope from below at sector MSA and follow it down.
Alberta_x51 wrote:I notice the report refers to the MUSCAT position that does not appear on the ILS chart but appears on the RNAV (GNSS) RWY 35 TRUE chart.

The report seems to allude that one can use the two approach charts at the same time?
My bet is this happens frequently, especially when a fix you want to use (like MUSAT) is not already on the approach plate for the ILS. I don't see this as a problem, I see it as good airmanship and CRM. Your approach is governed by the ILS plate and you comply with it. You make use of available resources (the RNAV procedure) for navigation to the ILS intercept point, and as a crosscheck of the localizer as was the case on flight 6560.
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ODA
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Re: First Air Crash Resolute Bay August 20 2011

Post by ODA »

It's ridicules but, there used to be a GPS IAF fix on the ILS approach. Nav Canada removed it from the approach I believe, the update just before the crash. Not sure why, but it was nice having the same approach loaded in the box you were about to fly. If nothing else makes your situational awareness a little bit better. That wasn't in the report either.
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wallflower
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Re: First Air Crash Resolute Bay August 20 2011

Post by wallflower »

Likewise the Cape Martyr beacon.
http://www.navcanada.ca/EN/products-and ... ute-EN.pdf
I know the RB NDB to the North is still there but as an old fart I like to have a beacon on the approach if possible, who knows if seeing it at a funny angle might have helped ?
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ettw
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Re: First Air Crash Resolute Bay August 20 2011

Post by ettw »

wallflower wrote:Likewise the Cape Martyr beacon.
http://www.navcanada.ca/EN/products-and ... ute-EN.pdf
I know the RB NDB to the North is still there but as an old fart I like to have a beacon on the approach if possible, who knows if seeing it at a funny angle might have helped ?
i have thought the same thing.

I have also wondered if he may have still had Cape Martyr on the brain when he was looking at the RMI. The relative bearing to RB would have been small....and that might have led someone who was fixating to believe that he wasnt that far off of the loc if he was thinking it was Capt Martyr.

Just a thought.....

ETTW
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