First Air Crash Resolute Bay August 20 2011

[1&2SpooledUp]

The main take away should be the widespread requirement for SOPs that allow critical commands like go-arounds to be initiated by PF or PNF, and that they have mandatory responses with no option for anybody to ignore or override them, PIC included. I suspect most companies already adhere to these standards on paper, but as Eric mentioned his company does, perhaps there needs to be more official emphasis on this throughout initial and recurrent training. This is a good reminder for chief pilots to take a second look at their company's SOPs and culture, and make some changes.

Aside from all of that, I would like to know more about why the Captain was so complacent -- the report didn't really seem to speculate as to what kind of guidance information he was seeing on his side. I am having a hard time believing he was seeing the same thing the FO was reporting and still continuing. With regards to the heading indication error, was that enough to make him think the autopilot was working at re-intercepting? Tracking to intercept or not, if the LOC was showing full deflection on his side, how on earth could he continue down as low as he did? Was this a case of him trusting the flight director (which wasn't configured properly), over the more important raw navigational data (the track bar)?

The report illuminates the roll that CRM (or lack of it) played in this accident, and rightfully emphasizes it. But I would have also liked them to explore why exactly the Captain seemed to lose his situational awareness, as this seems to be the primary technical error that the faulty CRM was unable to resolve.

+1

It's like he was completely zoned out. Defiantly strange and deserves a closer look. It would be really nice to be able to listen to the full CVR recording!

I've been in the scenario of having full track bar deflection a few times in the sim and once in real life. When the call was made " full deflection" it got the other guys attention right away and a quick assessment of position was made, verified and on all occasions a go -around was initiated without question.

Unfortunately we will never know what was going through the Captains head that day or why the FO didn't take control when he could clearly see that things were going south in a hurry.

[pelmet]

I admit that I have not read the report, but I can't see even the stupidest airline captain continuing down with a full scale localizer deflection. It makes me wonder if his instrument was accidentally showing on localizer while the FO's instrument was showing accurate. In other words, his needles were centred due to a fault but the flag was not displayed. I have seen sticking flags on an ADI on Boeing 737 jets more than once that were not in view when they should be and then suddenly appeared when the instrument was tapped. On the ones I flew, a depowered ADI meant centered needles with flags over top of the needles.

That is the only way I could see someone willing to continue down. But if you have differing instrument indications, then it would still be time to go around. Especially if the GPS based on ARP which is the centre of the runway shows off course as well.

[Trematode]

The captain had his HSI set 17 degrees off, and the inbound track for the localizer is 345. His HSI was showing 330 instead of 347, so to him it looked like he was intercepting at 15 degrees. Instead, he was diverging from the track at 2 degrees. From his perspective, he was flying left towards the localizer, and it didn't make sense that the track bar would have gone full deflection to the left and not come back in.

You re-intercept all you want, but can you descend below MSA, transition, or a vectored altitude if you're not yet established on the LOC? I can understand the confusion with the lateral position in this scenario, but I can't understand descending below minimums until the track bar is centered and staying that way.

The narrative the report seems to follow is one of the captain putting more faith in the automation and flight director, than information about what the aircraft is actually doing.

[Justjohn]

While the discussion so far has centered on the approach and the CRM issues in the cockpit, has anyone else noted that the aircraft was dispatched with not one, but two AD's not complied with?

While these AD's did not directly impact the flight, in my opinion it speaks to a whole company safety culture in jeopardy.

[whipline]

Work for the TSB? No.

I don't work for first air, I don't even know anyone who works there. 2 years ago I was told the FO knew what was going on. Went through loc never reintercepred. Told the Captain. Called for a go around 3 times. Captain basically told them to get lost. Maybe that's why it's not being released?

Stupid accident. TSB would have known 90% from just the CVR.

[Gilles Hudicourt]

In my early years of flying, in 1988, I was a F/O on a Curtiss C-46. We were doing a night flight from Barbados to San Juan International airport, Puerto Rico. We had no weather Radar. Most of the flight had been in clear weather but there were heavy showers over the island of Puerto Rico. The old C-46 cockpit leaked like sieve in rain showers through the side windows and my right leg, sock and shoe were soaked, as were the captain's, but on his left side. We had no intercom and made standard calls with hand signals, and shouted when we had things to say. The heavy rain made the cockpit even noisier than normal. We were also cold after flying several hours at 10,000 feet with no heater and now being wet. We were getting bumped around a lot and I can say that the tension level was a couple notches above normal. We were arriving from the South East for an Rwy 10 ILS and were being vectored by San Juan approach. The controller had us on a heading of 340 to position us behind the aircraft which was ahead of us on the ILS, but at a certain time he decided he didn't have enough separation, so he kept us on that heading a little too long and just as we were about to go through the LOC, he told us to turn right on a heading of 160 degrees and cleared us for an ILS approach runway 10 (maybe it was 09 in that time). As the captain began his turn from 340 to 160 degrees, the localizer needle on the CDI went from full left deflection, to center, to full right deflection and once established on the assigned heading, the needle began to come back to center. When I called localizer alive, he maintained his 160 degree heading, went right through again to full left deflection. He had completely lost situational awareness and could not comprehend what the CDI needle and myself were telling him. I told him in no uncertain terms to turn left to intercept the localizer but he maintained that heading while questioning my call, at which point the controller called and asked why we had not intercepted the localizer. That is when he accepted that I was correct and turned on an intercept heading but at that point the GS became alive and he proceeded to follow it while we still had a full left deflection on the localizer, calling for flaps, gear, windshield wipers and landing checklist..... . There is high terrain south of the runway axis. This was at night, in IMC, in heavy rain, with no radar, with no GPS, with no radar altimeter, with no GPWS, no autopilot, just the basics. What saved us was that we eventually established ground contact around 1000 feet, saw the lights and then maneuvered visually for a landing.
I've been there, but survived to tell the story. How can one explain such a reaction from a pilot ? Stress ? Pride? Superiority complex? Hardheaded ? A combination of all of the above.......

[rampman]

[quote="Diadem"][quote="Trematode"]Aside from all of that, I would like to know more about why the Captain was so complacent -- the report didn't really seem to speculate as to what kind of guidance information he was seeing on his side. I am having a hard time believing he was seeing the same thing the FO was reporting and still continuing. With regards to the heading indication error, was that enough to make him think the autopilot was working at re-intercepting? Tracking to intercept or not, if the LOC was showing full deflection on his side, how on earth could he continue down as low as he did? Was this a case of him trusting the flight director (which wasn't configured properly), over the more important raw navigational data (the track bar)?

The report illuminates the roll that CRM (or lack of it) played in this accident, and rightfully emphasizes it. But I would have also liked them to explore why exactly the Captain seemed to lose his situational awareness, as this seems to be the primary technical error that the faulty CRM was unable to resolve.[/quote]
The captain had his HSI set 17 degrees off, and the inbound track for the localizer is 345. His HSI was showing 330 instead of 347, so to him it looked like he was intercepting at 15 degrees. Instead, he was diverging from the track at 2 degrees. From his perspective, he was flying left towards the localizer, and it didn't make sense that the track bar would have gone full deflection to the left and not come back in.[/quote]

you'll get the same full scale deflection on an ils weather your set in true or mag or if your hsi is set 30 degrees off

[boxcut]

I have a feeling that northern operators attract a certain type of pilots. sadly enough, talking to ppl who fly in the north, the "what happens in vegas" mentality still exists. That type of shit would NEVER happen at a major carrier like AC or WJ.
The old boys club mentality has got to stop!!!!!!
Not necessarily pointing fingers at First air here.. but the northern operators in general.

If you have a strong enough safety culture, and members who speak up when there are issues that will affect flight safety, then you don't run into this sort of situation as often, or at least the holes in the cheese don't line up as often. There are good northern operators out there, and there are great pilots in the north (some of them working for the sketchiest airlines in the world outside of central africa). There are bad operators and pilots too, who let ego get in the way of safety, because 'its the north' and 'let's get it done'. The military has some crews like that too, and I think its a part of some peoples human nature to forget that most aviation rules and laws are written in blood and tragedy. What prevents these things from happening is a culture where being safe isn't punished, where in a disagreement the most conservative course of action is followed, and these values are reinforced repetitively and positively.

I have a lot of respect for the men and women who fly in Canada's north. They have some of the worst weather, worst weather reporting, worst weather forecasting, worst airport maintenance, worst navigation facilities and worst airfield conditions to deal with. A crew of a 737 going to a 5000 ft gravel strip holding a 500 mile alternate to another crappy 5000 ft gravel strip, in bad weather, with only an NDB approach (maybe a vor if you are lucky) is a hell of an undertaking. There are no diversion points because most airports are either too far, or too small for your aircraft type. If you go down in a blizzard, your hope of being rescued lies in the blizzard dying down before you all freeze to death (and that doesn't take long. So I have a lot of respect for most northern flyers who deal with all of the above and maintain a cautious and safe attitude in the execution of their duties to their profession and their passengers.

[pelmet]

A crew of a 737 going to a 5000 ft gravel strip holding a 500 mile alternate to another crappy 5000 ft gravel strip, in bad weather, with only an NDB approach (maybe a vor if you are lucky) is a hell of an undertaking. There are no diversion points because most airports are either too far, or too small for your aircraft type. If you go down in a blizzard, your hope of being rescued lies in the blizzard dying down before you all freeze to death (and that doesn't take long. So I have a lot of respect for most northern flyers who deal with all of the above and maintain a cautious and safe attitude in the execution of their duties to their profession and their passengers.

A good point about the reality of alternates and their potential influence. Does anybody have the Hall Beach forecast and actual weather that day along with how far below max landing weight they were. So many companies plan for minimum fuel now with marginal alternates and pilots frequently accept it. It can have an influence on someone deciding to press on when the weather is deteriorating at destination and things are not quite stable or there is some other potential problem. Sometimes there is room for extra fuel and that can make a missed approach a more comfortable option.

I have seen long transoceanic flights with an alternate 7 miles from destination in marginal but legal weather. And nothing realistic to land at in the last few hours short of destination.

[Independence]

I find it hard to believe that this was the only crew at First Air that had a casual approach to standard calls. Some of the blame needs to be placed on the company that didn't enforce their own standards.

[CFR]

Something else to observe on is that the time between when the flight rolled level from the turn to final (supposedly onto the ILS) until they hit the ground was less that 3 minutes (2:43 to be exact). That is precious little time to recognize and agree that something is wrong while in the midst of the other activities taking place during landing. It certainly is not the time to be in serious disagreement with each other and underscores the SOP that either pilot should be able to call for a missed approach.

[Old fella]

Sounds like a Captain with 13000 hrs TT and 5200 hrs on type(B737) didn't really want to or wasn't about to, listen to a FO with 4800hrsTT and 103hrs on type(B737) even though this newly minted FO has a good grasp of the shit that was going down. Not a positive reflection on the airline involved as I am sure the tort lawyers will be eager to point out..................

[RatherBeFlying]

I wouldn't call the captain complacent. More he was concentrating hard on making the intercept to a misentered course. At times like that the brain shuts out on conversation. Yes, the captain was not fully taking in what the FO was saying.

I was in the right seat in a sim with WWII style white on black AH when the PF went inverted at 16,000' and held attitude all the way into the ground while I was shouting in his ear.

Sometimes you have to grab the controls or push the throttles forward -- but social conditioning makes that real hard to do.

Sim rides need to present situations where PM has to take over.

[Rowdy]

Sounds like a Captain with 13000 hrs TT and 5200 hrs on type(B737) didn't really want to or wasn't about to, listen to a FO with 4800hrsTT and 103hrs on type(B737) even though this newly minted FO has a good grasp of the shit that was going down. Not a positive reflection on the airline involved as I am sure the tort lawyers will be eager to point out..................

Amazing to think, that even with close to 5k in the logbook and experience in a 705 turboprop (ATR) that you're still considered 'just' an FO and 'low time' by some.

[angry inch]

Sim rides need to present situations where PM has to take over.

Yes!! My experience in 2 crew sim training is modest, so maybe there's more of what's mentioned above than I know of. During the sim training/rides that I did do, I only remember having to take over during mock incapacitation scenario's. I'd also have to day that there is much more focus on the PIC being prepared to take over when the F/O (often new to the operation or a/c) loses situational awareness rather than the other way around.

I also can't help myself from emphasizing the fact that the TSB called out Transport Canada on being way behind in the subject of CRM. Many companies seem to uphold a "minimum Standard" when it comes to TC regs. Combine that with outdated standards written in a language only the author can speak.... What could possibly go wrong.

Very sorry that the affected families have had to re-live this tragic event after so long....

[Old fella]

Sounds like a Captain with 13000 hrs TT and 5200 hrs on type(B737) didn't really want to or wasn't about to, listen to a FO with 4800hrsTT and 103hrs on type(B737) even though this newly minted FO has a good grasp of the shit that was going down. Not a positive reflection on the airline involved as I am sure the tort lawyers will be eager to point out..................

Amazing to think, that even with close to 5k in the logbook and experience in a 705 turboprop (ATR) that you're still considered 'just' an FO and 'low time' by some.

Right oh.......... especially this day and age(2014) and emphasis on CRM.

[godsrcrazy]

Sounds like a Captain with 13000 hrs TT and 5200 hrs on type(B737) didn't really want to or wasn't about to, listen to a FO with 4800hrsTT and 103hrs on type(B737) even though this newly minted FO has a good grasp of the shit that was going down. Not a positive reflection on the airline involved as I am sure the tort lawyers will be eager to point out..................

Amazing to think, that even with close to 5k in the logbook and experience in a 705 turboprop (ATR) that you're still considered 'just' an FO and 'low time' by some.

the way i see it there are way to many people putting way to much emphasis on TT in the log book. I have flown with low timers with under 1,000 hrs in my right seat that are more common sense and better hands and feet with then some captains with 10,000 hrs. I personally think there are to many companies and clients that are more concerned about the TT in a log book. It still amazes me how some people even achieve their license.

[1&2SpooledUp]

As long as we have companies that are just barely meeting the minimum TC standards and TC,s Smoke and Mirrors SMS, we will continue to have these preventable accidents time and time again.

[ajet32]

I didn't know either crew member as I mentioned earlier but I am going to ask that post 13 and possibly 14 on this page by "Been_there" be edited or removed. Directly accusing someone who cannot defend themselves does not reflect well on the professional aviation community. There were a great many factors, 18 I believe mentioned in the report and name calling will only make things worse it will not create an environment that we can learn from as a result of this tragedy.

[Illya Kuryakin]

Blair Rutherford was unfit to be captain. The FO made approximately 18 attempts to have the approach aborted during the final 90 seconds of the approach. Disgusting negligence on the Captain's part for COMPLETELY disregarding those warning. Why have CRM at all with captains like that one at the controls. This is an accident that did NOT need to happen.

Pretty strong accusations there, Been_there (I'm sure you haven't) about a captain's fitness to command. The FO did make several attempts to indicate things were going down the drain. True. He did not take ultimate control of the obviously bad situation with..."I HAVE CONTROL, GO AROUND, MAX POWER....." This is the ONLY reaction that would have saved the day here. This is something that HAS to be trained into pilots from the get go. There is no shame in a missed approach. We all pooch the odd approach. The needles are not always crossed. The lesson here is, that immediate and decisive action has to be taken when needed. The trick is, to recognize a situation that requires such action.
Illya

[Illya Kuryakin]

Amazing to think, that even with close to 5k in the logbook and experience in a 705 turboprop (ATR) that you're still considered 'just' an FO and 'low time' by some.

Well put Rowdy. Herein lies a problem with the Captain, "Right Seat Meat" culture, if you will. Back in the day, the Captain was King.....the "Fool" in the right seat, no more than his loyal subject.
Today's airplanes require two PILOTS. Both have to able to, and more importantly, willing to take control of a situation if the need arises. It's a team effort. There is no I in team.
On a difficult, or low approach, I always ask "Everything look okay on your side...?" It's not really an SOP, but it just puts everything in perspective.
Thoughts are with families and coworkers on this one.
Illya

[Anthropomorphized]

The report spends a lot of time reviewing CRM and SMS and CVR's and FDR's and SOP's but very quickly rejects fatigue as a factor even though it is like a plague in aviation. The report only referenced a few days before the flight and all it really tells us is that the crew had 'legal' rest periods immediately prior to the flight, which has nothing to do with fatigue. More effort should have been made to investigate this issue and why the regulations allow for flight crews to be continually utilized to the maximum extent possible. I think those regulations are meant to be just that, a maximum. Not a goal.

Pilots make many decisions during the course of a flight that may seem momentous or very minute at the time but that usually result in completing the flight safely and in a timely manner. Use of CRM and SOP’s has proven to be a very strong aid in helping this happen. However, when fatigue is involved it is very easy for a train of thought to be broken down or delayed which can be the first link in the chain of events, as they say. It can also reduce the pilots ability to mentally stay ahead of the plane.

I have no idea if fatigue was an issue in this example but I do find it suspect that it was glossed over and dismissed so quickly given that maximum flight and duty times and fatigue for Pilots is such a hot topic right now and is currently under review by many Aviation Authorities.
These were obviously two very experienced and professional pilots flying at a reputable airline that ended up in a less than desirable situation and failed to correct it in time. Yes. Were there outside factors at play? Maybe.

I don't like seeing pilots hung out to dry like this.

[Gino Under]

There is no simple answer or comfort to be found by adding more crap to anyone's SOPs. A false sense of security can easily be found written in many airline SOPs.

If you clear your mind and think about not only the meaning of aviate, navigate, communicate but also how those simple basics might have played a part in preventing this and many others tragedies, we wouldn't even be having this discussion.

SOPs can quickly impair a crews use of better judgement and analytical skills when needed the most. This is merely another example of what might have ended differently if the communication part of that triad had been more effectively used.

SOPs aren't a one size fits all solution nor do most SOPs contain the perfection many seem to think they do. Know this, SOPs aren't aware of criticality, specific needs in a given situation AND certainly can't think for us. That's our job.

For those who need clarification, my comments aren't aimed at this accident specifically but accidents in general. It's a heartbreaking tragedy and my sympathy is for those who lost their lives. It is also with airline crews at this airline who soldier on despite the after effects.

If you think any one airline has CFIT mastered or SOPs mastered, then you better think again.

Sadly, our aviation industry and it's operators are over proceduralized. I could start with SMS and go from there. It may be time to allow the brain back into the flight deck.

Liquid Charlie
Thank you for your words of wisdom. Some of us get it.

Gino Under

[Diadem]

The captain had his HSI set 17 degrees off, and the inbound track for the localizer is 345. His HSI was showing 330 instead of 347, so to him it looked like he was intercepting at 15 degrees. Instead, he was diverging from the track at 2 degrees. From his perspective, he was flying left towards the localizer, and it didn't make sense that the track bar would have gone full deflection to the left and not come back in.

you'll get the same full scale deflection on an ils weather your set in true or mag or if your hsi is set 30 degrees off[/quote]
Yeah, you completely missed the point. He thought that his apparent 15 degree heading correction would bring him back onto the localizer. Perhaps he thought that since he was still outside the FAF he had more time to get back onto the loc even though he had full-scale deflection, and once he devised that plan he stuck with it. The point is that he expected his correction to the left to bring him back onto the approach, and when it didn't he became more confused; his incorrect heading actually made him diverge from the loc and made the situation worse. Yes, he would have gotten full-scale deflection regardless of whether [note spelling] he had it in MAG or DG, or whether his HSI was set 30 degrees off, but he wouldn't have expected to be flying back towards the loc when he was actually flying away from it if he'd set his heading correctly.

[Diadem]

The report spends a lot of time reviewing CRM and SMS and CVR's and FDR's and SOP's but very quickly rejects fatigue as a factor even though it is like a plague in aviation. The report only referenced a few days before the flight and all it really tells us is that the crew had 'legal' rest periods immediately prior to the flight, which has nothing to do with fatigue. More effort should have been made to investigate this issue and why the regulations allow for flight crews to be continually utilized to the maximum extent possible. I think those regulations are meant to be just that, a maximum. Not a goal.

Pilots make many decisions during the course of a flight that may seem momentous or very minute at the time but that usually result in completing the flight safely and in a timely manner. Use of CRM and SOP’s has proven to be a very strong aid in helping this happen. However, when fatigue is involved it is very easy for a train of thought to be broken down or delayed which can be the first link in the chain of events, as they say. It can also reduce the pilots ability to mentally stay ahead of the plane.

I have no idea if fatigue was an issue in this example but I do find it suspect that it was glossed over and dismissed so quickly given that maximum flight and duty times and fatigue for Pilots is such a hot topic right now and is currently under review by many Aviation Authorities.
These were obviously two very experienced and professional pilots flying at a reputable airline that ended up in a less than desirable situation and failed to correct it in time. Yes. Were there outside factors at play? Maybe.

I don't like seeing pilots hung out to dry like this.

I don't see how fatigue could remotely be considered a factor. The report only seemed to mention the 72 hours before the accident because that was the period in which the captain worked, subsequent to having at least 36 hours off. The captain worked 7 hours, then got 16.5 hours of rest, worked 12 hours followed by 17 hours of rest, and worked 5.5 hours followed by 11 hours of rest. He wasn't being worked to his max duty day, he was being given more than the minimum rest period, he wasn't alternating between day and night shifts, and the day previous he didn't even work what most people would consider a full work day. The FO had 85 hours off prior to reporting for duty. If you're not happy with that, what do you suggest for minimum rest periods? Should operators be required to give the crew a week off after each leg? If the crew wasn't adequately rested because they didn't take the opportunity to sleep, or they didn't have a restful sleep, or they were having chronic fatigue issues, it would have been their responsibility to report their fatigue to the company when they reported for duty.