First Air Crash Resolute Bay August 20 2011

[pelmet]

310 KIAS going through 10,000 feet says a lot about how the SA was of the Captain before they even began the approach.

310 knots at 10,000 should not be a problem. You have a tailwind on descent and know you will have one on approach so a right 270 turn or procedure turn type maneuver after crossing the localizer at or above MSA should deal with that no problem. Not a problem to do this sort of maneuver at an airport like this. Whenever you have a tailwind on approach especially to a relatively short runway, you should plan extra maneuvering room and early configuration. Especially on an aircraft that doesn't descend that quickly. But if it doesn't work out and if you are high go to plan B. A 360, another option takes about 2 minutes. Obviously, this was not done.

There is no need to be recovering to a stable approach at 200 feet as someone posted just because there is a tailwind. Just get gear and flaps out early with full flaps on final descent and plan ahead. If you can get stable at 200 feet, you can at 2000 feet.

The thing that makes me wonder about a faulty instrument indication on the captain's side is that he did say, we are on the localizer when questioned about being off the localizer.

[CpnCrunch]

310 knots at 10,000 should not be a problem.

Apart from the fact that it's illegal (as helpfully pointed out in the report).

[FICU]

310 knots at 10,000 should not be a problem.

I have been flying the 737-200 for over 8 years and have never had the jet that fast at 10,000 feet in a descent. 250 KIAS is always the target whether in radar or non-radar, controlled or uncontrolled airspace.

You fix the high/hot descent prior to 10,000 feet and not after it.

[CID]

Sidebar....I didn't write the comment you're attributing to me. I don't see how the captain could not have known the LOC was full scale.

[shimmydampner]

This is a very sobering report and should be food for thought for those on both sides of a two-crew cockpit. It's a shame that certain posters would instead prefer to take it as an opportunity to tar and feather "northern pilots" probably without any real understanding of the unique challenges faced in the north. To suggest that this accident could only have happened in the north because those that fly there are somehow inferior, is the height of both arrogance and ignorance.
There is much to be taken away from this report by EVERYONE.

[flyinthebug]

This is a very sobering report and should be food for thought for those on both sides of a two-crew cockpit. It's a shame that certain posters would instead prefer to take it as an opportunity to tar and feather "northern pilots" probably without any real understanding of the unique challenges faced in the north. To suggest that this accident could only have happened in the north because those that fly there are somehow inferior, is the height of both arrogance and ignorance.
There is much to be taken away from this report by EVERYONE.

Coming from a "northern pilot"...Well said! +1!

[trampbike]

When I read the report, there's one paragraph in particular that pissed me off greatly.
CpnCrunch already mentionned it:

"When asked whether a go-around was required with full-scale deflection of the localizer, all pilots interviewed stated that this condition required a go-around. However, all pilots interviewed agreed that an FO could not command a go-around, and could not see an FO taking control from the captain. They stated that the FO would likely make a suggestion or negotiate with the captain regarding the need for action."

Full scale deflection on the LOC, and these guys think it's time to negociate?
Scary.

[Colonel Sanders]

I have a really dumb question because I'm not as
smart as you guys:

If the HSI's had been working properly, would this
accident have happened?

Everyone here, sitting in their comfy chairs, knows
100% for certain that the HSI was reading 17 degrees
off, because six guys spent three years figuring that
out.

However, I'm pretty certain the captain didn't know
that. While everyone here is jumping up and down
about empowerment of FO's (got that) there is a
valuable lesson here that is being surprisingly ignored
by some supposedly pretty experienced people:

When sh1t goes wrong, you don't really know what's
happening until later, when it doesn't matter any more.

It's too bad everyone here is jumping up and down
about FO's instead of looking at what happened to
the captain, who IMHO totally lost SA because of the
HSI error. It completely incapacitated him, which is
not of any interest to anyone here, but I find mildly
interesting.

Not sure anyone here remembers the Air Transat
Azores glider, when the pilots pumped all of their
fuel out a leak of one of the engines. They didn't
understand what was really happening until much
later, either. They thought they had a fuel imbalance,
but completely mis-diagnosed it.

Valuable lesson to be learned. Too bad it won't be.

[teacher]

I have a really dumb question because I'm not as
smart as you guys:

If the HSI's had been working properly, would this
accident have happened?
.

I have been thinking the same thing. I've blown through the LOC before, picked up an intercept angle and brought it back. FO questions and CRM aside it's easy to see what the Captain was seeing and why he thought all was good. Remember, an accident is about MANY different occurrences leading up to it.

[shimmydampner]

it's easy to see what the Captain was seeing and why he thought all was good.

It's easy to see what he was seeing, but I don't think he thought all was good. There was a point where he confirmed full deflection but then questioned why if they were on the LOC. As the Colonel pointed out, it seems he lost SA enough to know something was wrong but was unable to process exactly what. Seems as though he may have had some incorrect assumptions based on HSI, FD, AP, etc that lead him to believe he was on the LOC but the CDI was in error. Perhaps he was trying so hard to reconcile all of that, that he didn't avail himself of the other resources in the cockpit that indicated he was off the approach. Unfortunately, descending to mins is not the time to be sorting that stuff out. At the end of the day, full scale deflection= missed.

[flyinthebug]

Not sure anyone here remembers the Air Transat
Azores glider, when the pilots pumped all of their
fuel out a leak of one of the engines. They didn't
understand what was really happening until much
later, either. They thought they had a fuel imbalance,
but completely mis-diagnosed it.
Valuable lesson to be learned. Too bad it won't be.

I agree that the anger towards the Captain and piling on is a bit over the top. They had less than 3 mins to try to figure out the problems they were experiencing. That doesn't leave much time for debate or negotiations.

In regards to this Air Transat flight, I do remember it. What I don't recall is what the Captain was charged with afterwards? Wasn't he found to be under the influence of marijuana? Or didn't he get charged with drug charges immediately after the incident? He went from hero to zero overnight, but I cant recall what the particular charge was...something to do with drugs from what I recall. Maybe if he wasn't so HIGH on the flightdeck, they wouldn't have dumped all their fuel and been forced to do a dead stick landing in a widebody. Just a thought Colonel. Im not sure this example is a good one to use...especially if my memory serves and the Captain was the scoundrel they made him out to be.

Fly safe all.

[CID]

Colonel Sanders....so what you are saying is that you would have also started a descent with the LOC at full scale deflection? The heading error, although a factor in the entire accident, was not a significant factor in my opinion. And let's discuss for a moment WHY the compass was in error.

When the compass was de-slaved, the pilots were responsible for setting it correctly to the true heading. Even though they had the mandatory astro-compass on board they didn't do a sun shot, instead they did (likely) what almost everyone else with similar aircraft equipment does in Northern Domestic Airspace and set the GPS true track as the heading. The resulting indicated heading would not take any winds into consideration. They can't just look at their magnetic standby compass and apply variation correction because at the latitudes the flux density of the earth's magnetic field isn't dense enough or aligned properly to provide consistent accurate magnetic heading readings.

Again, "most" operators doing it this way (using GPS true track) in Northern Domestic Airspace would expect some heading errors on the approach but the LOC will sort it out for them and the AFCS would at first just try to adjust for a horrendous cross wind. It eventually washes out the error after a few steering adjustments. (overshoot, undershoot etc)

So, if the pilot didn't expect a POSSIBLE heading error after using a non-approved method of setting heading, he absolutely should have.

Air Transat dead-sticking in the Azores? Absolutely no comparison.

[Gino Under]

Having flown the 200 series B737 I'm very comfortable in saying the f**kin' auto pilot set the wheels in motion for this crew. Starting with the amazing job it did of capturing the localizer. Failure of not only SOPs but more importantly CRM ran this ship aground.
With the time the Captain had on this antique, he must have experienced auto pilot anomalies before.

Gino Under

[teacher]

It's easy to see what he was seeing, but I don't think he thought all was good. There was a point where he confirmed full deflection but then questioned why if they were on the LOC.

Agreed, my point was that a lot of attention is being placed on not listening to the FO which was bad since it was apparent that he had the big picture. However the poor compass setting explains a lot about his mental picture and where he thought he was and where he thought he was going.

Again, having said all that I can only speak to the SOPs at Jazz but full deflection on the LOC is definitely cause for a Go Around, especially past the FAF.

On a side note, I wouldn't be surprised to see TAWS become mandatory after this accident

[CID]

TAWS is mandatory for aircraft like this for new aircraft manufactured after July 4, 2012 and July 4, 2014 for aircraft manufactured before July 4, 2012. The requirement was published in July 2012.

http://www.tc.gc.ca/eng/civilaviation/o ... 3-1347.htm

[trampbike]

If the HSI's had been working properly, would this
accident have happened?

Probably not, the Captain would likely not have lost his SA as much.

When sh1t goes wrong, you don't really know what's
happening until later, when it doesn't matter any more.

Even with a total loss of SA, there were still unquestionable signs that a go-around had to be initiated: unstable approach below 1000' and not configured, well above GP and correcting with a high rate of descent, LOC fully deflected while inside the FAF... this is not a time to try to figure it out, it's a time to go-around, get some distance between you and the ground, and then try to sort it out.

It's too bad everyone here is jumping up and down
about FO's instead of looking at what happened to
the captain, who IMHO totally lost SA because of the
HSI error. It completely incapacitated him, which is
not of any interest to anyone here, but I find mildly
interesting.

It's of interest to pretty much everyone here.

Maybe if he wasn't so HIGH on the flightdeck, they wouldn't have dumped all their fuel and been forced to do a dead stick landing in a widebody.

Yeah the fact that he was found guilty in 1983 of drug smuggling implies he was high in 2001 when on duty...

[tbaylx]

Not sure anyone here remembers the Air Transat
Azores glider, when the pilots pumped all of their
fuel out a leak of one of the engines. They didn't
understand what was really happening until much
later, either. They thought they had a fuel imbalance,
but completely mis-diagnosed it.
Valuable lesson to be learned. Too bad it won't be.

I agree that the anger towards the Captain and piling on is a bit over the top. They had less than 3 mins to try to figure out the problems they were experiencing. That doesn't leave much time for debate or negotiations.

In regards to this Air Transat flight, I do remember it. What I don't recall is what the Captain was charged with afterwards? Wasn't he found to be under the influence of marijuana? Or didn't he get charged with drug charges immediately after the incident? He went from hero to zero overnight, but I cant recall what the particular charge was...something to do with drugs from what I recall. Maybe if he wasn't so HIGH on the flightdeck, they wouldn't have dumped all their fuel and been forced to do a dead stick landing in a widebody. Just a thought Colonel. Im not sure this example is a good one to use...especially if my memory serves and the Captain was the scoundrel they made him out to be.

Fly safe all.

Oh come on..really? If you're going to accuse a pilot of being under the influence while on duty at least do your homework. The Transat pilot had been convicted almost 20 years earlier of a drug related offence. He was not under the influence and that had nothing to do with the Azores incident. People like you who post out of their ass without engaging whatever brain cells you may have are why these forums are tough to read most of the time. IF you aren't sure then look it up before you post crap like that.

[Colonel Sanders]

Few points:

- Air Transat Azores Glider pilot (Dick Piche - nice guy)
was NOT under the influence at the time. Yes, he ran
a little grass when he was a kid, but he got a pardon
for that.

- I think we can all agree that the HSI error totally
screwed the Captain up. He never figured out what
was really going on. If he did, he would have overshot
much earlier.

- It was educational for me to learn that First Air
runs single-pilot. Elsewhere in the world, the FO in
the right seat with 5k TT would be in the left seat,
but in Canada he's a low-timer that gets ignored.
Interesting.

- If the FO had been by himself in the cockpit, this
accident would never have happened - see First
Air single pilot, above. They just needed a different
single pilot - one that knew what was going on.

[flyinthebug]

Oh come on..really? If you're going to accuse a pilot of being under the influence while on duty at least do your homework. The Transat pilot had been convicted almost 20 years earlier of a drug related offence. He was not under the influence and that had nothing to do with the Azores incident. People like you who post out of their ass without engaging whatever brain cells you may have are why these forums are tough to read most of the time. IF you aren't sure then look it up before you post crap like that.

Wow. Easy there big fella. I clearly said I didn't recall what occurred with that incident and I thought I remembered him being charged for something AFTER the flight. I may be wrong about that but I didn't accuse anyone of anything...I simply replied with my few remaining brain cells...why so much passion? I made a mistake, sue me. If you ask me its people like YOU that attack people for a simple faux pas like mine that make these forums UNreadable at times. Why so angry? A simple "no FTB that is wrong, he was charged 20 years prior to this incident and has nothing to do with what happened on that flight"... would have sufficed. I get told to be less aggressive on here and god knows I try but then some a$$ hole comes on and gets my feathers ruffled like you...but I digress. I was wrong. I apologize to Air Transat, the pilot of that flight, the entire aviation community in fact.

Edit* Add information about Robert Piche...apparently it wasn't quite as minor of a conviction as you & the Colonel concluded. Seems he did more than "run a little weed when he was a kid". It was 13 years before his hire date at Transat and he was sentenced to 10 years of which he only did 16 months. He couldn't have applied for a pardon until 5 years after the last day of his sentence. You`ll note he was hired at Transat without a pardon. Either way, it wasn't a minor drug charge...it was a fairly major one for trafficking drugs into the US.

From Wiki...
After graduation he worked for regional airlines until he was laid off by Quebecair. After being laid off, he worked odd jobs which consisted of smuggling marijuana to the United States by plane.[1]

In 1983, Piché served 16 months of a 10-year sentence in prison after a plane he landed solo at a small airfield in Georgia, USA was found to be full of marijuana smuggled from Jamaica. He was pardoned in 2000 and is considered fully rehabilitated.[2]

In 1996, at the age of 43, Air Transat hired Piché. He rose rapidly from co-pilot to captain on Lockheed L-1011s, and transitioned to the Airbus A330 in the spring of 2000.[3]

As you were...

[trampbike]

Googling to get the proper information takes way less time than to write what you think you remember...
Took me 15s to find the date of his conviction. And that's because my internet is slow.

[flyinthebug]

Googling to get the proper information takes way less time than to write what you think you remember...
Took me 15s to find the date of his conviction. And that's because my internet is slow.

Ok ok jesus I get it!! Move on!!

Does it make you feel tough or smart to belittle someone on an anonymous public forum?

I was wrong, move the hell on.

[Colonel Sanders]

I'm sure my opinion won't be popular on this
very politically-correct forum, but ...

Pilots that have done some night runs have
often learned an awful lot about flying from that.

A very good friend of mine, who used to do that
sort of thing a long time ago - statute of limitations
has long since run out - was very skilled at setting
up temporary fuel systems and doing long over-water
flights with a minimum of assistance. Fascinating
approach to wx.

I learned a lot from him.

Knowledge and skill are good things, people. They
keep you alive.

[Illya Kuryakin]

When I read the report, there's one paragraph in particular that pissed me off greatly.
CpnCrunch already mentionned it:

"When asked whether a go-around was required with full-scale deflection of the localizer, all pilots interviewed stated that this condition required a go-around. However, all pilots interviewed agreed that an FO could not command a go-around, and could not see an FO taking control from the captain. They stated that the FO would likely make a suggestion or negotiate with the captain regarding the need for action."

Full scale deflection on the LOC, and these guys think it's time to negociate?
Scary.

Perhaps the single most bizarre thing I've ever read. Really.
Illya

[GRK]

Not as bizarre as you would imagine…shall we talk about Asiana, or any number of accidents (hull losses) in Indonesia or other non western places? Hell, it still rears it's ugly head in more places than ICAO wants. It indicates a serious problem in a company with a culture like that. Many many companies have tried to move on from the punitive culture of go arounds, as well as implementing a stabilized approach criteria…if not stabilized by a certain altitude, it's a mandatory go around which MUST be called by any pilot. No jeopardy…none…it works in principle until you introduce culture…company or country. To read that the First Officers at First Air feel that they can't call for a go around indicates there has been a tragic failure of the company culture and has saddened many in the Canadian airline industry. When will these companies learn it will kill people unless they sit up and pay attention to the rules…the simple rule? A JUST safety culture…make an honest mistake? Be honest in your reporting and the company backs you up…it's investigated so as not to make it a recurring problem and there is no punishment. HIDE a mistake? If you as a crew were negligent and tried to hide a mistake or cover up a non stabilized approach for example? The investigation will lead to a dismissal or level of remedial action to the perpetrators. First Air management and ownership have to make a lot of changes to recover from this one. How tragic it got this far without a regulatory issue being raised…Transport has to face this one as well in my opinion.

[ODA]

Colonel Sanders....so what you are saying is that you would have also started a descent with the LOC at full scale deflection? The heading error, although a factor in the entire accident, was not a significant factor in my opinion. And let's discuss for a moment WHY the compass was in error.

When the compass was de-slaved, the pilots were responsible for setting it correctly to the true heading. Even though they had the mandatory astro-compass on board they didn't do a sun shot, instead they did (likely) what almost everyone else with similar aircraft equipment does in Northern Domestic Airspace and set the GPS true track as the heading. The resulting indicated heading would not take any winds into consideration. They can't just look at their magnetic standby compass and apply variation correction because at the latitudes the flux density of the earth's magnetic field isn't dense enough or aligned properly to provide consistent accurate magnetic heading readings.

Again, "most" operators doing it this way (using GPS true track) in Northern Domestic Airspace would expect some heading errors on the approach but the LOC will sort it out for them and the AFCS would at first just try to adjust for a horrendous cross wind. It eventually washes out the error after a few steering adjustments. (overshoot, undershoot etc)

So, if the pilot didn't expect a POSSIBLE heading error after using a non-approved method of setting heading, he absolutely should have.

Air Transat dead-sticking in the Azores? Absolutely no comparison.

Well "most" operators I work with in the arctic would tune in the Resolute NDB and hit the nearest page on the GPS/FMS and set the tail of the NDB to the bearing from the GPS to take into account the wind so that they do in fact have True "Heading" set and not track which you're talking about. If you read the report you will find out that is in fact what they did. TSB couldn't determine why the precession happened.

On a different note. Anybody noticed where the pole is lately?? Left Canada in 2011, even though the current AIM states it's in the middle of the Northern Domestic Airspace.