First Air Crash Resolute Bay August 20 2011

[CpnCrunch]

The issues identified by the TSB report have been jumped on by First Air, and repaired

So, there was a problem, but people's personalities
have been quietly and fundamentally altered since then?

You did more CRM training, which didn't work before,
so you did more of it?

Do you do marriage counselling, too?

Nope, if you read the report you'll see that their CRM training was hopelessly inadequate.

[CpnCrunch]

Please delete.

[CpnCrunch]

Regarding the FO taking the control, When I worked at 7f we routinely did a scenario in Sim where the captain became incapacitated at a critical moment in flight. In our scenario though the captain was completely incapacitated not like this accident. Further the CRM course, i thought, was actually pretty good. We did it yearly and always discussed scenarios where the Captain and FO did not agree and how to work through them.

I don't think this accident is as simple as FO needing to call go around / take control. As an FO at 7F i have called go around and had the captain do one. There seemed to be a loss of situational awareness from the guy in the left seat, on what otherwise seemed to be a relatively straight forward approach. I didn't see in the TSB report if any of the training files were released? Maybe this would have yielded more of the story.

Perhaps you need to update your CRM training. From the report, when discussing the PACE model:

The final step is emergency intervention, with the PNF taking over control of the aircraft.

[Illya Kuryakin]

Hey Swordfish.....the Valium worked great man. Everything is so much clearer now. Cheers
Illya

[Illya Kuryakin]

Every time I think of CRM I'm reminded of the theme from Ghost Busters.
Don't laugh......If there's something wrong, who ya gonna call.....is exactly the basis for CRM.
Too simple? Perhaps. But, it's not far off.
Illya

[onspeed]

CC - Your assuming the guy was going to give up control, its not always that simple especially when the other guy thinks he is right.

[CID]

I find it a little disturbing that some pilots here consider CRM some kind of PC voodoo. Sorry but if you think it's all just smoke and mirrors you shouldn't be a pilot in a multi-crew cockpit regardless of the size of the airplane or type of operation.

[Sidebar]

I find it a little disturbing that some pilots here consider CRM some kind of PC voodoo. Sorry but if you think it's all just smoke and mirrors you shouldn't be a pilot in a multi-crew cockpit regardless of the size of the airplane or type of operation.

+1

[Illya Kuryakin]

I find it a little disturbing that some pilots here consider CRM some kind of PC voodoo. Sorry but if you think it's all just smoke and mirrors you shouldn't be a pilot in a multi-crew cockpit regardless of the size of the airplane or type of operation.

While I agree wholeheartedly with your comment, I fail to see where you came up with the idea that pilots see CRM in that light? It's no different than working in other walks of life. You use all available data, delegate, and come up with the best way to deal with any situation. You don't seem to hold pilots in very high esteem. Most of us are total cowards, who will reduce our workloads and our exposure to hazard in any was possible. There are things we do for the sake of PC. CRM is NOT one of them.
Illya

[trey kule]

I found some of the posts on this thread rather interesting.

The sense I have is that some of the posters do not understand that when someone loses situational awareness, they do not know it. And they do not have the benefit of sitting behind a computer screen with the leisure time to look at everything that was happening.

The second thing is the vilification of captains. Seems that some of the posters are under two impressions. The first is that FO's never lose situational awareness, so when there is an issue in the cockpit it is the Captain that is wrong. And, much more troubling is the repeated posts that the solution to a discrepancy is for the FO to immediately grab a handful of throttles and seize control of the aircraft.

Proper CRM is about two crew identifying an abnormal set of indications, and resolving it safely.

It is about both crew members understanding that they just might be the one who has lost SA. And, unless the situation is critical, resolve it in a somewhat more professional way then trying to commander control from the PF.

This was a tragic and sad event. People lost their lives. And pilots have brain farts. Even experienced ones. But it really is a bit troubling to read the solution some people here seem to suggest as an SOP.

[howard40]

When we head into the clouds , specially when close to the ground , we have to bring our A game.. Some really smart folks, that knew some really smart folks that crashed airplanes, came up with some rules that said when the needle goes full scale, you dont know (for sure) exactly where you are,and if you are close to the ground , you climb ,and miss, and try again. They did not make these "rules" because they thought there was no way a good pilot could recover by turning and waiting till the needle came alive again, and landing safely, they made these rules because once in a while it goes very very badly...... Captains and Copilots both have to decide they never ever want it to go very badly.....ever.

[trey kule]

Full deflection!

Well let me be the devils advocate here. That was not the point where the missed should have occurred. They were above the target airspeed... What was the PM doing at that point?
What happened when the HSI was not set properly? The PM should have caught the error..that is why the PM is there. People make errors.
But to say wait until the situation deteriorates and then take control..this is not grand theft Boeing.

My point was not to discuss the specifics of the accident. Lots of experts on here to do that.

It was a comment on the perception that some posters have that the FO is always right. That it is perfectly OK to suddenly take control of the aircraft....and of course not to notice the CRM failure in the PM not checking the instrument settings or calling for a missed when the airspeed was out of limits......long before (relatively) they got into the corner. To quote....another example of a pig headed Captain not listening to his FO....

[Illya Kuryakin]

Trey, I don't think anybody ever stated that the FO is always correct. Both are human, therefore both are capable of being wrong. The number is discrepancies here certainly called (screamed?) missed approach.
Someone stated they have a "no fault" missed approach policy. Another stated that if either pilot called for a missed approach, it became mandatory. These are great ideas, and in my limited experience, would make very good SOPs.
Where I fly (two crew t-prop) we're a little less formal. First one to chicken out, wins.
Illya

[Sidebar]

Full deflection!

Well let me be the devils advocate here. That was not the point where the missed should have occurred.

Full deflection happened above the altitude where the stable approach policy became effecitve.

According to the TSB, this is definitely the point where the go-around should have been done. From section 1.17.2.8.2 of the report: "General procedural guidance for instrument flying in Canada (Footnote 64) states that, during ILS approaches, a missed approach must be initiated if full-scale deflection of the localizer occurs at any time on final approach before decision height. " Footnote 64 is Transport Canada, TP 2076 – Instrument Procedures Manual (4th edition, January 2000), section 4.6.7.

That guidance is good enough for me. Full deflection = go-around.

What happened when the HSI was not set properly?

TSB couldn't say what the HSI settings were. Section 1.12.2 of the report: "Laboratory examination of both HSIs could not make any conclusions as to their pre-impact condition."

TSB concluded this in section 2.6.1:

after completion of the in-range check, the following conditions were likely ... Course selector 347°

[co-joe]

OK so I know when you transition to NDA, that you have to uncouple the HSI and set degrees true manually in a King Air, but is there not a better more automated system that can be installed in a transport category aircraft like the 73? Seriously that's where this started. CRM is the last resort here, when all else fails, and ok in this case it failed too, but it sounds to me that the first link in the events cascade was a few hundred dollar piece of shit HSI set wrong! My god man is that the best we have available? Maybe they should go back to fixed card ADF and keep it simple...

[CID]

Three letters. INS. Combined with GPS of course. Unfortunately they are not cheap to install and maintain. And often difficult to justify in some operations.

[ODA]

Why do we uncouple our compass when we transition to NDA? CID is right that INS or IRS systems are expensive so heaven forbid the regulator made them mandatory. However the magnetic north pole has move 900 miles since NDA was created and yet the line is in the same place. We uncouple our compass and essentially induce error in our compass systems because no one at TC is paying attention to the north. Granted the line probably won't move north of Resolute I'm shocked this wasn't a finding in the report. Guess a plane will need to crash further south due to compass error for someone to pay attention.

While I'm venting let's keep talking about TC. This airplane went down without TAWS even though in 1993 the TSB recommended to TC that it should be mandatory. Over 20 years later this will become law. Great job TC. I believe this was a Finding as to Risk in the report, but I'm again shocked that this wasn't a contributing factor. TSB made it clear TAWS would help prevent incidents like this. The US made it mandatory in 2000, Europe in 2004 and Canada 2014. Our regulator is doing a fantastic job. Regulating 1990 technology in aircraft in 2014. Wonder what it will take for TSB to recommend something like moving map displays to increase situational awareness instead of increased layers of CRM training. Not saying CRM isn't important, but with the technology that exists today I can't believe we're not required to use some of it. Guess TC is trying to save companies some money.

TC also gave the military control of the CYRB airspace. Would love to know how much work went into asking the Military how they where going to assume control of the airspace, because it was one of the biggest gong shows I've ever witnessed up north.

Anyway seems like some issues where missed in the report. I guess they have to be directly related to the crash for TSB to make recommendations.

[co-joe]

That's what I'm getting at. I could care less about CRM as a contributing factor and I'm getting sick of hearing people posthumously hang the crew for it. I can handle northern mentalities and egos, I get it. What I can't handle is the old junk equipment that northern operators are too cheap to upgrade. You can say "Oh the culture has changed and we've upgraded training and SOP standards" all you want.

If you GAF about this not happening again you'd spend money on newer technologies and prove it. Put INS or IRS in your planes, train people how to use it, and show me that you've learned from your mistaskes. TAWS is too expensive yet Alaskan bush operators have it in single engine Cessnas? Did the captain set it wrong of did it just precess that much because it was an old piece of junk and nobody noticed? How much does INS cost vs how much will this crash cost?

[jpilot77]

Speaking of situational awareness a Garmin 430 in the cockpit would have prevented this.

[1&2SpooledUp]

If you GAF about this not happening again you'd spend money on newer technologies and prove it. Put INS or IRS in your planes, train people how to use it, and show me that you've learned from your mistaskes. TAWS is too expensive yet Alaskan bush operators have it in single engine Cessnas? Did the captain set it wrong of did it just precess that much because it was an old piece of junk and nobody noticed? How much does INS cost vs how much will this crash cost?

It's a real shame to think how there are people flying around in homebuilts with more technology (dual moving map gps's and a hand held just I case the other 2 quit, TAWS, sat tracking, etc,etc.....) in them than some of our 705 machines here in canada.

It's time for TC to step it up and make this stuff mandatory instead of F@$&ing around with this SMS bull. If the operators don't want to comply then it's time to hang up the towel and let someone else do it right.

In my opinion, additional CRM training wouldn't have prevented this accident. It's time to retire these old planes with Frankenstein cockpits or at least through a moving map in them.

Hey TC, it's 2014. Get with the program!!

[Colonel Sanders]

Speaking of situational awareness a Garmin 430 in the cockpit would have prevented this

Hell, they didn't need a G430W/530W. All they
needed was a handheld GPS. Or an iPad. Or a
cellphone.

No one here is old enough to remember what
happened in 1996 but here's the URL:

http://en.wikipedia.org/wiki/1996_Croat ... T-43_crash

NDB approach, lost of SA, CFIT. Sound familar?

You know what the USAF did after that? Gave
out handheld GPS's to it's pilots.

The lessons of nearly 20 years ago have been
forgotten.

[Gilles Hudicourt]

It's time to retire these old planes with Frankenstein cockpits or at least through a moving map in them.
Hey TC, it's 2014. Get with the program!!

The 727 and 737-200 were gravel capable. Newer Boeings are not. I don't think any Airbus aircraft are either.

That leaves the BAe-146 if you want another old beat up aircraft:

http://www.aviationweek.com/Blogs.aspx? ... 951507c606

But if you want a modern jet with 5 abreast cabin and glass cockpit, there is always the Ukrainian (not Russian) An-148/158 which would make a great northern aircraft.

https://www.youtube.com/watch?v=lxsf85ulCl0

[1&2SpooledUp]

It's time to retire these old planes with Frankenstein cockpits or at least through a moving map in them.
Hey TC, it's 2014. Get with the program!!

The 727 and 737-200 were gravel capable. Newer Boeings are not. I don't think any Airbus aircraft are either.

That leaves the BA-146 if you want another old beat up aircraft:

http://www.aviationweek.com/Blogs.aspx? ... 951507c606

But if you want a modern jet with 5 abreast cabin and glass cockpit, there is always the Ukrainian (not Russian) An-148/158 which would make a great northern aircraft.

https://www.youtube.com/watch?v=lxsf85ulCl0

I realize that gravel capability is a huge issue and their are currently no replacements for the 37-200 but the time is coming when these planes will have to be retired to museums. It looks like even the Russians have realized this and are looking into the future!!

I meant no disrespect to the 37-200, but it does lack the modern technology that the rest of the world is using to increase safety and situational awareness for flight crews. You would think that this technology would/should be available for the crews that fly in the most challenging conditions.

I still think that the FO was the last line of defence in this situation and should have tried to take control of the A/C. Maybe the captain would have snapped out of it and realized what was going on.

[fish4life]

I don't know so out of curiosity do those old 37's just have old school gyros or were they at least laser gyro's?

[Old fella]

Yup, looking at the avionics panel, the various modes and auto pilot functions and the separate panel/modes for the GPS stuff on these 40 yr. old smokers, tis certainly steam driven technology at its finest. Then again , these old clunkers still serve a purpose in that neck of the woods.