Resolute Bay Accident - Pilots Discussion Thread

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gwengler
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Re: First Air Crash Resolute Bay August 20 2011

Post by gwengler » Tue Aug 23, 2011 7:26 am

ATTENTION: PLEASE DON’T READ THIS IF YOU ARE OFFENDED BY PURE SPECULATION!

IF the trail of debris depicted previously on Google Earth is mostly correct, so that it heads directly to the VOR on a heading of roughly 350T, i.e. parallel and offset with the runway,
IF the GS was perhaps U/S or perhaps not,
IF the crew dialled in the VOR frequency instead of the ILS frequency and thought the GS to be U/S, so they thought to fly the LOC approach (MDA 540), and
IF perhaps they also took the distance from the VOR instead of IRB,

THEN the point of impact (terrain rises very at point of impact to 653’) could be explained with the LOC MDA and the heading to the VOR. This point is also about 2.5NM from the VOR at which one had to go missed.

I am not saying at all that this is even what I believe has happened, it is pure speculation, but it would explain the strange offset from the ILS by about 1NM (full deflection).

I am very saddened by what happened. I have flown to CYRB myself and did the LOC BC approach. I do remember clearly that I could not see the runway many miles out even though I was clear of clouds in good visibility. It’s all gravel, the runway is not clearly visible at all against the background and the lights are useless, because it’s all uniformly looking gravel. It is very deceiving because all the little roads seem to delineate the runway, which they aren’t.

I know Aziz and have sent him my condolences.

Gerd
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Last edited by gwengler on Tue Aug 23, 2011 12:51 pm, edited 1 time in total.

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Re: First Air Crash Resolute Bay August 20 2011

Post by cncpc » Tue Aug 23, 2011 12:01 pm

gwengler wrote:ATTENTION: PLEASE DON’T READ THIS IF YOU ARE OFFENDED BY PURE SPECULATION!

IF the trail of debris depicted previously on Google Earth is mostly correct, so that it heads directly to the VOR on a heading of roughly 350T,
IF the GS was perhaps U/S or perhaps not,
IF the crew dialled in the VOR frequency instead of the ILS frequency and thought the GS to be U/S, so they thought to fly the LOC approach (MDA 540), and
IF perhaps they also took the distance from the VOR instead of IRB,

THEN the point of impact (terrain rises very at point of impact to 653’) could be explained with the LOC MDA and the heading to the VOR. This point is also about 2.5NM from the VOR at which one had to go missed.

I am not saying at all that this is even what I believe has happened, it is pure speculation, but it would explain the strange offset from the ILS by about 1NM (full deflection).

I am very saddened by what happened. I have flown to CYRB myself and did the LOC BC approach. I do remember clearly that I could not see the runway many miles out even though I was clear of clouds in good visibility. It’s all gravel, the runway is not clearly visible at all against the background and the lights are useless, because it’s all uniformly looking gravel. It is very deceiving because all the little roads seem to delineate the runway, which they aren’t.

I know Aziz and have sent him my condolences.

Gerd
It seems from the photo that the debris trail is aligned very close to runway alignment.

If the VOR frequency was tuned in error, there would have been no GS. The GS needles would have indicated on GS at all times, i.e. they would have remained in the center. It may be that the crew reported the GS unserviceable and continued on a LOC/DME approach. The missed approach point would have been 0 DME, on my reading of the chart, which is the far end of the runway, or in this case, the VOR itself.

If this happened, it isn't the first time. There was an incident at Prince George in the 70s or 80s where a CP 737 crew flew the localizer approach tuned to the Prince George VOR and only pulled up when they heard the trees hitting the bottom of the aircraft up on Tabor Mountain. Or so the story goes. At any rate, they made it.

I think for now the picture speaks for itself. The TSB has the scenario. The boxes will tell the story.
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Re: First Air Crash Resolute Bay August 20 2011

Post by another_try » Tue Aug 23, 2011 1:55 pm

Gino Under wrote: There is nothing wrong with speculation as an expert as long as you understand and accept the fact you could be way off on your speculation.

Those who wish to stay out of speculative commentary should feel free to do so. But please don't tell those who wish to speculate to STFU. Even the speculators understand and appreciate the need for sensitivity and respect for grieving survivors.

Gino
Here, here. +1.

I'm sick of people on this board who pretend as though speculation is illegal. And my post was edited because I agreed with the suggestion that CFIT was the likely cause? Give me a f'ing break.
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Re: First Air Crash Resolute Bay August 20 2011

Post by Bede » Tue Aug 23, 2011 2:33 pm

While it is important to pay our respects to fallen aviators and passengers, we can still discuss ways to make our profession safer given the information we have. It is never to early to learn from an accident. There is a huge difference between drawing conclusions based on a lack of evidence and knowledgeable pilots discussing known facts and attempting to make sense of it.

We know the weather was poor and we know the location of the accident relative to the runway. Based on the photographs indicating a low impact angle, I think it is safe to call this a CFIT accident, which is a pretty broad category of accidents. Is there anyone one this board who believes otherwise? Honestly? It certainly wasn't an "uncontrolled" impact or a a runway over run. However, why this happened accident happened is something that will take much longer to determine and I think that sort of speculation needs to wait.

I read an article a while ago that claimed that there had not been a CFIT accident involving North American carriers since EGPWS was introduced. The article also mentioned a potential hazard of EGPWS in that it is largely based on a terrain database and a failure of the database would decrease the performance of the system. I have flown in the Arctic, but not as far as YRB. Is there TAWS/EGPWS information that far north?
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Re: First Air Crash Resolute Bay August 20 2011

Post by cncpc » Tue Aug 23, 2011 3:15 pm

Bede wrote:While it is important to pay our respects to fallen aviators and passengers, we can still discuss ways to make our profession safer given the information we have. It is never to early to learn from an accident. There is a huge difference between drawing conclusions based on a lack of evidence and knowledgeable pilots discussing known facts and attempting to make sense of it.

We know the weather was poor and we know the location of the accident relative to the runway. Based on the photographs indicating a low impact angle, I think it is safe to call this a CFIT accident, which is a pretty broad category of accidents. Is there anyone one this board who believes otherwise? Honestly? It certainly wasn't an "uncontrolled" impact or a a runway over run. However, why this happened accident happened is something that will take much longer to determine and I think that sort of speculation needs to wait.

I read an article a while ago that claimed that there had not been a CFIT accident involving North American carriers since EGPWS was introduced. The article also mentioned a potential hazard of EGPWS in that it is largely based on a terrain database and a failure of the database would decrease the performance of the system. I have flown in the Arctic, but not as far as YRB. Is there TAWS/EGPWS information that far north?
I thought it was based on radar altimeter data, but database makes sense.
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Re: First Air Crash Resolute Bay August 20 2011

Post by onspeed » Tue Aug 23, 2011 3:29 pm

As far as flying the ILS approach off a VOR frequency, I'd think the GS would be flagged not show on center.

For CFIT, there are other malfunctions that could have occurred, ie. engine out, reverse deployed etc... There is TAWS and EGPWS info for databases this far north.
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Re: First Air Crash Resolute Bay August 20 2011

Post by Rudy » Tue Aug 23, 2011 4:25 pm

Let's not forget a First Air 737 had an engine failure only hours after this accident. What did these two aircraft have in common? The same parts suppliers? Maintenance procedures? Fuel source? There's lots of information that needs to come in before we can flatly say CFIT. Although I agree with Bede that the weather is telling, failures don't always happen like they do on a flight test. P6SM SKC and you're just waiting for it. Running emergencies procedures through head before it even happens. I know there were only 15 people on board but what was the rest of the load? I can't imagine someone would charter a 737 for only a few passengers. How heavy were they? Engine failure on a slow-responding turbojet when you're heavy, low and slow, with everything hanging out, and in the soup, with rising terrain right beside the runway. Shudder.
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Re: First Air Crash Resolute Bay August 20 2011

Post by nutbutter » Tue Aug 23, 2011 6:55 pm

cncpc wrote:I assume this was the last weather.

Correction, this was the weather 20 minutes after the accident.

METAR CYRB 201800Z 19008KT 10SM VCFG SCT003 OVC010 07/07 A2983 RMK
SF3ST5 SLP108=

At the airport, there doesn't seem to be any difficulty in getting in on either the full ILS or the localizer. It looks like its not so good to the E-SE.

I'm not a heavy aircraft pilot, but I would think the reaction to an engine failure would be to continue on to land if within 3 miles and all ok otherwise.

I can't see circling being involved when a straight in ILS was easy. Maybe the weather changed, and it wasn't easy, but in that case circling wouldn't be an option.

I don't see an emergency and pull up without a radio call being likely, given that the crew would have known they had Borek somewhere out on the backcourse.

And there's a lot of things that don't make sense on the mistuned VOR bit as well.
At what point do you call it quits as a First Air Captain flying into CYRB with regards to tail winds, and how much could a wind check from Tower somewhere prior to or on approach affect the decision to commence a circling? How big a difference does it have to be to issue a Special with regards to winds on METARS? Also where does rad alt, and GPWS come into play?? Ignored? Malfunctioned? Inop? Misunderstood? Lots of questions.

Best guess is all, I have no idea what happened.
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Re: First Air Crash Resolute Bay August 20 2011

Post by cncpc » Tue Aug 23, 2011 7:27 pm

The step down approach (localizer) really comes into the equation if the aircraft is mistakenly inbound on the 167T radial from YRB. In that scenario, the crew believes it is tuned to the ILS, can't get glideslope, and switches to a localizer approach with the final drop only 160 feet four miles back. They keep tracking the 167T radial as if it were the localizer. They don't have glideslope because they're tuned to 112.1 instead of 110.3. Their DME is coming off the VOR.

In the mistuned VOR scenario, they have to have POKAN on the 167 radial at 4 DME, basically a mile east of proper track. Then do the PT and back inbound on the false localizer. To me, and I welcome correction, that seems to be a situation where they left the VOR eastbound with 167 already set on the OBS, flew it needle centered to the false POKAN, did the PT and reintercepted inbound. Get no GS, maybe call it in U/S, and fly the localizer approach instead. That scenario ends exactly where the accident happened.

I can't see a late tuning of the VOR and nobody noticing that the needle moved when the OBS was turned. If they'd been tracking 167 outbound to Pokan, and then set up the inbound course on the CDI, they wouldn't have noticed it so much as they would have been in the PT where they would expect it to be deflected.

What kind of radar coverage is there around there, if any? Would vectors to the localizer be possible or too low? I know there was military radar, but it can't have been in operation or they'd have warned the flight that it was well off track.

It would be interesting to know the sequence of events leading up to the issuance of the GS U/S Notam?

I've had a look at the CADOR and the accident time was 1740Z. From the description in the CADOR, it seems the location of the wreckage trail on the google plot is quite accurate.
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Re: First Air Crash Resolute Bay August 20 2011

Post by cncpc » Tue Aug 23, 2011 8:04 pm

I don't know.

Here's the ILS notam.

110129 CYRB RESOLUTE BAY
CYRB ILS 35 U/S
TIL APRX 1108312359

I read that to say there was no serviceable ILS at the time of this accident. Does that mean no GS only, with a good localizer, or nothing? Must have had a localizer, because Borek was doing a back course.

What does a temporary tower add? Was there PAR? Could the flight have used it? If it was operational, why didn't somebody warn the crew?

There used to be a Cape Martyr beacon RU about 2 miles from the button of 35 but I see it's gone and the plate is only two months old.
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Re: First Air Crash Resolute Bay August 20 2011

Post by Lost in Saigon » Tue Aug 23, 2011 8:47 pm

cncpc wrote:
Does that mean no GS only, with a good localizer, or nothing? Must have had a localizer, because Borek was doing a back course.

What does a temporary tower add? Was there PAR? Could the flight have used it? If it was operational, why didn't somebody warn the crew?

There used to be a Cape Martyr beacon RU about 2 miles from the button of 35 but I see it's gone and the plate is only two months old.

ILS U/S means ILS U/S. It ain't rocket science. The NOTAM was issued AFTER the accident. Even you know that because you questioned how Borek did the Back Course. Maybe you should give it a rest because you seem to be running around in circles accomplishing nothing with all your theories.

Almost every accident has multiple factors. I am sure that is also the case here. They have the CVR and FDR so I expect we will know very soon what happened.

At this point there are too many unanswered questions to accurately guess what happened.....

Was there really a control tower and control zone in effect with positive control? (I don't think so)
Was it really 10 minutes from the time they reported 3 miles final until they hit the ground? (that is a very long time)
Why were there no other radio calls during those 10 minutes?
Did they broadcast their intentions for an ILS 35T? or for an ILS 35T circling for 17T? or something else?
Did they do a procedure turn?
Why did Borek do the approach while an aircraft was still missing?
What was the elapsed time between the last position report and the Borek Back Course approach?
What was the landing weight of the aircraft?
How much tailwind could it accept?
Were there any systems unserviceable that might affect landing performance or Standard Operating Procedures?

Somebody out there probably knows the answers to most of these questions...... They just haven't made it public yet.....
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Re: First Air Crash Resolute Bay August 20 2011

Post by cienki » Tue Aug 23, 2011 10:04 pm

Close-up photos of the crash site. So devastating.

I had been on that plane so many times.

http://www.tsb.gc.ca/eng/medias-media/p ... 1H0002.asp
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Re: First Air Crash Resolute Bay August 20 2011

Post by Panama Jack » Tue Aug 23, 2011 10:11 pm

Gino Under wrote:This will surprise few of you, but I looked up the definition of expert. As it turns out, even though I've never consider myself one, not only am I an aviation expert but most of you are as well.

If you're flying professionally, you've already accepted a degree of responsibility beyond that of most individuals, so don't be afraid to express your expert opinion on this or any other accident.
There is nothing wrong with speculation as an expert as long as you understand and accept the fact you could be way off on your speculation.

Those who wish to stay out of speculative commentary should feel free to do so. But please don't tell those who wish to speculate to STFU. Even the speculators understand and appreciate the need for sensitivity and respect for grieving survivors.

Gino
I am glad that Gino Under has the courage and the eloquence to state the above.

As much as some theories may be repugnant to us, in other cases, like AF447, improvements have already been implemented based on theories of weaknesses and incomplete information. This has resulted in us already enhancing safety and possibly avoiding other accidents. As most people are aware no Final Report has been published yet.

Whether a factor or not in the accident, based on my personal theories and those expressed here on the forum, I have placed a new emphasis on the importance of cross-checking during my daily flight operations. Like most other pilots here, I have always known the importance of this but sometimes you need an incident/accident close to the emotional "home" to serve as a wake-up call. One may argue that to do nothing and sit on one's hands until final results come out months or even years later would be negligent in itself.

This is in no way meant to be a statement of disrespect to industry colleagues from First Air, or other airlines, who have been victims of aviation accidents.
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Re: First Air Crash Resolute Bay August 20 2011

Post by cncpc » Tue Aug 23, 2011 11:44 pm

Lost in Saigon wrote:ILS U/S means ILS U/S. It ain't rocket science. The NOTAM was issued AFTER the accident. Even you know that because you questioned how Borek did the Back Course. Maybe you should give it a rest because you seem to be running around in circles accomplishing nothing with all your theories.
The NOTAM appears to have been issued on the 11th of August and is valid until August 31st. I'm perfectly capable of deciding when it is time to rest and I don't have any theory other than the one that the facts seem to point to.

If the ILS was NOTAMed U/S after the accident, and it is still U/S, was it U/S but not NOTAMed during the approach?
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Re: First Air Crash Resolute Bay August 20 2011

Post by Rudy » Wed Aug 24, 2011 5:24 am

I believe the 11 indicates the year, 2011. The other digits are just the NOTAM number.
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Re: First Air Crash Resolute Bay August 20 2011

Post by Lost in Saigon » Wed Aug 24, 2011 5:28 am

110129 CYRB RESOLUTE BAY
CYRB ILS 35 U/S
TIL APRX 1108312359
That is the official Nav Canada NOTAM for the CYRB ILS. http://www.flightplanning.navcanada.ca/ ... ni_File=on

110129 is the "NOTAM continuity number". That is not the date the NOTAM was issued.

There is also no beginning period for the NOTAM.

"1108312359" means 2011 Aug 31 23:59Z
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Re: First Air Crash Resolute Bay August 20 2011

Post by gwengler » Wed Aug 24, 2011 6:50 am

A friend who is a (jet) charter pilot had this to say when I told him about the VOR speculation: "It was an “old” B737, with mechanical radio tuning knobs. Mistuning is more likely to happen, unless the pilots identify the frequency. Frequencies are NOT auto-tuned and auto-identified. And they are not displayed on the PFD in the direct vision of both pilots. Same goes most likely for the DME readouts which are only referred to no1 or no2 NAV, not station name. Most likely no moving map and fully integrated GPS / Autopilot system in the aircraft. I wonder what the GPWS told them. May be they were fully landing configured, only then there will be no warning. Resolute airport may not be in the EGPWS database. Hope they find out and everybody learns from it. So far speculation only."

Gerd
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Re: First Air Crash Resolute Bay August 20 2011

Post by Gino Under » Wed Aug 24, 2011 8:26 am

I have this sinking feeling they might have been circling.
If so, it might turn out to be the biggest contributing factor.
Circling in jet transports shouldn't be allowed. It's a simulator maneuver and nothing more.

http://flightsafety.org/aerosafety-worl ... approaches

thoughts?

Gino
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Re: First Air Crash Resolute Bay August 20 2011

Post by cncpc » Wed Aug 24, 2011 8:40 am

Rudy wrote:I believe the 11 indicates the year, 2011. The other digits are just the NOTAM number.
Correct. Thanks.
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Resolute Bay Accident - Pilots Discussion Thread

Post by cncpc » Wed Aug 24, 2011 10:06 am

As some wish the original thread to be a condolences thread, I've started this one.

The original ILS U/S NOTAM was issued as 11022 August 21, 0047Z, or nine hours after the accident. It was originally for one day, renewed for another day, then set to the end of this month.
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Re: Resolute Bay Accident - Pilots Discussion Thread

Post by 1&2SpooledUp » Wed Aug 24, 2011 10:55 am

With the availability of a Straight in LOC/BC or GNSS approach to RWY 17 and the crews knowledge and familiarity of local terrain and given a wx report like this, I think the last thing the crew would have been doing is a circling approach to the east towards that hill. If you look at the photo you can see the fog bank lingering in the background and wasn't there an eye-wittiness report that stated the crash site was not visible initially because of the fog. Remember folks, a circling approach is a visual maneuver.

METAR CYRB 202000Z 18009KT 8SM VCFG SCT003 OVC005 07/07 A2986 RMK
SF2SC5 VIS E-SE 3 FG SLP116=
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Re: Resolute Bay Accident - Pilots Discussion Thread

Post by CpnCrunch » Wed Aug 24, 2011 11:47 am

Bede wrote: I read an article a while ago that claimed that there had not been a CFIT accident involving North American carriers since EGPWS was introduced. The article also mentioned a potential hazard of EGPWS in that it is largely based on a terrain database and a failure of the database would decrease the performance of the system. I have flown in the Arctic, but not as far as YRB. Is there TAWS/EGPWS information that far north?
There have been 3 CFIT accidents on EGPWS equipped planes. However none of the planes had a graphical terrain display.

http://en.wikipedia.org/wiki/Terrain_aw ... _incidents

Also bear in mind that TAWS is only mandatory on planes manufactured in the USA after March 2002.
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Re: Resolute Bay Accident - Pilots Discussion Thread

Post by cncpc » Wed Aug 24, 2011 2:22 pm

Looks like the ILS is serviceable again. NOTAM cancelled.
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Re: Resolute Bay Accident - Pilots Discussion Thread

Post by Brewguy » Wed Aug 24, 2011 3:12 pm

I just posted this article as general information in the other thread. But it perhaps adds a bit of fuel to the fire so to speak for those suggesting this accident should fall into the 'CFIT' category. Which again, could be caused by a number of things...
POSTMEDIA NEWS wrote:First Air passengers had no warnings before crash: RCMP

By Jordan Press, Postmedia News
August 24, 2011 2:46 PM


Passengers aboard First Air flight 6560 had no warning that they were about to crash in the seconds before their plane slammed into a hillside in Resolute Bay, the youngest survivor of the crash has told investigators.

Shortly after the crash, investigators spoke with seven-year-old Gabrielle Pelky who told investigators that as the plane began to descend to the airport in the tiny Arctic hamlet, everything appeared fine.

She described seeing buildings and the landscape just before impact.

"When the plane was going down into Resolute, it all felt normal," said RCMP Supt. Howard Eaton.

"Next thing you know, it was bang. There were no bells, no warnings."

Eaton said Pelky gave a detailed description of the flight, including where everyone was sitting, and the final seconds before the crash.

"She was very together. Seven going on 20," Eaton said.

Saturday's crash killed 12 people. Pelky and two other passengers survived.

Pelky and Nicole Williamson, 23, walked away from the crash site. Robin Wyllie, 48, was helped away from the site by rescuers.

Williamson and Wyllie are recovering at the Ottawa Hospital. Pelky was released from the Children's Hospital of Eastern Ontario on Monday.

Williamson is to have surgery on her foot, her father Mark Williamson said.

"She's in pretty good condition, considering what she's gone through," he said. "As you can imagine, walking away from something like that is a fairly traumatic thing."

First Air has said it lost communication with the Boeing 737-200 around 12:40 p.m. local time Saturday when the plane was eight kilometres from the airport. A few minutes later, the plane crashed, splintering into three pieces and sending debris across a one-kilometre area.

The RCMP have removed all the remains from the site, said Sgt. Paul Solomon in Resolute Bay.

Investigators have not been able to hand over the site to the Transportation Safety Board because of the weather. Solomon said high winds on Wednesday whipped up debris and forced investigators off the hillside for safety reasons.

The Transportation Safety Board will be responsible for determining what caused the plane to crash.

With files from the Ottawa Citizen
© Copyright (c) Postmedia News

Read more: http://www.canada.com/First+passengers+ ... z1VzEJygrK
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Re: Resolute Bay Accident - Pilots Discussion Thread

Post by Just another canuck » Wed Aug 24, 2011 3:25 pm

Sounds like CFIT to me. And if it is, it wasn't the first time and it certainly won't be the last.
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