First Air Crash Resolute Bay August 20 2011

[Sidebar]

Quote is pasted in from the Ornge CYMO thread.

Does anyone here wonder if political considerations can be part of the wording of the TSB's findings when they finally release their version of what they think caused this crash?

Or is it to tireing trying to look that far into the future.

There are certainly political considerations behind the silence on the Resolute accident.

You seem to think you are well informed.

What are these "political considerations" you're mentioning?

[ozone]

I'm guessing the fact that coincidentally the military was operating out of there at the same time of the accident. I'm sure there was a lot of confusion because of the temporary control tower they had set up.

[cncpc]

I'm guessing the fact that coincidentally the military was operating out of there at the same time of the accident. I'm sure there was a lot of confusion because of the temporary control tower they had set up.

That is a pretty fair observation.

I'm not sure what the situation has been in recent months, but there has been an unprecedented lockdown on information about the investigation. Even other TSB investigators are shut out from information.

Something out of the ordinary caused the aircraft to contact the ground parallel to the runway pointed at the VOR. That is a fact. The only thing out of the ordinary was the presence of the military.

Lawsuits have been launched. The military is named as one of the defendants. From what I can recall, one of the claims is that the military failed to warn the crew that they were a mile off course. For that argument to succeed, it would have to be true that military radar was functioning.

I don't know of any reason why TSB would treat this accident any differently than any other one. It seems that they are. That could only be a perception.

It does seem to me, though, that if there was some failure of a system or systems which would have been initially identified, and there was a danger that could be repeated and a warning by way of early release of suspected cause, then some word of CVR, FDR, ground to aircraft communication related to the cause would already be out there.

Here's the CBC summary of the lawsuit claims...

10 allegations of negligence

The lawsuit lists seven ways in which the air traffic controllers failed to do their jobs, and weren't properly briefed about how to handle civilian aircraft. It says they didn't have enough training, that there weren’t enough air traffic controllers on duty to handle the traffic and that there was confusion about their responsibilities.

The documents specify that NAV Canada and DND should have done more to warn the pilots that they weren’t aligned with the runway and were heading for the hill.

Both lawsuits say First Air was responsible for the actions of the pilots who failed to realize the plane was not alligned with the runway and was heading into land; didn't use the landing equipment correctly; and didn't communicate with air traffic controllers properly.

One lawsuit alleges DND, NAV Canada and First Air are "jointly and severally liable" for damages.

The other lawsuit is from the widow of arctic scientist Marty Bergmann, who was a passenger.

Sheila Bergmann McCrae also said in her statement of claim the "accident was caused by negligence." She does not list DND among the defendants but she includes the same allegations against NAV Canada and First Air.

The alleged negligence claimed by plaintiffs includes failing to warn pilots the aircraft was not aligned with the runway and failing to ensure the instrument landing system was working.

[Rhys Perraton]

Aviation safety advisory A11H0002-D2-A1



08 February 2012

Major-General J.A.J. Parent
Commander
1 Canadian Air Division Headquarters
PO Box 17000 STN Forces
Winnipeg, MB
R3J 3Y5


Aviation investigation A11H0002

Re: AVIATION SAFETY ADVISORY A11H0002-D1-A1
IFR separation in Class D airspace



Dear Major-General Parent,

On 20 August 2011, a First Air Boeing 737-210C combi aircraft (registration C-GNWN, serial number 21067) was being flown as a charter flight from Yellowknife, North West Territories, to Resolute Bay, Nunavut. At 1142 Central Daylight Time, during the approach to Runway 35T, First Air Flight 6560 (FAB6560) collided with a hill about 1 nautical mile east of the Resolute Bay Airport runway. The aircraft was destroyed by impact forces and an ensuing post-crash fire. Eight passengers and four crew members suffered fatal injuries. Three passengers suffered serious injuries and were rescued by Canadian military personnel who were in Resolute Bay as part of Operation Nanook 11. The Canadian Forces had set up a temporary Class D control zone in Resolute Bay to handle increased air traffic for this exercise. At 1139, a second aircraft operating under instrument flight rules (IFR) entered the Class D control zone without appropriate IFR separation. There was a loss of separation and had the First Air flight not hit the ground there could have been a risk of a mid-air collision. The investigation (A11H0002) is ongoing.

Within Class D airspace aircraft must be equipped with radios capable of communicating with the air traffic control agency, and must receive permission to enter the airspace. The control agency has the responsibility to separate IFR flights from each other, and provide traffic information to flights being operated under visual flight rules (VFR). IFR separation is normally provided by using radar information. The military radar installed for OP Nanook was not useable at the time of the accident as a flight check had not yet been performed to verify radar accuracy.

The Canadian Forces Supplement to the Nav Canada Manual of Operations permits the application of non-radar IFR separation services to aircraft in airspace that is not served by radar. However, the military air traffic control (ATC) unit in Resolute Bay did not have procedures in place to direct controllers to apply non-radar separation standards in the Class D control zone. IFR separation standards were not established between FAB6560 and the second aircraft.

The military agency responsible for providing the ATC equipment and for the ATC operation is very experienced in deployed operations and routinely sets up precision approach radar (PAR) units in support of Operation Box Top, the far northern resupply of the Alert research station. As well, each year the unit sets up a complete airfield operation on the military base in Wainwright, Alberta. This operation in Resolute Bay was to be the first such complete airfield operation in a civil environment as part of the military's expeditionary air traffic management program (EATM). The planning for this operation did not include the contingency for the provision of IFR services in a non-radar environment. Although the implementation of this type of temporary control zone is rare in Canada, the consequences of not providing expected IFR services could be catastrophic.

The use of radar information and, in a non-radar environment, procedural methods, can be used to ensure IFR separation of aircraft. In the absence of these two defences, closing the Class D control zone would have alerted crews that ATC was not providing IFR separation, forcing them to revert to the normal procedures for uncontrolled airspace.

Because military ATC continued to operate the Class D control zone without the ability to provide IFR separation in instrument meteorological conditions, there was an increased risk of mid-air collision. Unless future EATM operations include the provision for all the air traffic services required for the class of airspace, this risk will persist. Therefore, the Canadian Forces may wish to amend their EATM planning process.

Yours sincerely,

Mark Clitsome
Director, Air Investigations Branch

cc: Martin Eley, Director General Civil Aviation, Transport Canada
John David, Director of Safety, NAV CANADA
Colonel Yvan Choinière, Director of Flight Safety, Royal Canadian Air Force

[gwengler]

That is VERY interesting; however, it does not really explain why the First Air Boeing flew into the hill. Perhaps the pilots let their guard down when they spoke (do we know there was communication?) to the temporary control tower.
Gerd

[55+]

Sources told me there will definitely be communication issues in this report

[whipline]

My source told me they knew the cause of the accident a very short period after it happened. Why it has taken so long to come out is a mystery. Sounds like everyone's trying to blame everyone else.

[cncpc]

That is VERY interesting; however, it does not really explain why the First Air Boeing flew into the hill.
Gerd

Exactly.

It does seem to eliminate a story that came out early on that the controllers were asking for radial and DME information off the VOR, which I take it would be a form of procedural IFR.

[Liquid Charlie]

My source told me they knew the cause of the accident a very short period after it happened. Why it has taken so long to come out is a mystery. Sounds like everyone's trying to blame everyone else.

"how" is straight forward - "why" is by far the larger and certainly more complex question

Certainly it would be easy to establish the obvious cause in a relatively short period of time but this is Canada not the USA where they just find the cause and point the finger and are done -- In Canada they dig a lot deeper and go deeply into human factors and anything else that might of contributed even if it was very minor -- from the get go it was made clear that 2 years minimum would be the length of the investigation - after Arrow Air I don't think the board wants any second guessing -- besides -- as an end user I want a factual and extensive investigation, not something that was generated to a structured time line. There appears to be litigation pending that will be based a lot on this report so I'm sure they want to get it right --

[CID]

There's going to be a fair amount of shyte hitting the fan on this one in my opinion and it's going to get on everything. I have a feeling that the airline, TC and the military are going to take a beating. As to why it's taking so long, it may be due to the impending legal battles. Maybe the lawyers at TSB want to get it perfectly right in order to prevent placing the military or the government in an unnecessary bad light..

Or it could be a tactic to allow a bit of the sting to wear off before the public is awoken to the facts.

Another possibility is that the military is fighting to have much of the report classified for limited release and the TSB is flighting back.

[Sidebar]

Maybe it just took a long time to do a thorough investigation and draft a good report?

[pelmet]

Maybe it just took a long time to do a thorough investigation and draft a good report?

A part of the long time is......not having the report released until it is translated into another language. The fact that several pilots could have read the report, said....."hey, I never thought about that before", and then applied the lessons learned in a future real world scenario and therefore saved a bunch of lives comes as a distant second priority to many advocates of certain language policies.

[swordfish]

Maybe it just took a long time to do a thorough investigation and draft a good report?

3 years, with a team working on it 40hrs/week, or more? Now THAT'S productivity....

[Sidebar]

3 years...

The accident was in Aug 2011, so that makes the current date Aug 2014? Exaggeration weakens the point you are trying to make.

[TeePeeCreeper]

A part of the long time is......not having the report released until it is translated into another language. The fact that several pilots could have read the report, said....."hey, I never thought about that before", and then applied the lessons learned in a future real world scenario and therefore saved a bunch of lives comes as a distant second priority to many advocates of certain language policies.

That is the biggest load of drivel I've had the displeasure of reading on this website.
Care to back up your statement with facts?

Regards,
TPC (happens to know some of translators whom work for/or on behalf of TC and the TSB)

[cncpc]

Maybe it just took a long time to do a thorough investigation and draft a good report?

A part of the long time is......not having the report released until it is translated into another language. The fact that several pilots could have read the report, said....."hey, I never thought about that before", and then applied the lessons learned in a future real world scenario and therefore saved a bunch of lives comes as a distant second priority to many advocates of certain language policies.

I think you can take it from that that there are no lessons to be learned, or no lessons to be learned that could save lives. Whatever caused this accident is not something that will happen again until the report is released. If at all.

[crazy_aviator]

There's going to be a fair amount of shyte hitting the fan on this one in my opinion and it's going to get on everything. I have a feeling that the airline, TC and the military are going to take a beating. As to why it's taking so long, it may be due to the impending legal battles. Maybe the lawyers at TSB want to get it perfectly right in order to prevent placing the military or the government in an unnecessary bad light..

Or it could be a tactic to allow a bit of the sting to wear off before the public is awoken to the facts.

Another possibility is that the military is fighting to have much of the report classified for limited release and the TSB is flighting back.

And to me , that is what is called stinking politics !

[jeta1]

Maybe it just took a long time to do a thorough investigation and draft a good report?

indeed. I understand as well that a confidential draft report is now being circulated to interested parties and it is a large one. Considering everything, and the fact that the TSB has many other accidents to investigate, not bad timings.

[pelmet]

A part of the long time is......not having the report released until it is translated into another language. The fact that several pilots could have read the report, said....."hey, I never thought about that before", and then applied the lessons learned in a future real world scenario and therefore saved a bunch of lives comes as a distant second priority to many advocates of certain language policies.

That is the biggest load of drivel I've had the displeasure of reading on this website.
Care to back up your statement with facts?

Regards,
TPC (happens to know some of translators whom work for/or on behalf of TC and the TSB)

This is based on comments made directly to me by a former TSB investigator. Maybe he was lying. As far as I know, this is standard government policy. Of course they normally don't advertise this.

But, to give an example of aviation safety delayed by what I mentioned earlier....read on.

SCDA approaches are known to increase safety(ie. save lives). So...after a King Air crash, the TSB recommended that:
"The Department of Transport require the use of the stabilized constant descent angle approach technique in the conduct of non-precision approaches by Canadian operators."

TC has promoted SCDA approaches earlier but has decided to make revisions to publications such as the AIM and the flight test guide and approved check pilot courses as part of their short term strategy on the issue. Obviously this is something where time is of the essence. as lives could be saved. But as is said on the TC response..."The next draft version is in the advance stage and should be ready in 2013. Translation and publication processes could add some delays."

http://www.bst-tsb.gc.ca/eng/recommanda ... _a1202.asp

How about we publish the next draft version immediately in whatever language it is in and then continue translations as a separate parallel thing.

Sorry teepee creeper, I don't post drivel. Just because you know a translator or two means nothing.

[Sidebar]

To minimize translation delays, the TSB currently translates reports during the confidential draft review phase. Once representations are received and any revisions are made, the original translation is also revised.

[Doc]

Maybe it just took a long time to do a thorough investigation and draft a good report?

A part of the long time is......not having the report released until it is translated into another language. The fact that several pilots could have read the report, said....."hey, I never thought about that before", and then applied the lessons learned in a future real world scenario and therefore saved a bunch of lives comes as a distant second priority to many advocates of certain language policies.

You speak much truth here. Canada...the world's largest sheep farm in action.

[KK7]

How long do you think it takes to translate a report?

[TeePeeCreeper]

How long do you think it takes to translate a report?

Thank you, I couldn't have asked the question any differently! (Sorry Pelmet and Doc I was going to try and let "sleeping dogs lie")

Anyone (and that certainly includes the TSB) who insinuates that translating a report be it from English to French or French to English may be the cause for a delay (more than a few hours at best) in the release of a document to public domain is deflecting in a manner that our civil servants have become experts at regardless of their mother tongue.

Gentlemen with all due respect, your personal views in regards to living, working and/or being a citizen of a country with two official languages should not be the cause of a sparing match when it comes to aviation safety.

Regards,
TPC

[URC]

According to the TSB's website there are 14 current active investigations that have yet to release a final report for accidents that occured prior to the First Air accident in August 2011. Still waiting for the report on the United Express Embraer overrun in YOW that occured on June 16, 2010.

http://www.tsb.gc.ca/eng/enquetes-inves ... /index.asp

[Doc]

According to the TSB's website there are 14 current active investigations that have yet to release a final report for accidents that occured prior to the First Air accident in August 2011. Still waiting for the report on the United Express Embraer overrun in YOW that occured on June 16, 2010.

http://www.tsb.gc.ca/eng/enquetes-inves ... /index.asp

Get off your asses girls! That's just a bloody embarrassing disgrace! It's well into 2013!!!