First Air Crash Resolute Bay August 20 2011

[Commonwealth]

This is a very personal accident for me, so I will keep my biased opinions about
the crew's actions to myself.

I would like to make a recommendation to Boeing on this accident regarding the autopilot. Now I know later versions of the 737 don't have this issue, but could a simple, read inexpensive, modification be made to the autopilot? One where the sutle change in mode that led to some of the Captain's confusion is made to be not so sutle. I'm thinking an aural alert of some kind. Seems like it would be one less hole in the Swiss cheese.

Anyway, for what it is worth. No one ever recommends that an airplane be changed in an accident report.

Profoundly sad,

CW

[tbaylx]

This is a very personal accident for me, so I will keep my biased opinions about
the crew's actions to myself.

I would like to make a recommendation to Boeing on this accident regarding the autopilot. Now I know later versions of the 737 don't have this issue, but could a simple, read inexpensive, modification be made to the autopilot? One where the sutle change in mode that led to some of the Captain's confusion is made to be not so sutle. I'm thinking an aural alert of some kind. Seems like it would be one less hole in the Swiss cheese.

Anyway, for what it is worth. No one ever recommends that an airplane be changed in an accident report.

Profoundly sad,

CW

Exactly what I was thinking when i read the report. The -200's have many little subtle "gotcha's" that have been addressed in later model Boeings. Had they been flying a -400 on this approach it's highly unlikely that the accident would have happened. Problem is hardly anyone flies the -200's anymore, so industry is unlikely to introduce a costly change that applies to a couple of airplanes. It all comes down to the $$ involved there unfortunately.

For all of you armchair quarterbacks out there vilifying the crew, you really need to check yourselves. But for the grace of god and all that. Could be you next time everyone is commenting on here on the nice anonymous forums. Don't thinks so? Then you haven't been flying very long or you are more dangerous than you think.

[CpnCrunch]

Exactly what I was thinking when i read the report. The -200's have many little subtle "gotcha's" that have been addressed in later model Boeings. Had they been flying a -400 on this approach it's highly unlikely that the accident would have happened. Problem is hardly anyone flies the -200's anymore, so industry is unlikely to introduce a costly change that applies to a couple of airplanes. It all comes down to the $$ involved there unfortunately.

For all of you armchair quarterbacks out there vilifying the crew, you really need to check yourselves. But for the grace of god and all that. Could be you next time everyone is commenting on here on the nice anonymous forums. Don't thinks so? Then you haven't been flying very long or you are more dangerous than you think.

I think First Air deserves at least as much blame as the pilots. I think there is no question that this accident could have been avoided if First Air had their house in order.

The first item that comes to mind is the lack of TAWS. It's likely that TC's mandate to install TAWS on all 6+ passenger turbine aircraft was due to this accident. According to news stories, this aircraft was the only 737 in First Air's fleet that didn't have TAWS. Assuming the crew didn't ignore the TAWS, they would have been given at least 30 seconds warning before impact.

The other major @#$!-up seems to be in CRM:

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

If you read the report, it's clear that First Air's CRM training was woefully inadequate and didn't even meet TC's requirements.

[CID]

The -200 autopilot does have a couple of subtle gotchas (Like the switch for the HDG mode) but how much more of an indication does a pilot need that the autopilot isn't doing what you think it's doing? The LOC was full scale and he decided to descend at that point. That was the fatal error. Notwithstanding the SOP, why would anyone descend below MSA with the LOC at full scale?

[tbaylx]

The -200 autopilot does have a couple of subtle gotchas (Like the switch for the HDG mode) but how much more of an indication does a pilot need that the autopilot isn't doing what you think it's doing? The LOC was full scale and he decided to descend at that point. That was the fatal error. Notwithstanding the SOP, why would anyone descend below MSA with the LOC at full scale?

From what i gathered he didn't realize the LOC was at full scale while the F/O did. I can only assume he was focused on the FD. Combination of one pilot without the full picture, and the other pilot a bit new on type so not as confident in his observations as he should have been. There is no doubt that there were some serious issues going on, but any pilot that I know who is only a couple of months on a new type in that situation is going to be a bit hesitant wondering if he's missing something.

[flyinthebug]

From what i gathered he didn't realize the LOC was at full scale while the F/O did. I can only assume he was focused on the FD. Combination of one pilot without the full picture, and the other pilot a bit new on type so not as confident in his observations as he should have been. There is no doubt that there were some serious issues going on, but any pilot that I know who is only a couple of months on a new type in that situation is going to be a bit hesitant wondering if he's missing something.

Sadly, I think you nailed it. This accident report has me thinking back to personal experiences I had as a fairly new co pilot. I have to be honest that there were some Captains I would have definitely hesitated to question, let alone take control from them. They only had 3 mins to try to sort it out and the FO just hadn't built up the confidence in what he was seeing until the last few seconds when he knew it was bad. By then they ran out of time.

As much as we would all like to think we would heroically take control from our Captain and save the flight, I wonder how many FO`s would actually do it? (unless it was clearly defined in company SOP`s). Id be willing to bet less than half of us would. We still all feel some form or level of respect for the guy or gal in the left seat. We know they earned it and gained a lot of experience en route to that seat. It would be difficult for the FO to do anything more than he did in the limited time he had to try to work it out for himself. He likely wasn't 100% sure of himself, and was questioning his instruments and what he believed was occurring. He didn't let the Captain kill him, as he still believed in the back of his head that the Skipper knew what was happening and he was missing something. That doesn't explain why the Captain didn't respond to the First officers prompts though...as has been discussed previously in this thread.

That's just my opinion. I met Blair many years ago when I was still fairly new. Likeable guy, good pilot from all accounts I heard. I am not surprised by the passion of some that are angry and saying things that are very emotional about him. Just a very sad and tragic accident.

I do believe in this particular accident, that a change to ALL company SOPs could actually do something positive for safety. If it was in the SOPs for First Air and read that "ANY unstable approach at 1000' above MDA/DH occurs, that equates to immediate go around"...also giving the First Officer full authority to do so if the aircraft is not stable at those limits. Set an SOP for all airlines that the aircraft must not be unstable 1000' above MDA or DH and if so, an immediate go around shall be initiated. If First air had that SOP, we wouldn't have this 14 page thread discussing this tragic accident. Id rather read 5500+ CADORs than this thread.

RIP and sending my most sincere condolences to the families and friends on this board and not.

[tbaylx]

From what i gathered he didn't realize the LOC was at full scale while the F/O did. I can only assume he was focused on the FD. Combination of one pilot without the full picture, and the other pilot a bit new on type so not as confident in his observations as he should have been. There is no doubt that there were some serious issues going on, but any pilot that I know who is only a couple of months on a new type in that situation is going to be a bit hesitant wondering if he's missing something.

Sadly, I think you nailed it. This accident report has me thinking back to personal experiences I had as a fairly new co pilot. I have to be honest that there were some Captains I would have definitely hesitated to question, let alone take control from them. They only had 3 mins to try to sort it out and the FO just hadn't built up the confidence in what he was seeing until the last few seconds when he knew it was bad. By then they ran out of time.

As much as we would all like to think we would heroically take control from our Captain and save the flight, I wonder how many FO`s would actually do it? (unless it was clearly defined in company SOP`s). Id be willing to bet less than half of us would. We still all feel some form or level of respect for the guy or gal in the left seat. We know they earned it and gained a lot of experience en route to that seat. It would be difficult for the FO to do anything more than he did in the limited time he had to try to work it out for himself. He likely wasn't 100% sure of himself, and was questioning his instruments and what he believed was occurring. He didn't let the Captain kill him, as he still believed in the back of his head that the Skipper knew what was happening and he was missing something. That doesn't explain why the Captain didn't respond to the First officers prompts though...as has been discussed previously in this thread.

That's just my opinion. I met Blair many years ago when I was still fairly new. Likeable guy, good pilot from all accounts I heard. I am not surprised by the passion of some that are angry and saying things that are very emotional about him. Just a very sad and tragic accident.

I do believe in this particular accident, that a change to ALL company SOPs could actually do something positive for safety. If it was in the SOPs for First Air and read that "ANY unstable approach at 1000' above MDA/DH occurs, that equates to immediate go around"...also giving the First Officer full authority to do so if the aircraft is not stable at those limits. Set an SOP for all airlines that the aircraft must not be unstable 1000' above MDA or DH and if so, an immediate go around shall be initiated. If First air had that SOP, we wouldn't have this 14 page thread discussing this tragic accident. Id rather read 5500+ CADORs than this thread.

RIP and sending my most sincere condolences to the families and friends on this board and not.

Well said, and I agree completely. Should be a lesson for all captains out there. Make sure you aren't that guy that an F/O would be hesitant to speak up with. Provide an environment that your colleague feels free to ask questions and question what's going on without fear of ridicule or repercussions. He might just save your ass when you make a mistake. Sadly there are still those pilots out there that figure they are somehow better than the guy in the right seat because they have more experience or time on type or whatever. I don't care if you're . Yeager, you are going to mess up and you'd better hope your colleague feels empowered enough to call you on it.

You can put whatever you want into the Company SOP's and CRM training. It helps if its there, but ultimately it's up to the captain to make sure the crew (including the F/A's) operates in an open, team environment. I'm sure most people can think of a captain or two they've flown with that kills CRM dead right from the time you get together in the crew room through their body language, manner of speaking or whatever. Don't be that guy.

[CFR]

From what i gathered he didn't realize the LOC was at full scale while the F/O did. I can only assume he was focused on the FD. Combination of one pilot without the full picture, and the other pilot a bit new on type so not as confident in his observations as he should have been. There is no doubt that there were some serious issues going on, but any pilot that I know who is only a couple of months on a new type in that situation is going to be a bit hesitant wondering if he's missing something.

Sadly, I think you nailed it. This accident report has me thinking back to personal experiences I had as a fairly new co pilot. I have to be honest that there were some Captains I would have definitely hesitated to question, let alone take control from them. They only had 3 mins to try to sort it out and the FO just hadn't built up the confidence in what he was seeing until the last few seconds when he knew it was bad. By then they ran out of time.

As much as we would all like to think we would heroically take control from our Captain and save the flight, I wonder how many FO`s would actually do it? (unless it was clearly defined in company SOP`s). Id be willing to bet less than half of us would. We still all feel some form or level of respect for the guy or gal in the left seat. We know they earned it and gained a lot of experience en route to that seat. It would be difficult for the FO to do anything more than he did in the limited time he had to try to work it out for himself. He likely wasn't 100% sure of himself, and was questioning his instruments and what he believed was occurring. He didn't let the Captain kill him, as he still believed in the back of his head that the Skipper knew what was happening and he was missing something. That doesn't explain why the Captain didn't respond to the First officers prompts though...as has been discussed previously in this thread.

That's just my opinion. I met Blair many years ago when I was still fairly new. Likeable guy, good pilot from all accounts I heard. I am not surprised by the passion of some that are angry and saying things that are very emotional about him. Just a very sad and tragic accident.

I do believe in this particular accident, that a change to ALL company SOPs could actually do something positive for safety. If it was in the SOPs for First Air and read that "ANY unstable approach at 1000' above MDA/DH occurs, that equates to immediate go around"...also giving the First Officer full authority to do so if the aircraft is not stable at those limits. Set an SOP for all airlines that the aircraft must not be unstable 1000' above MDA or DH and if so, an immediate go around shall be initiated. If First air had that SOP, we wouldn't have this 14 page thread discussing this tragic accident. Id rather read 5500+ CADORs than this thread.

RIP and sending my most sincere condolences to the families and friends on this board and not.

Well said, and I agree completely. Should be a lesson for all captains out there. Make sure you aren't that guy that an F/O would be hesitant to speak up with. Provide an environment that your colleague feels free to ask questions and question what's going on without fear of ridicule or repercussions. He might just save your ass when you make a mistake. Sadly there are still those pilots out there that figure they are somehow better than the guy in the right seat because they have more experience or time on type or whatever. I don't care if you're . Yeager, you are going to mess up and you'd better hope your colleague feels empowered enough to call you on it.

You can put whatever you want into the Company SOP's and CRM training. It helps if its there, but ultimately it's up to the captain to make sure the crew (including the F/A's) operates in an open, team environment. I'm sure most people can think of a captain or two they've flown with that kills CRM dead right from the time you get together in the crew room through their body language, manner of speaking or whatever. Don't be that guy.

Sorry I don't buy it. Looking at the abbreviated transcript seems to indicate to me that the F/O did much more than you might expect an inexperienced on type pilot to do. The only thing he didn't do was take command of the aircraft and we have no way of knowing if he was in the process of doing so when the accident occurred. He made around 19 statements to the Capt that there were problems with the approach and advised (2 or 3 times) to abort the landing. The Capt simply overrode him each time. There is no point in being a Capt who encourages their F/O to speak up, if you're going to ignore them!

I have no knowledge of the 737 cockpit, but if the LOC was at full deflection and the GPS reported off track as well, what instrument was the Capt using to make himself believe that the approach was OK?

I recall a show on accident investigation where the investigator said it was hard to listen to the CVR, especially where the cause of the accident is clear. He said sometimes he found himself speaking to the tape to try and will the crew to recognize the errors in play because he knew how it was going to play out. For me that moment is around 16:40 where I want the Capt to recognize what the LOC is telling him!

[tbaylx]

If you don't have knowledge of the 737-200 cockpit and autopilot system, then you can't really understand why the captain might not have realized why he was not on the loc while looking at the FD. There are several ways that the -200 SP-77 autopilot can trap you into thinking its doing something it isn't.

While not condoning the captain's CRM and situational awareness, and the F/O made several attempts to tell the captain that he wasn't where he thought he was, but he didn't do it effectively. Part of CRM is effective communication and if your colleague isn't getting something its up to you to make sure he does, and taking control is a last resort that can be quite a difficult escalation to judge when to take as an F/O.

I agree that the F/O made many attempts to convey that something was wrong, but it's clear that the F/O himself wasn't sure exactly what that was, and failed to convince the Captain that he wasn't on the LOC. This wasn't a case of the Captain ignoring the F/O on purpose, it was a case of both pilot's having different situational awareness and failing to resolve the ambiguity effectively in a timely manner. The F/O didn't communicate his concerns effectively, and I believe a good part of that was his inexperience on type. He was an experienced pilot with lots of previous PIC time, but when transitioning to a new type, particularly from a turboprop to a jet there is a learning curve where you aren't always sure of yourself, especially as things are happening much faster than you are used to.

As a crew here the lesson ought to be (IMHO) that if you are having a conversation with your fellow pilot during an approach that indicates any sort of ambiguity, you should be executing a missed approach and sorting it out at MSA rather than risk a CFIT.

[CFR]

As a crew here the lesson ought to be (IMHO) that if you are having a conversation with your fellow pilot during an approach that indicates any sort of ambiguity, you should be executing a missed approach and sorting it out at MSA rather then risk a CFIT.

Agreed. And reinforces my point. The F/O's multiple concerns, expressed perhaps less forcibly than some would like, should have resulted in an overshoot. The ultimate responsibility for not over shooting rests with ???

[Illya Kuryakin]

Did I see somewhere that "an FO can't initiate a go around (missed approach)"...? Seriously? From what little green man did they think up this absolutely ludicrous SOP? First pilot that sees a problem, where I live, can call a go around, or a reject! That SOP (if it really exists) could very well have been THE root cause of this accident. That goes even deeper than the "Captain is King" culture....these guys put that in writing??
Illya

[tbaylx]

As a crew here the lesson ought to be (IMHO) that if you are having a conversation with your fellow pilot during an approach that indicates any sort of ambiguity, you should be executing a missed approach and sorting it out at MSA rather then risk a CFIT.

Agreed. And reinforces my point. The F/O's multiple concerns, expressed perhaps less forcibly than some would like, should have resulted in an overshoot. The ultimate responsibility for not over shooting rests with ???

No doubt about it. The captain should have made the go around and didn't.

I guess the point that i'm trying to get across is that if you're confused and you've lost situational awareness it's not as easy as some of the airmchair pilot's here would like you to believe to stop trying to figure out what is going on, snap out of it and make the decision to execute the missed approach. That's what should have happened, but didn't, and not because the captain was incompetent, suicidal or just felt like ignoring the F/O and has been insinuated in previous posts.

[CID]

Sorry I don't buy the argument that an experienced pilot on a -200 would think the flight director is any indication of what the autopilot is doing. Unlike most other modern AFC systems, the autopilot and FD are two different independent systems. They have their own mode selectors and their own computers (roll computer and steering computer). You can set the FD to AUTO APP and have the autopilot following HDG, for example (and heading on the A/P is indicated by a toggle switch position) but that's the way it's been for over 40 years so it shouldn't be a surprise. Unless of course the pilot was woefully under-trained or didn't understand the fundamental layout of the AFCS.

Furthermore, between the expanded scale on the FD and the LOC/GS on the HSI and the progress annunciators and the mode annunciators on the FD and the comparator should have been more than enough for a pilot to know he/she shouldn't descend below MSA. Never mind the 15 or 20 suggestions from the right seat that included reference from the GPS as well.

The change of mode to CWS by nudging the column isn't new but it isn't exactly un-indicated. If your autopilot isn't coupled to the ILS and was suddenly in manual mode, I would hazard a guess that almost any pilot would realize it even without an specific annunciation.

Having said all that, I must concede that I wasn't there so I don't know what the mental state of the captain was or what his training was or what exactly he was thinking so it's tough to jump on the bandwagon and accuse him of any specific wrongdoing.

[CFR]

As a crew here the lesson ought to be (IMHO) that if you are having a conversation with your fellow pilot during an approach that indicates any sort of ambiguity, you should be executing a missed approach and sorting it out at MSA rather then risk a CFIT.

Agreed. And reinforces my point. The F/O's multiple concerns, expressed perhaps less forcibly than some would like, should have resulted in an overshoot. The ultimate responsibility for not over shooting rests with ???

No doubt about it. The captain should have made the go around and didn't.

I guess the point that i'm trying to get across is that if you're confused and you've lost situational awareness it's not as easy as some of the airmchair pilot's here would like you to believe to stop trying to figure out what is going on, snap out of it and make the decision to execute the missed approach. That's what should have happened, but didn't, and not because the captain was incompetent, suicidal or just felt like ignoring the F/O and has been insinuated in previous posts.

Again agreed. My point was that some seemed to be excusing the Capt because the F/O was not forceful enough in expressing his misgivings. If the enforced culture at First Air was that disagreement results in a mandatory overshoot AND if that culture was followed, we would not be having this conversation. It also means the PF doesn't have to continue to try and reconcile the conflicting information while on short final and simply has to shift mental gears to flying a standard overshoot.

[FICU]

[CpnCrunch]

Did I see somewhere that "an FO can't initiate a go around (missed approach)"...? Seriously? From what little green man did they think up this absolutely ludicrous SOP? First pilot that sees a problem, where I live, can call a go around, or a reject! That SOP (if it really exists) could very well have been THE root cause of this accident. That goes even deeper than the "Captain is King" culture....these guys put that in writing??
Illya

No, it wasn't an SOP. It was just the opinion of every single pilot at First Air that they interviewed.

[Illya Kuryakin]

Did I see somewhere that "an FO can't initiate a go around (missed approach)"...? Seriously? From what little green man did they think up this absolutely ludicrous SOP? First pilot that sees a problem, where I live, can call a go around, or a reject! That SOP (if it really exists) could very well have been THE root cause of this accident. That goes even deeper than the "Captain is King" culture....these guys put that in writing??
Illya

No, it wasn't an SOP. It was just the opinion of every single pilot at First Air that they interviewed.

That's even more scary than a written SOP. A "perceived" SOP with no basis in fact. I think the training department has some 'splaining to do here. How could an entire (or close to it) pilot group be THAT misinformed on something this important?
Illya

[Sidebar]

From what i gathered he didn't realize the LOC was at full scale while the F/O did.

The captain knew they were full deflection. From Appendix A of the report:

1640:07 FO queries captain to confirm full deflection.
1640:08 Captain concurs, and questions why full deflection when they are on the localizer.

[Sidebar]

I have no knowledge of the 737 cockpit, but if the LOC was at full deflection and the GPS reported off track as well, what instrument was the Capt using to make himself believe that the approach was OK?

According to section 2.8.5 of the TSB report:

At this time, the captain's likely desired course of action was to maintain the current heading to re-intercept the localizer and ultimately to land at CYRB. His desired course of action was influenced by the following:
•The autopilot mode likely switched to MAN and HDG HOLD during the roll-out from the turn, and the captain still believed that it was in VOR/LOC and that it was intercepting and would track the localizer.
•The current erroneous heading resulted in an apparent intercept angle when, in fact, the true heading was divergent. This powerful supporting cue was displayed directly in front of him on the HSI.
•The captain's flight director was likely in AUTO APP intercept mode, and would have been commanding wings-level.

Also see Figure 16 in section 2.6.4 for the HSI indication with the heading error.

[Sidebar]

Did I see somewhere that "an FO can't initiate a go around (missed approach)"...?

See section 1.17.2.9.4

Neither of these portions of the AOM provide for the PNF to make a go-around call.

[swordfish]

I don't propose to comment on the crew, CRM, SOP, 7F, or the TSB report. There's nothing to add to any of it.

I will say, however, that if you're not typed on the 732 or familiar with the area (tbaylx and FICU ARE) there's not much you can contribute to this thread.

There are a couple of things that southerners may not know or understand about flying up here:

• 1. In the North, it is not uncommon to make downwind approaches on the ILS - particularly at Yellowknife, Frobisher and Resolute - or you can kiss goodbye to getting in when it's 300' and a mile.
  2. Therefore scorching down the glide path at 800-900 fpm at low power settings, then recovering at 200' AGL, to land on a compacted snow runway, is a skill you must develop.
  3. The ("suitable") alternates for Cambridge, Resolute and Frobisher are more than 200 nm away (and sometimes 300+ nm), and the infrastructure at them is marginal to handle a pile of pax, and perishable cargo. Yes, I realize Arctic Bay IS a paper alternate for Resolute, but pity help you if you arrive there in 1400' and 3 miles and you can't leave for 3 days because you can't make the SPEC VIS climb requirements, or you don't have an alternate within 60 minutes on 1 engine. The missed approach procedures here tell the complete story.
  4. At Resolute, the wind can be blowing 15+ kt from the East on the approach and touchdown to 35, and almost calm at the terminal building. The CARs operator therefore reports winds less than 5 kt or 9900, making you wonder where the gale and turbulence came from on approach.
  5. These -and other - unique trivia add much pressure to the Captain of a large plane, deciding how, and when he's going to react to the constantly changing weather conditions at these places.
  6. Many of us (yes, that includes YOU) have attempted to recover an unstable approach before the FAF, and most of us succeed. It will do you well to remember this as you read the TSB report.

[Illya Kuryakin]

Ah swordfish, all very true....but non has anything to do with the goings on in that particular cockpit, on that particular day. I have spent more than a few hours in the area, and a year flying a 733... Neither of which are requirements to understand the unfortunate circumstances of this accident.
Somebody mentioned fatigue. I'd be interested in knowing what this crew was doing in the 72 or so hours immediately preceding the accident. To me, the transcript makes the captain come across as perhaps tired, and the FO unwilling to take control of the situation. Both could very well indicate fatigue. Thoughts?
Illya

[1&2SpooledUp]

I don't propose to comment on the crew, CRM, SOP, 7F, or the TSB report. There's nothing to add to any of it.


There are a couple of things that southerners may not know or understand about flying up here:

• 1. In the North, it is not uncommon to make downwind approaches on the ILS - particularly at Yellowknife, Frobisher and Resolute - or you can kiss goodbye to getting in when it's 300' and a mile.
  
  Agree 100% and this is where TC and Nav Canada have dropped the ball big time. How many WAAS approaches do we have in Canada vs the US?? Operators need to be putting more pressure on TC to get this changed instead of just accepting downwind approaches as the norm.
  
  5. These -and other - unique trivia add much pressure to the Captain of a large plane, deciding how, and when he's going to react to the constantly changing weather conditions at these places.
  
  Yes it does, that's why you should always be ready to do the missed if things don't look right. Should be the opening statement in any crew briefing.
  
  
  6. Many of us (yes, that includes YOU) have attempted to recover an unstable approach before the FAF, and most of us succeed. It will do you well to remember this as you read the TSB report.

Yes I have but the weather wasn't at minimums, the LOC wasn't at full deflection and the FO wasn't sitting there saying "we are off course" (18 times). That's why I'm still alive to post on this forum.

This is the type of accident that usually happens to an inexperienced crew at an unfamiliar airport and that's why everybody was so surprised at the outcome of the investigation.

The TSB are the ones that listened to the CVR and I'm positive that's why the report is so heavily focused on CRM. This approach should have ended the first time the FO said they were off corse and had full LOC deflection, but it didn't for some unknown reason.....

This report still leaves a lot of unanswered questions.

[MrWings]

The F/O's multiple concerns, expressed perhaps less forcibly than some would like, should have resulted in an overshoot. ???

Again, how do we know how forcibly the F/O the pointed out the error?

EDITED

Without the CVR transcript, we don't know how for sure. We do know he pointed out the deviation over and over. That persistance, one might argue, suggests being forceful.

[jeta1]

If you read the report, it's clear that First Air's CRM training was woefully inadequate and didn't even meet TC's requirements.

Indeed, and likely why the TSB did not make a formal recommendation on CRM... just a "safety concern". Truth of the matter is, the current CRM Standard for 705 carriers, despite the lack of a formal module on Threat and Error Management (TEM), should have been sufficient to properly educate and train the crews on proper communication, ambiguity, assertiveness and the need for a modern F/O to speak up when needed. The needle deflection alone should have warranted a go-around, no matter CRM considerations.

The "new" CRM standard, whenever that arrives in 10 years or more, will just be a mildly tuned-up version of same, + TEM. So at the end of the day, it is not about this standard, or the next standard, it is about the operator and how seriously they implement CRM training, how much time they dedicate to it, and how they make sure all their crews are 100% ready to face such situations. My guess is that these two guys were relatively well-trained on CRM in the first place, they just failed to apply what they learned. So even if the First Air training had been 2 days, heck, even a week, the screw-up probably would still have happened. Nobody can say for sure if more CRM training would have prevented this.

This is not about the TC standard for CRM, one bit. As far as CRM instructor accreditation goes, again, airlines must make sure their instructor - usually an in-house experienced crew member - is properly qualified and has relevant experience. Can you just imagine if CRM instructors had to be accredited from TC or some other outfit? I'll telll you what would happen... operators would quickly default on CRM recurrent training due to the lack of an accredited instructor. They would wing it with non-accredted, then TC inspectors on PVIs would have to make or ignore a finding, and then shaggy CRM instructor schools would come out of the woodwork and all that crap... no way. No touching this BS of accreditating people to instruct CRM. As long as the Accountable Executive (lol... SMS ?) vouches for him or her, good enough for me.

This was a pilot error on top of pilot error on top of pilot error, unfortunately. First Air "could" have at least given them more CRM, but if you look around, most companies shortchange their CRM/ PDM training, even TC's own Aircraft Services Directorate.