First Air Crash Resolute Bay August 20 2011

[CpnCrunch]

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

Flight data monitoring goes a long way to solving this problem, as it essentially enforces the stabilized approach criteria (among other things). According to the report First Air did have an FDM programme, but at the time of the accident it was temporarily unoperational. I have no idea how effective their FDM programme was in the first place, but I'm guessing they will be improving it. If you look through posts on this forum, you'll see that Westjet has a particularly effective and useful FDM programme, and I imagine all the "real" airlines implement it. FDM isn't mandatory in the USA or Canada, which IMO is a major safety concern.

[pdw]

Having read the full report, this was the most piss-poor cockpit management imaginable. A promising FO killed by an obstinate captain. What a waste.

We see the uttered words "Go for it" right at/after the "sink" warning at 5 seconds (~ 1000ft) prior to striking that hill. Is this to be seen as part of the tragedy ?

[pdw]

Edit ( "just once" was my response to an immediately previous comment / preceding post, which has been deleted / disappeared).

[Illya Kuryakin]

What part of:
I HAVE CONTROL, MISSED APPROACH, MAX POWER.....
Do you people just not get?
I did this to a captain one dark night. Not because of anything he was doing wrong, but because I saw something he didn't, and there was NO time to communicate.
I saw the herd of caribou bedded down on the runway. He did not.
It got to the point here, where the communication was NOT working. A fact that should have been apparent to the PNF.
Illya

[goldeneagle]

Having read the full report, this was the most piss-poor cockpit management imaginable. A promising FO killed by an obstinate captain. What a waste.

Personal bias is showing thru pretty strongly here.

The report I read said there was a crew of 4 on board, along with 11 paying customers. That same report, said there was not one, but two pilots in the cockpit, both qualified on type.

More than an FO lost lives in this incident, most of which were not in a position to rectify the situation. But two of them were in a position to do something about it. Plenty of blame to go around here, no need to dump it all into one chair.

[Illya Kuryakin]

I'll never understand a culture so mired in manure, that the FO wouldn't have grabbed a fist full of throttles and gotten the Hell out of there???
Illya

[pdw]

The approach duration shortened up in higher groundspeed perhaps more than we think; even less time for catching misreading "HSI" while recovering the high speed overshoot of centre-line. From "10K" to 1/2 mile final is barely 2.5 minutes ... yes, maybe to the accident location (mid runway) is the "3 minutes".

[Gino Under]

A lot of bravado written in this thread is based on 'after the fact'.

We now know what took place at the end of this flight.

If this arrival had been flown differently, if the go around hadn't resulted in CFIT, many of the bright ideas posted here would never have been posted.

I can only imagine the pilot victims on this fatal flight would be writing similar prose if it weren't them who lost their lives.

Gino Under

[5dayer]

I'll never understand a culture so mired in manure, that the FO wouldn't have grabbed a fist full of throttles and gotten the Hell out of there???
Illya

It's a northern culture thing. This captain is god bullshit has to end. ramp hands are shit, FOs are one step up but not much more. It doesn't matter weather it's a twin otter or a 737. I'm surprised this hasn't happened sooner. I wonder how many fos on ice pilots would take control. Devan Brook (not sure of the name) doesn't exactly excercise great crm or 2 crew. What would happen if someone took control from Joe? Just because this was a 737 means nothing, at least the FO spoke up, over and over again by the sounds of it.he is still dead. Arrogance is a killer, there is more arrogance in the north than anywhere

[shimmydampner]

"The north" is a huge place where a good many pilots are involved in a wide variety of operations. I assume you must have substantial experience in these areas conducting various types of aviating to make such a bold claim. I'm curious, at what latitude can one expect such arrogance to become so prevalent a problem?

[swordfish]

that the HSI was reading 17 degrees
off, because six guys spent three years figuring that
out.

This can happen easily when resetting your compasses, even when you're using the GPS to get bearing information to set the compasses to TRUE. (Well, maybe not "easily", but it can certainly happen under pressure.)

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

The root cause of THAT accident was a blind, un-thinking adherence to the SOP as dictated by ECAM actions, not a mis-diagnosis. You have to stay thinking (and testing - in this case: fuel quantity) even outside the box defined by the ECAM.

In the of 7F accident, this does not apply. Here, they had to think for themselves, not get everything spoon-fed to them by a computer.

[swordfish]

5dayer and Mr Kuriyakin, and many others: you both have to take a Valium and step back from your keyboards. I know a lot of the crew at First Air, and other operators in the north, and I can safely tell you that the attitudes you claim to be experts on, and bemoan, do not exist in this day and age. Most of the pilots around here are "new age", born and raised in Aviation Colleges, with a new and different approach to their professions, and with CRM courses at many different levels. After 10 years of hearing the same tired course material year after year, you begin to wonder how can our CRM possibly fail us in the cockpit in 2011. Well, unbelievably, it DID fail one day, so let's all learn from it.

7F and 5T do literally HUNDREDS of 705 flights a week successfully up here, and every self-proclaimed expert has to run off at the mouth with the same verbal diarrhea echoed throughout this thread that they learned when they were preppies.

It has been reiterated to death, and nothing more can be accomplished by going on & on about it.

The issues identified by the TSB report have been jumped on by First Air, and repaired. It's time to leave it - and the company - alone.

[righthandman]

Sim rides need to present situations where PM has to take over.

I think this is the best suggestion/solution of all. I HAVE flown up north (Capt. on B1900D) and I HAVE been a low time FO (<400 hrs on type before company went tits-up) on a 737-200 so I sort of can "identify" with this accident a little. I have read the first 1/3 of the accident report so far and thus a reasonably good idea of how things unfolded in terms of the facts.

There is no question that flying up north presents unique challenges/situations and therefore stresses/influences (especially for the PIC) that if you have not been there, you might not fully appreciate. And being a low time relatively inexperienced pilot on type (as second in command) does have it's own pressures. You know what the SOP's say, you have taken the CRM training and so on but when the apparent gravity of the situation suddenly requires you to "do your job" it can certainly be intimidating. And by "suddenly" I mean that things are unfolding at jet speeds.

I once read in a corporate jet trade magazine advertisement, that your corporate pilots are the only ones in your company that have to make "million dollar decisions every second". That is why simulators are such great tools. You can put into practise all the theory before you (may) have to apply it in the real world. I think presenting scenarios well past the usual "pilot incapacitation" is a great way to both demonstrate you know What to do, When and How to do it. It's great all 'round experience.

[jjj]

Some posters think that all the FO had to do was take control.

I object to that opinion because it assumes that the Captain would concede control. There is a dynamic at play that may not even be apparent to those who are privy to the tapes.

I once initiated a go-around in a Lear 35 as PF in a horribly unstabilized approach in mountainous terrain. The Captain objected to my go-around and dragged the thrust levers back to idle as I was pitching up. I over-powered the Captain and got the F outa there. I won the battle for control that night. Even the go-around was an argument as the Captain objected to me following the published missed but at least I was increasing the delta between us and the rocks as we had it out.

Sorry kids but saying "I have control - go around" does not mean that the other guy will concede control and defer to the judgment of the person with whom there was the original disconnect.

JJJ

[pelmet]

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

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

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

Correct, that is the standard way of setting compasses. If you want to be picky, you can adjust for the remaining convergence.

[swordfish]

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

Correct, that is the standard way of setting compasses. If you want to be picky, you can adjust for the remaining convergence.

If you do it right before you hit MUSAT, you won't have to worry much about convergence or precession, no matter what type, as you'll be on the ground in 4 minutes. btw...it will be the HEAD of the needle if you're doing an ILS approach...not the tail.

And just to clarify: you set the compass (in FREE mode) to the bearing of the head of the needle, indicated by the bearing of the NDB displayed by the GPS

[Colonel Sanders]

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?

It's time to leave it - and the company - alone.

I'm a huge fan of censorship, too. So was Stalin,
Hilter and Saddam Hussein. All great guys, who
knew how to manage information.

You sound awfully young, so here's some insight:

You don't get to choose why you become famous.

[Colonel Sanders]

Anyone here old enough to remember Korean Air 2033?

http://code7700.com/mishap_korean_air_2033.html

A fight in the cockpit between a Canadian left-seater
and a local FO results in a crashed airplane.

"The Korean Air Airbus A300 made its approach faster than usual to avoid potential windshear. Fifty feet above the runway the copilot, who was not flying the aircraft, decided that there was insufficient runway left to land and tried to perform a go-around against the captain's wishes. The aircraft touched down 1,773 meters beyond the runway threshold. The aircraft could not be stopped on the remaining 1,227 meters of runway and overran at a speed of 104 knots. After striking the airport wall and a guard post at 30 knots, the aircraft burst into flames."

I suspect they could have safely landed had the copilot not intervened.

I also suspect the safer course of action would have been to go around and that they could have done that had the decision been made. But as poster children for Crew Resource Management, they elected to fight and neither safe outcome could happen and they lost the airplane.

Speaking of poster children for CRM, about 20
years ago, a guy I knew, left seat on a twotter
for First Air, got into a fistfight with his co-pilot
on final approach in the cockpit. Co-pilot was fired.
Left seater was demoted to right seat twotter
and now has single-digit seniority at Jazz.

[GRK]

I remember that one…(Mostly…getting into the hazy part of memory banks!) If I'm not mistaken the Captain went straight to jail... did not pass go or collect 200 dollars... Took an intervention by CALPA or the Feds at the time to get him out and home before he was tried and found guilty...

[Eric Janson]

Not as bizarre as you would imagine…shall we talk about Asiana, or any number of accidents (hull losses) in Indonesia or other non western places? Hell, it still rears it's ugly head in more places than ICAO wants. It indicates a serious problem in a company with a culture like that. Many many companies have tried to move on from the punitive culture of go arounds, as well as implementing a stabilized approach criteria…if not stabilized by a certain altitude, it's a mandatory go around which MUST be called by any pilot. No jeopardy…none…it works in principle until you introduce culture…company or country.

Having worked at an Asian Airline I fully agree. The Airline had a no fault go-around policy/stabilised approach criteria but there were a number of incidents where a go-around was not made even though it should have been.

All the policies in the world won't help if they are not going to be followed.

CRM was something taught in class - what happened online was cultural values replaced CRM. They always looked at what others did wrong - never took a good long look at their own issues.

I wouldn't have expected any local F/O to tell me to go-around. Basically you were on your own. Incident = fired.

There were 2 sets of Standards - one for the Locals one for the Expats.

It's a lucky Airline - they've had a number of incidents that could easily have resulted in a wide body hull loss. Sooner or later their luck will run out.

This was one of the better operations in the region - things were much worse to the North and East.


Back to First Air

This accident was a result of a sequence of events. It's not correct to focus on only 1 aspect. The difference between incident and accident in this case was a failure to stop the sequence. There were a number of places where this should have happened but it didn't.


For my own curiosity:-

My company allows a F/O to call for a go-around and at that point a go-around is mandatory - no discussion.

This is the first company I've worked for where I have seen this written on paper. How many of your companies have this in your SOPs?

I'd be very curious to see what the SOPs say at Air Canada/Westjet/Jazz/Transat and other operators.

[55+]

Back in 1989, I had the opportunity to attend a 3day seminar/course given by Continental Airlines on Crew Resource Management in Toronto. In my time (like others), I have been on many a training courses and the like, however this seminar was probably one of the best I ever attended. I still remember it and I still have to old documentation given to us. The emphasis was on “resource management” and the interesting case study was that United Airlines DC-8 that ran out of fuel Portland Oregon troubleshooting a perceived gear issue. CRM was/is a valuable tool and what part it paid, if any in this FirstAir incident, I have no idea as I am not familiar with that airline and it’s operations. However the TSB seems to think so and I will leave it at that.

[onspeed]

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.

[CID]

On the compass...yes my mistake. I was talking enroute if there is no NDB in range.

Anyway....interesting that nobody is talking "culture" like they were for the Asiana crash.

[iflyforpie]

Sure they are talking about culture. I've seen a few references to bush/northern/get r dun culture in this thread.

Just because something may or may not be divided by race does not mean that race has anything to do with it other than as a method of identification.

Kind of like the Natives. If you took everyone that was born on the last Wednesday of the month, gave them special recognition and entitlements, and created a culture that was lazy, dependent, and depressed... I'd feel the same way about them.

[Rookie50]

Reading this it does seem like confusion and confirmation bias. As a humble SP IFR GA pilot, I made a mistake on an approach not too long ago that could have been serious but, being controlled airspace, Approach corrected me with a vector, which confused me, then I picked up my mistake.

I was being vectored but not yet cleared for an ILS at a US airport. I was vectored from the north, southbound right through and above the final approach course above traffic on final below me, with the Anticpation I would be turned, descended and vectored onto final in sequence. I therefore loaded but did not activate the ILS approach in my 430W, and left the CdI on gps mode. ( I think they were vectoring me towards a vor outside of the approach -- so I was tracking to that)

South of the approach course, I was turned, descended and vectored to intercept. But -- you guessed it --- due to the delay and being vectored around, -- I forgot to activate the approach/ switch the CdI input. So for a moment or so I'm tracking the wrong input, until approach told me to turn left, which totally confused me --- the CdI said right ( to the airport) -- then I woke up, smacked myself, and pushed buttons. Fortunately I realized the error immediately, it was only quasi IMC, with no close terrain. Oops -- now I double, triple check the approach is active and CDI indicator is correct on final.