First Air Crash Resolute Bay August 20 2011

[Gino Under]

I'm finally reading the report.
Interesting read...

Having flown the 200, I'd say a significant contribution to this accident in my opinion would have likely been the sh*t AP FD and the antiquated GPWS. It sounds to me like each had a role to play. This particular model should have been removed from service. Especially running around the north. I wonder how much terrain data was missing from the terrain database when no "CAUTION. TERRAIN" was generated approaching the sloping terrain?
And the GPS unit they were using...
Really?? In this day and age.
How embarrassing (not to mention cheap).

Any -200 crew care to comment?

Gino Under

[ditar]

My understanding is that an old school GPWS doesn't have a terrain database at all. It relies on the radar altimeter looking straight down, and merely calculates trends as to terrain closure rate. If there is a significant terrain change ahead, GPWS may not detect the closure rate until it is too late. That's why EGPWS was born.

Even though the -200 cockpit is antiquated, the ones I fly have dual FMS, TAWS, moving map MFD with terrain display, etc.

[Gino Under]

ditar

Sounds like your 200s are just what's needed in the north. I wonder why other operators haven't moved in the same direction? Maybe safety does have a price tag.

Yes. EGPWS has the enhancements, including "CAUTION TERRAIN" mode 2B. Which this machine didn't. Apparently, it was due for an upgrade on it's next C check.

My sarcasm was lost in the way I wrote that, I guess. The point being in today's day and age running around the Arctic is challenging enough without these additional handicaps. Kinda like flying DC-3s up there. Some things are just stupid in the jet age.

As soon as I read about the attempted localizer capture and the confusion that followed, it reminded of that antiquated AP/FD. We can debate CRM and taking over control all we want but the ball was tossed into play when that useless AP/FD created some unnecessary confusion at the most inopportune time which needed some resolution by a pilot who sounds to me like he was slightly behind the whole approach.

Anyone willing to say they've never been there, done that?

Gino Under

[FICU]

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

Canadian North 737-200s have had full graphic TAWS on separate MFDs with moving maps for many, many years. We also have EGPWS, and a FMS with psuedo glide-slipe capability. We also have WAAS capability for LPV approaches.

TAWS would have definitely saved that jet, crew, and pax.

These are old machines but they can be equipped with new technology if so desired.

[FICU]

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

We use grid Nav for NDA operations which is very effective. I was in Resolute a few weeks ago in a 737-200 and after pre-setting in CYFB our compasses were perfectly aligned in CYRB.

[Trematode]

With regards to more modern equipment offering increased situational awareness, you guys all have valid points... But none of that changes the fact that it is still legal, and more importantly, perfectly safe to fly up there with older equipment. It was an ILS for crying out loud. I maintain that what caused this was a problem with basic adherence to IFR with regards to safe altitudes. You simply don't descend on an ILS unless you are established on the LOC.

I am still having trouble understanding how the PF could have allowed continued descent, and then not responded to repeated prompting by the other crew member. With all of the lip service the report does to CRM, problems with automation, and instrument error, it still does not satisfactorily explain this fundamental and egregious error, in my opinion. I wish there was a way of knowing exactly what the guy in the left seat was seeing that day. My gut tells me there has to be some better explanation than what the report offered.

Throw a bunch of TAWS, moving maps, and automation systems at the problem, and you might salvage a bad situation, but at the end of the day you've still got a pilot that was perfectly happy to do the one thing you're not supposed to do in IMC: Go below minimums.

[1&2SpooledUp]

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

Canadian North 737-200s have had full graphic TAWS on separate MFDs with moving maps for many, many years. We also have EGPWS, and a FMS with psuedo glide-slipe capability. We also have WAAS capability for LPV approaches.

TAWS would have definitely saved that jet, crew, and pax.

These are old machines but they can be equipped with new technology if so desired.

Sounds like CN have their S?&t together and have given their pilots the necessary tools to operate safely in the north. It all comes back to the bean counters and what they are willing to spend on safety. I bet they are kicking themselves at 7F right now cause this is gonna cost a lot more than an avionics upgrade!!

As someone else mentioned, this was not a complicated approach. It was your everyday run of the mill ILS. This accident could have happened anywhere in the world. Any crew can get blown off the loc due to a combination of winds, excess speed and poor intercept angle. You either re intercept before descending on the slope or you go missed, Plain and simple. The captain defiantly met the criteria outlined in SOP's for pilot incapacitation. Maybe he had a stoke or something.

If the TSB is really that concerned about the effect CRM had on contributing to this accident, then they should release the CVR recordings so they can be used in company CRM courses.

[complexintentions]

I do get the sense there are an awful lot of FO's posting on this thread. Let it out, let it all out...all that repressed rage against the captains!

[CFR]

... If the TSB is really that concerned about the effect CRM had on contributing to this accident, then they should release the CVR recordings so they can be used in company CRM courses.

I guess it needs to be said again. The TSB cannot release the transcript, they do not have the authority to do so. And if they started to do so there would be a huge backlash. Back when planes were wood and men were steel, pilots and pilot associations carried some weight. When it was first proposed that CVR's be installed in aircraft there was significant resistance as Pilots did not feel there should be someone looking over their shoulder recording and listening to their conversations, both those related to the flight and less important personal items. The only way it was agreed to let ICAO mandate it, was if the information was privileged and only used to support accident investigations.

There are some limited circumstances where it can be released. Here is the section of the regs that apply to privilege.

PRIVILEGE

Marginal note:Definition of “on-board recording”

28. (1) In this section, “on-board recording” means the whole or any part of
(a) a recording of voice communications originating from, or received on or in,
(i) the flight deck of an aircraft,
(ii) the bridge or a control room of a ship,
(iii) the cab of a locomotive, or
(iv) the control room or pumping station of a pipeline, or
(b) a video recording of the activities of the operating personnel of an aircraft, ship, locomotive or pipeline
that is made, using recording equipment that is intended to not be controlled by the operating personnel, on the flight deck of the aircraft, on the bridge or in a control room of the ship, in the cab of the locomotive or in a place where pipeline operations are carried out, as the case may be, and includes a transcript or substantial summary of such a recording.
Marginal note:Privilege for on-board recordings

(2) Every on-board recording is privileged and, except as provided by this section, no person, including any person to whom access is provided under this section, shall
(a) knowingly communicate an on-board recording or permit it to be communicated to any person; or
(b) be required to produce an on-board recording or give evidence relating to it in any legal, disciplinary or other proceedings.
Marginal note:Access by Board

(3) Any on-board recording that relates to a transportation occurrence being investigated under this Act shall be released to an investigator who requests it for the purposes of the investigation.
Marginal note:Use by Board

(4) The Board may make such use of any on-board recording obtained under this Act as it considers necessary in the interests of transportation safety, but, subject to subsection (5), shall not knowingly communicate or permit to be communicated to anyone any portion thereof that is unrelated to the causes or contributing factors of the transportation occurrence under investigation or to the identification of safety deficiencies.
Marginal note:Access by peace officers, coroners and other investigators

(5) The Board shall make available any on-board recording obtained under this Act to
(a) [Repealed, 1998, c. 20, s. 17]
(b) a coroner who requests access thereto for the purpose of an investigation that the coroner is conducting; or
(c) any person carrying out a coordinated investigation under section 18.

(6) Notwithstanding anything in this section, where, in any proceedings before a court or coroner, a request for the production and discovery of an on-board recording is made, the court or coroner shall
(a) cause notice of the request to be given to the Board, if the Board is not a party to the proceedings;
(b) in camera, examine the on-board recording and give the Board a reasonable opportunity to make representations with respect thereto; and
(c) if the court or coroner concludes in the circumstances of the case that the public interest in the proper administration of justice outweighs in importance the privilege attached to the on-board recording by virtue of this section, order the production and discovery of the on-board recording, subject to such restrictions or conditions as the court or coroner deems appropriate, and may require any person to give evidence that relates to the on-board recording.
Marginal note:Use prohibited

(7) An on-board recording may not be used against any of the following persons in disciplinary proceedings, proceedings relating to the capacity or competence of an officer or employee to perform the officer’s or employee’s functions, or in legal or other proceedings, namely, air or rail traffic controllers, marine traffic regulators, aircraft, train or ship crew members (including, in the case of ships, masters, officers, pilots and ice advisers), airport vehicle operators, flight service station specialists, persons who relay messages respecting air or rail traffic control, marine traffic regulation or related matters and persons who are directly or indirectly involved in the operation of a pipeline.
Marginal note:Definition of “court”

(8) For the purposes of subsection (6), “court” includes a person or persons appointed or designated to conduct a public inquiry into a transportation occurrence pursuant to this Act or the Inquiries Act.

[URC]

I guess it needs to be said again. The TSB cannot release the transcript, they do not have the authority to do so.

I think the point is that this needs to be changed. See the NTSB on how it should be done.

http://dms.ntsb.gov/pubdms/search/hitli ... XTSEARCHT=

[Liquid Charlie]

If the TSB is really that concerned about the effect CRM had on contributing to this accident, then they should release the CVR recordings so they can be used in company CRM courses.

Really -- what good would that do -- I'm sure that would be very constructive to hear someone live the last few minutes of their life knowing it was coming to an abrupt halt.

There is enough information available through accident reports along with graphic simulations to create a good CRM topic for training -- there is no way CVR recordings should be made available for anyone except the accident investigators.

[CYAMmy]

WTF...CADOR 2014C1147 : A First Air Boeing 737-200 (FAB955) from Rankin Inlet, NU (CYRT) to Iqaluit, NU (CYFB) was observed on radar 165 miles north of the flight's planned route. No impact to operations.
Can't even navigate enroute let alone on an approach.

[trey kule]

Plus 1...

...and also for a whole bunch of additional reasons

[john_seymour]

If the TSB is really that concerned about the effect CRM had on contributing to this accident, then they should release the CVR recordings so they can be used in company CRM courses.

Really -- what good would that do -- I'm sure that would be very constructive to hear someone live the last few minutes of their life knowing it was coming to an abrupt halt.

There is enough information available through accident reports along with graphic simulations to create a good CRM topic for training -- there is no way CVR recordings should be made available for anyone except the accident investigators.

Yes, they should be made available. I have found CVR transcripts to be very informative throughout my career.

The military also has cameras on some of their types, and the same should be installed in civilian fleets. Pilots will present the same, tired arguments against both items, but really, what are you trying to hide? Your game of Angry Birds, or the movie you were watching on the iPad. Don't claim it doesn't happen, because we all know that it does.

There is no good reason to keep the transcripts secret.

[Diadem]

Yes, they should be made available. I have found CVR transcripts to be very informative throughout my career.

The military also has cameras on some of their types, and the same should be installed in civilian fleets. Pilots will present the same, tired arguments against both items, but really, what are you trying to hide? Your game of Angry Birds, or the movie you were watching on the iPad. Don't claim it doesn't happen, because we all know that it does.

There is no good reason to keep the transcripts secret.

How about personal problems that they don't want aired to the world? If I were discussing marital issues or my secret second family, I wouldn't want that being published for everyone to read. Would you really want your spouse's last memory of you to be that you were questioning your relationship? I have a reasonable expectation that when I talk about something private with my co-pilot, it won't be made public knowledge because some guy on the internet feels the need to pry into every word I spoke before I died.

[john_seymour]

How about personal problems that they don't want aired to the world? If I were discussing marital issues or my secret second family, I wouldn't want that being published for everyone to read. Would you really want your spouse's last memory of you to be that you were questioning your relationship? I have a reasonable expectation that when I talk about something private with my co-pilot, it won't be made public knowledge because some guy on the internet feels the need to pry into every word I spoke before I died.

Go scour the NTSB's web site and find me one instance of personal problems being published in a CVR transcript. You won't be able to, because it doesn't happen. The transcripts can be edited to omit non-flying-related conversation. And they typically only publish the portion from the onset of the emergency. Hopefully nobody's dicussing family problems at that point. Or maybe that's what led to the crash...?

[jump154]

Go scour the NTSB's web site and find me one instance of personal problems being published in a CVR transcript. You won't be able to, because it doesn't happen. The transcripts can be edited to omit non-flying-related conversation. And they typically only publish the portion from the onset of the emergency. Hopefully nobody's dicussing family problems at that point. Or maybe that's what led to the crash...?

And is this not exactly what was done here?

In this report, the TSB has made extensive use of the CVR recording. In each instance, the material has been carefully examined to ensure that the extracts used are related to the causes or contributing factors of this accident or to the identification of safety deficiencies.

How I read the requests from here was for release of the recordings so the general public can make their own analysis of the conversation (inflection, anger, etc..) - which would inevitably include all information, not just that pertinent to the investigation.

We know the TSB listened to everything. At some point we have to trust that those tasked with the report correctly distilled the pertinent details, and the rest was irrelevant.

[Diadem]

How about personal problems that they don't want aired to the world? If I were discussing marital issues or my secret second family, I wouldn't want that being published for everyone to read. Would you really want your spouse's last memory of you to be that you were questioning your relationship? I have a reasonable expectation that when I talk about something private with my co-pilot, it won't be made public knowledge because some guy on the internet feels the need to pry into every word I spoke before I died.

Go scour the NTSB's web site and find me one instance of personal problems being published in a CVR transcript. You won't be able to, because it doesn't happen. The transcripts can be edited to omit non-flying-related conversation. And they typically only publish the portion from the onset of the emergency. Hopefully nobody's dicussing family problems at that point. Or maybe that's what led to the crash...?

Really? You don't think I can find a single example? How about this one from the Colgan crash: http://www.planecrashinfo.com/cvr090212.htm It has every second of the flight on it, including personal discussions. If that's not enough, you can scroll through any of these: http://www.planecrashinfo.com/lastwords.htm
If the TSB published CVR transcripts with portions cut out, no doubt the conspiracy theorists would be decrying that something important was cut out of the recording and that there are sinister forces at work.

[Illya Kuryakin]

John Seemore, I find it very distressful that a pilot (if, indeed you are one?) would come out for what basically constitutes "spying" on a fellow pilot's last half hour of life. It's macabre, to say the least. There are other issues to whine about in regards to the TSB. Like the two to three years it takes to come up with report in the first place? Your priorities are out in left field.
Illya

[GRK]

John_Seymour…how relevant is the background chatter on a CVR to you or the general public? My answer is that none of it is…quite simply because it's none of anyone's GD business. The investigation team releases what is required and the public gets nothing more. Would you like to have your last few hours or minutes released to FOX News or CNN (see the junk out there about MH370) or the glad rags that pass for newspapers? Not me buddy…I think the way it's handled right now in Canada shows class and distinction. Period.

[Kid]

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.

Just for the record, 20 years at jazz will get you 3 digit seniority at best.

[Whiskey25]

The military also has cameras on some of their types

Aside from HUD cameras, to which aircraft types are you referring?

[bobcaygeon]

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.

Just for the record, 20 years at jazz will get you 3 digit seniority at best.

Pssttt.... He could have been a Twin Otter Captain 25 years ago and had a Jazz(now) seniority number too!! Pretty Yellow Twin Otters.

The original #1 pilot at Jazz (now retired) started on the Cessna 180 and actually joined the company as a wireless operator.

[pelmet]

John_Seymour…how relevant is the background chatter on a CVR to you or the general public? My answer is that none of it is…quite simply because it's none of anyone's GD business. The investigation team releases what is required and the public gets nothing more. Would you like to have your last few hours or minutes released to FOX News or CNN (see the junk out there about MH370) or the glad rags that pass for newspapers? Not me buddy…I think the way it's handled right now in Canada shows class and distinction. Period.

I have read a lot of accident reports and I have found CVR transcripts to be extremely helpful in adding to understanding the accident causes. Frequently, it allows one to come to conclusions about certain factors that the report did not mention. Normally for the NTSB at least, there will be sections edited out which state non-pertinent conversation for two minutes or something similar.

For the Colgan CVR transcript, the NTSB decided to publish it all because they felt that this non-pertinent conversation was part of a basic cause leading up to the accident.

[Illya Kuryakin]

John_Seymour…how relevant is the background chatter on a CVR to you or the general public? My answer is that none of it is…quite simply because it's none of anyone's GD business. The investigation team releases what is required and the public gets nothing more. Would you like to have your last few hours or minutes released to FOX News or CNN (see the junk out there about MH370) or the glad rags that pass for newspapers? Not me buddy…I think the way it's handled right now in Canada shows class and distinction. Period.

I have read a lot of accident reports and I have found CVR transcripts to be extremely helpful in adding to understanding the accident causes. Frequently, it allows one to come to conclusions about certain factors that the report did not mention. Normally for the NTSB at least, there will be sections edited out which state non-pertinent conversation for two minutes or something similar.

For the Colgan CVR transcript, the NTSB decided to publish it all because they felt that this non-pertinent conversation was part of a basic cause leading up to the accident.

For sure...use it as a tool to solve accidents. Releasing it to the ignorant, drooling, uninformed public, however, serves NO purpose whatsoever. If you think, the crew's opinions about the Toronto Maple Loafs, missing the playoffs YET AGAIN are relevant to the cause of an accident, you are saddly in dreamland.
Illya