Narrative:
A Boeing 737-200 passenger plane was destroyed when it flew into terrain while on approach to Resolute Bay Airport, NU (YRB), Canada. There were 11 passengers and four crew members on board. Eight passengers and all four crew members were killed.
The airplane had departed Yellowknife Airport, NT (YZF) on a domestic charter flight to Resolute Bay. During the approach to Runway 35T, the aircraft impacted a hill at 396 feet above sea level (asl) and about 1 nautical mile east of the midpoint of the Resolute Bay Airport runway which, itself, is at 215 feet asl.
The crew had initiated a go-around 2 seconds before impact. At this time, the flaps were set to position 40, the landing gear was down and locked, the speed was 157 knots and the final landing checklist was complete.
In the hours before the accident, the weather in Resolute Bay was variable with fluctuations in visibility and cloud ceiling. Forty minutes before the accident, the visibility was 10 miles in light drizzle with an overcast ceiling at 700 feet above ground level (agl). A weather observation taken shortly after the accident, reported visibility of 5 miles in light drizzle and mist with an overcast ceiling of 300 feet agl.
TSB stated the following findings as to causes and contributing factors:
1. The late initiation and subsequent management of the descent resulted in the aircraft turning onto final approach 600 feet above the glideslope, increasing the crews workload and reducing their capacity to assess and resolve the navigational issues during the remainder of the approach.
2. When the heading reference from the compass systems was set during initial descent, there was an error of -8°. For undetermined reasons, further compass drift during the arrival and approach resulted in compass errors of at least -17° on final approach.
3. As the aircraft rolled out of the turn onto final approach to the right of the localizer, the captain likely made a control wheel roll input that caused the autopilot to revert from VOR/LOC capture to MAN and HDG HOLD mode. The mode change was not detected by the crew.
4. On rolling out of the turn, the captains horizontal situation indicator displayed a heading of 330°, providing a perceived initial intercept angle of 17° to the inbound localizer track of 347°. However, due to the compass error, the aircrafts true heading was 346°. With 3° of wind drift to the right, the aircraft diverged further right of the localizer.
5. The crews workload increased as they attempted to understand and resolve the ambiguity of the track divergence, which was incongruent with the perceived intercept angle and expected results.
6. Undetected by the pilots, the flight directors likely reverted to AUTO APP intercept mode as the aircraft passed through 2.5° right of the localizer, providing roll guidance to the selected heading (wings-level command) rather than to the localizer (left-turn command).
7. A divergence in mental models degraded the crews ability to resolve the navigational issues. The wings-level command on the flight director likely assured the captain that the intercept angle was sufficient to return the aircraft to the selected course; however, the first officer likely put more weight on the positional information of the track bar and GPS.
8. The crews attention was devoted to solving the navigational problem, which delayed the configuration of the aircraft for landing. This problem solving was an additional task, not normally associated with this critical phase of flight, which escalated the workload.
9. The first officer indicated to the captain that they had full localizer deflection. In the absence of standard phraseology applicable to his current situation, he had to improvise the go-around suggestion. Although full deflection is an undesired aircraft state requiring a go-around, the captain continued the approach.
10. The crew did not maintain a shared situational awareness. As the approach continued, the pilots did not effectively communicate their respective perception, understanding, and future projection of the aircraft state.
11. Although the company had a policy that required an immediate go-around in the event that an approach was unstable below 1000 feet above field elevation, no go-around was initiated. This policy had not been operationalized with any procedural guidance in the standard operating procedures.
12. The captain did not interpret the first officers statement of "3 mile and not configged" as guidance to initiate a go-around. The captain continued the approach and called for additional steps to configure the aircraft.
13. The first officer was task-saturated, and he thus had less time and cognitive capacity to develop and execute a communication strategy that would result in the captain changing his course of action.
14. Due to attentional narrowing and task saturation, the captain likely did not have a high-level overview of the situation. This lack of overview compromised his ability to identify and manage risk.
15. The crew initiated a go-around after the ground proximity warning system "sink rate" alert occurred, but there was insufficient altitude and time to execute the manoeuvre and avoid collision with terrain.
16. The first officer made many attempts to communicate his concerns and suggest a go-around. Outside of the two-communication rule, there was no guidance provided to address a situation in which the pilot flying is responsive but is not changing an unsafe course of action. In the absence of clear policies or procedures allowing a first officer to escalate from an advisory role to taking control, this first officer likely felt inhibited from doing so.
17. The crews crew resource management was ineffective. First Airs initial and recurrent crew resource management training did not provide the crew with sufficient practical strategies to assist with decision making and problem solving, communication, and workload management.
18. Standard operating procedure adaptations on FAB6560 resulted in ineffective crew communication, escalated workload leading to task saturation, and breakdown in shared situational awareness. First Airs supervisory activities did not detect the standard operating procedure adaptations within the Yellowknife B737 crew base.
» First Air media release
» CADORS 2011C3091
» SKYbrary
accident date: 20-08-2011
type: Boeing 737-210C
registration: C-GNWN
accident date: 20-08-2011
type: Boeing 737-210C
registration: C-GNWN
accident date: 20-08-2011
type: Boeing 737-210C
registration: C-GNWN
accident date: 20-08-2011
type: Boeing 737-210C
registration: C-GNWN
accident date: 20-08-2011
type: Boeing 737-210C
registration: C-GNWN
accident date: 20-08-2011
type: Boeing 737-210C
registration: C-GNWN
| Status: | Accident investigation report completed and information captured |
| Date: | Saturday 20 August 2011 |
| Time: | 11:42 |
| Type: |  Boeing 737-210C |
| Operator: | First Air |
| Registration: | C-GNWN |
| MSN: | 21067/414 |
| First flight: | 1975-05-08 (36 years 4 months) |
| Engines: | 2 Pratt & Whitney JT8D-17 |
| Crew: | Fatalities: 4 / Occupants: 4 |
| Passengers: | Fatalities: 8 / Occupants: 11 |
| Total: | Fatalities: 12 / Occupants: 15 |
| Aircraft damage: | Destroyed |
| Aircraft fate: | Written off (damaged beyond repair) |
| Location: | 1,8 km (1.1 mls) E of Resolute Airport, NU (YRB) ( Canada)
|
| Crash site elevation: | 121 m (397 feet) amsl |
| Phase: | Approach (APR) |
| Nature: | Domestic Non Scheduled Passenger |
| Departure airport: | Yellowknife Airport, NT (YZF/CYZF), Canada |
| Resolute Airport, NU (YRB/CYRB), Canada | |
| Flightnumber: | 6560 |
A Boeing 737-200 passenger plane was destroyed when it flew into terrain while on approach to Resolute Bay Airport, NU (YRB), Canada. There were 11 passengers and four crew members on board. Eight passengers and all four crew members were killed.
The airplane had departed Yellowknife Airport, NT (YZF) on a domestic charter flight to Resolute Bay. During the approach to Runway 35T, the aircraft impacted a hill at 396 feet above sea level (asl) and about 1 nautical mile east of the midpoint of the Resolute Bay Airport runway which, itself, is at 215 feet asl.
The crew had initiated a go-around 2 seconds before impact. At this time, the flaps were set to position 40, the landing gear was down and locked, the speed was 157 knots and the final landing checklist was complete.
In the hours before the accident, the weather in Resolute Bay was variable with fluctuations in visibility and cloud ceiling. Forty minutes before the accident, the visibility was 10 miles in light drizzle with an overcast ceiling at 700 feet above ground level (agl). A weather observation taken shortly after the accident, reported visibility of 5 miles in light drizzle and mist with an overcast ceiling of 300 feet agl.
Probable Cause:
TSB stated the following findings as to causes and contributing factors:
1. The late initiation and subsequent management of the descent resulted in the aircraft turning onto final approach 600 feet above the glideslope, increasing the crews workload and reducing their capacity to assess and resolve the navigational issues during the remainder of the approach.
2. When the heading reference from the compass systems was set during initial descent, there was an error of -8°. For undetermined reasons, further compass drift during the arrival and approach resulted in compass errors of at least -17° on final approach.
3. As the aircraft rolled out of the turn onto final approach to the right of the localizer, the captain likely made a control wheel roll input that caused the autopilot to revert from VOR/LOC capture to MAN and HDG HOLD mode. The mode change was not detected by the crew.
4. On rolling out of the turn, the captains horizontal situation indicator displayed a heading of 330°, providing a perceived initial intercept angle of 17° to the inbound localizer track of 347°. However, due to the compass error, the aircrafts true heading was 346°. With 3° of wind drift to the right, the aircraft diverged further right of the localizer.
5. The crews workload increased as they attempted to understand and resolve the ambiguity of the track divergence, which was incongruent with the perceived intercept angle and expected results.
6. Undetected by the pilots, the flight directors likely reverted to AUTO APP intercept mode as the aircraft passed through 2.5° right of the localizer, providing roll guidance to the selected heading (wings-level command) rather than to the localizer (left-turn command).
7. A divergence in mental models degraded the crews ability to resolve the navigational issues. The wings-level command on the flight director likely assured the captain that the intercept angle was sufficient to return the aircraft to the selected course; however, the first officer likely put more weight on the positional information of the track bar and GPS.
8. The crews attention was devoted to solving the navigational problem, which delayed the configuration of the aircraft for landing. This problem solving was an additional task, not normally associated with this critical phase of flight, which escalated the workload.
9. The first officer indicated to the captain that they had full localizer deflection. In the absence of standard phraseology applicable to his current situation, he had to improvise the go-around suggestion. Although full deflection is an undesired aircraft state requiring a go-around, the captain continued the approach.
10. The crew did not maintain a shared situational awareness. As the approach continued, the pilots did not effectively communicate their respective perception, understanding, and future projection of the aircraft state.
11. Although the company had a policy that required an immediate go-around in the event that an approach was unstable below 1000 feet above field elevation, no go-around was initiated. This policy had not been operationalized with any procedural guidance in the standard operating procedures.
12. The captain did not interpret the first officers statement of "3 mile and not configged" as guidance to initiate a go-around. The captain continued the approach and called for additional steps to configure the aircraft.
13. The first officer was task-saturated, and he thus had less time and cognitive capacity to develop and execute a communication strategy that would result in the captain changing his course of action.
14. Due to attentional narrowing and task saturation, the captain likely did not have a high-level overview of the situation. This lack of overview compromised his ability to identify and manage risk.
15. The crew initiated a go-around after the ground proximity warning system "sink rate" alert occurred, but there was insufficient altitude and time to execute the manoeuvre and avoid collision with terrain.
16. The first officer made many attempts to communicate his concerns and suggest a go-around. Outside of the two-communication rule, there was no guidance provided to address a situation in which the pilot flying is responsive but is not changing an unsafe course of action. In the absence of clear policies or procedures allowing a first officer to escalate from an advisory role to taking control, this first officer likely felt inhibited from doing so.
17. The crews crew resource management was ineffective. First Airs initial and recurrent crew resource management training did not provide the crew with sufficient practical strategies to assist with decision making and problem solving, communication, and workload management.
18. Standard operating procedure adaptations on FAB6560 resulted in ineffective crew communication, escalated workload leading to task saturation, and breakdown in shared situational awareness. First Airs supervisory activities did not detect the standard operating procedure adaptations within the Yellowknife B737 crew base.
Accident investigation:
 |
|
Classification:
Controlled Flight Into Terrain (CFIT) - Mountain
Sources:
» TSB Media release» First Air media release
» CADORS 2011C3091
» SKYbrary
Follow-up / safety actions
TSB issued 1 Safety Recommendation
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Photos
accident date: 20-08-2011
type: Boeing 737-210C
registration: C-GNWN
accident date: 20-08-2011
type: Boeing 737-210C
registration: C-GNWN
accident date: 20-08-2011
type: Boeing 737-210C
registration: C-GNWN
accident date: 20-08-2011
type: Boeing 737-210C
registration: C-GNWN
accident date: 20-08-2011
type: Boeing 737-210C
registration: C-GNWN
accident date: 20-08-2011
type: Boeing 737-210C
registration: C-GNWN
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Yellowknife Airport, NT to Resolute Airport, NU as the crow flies is 1546 km (966 miles).
Accident location: Approximate; accuracy within a few kilometers.
Distance from Yellowknife Airport, NT to Resolute Airport, NU as the crow flies is 1546 km (966 miles).
Accident location: Approximate; accuracy within a few kilometers.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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Boeing 737-200
- 1114 built
- 122nd loss
- 58th fatal accident
- 40th worst accident (at the time)
- 42nd worst accident (currently)
Canada- 29th worst accident
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