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First Air 737 crash - Canada

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  • #31
    Originally posted by Gabriel View Post
    But if you think that your wrongly selected course is the right one, you can think that you are flying an intercepting heading towards the ILS when, in fact you are still flying away from it.
    That's exactly what I meant probably could have expressed myself a little better.
    AD.com apocalypse survivor. 727 Fan.

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    • #32
      Originally posted by Gabriel View Post
      That is a very human mistake, understandable and expectable mistake. And was a causal link in the chain of events that led to this accident, meaning that if the pilots would have not made this mistake, the accident would have not happened.
      I still don't follow. The report states that an initial heading reference error of -8° was entered and this developed for unexplained reasons to a -17° error. It also states that during the turn to final the PF inadvertently exerted force on the yoke causing the AP to revert from LOC capture mode to MAN/HDG HOLD and this was not detected by the crew. Therefore the FD was giving guidance to wings level rather than to the LOC. The Capt (PF) was probably subjected to confirmation bias as he remained convinced that he was following the LOC. I don't see the error you are speaking of in the report but perhaps I am not understanding it correctly.

      Anyway, the ultimately fatal issue was a failure to abandon an obviously unstable approach and a culture that failed to address the cockpit gradient as the F/O would certainly have abandoned the approach earlier on.

      Comment


      • #33
        Evan pretty much has it.

        The Captain thought the aircraft had captured the Localiser, had gone through it, but had turned back through the ILS heading to re-intercept automatically. It had not, and had gone to a 'heading hold' type of mode commanding wings level.

        However, the heading the instruments showed that the aircraft was flying was a suitable one to re-intercept, except the 17 degree error in the instrument meant that the aircraft was merely paralleling the loc, not moving back towards it as he expected.

        His brain and basic instruments were telling him that he had gone through the localizer but was on a track to re-intercept it. The Localizer indicator was not getting any closer, and failed to notice the flight mode was not the one he would have expected it to be. The GPS indicator also showed they were not tracking correctly.

        None of that forgives the fact they descended while outside tolerances, didn't go around when they remained outside the limits, etc etc etc.

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        • #34
          Originally posted by MCM View Post
          Evan pretty much has it.

          The Captain thought the aircraft had captured the Localiser, had gone through it, but had turned back through the ILS heading to re-intercept automatically. It had not, and had gone to a 'heading hold' type of mode commanding wings level.

          However, the heading the instruments showed that the aircraft was flying was a suitable one to re-intercept, except the 17 degree error in the instrument meant that the aircraft was merely paralleling the loc, not moving back towards it as he expected.

          His brain and basic instruments were telling him that he had gone through the localizer but was on a track to re-intercept it. The Localizer indicator was not getting any closer, and failed to notice the flight mode was not the one he would have expected it to be. The GPS indicator also showed they were not tracking correctly.

          None of that forgives the fact they descended while outside tolerances, didn't go around when they remained outside the limits, etc etc etc.
          Would both left and right heading indicators fail together? Are they slaved to the same magnetic field sensor?

          I guess that the magnetic compass would be displaying the correct heading, but I admit that looking to the old whiskey compass is not something that would occur to a pilot naturally, especially no to one flying slaved heading indicators. (small planes with round instruments are typically fitted with gyro compass, which must be manually set to match the heading in the whisky compass before take off, and reset every about 15 minutes due to gyro drift, so small planes pilots are more used to look at the magnetic compass from time to time).

          --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
          --- Defend what you say with arguments, not by imposing your credentials ---

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          • #35
            Originally posted by Gabriel View Post
            Would both left and right heading indicators fail together? Are they slaved to the same magnetic field sensor?

            I guess that the magnetic compass would be displaying the correct heading, but I admit that looking to the old whiskey compass is not something that would occur to a pilot naturally, especially no to one flying slaved heading indicators. (small planes with round instruments are typically fitted with gyro compass, which must be manually set to match the heading in the whisky compass before take off, and reset every about 15 minutes due to gyro drift, so small planes pilots are more used to look at the magnetic compass from time to time).
            Interesting thought on the wet compass...I'm thinking that's something you sort of avoid on an ILS due to all of it's acceleration errors at a time when you need awfully precise heading control. Of course a quick check somewhere along the line never hurts, as does the rule to go around if the ILS needles get fully deflected.
            Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

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            • #36
              The approach being conducted was in an area where True headings (not magnetic) were being used - a long way north. Magnetic tracks are next to useless. The crew turn off magnetic slaving of the DG's for that reason, and the magnetic compass would be considered practically useless. Flight is done according to True tracks/headings.

              On the way in, the crew intentionally switch off the DG slaving and turn on a latitude compensator to minimise precession. Interestingly from the report:

              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.
              The crew were facing conflicting information, and the Captain clearly lost situational awareness. The F/O managed to keep is awareness and knew that the aircraft was not where it was supposed to be, but for reasons best explained by the report, didn't act with sufficient force to get the Captain to fully understand the situation.

              Comment


              • #37

                The accident investigators seem to have made a lot of assumptions on their road to blaming everything on the crew:


                For undetermined reasons.... ...the captain likely made... Undetected by the pilots... The wings-level command on the flight director likely assured the captain that... ...the first officer likely put more weight... Due to attentional narrowing and task saturation, the captain likely did not have.... It is likely that both pilots switched from GPS to VHF NAV...
                ...it was earlier concluded that the maximum heading difference between the compass systems during flight likely did not exceed 8° with wings level...

                The TSB analysed that it was likely VOR/LOC approach mode had been selected prior to commencing the turn onto final. "Therefore, in this scenario, it is likely that the autopilot reverted from VOR/LOC mode to MAN mode.... It was unlikely however that this manual reversion occurred prior to.... "

                Therefore, it is likely that the no. 1 compass system was also drifting.... ....it is unlikely that the pilots would notice this sound." ....It is unlikely that the pilots would detect the absence of this light.... Therefore, it is likely that the crew did not detect the autopilot mode change."

                ....the captain likely made a control wheel roll input that caused the autopilot to revert... As before, it is likely that the captain did not fully comprehend....


                /

                Comment


                • #38
                  Originally posted by starviego View Post
                  The accident investigators seem to have made a lot of assumptions on their road to blaming everything on the crew:


                  For undetermined reasons.... ...the captain likely made... Undetected by the pilots... The wings-level command on the flight director likely assured the captain that... ...the first officer likely put more weight... Due to attentional narrowing and task saturation, the captain likely did not have.... It is likely that both pilots switched from GPS to VHF NAV...
                  ...it was earlier concluded that the maximum heading difference between the compass systems during flight likely did not exceed 8° with wings level...

                  The TSB analysed that it was likely VOR/LOC approach mode had been selected prior to commencing the turn onto final. "Therefore, in this scenario, it is likely that the autopilot reverted from VOR/LOC mode to MAN mode.... It was unlikely however that this manual reversion occurred prior to.... "

                  Therefore, it is likely that the no. 1 compass system was also drifting.... ....it is unlikely that the pilots would notice this sound." ....It is unlikely that the pilots would detect the absence of this light.... Therefore, it is likely that the crew did not detect the autopilot mode change."

                  ....the captain likely made a control wheel roll input that caused the autopilot to revert... As before, it is likely that the captain did not fully comprehend....


                  /
                  Very interesting , but it begs the question ; where would YOU put the blame ?

                  Comment


                  • #39
                    All of those things are 'likely' because they are unable to be proven. They are the events leading up to the accident - contributing factors.

                    However, none of those things actually fully matter when it comes to the 'blame game' (which I don't like).

                    At the end of the day, the TSB KNOW that the aircraft did not meet the stable criteria, and that the F/O made numerous comments to that fact but did not put sufficient emphasis on them to force the Captain to act. Similarly, the Captain did not hear (or take heed) of the F/O's comments.

                    The approach required a mandatory go around in accordance with the airline's procedures, and did not. That part is not a 'likely' - it is known - and is sufficient to place some 'blame' on the crew. We know that through the CVR and FDR data.

                    The actual reasons the aircraft got in that position can only be supposition - the FDR and CVR do not provide proof - however having read the report the assumptions that the TSB make are entirely reasonable and do not seek to blame the crew at all.

                    Its one of the better accident reports that I've ever read.

                    Comment


                    • #40
                      Originally posted by MCM View Post
                      The approach required a mandatory go around in accordance with the airline's procedures, and did not. That part is not a 'likely' - it is known - and is sufficient to place some 'blame' on the crew.
                      I generally understand why you don't like the blame game but please...

                      The crew, specifically the PIC, is entirely to blame for this crash. There can be no excuse for failing to abandon this approach. There can be no excuse for failing to heed the concerns of the F/O.

                      Blame has a productive purpose. This is about as good an example of that as I've ever seen.

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                      • #41
                        I don't agree with entirely, because there was confusing and conflicting information that likely lead to his overload. But yes, there is some blame there.

                        The F/O also wears responsibility for not acting forcefully when he needed to do so.

                        I don't mind some blame being apportioned. As long as that isn't the end of the corrective action as used to happen. We can all remember reading the 'insightful' comments where 'pilot error' was used as the end of the discussion - and I would hate to see a return to those days.

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                        • #42
                          Originally posted by TheKiecker View Post
                          Very interesting , but it begs the question ; where would YOU put the blame ?
                          The pilot had almost 13k flight hours and had been with First Air for 15 years. So it appears he had plenty of experience flying in the difficult conditions of the far north, probably including many landings at Resolute Bay in all types of weather.

                          And he did all this at an airport without any ATC:


                          The lawsuits say the Resolute Bay Airport is normally an “uncontrolled airspace,” meaning pilots land using instruments and don’t usually use air traffic control services. The pilots ensure other aircraft aren’t landing at the same time and plan their approach to the runway.

                          So the question needs to be asked, what was different on that day?

                          Well of course the Canadian military(aka DND) had set up a temporary tower and terminal controller which were nominally in charge though at the same time were apparently not monitoring the landing of the First Air flight.

                          Aviation Herald - News, Incidents and Accidents in Aviation

                          CBC News Posted: May 18, 2012 9:48 AM CT
                          It(the lawsuit) states DND had established a ground-based radar system, which was in operation at the time of the accident and was capable of providing air traffic control personnel with information on the location and speed of the aircraft.
                          It also states the air traffic control personnel were in communication with the crew and "were or ought to be providing pilots with detailed information pertaining to aircraft location."

                          Read the latest breaking news in Canada and the rest of the world. We bring all of today's top headlines and stories to your fingertips.

                          The (law)suits detail how the military made an agreement with Nav Canada, Canada’s civilian air traffic authority, to establish a temporary air traffic control tower and guide in all aircraft.

                          Though in some unexplained fashion this did not happen:

                          Aviation Herald - News, Incidents and Accidents in Aviation

                          "....the terminal controller was not providing control services and was not actively monitoring the radar displays. Consequently, the terminal controller was not aware of FAB6560’s proximity to terrain. Neither the tower nor the terminal controller had sufficient valid information available to cause them to issue a position advisory to FAB6560."

                          Clearly First Air thought the military had a hand in the crash:

                          The families of the First Air flight attendants and pilots have filed lawsuits against NAV Canada and the Attorney General of Canada over the fatal plane crash in Resolute, Nunavut, last August.

                          First Air is suing DND for negligence.

                          A commenter also noticed the lack of attention given to the actions or non-actions of the military:

                          Aviation Herald - News, Incidents and Accidents in Aviation

                          By Eric on Wednesday, Mar 26th 2014 01:53Z
                          Operation Nanook was a change in the Resolute Bay skies for pilots.
                          I am surprised that this different environment was not mentioned in other findings. A different control tower, changes to the routine.


                          So was this just some big accident compounded by confusion over the role of the temporary ATC presence? Or was something more pernicious involved? Did the military deliberately auger the aircraft into the ground to make their mock casualty exercise more 'interesting?' Certainly it wouldn't be the first time a 'drill' had suddenly gone 'live.'


                          /

                          Comment


                          • #43
                            Originally posted by MCM View Post
                            I don't agree with entirely, because there was confusing and conflicting information that likely lead to his overload. But yes, there is some blame there.
                            Isn't that when you abandon the approach? The F/O seemed to think so.

                            I don't mind some blame being apportioned. As long as that isn't the end of the corrective action as used to happen. We can all remember reading the 'insightful' comments where 'pilot error' was used as the end of the discussion - and I would hate to see a return to those days.
                            Absolutely. What I'm saying is first assess the blame, let all other pilots know that they will be accountable for what happens when you let your experience and instincts trump safe procedure. Then investigate and discuss why this continues to happen and what can be done to keep pilots on a very basic set of rules governing stable approach.

                            Comment


                            • #44
                              Originally posted by Evan View Post
                              What I'm saying is first assess the blame, let all other pilots know that they will be accountable for what happens when you let your experience and instincts trump safe procedure.
                              Accountable? Are you kidding? These two pilots are DEAD. That should be more motivating that accountability.

                              --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
                              --- Defend what you say with arguments, not by imposing your credentials ---

                              Comment


                              • #45
                                Originally posted by Gabriel View Post
                                Accountable? Are you kidding? These two pilots are DEAD. That should be more motivating that accountability.
                                If it was, we'd have less of these kind of accidents. The fear of death is strangely less of a deterrent than the fear of humiliation to the risk taking personality. Ask any pilot which is worse: dying in a plane crash as a victim of circumstances or dying in a plane crash involving massive loss of life that you will be squarely blamed for. I think the added gravity of that condemnation could be enough to overcome the bravado confidence thing and make adherence to safe procedure more appealing. That's my theory anyway.

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