First Air ignored advice on crucial alarm system prior to Resolute crash

by Jack Danylchuk

EDGE online

June 28, 2012

An alarm system that might have prevented the First Air crash at Resolute Bay last August 20 was not installed, despite an opportunity and recommendation from senior company employees.

The incident that Transportation Safety Board (TSB) inspectors have classed as a Controlled Flight into Terrain (CFIT) took the lives of all four crew members and all but three of the 11 passengers on the charter flight from Yellowknife.

According to sources, the Boeing 737-210 C used on flight 6560 to Resolute Bay was the only plane in First Air’s fleet of Boeing 737s not equipped with a Terrain Avoidance Warning System (TAWS).

Before the plane’s last “heavy check” – a scheduled maintenance procedure in which the plane was thoroughly examined for defects – it was recommended TAWS be installed, but it was not, the sources said.

TAWS emits a warning when an aircraft flies too close to the ground and is credited by experts with reducing the incidence of CFIT – one of the major causes of airline fatalities. Last December, the federal government proposed a new regulation that would require all aircraft carrying six or more passengers to be equipped with TAWS.

CFIT occurs when an airworthy aircraft, under the control of the flight crew, is flown unintentionally into terrain, obstacles or water, usually with no prior awareness by the crew.

Jennifer Alldred, a spokesperson for First Air, said in an email the company would not discuss the TAWS question while the TSB continues its investigation.

A lawyer for Scott Bateman, who resigned as president of First Air last December, told Nunatsiaq News the departure from the company Bateman led for four years had nothing to do with the fatal crash, but did not reply to an emailed question about the failure to install TAWS in all First Air planes.

Flight’s final minutes

When drawn on paper, using information compiled by EDGE, the final minutes of First Air flight 6560 present a baffling picture.

The weather was sketchy last August 20 as the flight crew approached Resolute Bay, and switched from GPS, which had managed the flight from Yellowknife, to the instrument landing system that could take the plane to within 200 feet of the ground.

But instead of turning toward Resolute Bay, flight 6560 flew past a GPS waypoint 10 miles out from the runway and only then banked toward its final destination.

Cockpit instruments would have indicated to the crew they were off course after the plane passed the 10-mile marker, yet almost four minutes elapsed before the jet crashed into a hillside a mile east of the runway.

preliminary report released by TSB inspectors in January said the landing gear was down and locked and the final checklist complete when the crew tried to abort the landing two seconds before impact.

A technical examination of the aircraft revealed no problems and analysis of the flight data recorder indicated the engines were operating and developing considerable power at the time of the accident, the inspectors said.

There was no evidence on the cockpit voice recorder of any disagreement between Capt. Blair Rutherford and First Officer David Hare, either. Together, they flew flight 6560 into the ground at almost 200 miles per hour.

CFIT is considered a form of spatial disorientation, where the pilot(s) do not correctly perceive their position and orientation with respect to the Earth’s surface. Pilot error is the single biggest factor in CFIT incidents, according to an extensive Wikipedia entry on the subject. Among the typical scenarios described in the entry:

“The pilot encountered weather conditions that were worse than forecast and, in an attempt to maintain or regain visual contact with the ground in an area of very low cloud, descended below minimum safe altitude and the aircraft struck the ground.

“Contributing to this accident was the pilot’s over-reliance on GPS while attempting to maintain Visual Meteorological Conditions and a resultant lack of adequate situational awareness of terrain.”

Aircraft manufacturer Boeing counts CFIT as a leading cause of airplane accidents involving the loss of life.

Some pilots, convinced advanced electronic navigation systems coupled with flight management system computers, or over-reliance on them, are partially responsible for these accidents, have called CFIT accidents “computerized flight into terrain.”

To prevent CFIT crashes, manufacturers and safety regulators developed TAWS, which has mandatory pilot procedures and actions following any caution or warning event.

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