On 20 August 2011, a First Air Boeing 737-200 making an ILS approach to Resolute Bay struck a hill east of the designated landing runway in IMC and was destroyed. An off-track approach was attributed to the aircraft commander s failure to recognise the effects of his inadvertent interference with the AP ILS capture mode and the subsequent loss of shared situational awareness on the flight deck. The approach was also continued when unstabilised and the Investigation concluded that the poor CRM and SOP compliance demonstrated on the accident flight were representative of a wider problem at the operator.
Description
On 20 August 2011, a Boeing 737-200C (C-GNWN) was being operated by First Air on a domestic passenger charter flight (FAB 6560) from Yellowknife, Northwest Territories, to Resolute Bay, Nunavut. Whilst in the final stages of a daylight Instrument Landing System (ILS) approach at destination in Instrument Meteorological Conditions (IMC), the aircraft struck a hill about 1 mile to the east of the landing runway and was destroyed by the effects of the impact and subsequent post-crash fire. The military TWR controller at the destination airport did not see the aircraft at any time and there was a significant delay before the wreckage was located. Twelve of the 15 occupants were killed and the remaining 3 sustained serious injuries.
Investigation
An Investigation was carried out by the Canadian TSB. The Flight Data Recorder (FDR) and 30 minute Cockpit Voice Recorder (CVR) were both recovered and, despite an intermittent fault with the former, relevant recordings from both were successfully downloaded. However, the FDR recorded only 24 parameters and these did not include position or time, so an available military radar recording (which had not been available to Resolute Bay ATC at the time of the accident) plus surveyed ground impact markings were used to re-create the aircraft track. The FDR data on altitude, indicated airspeed and heading was then used to create a flight path which was linearly interpolated to the track to create a smoothed and accurate replication of the flight path.
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