OTTAWA
A flustered pilot, a faulty compass, bad weather, and unheeded warnings from the co-pilot were all contributing factors in the crash of First Air flight 6560, which caused the deaths of 12 people on Aug. 20, 2011.

Members of the Transportation Safety Board of Canada (TSB) investigation team survey the wreckage of First Air flight 6560, which crashed just outside the Resolute Bay airport on Aug. 20, 2011. - NNSL file photo

On March 25, the Transportation Safety Board of Canada (TSB) released its long-awaited report on what caused the charter flight from Yellowknife to crash into a hill roughly one kilometre east of the runway near Resolute, Nunavut.

The report names 18 factors that contributed to the accident, but lead investigator Brian MacDonald shied away from using the term "pilot error" or pointing to any single issue that caused the Boeing 737 jet aircraft to descend off course.

"It's very difficult to pull out any factor as 'the factor.' So, it's important not to over-simplify, because this was a very complex series of events - one of the most complex I've had to investigate over almost 18 years," he said in an interview with Nunavut News/North.

Four crew members and eight passengers died. Three passengers survived but suffered serious injuries. The report publicly details the final minutes of the flight for the first time.

Weather conditions in Resolute included light rain and fog, with scattered clouds under a cloud ceiling that was estimated at 152 metres at 4:34 p.m., when the pilots were given their pre-approach weather report.

Due to these conditions, an instrument-assisted landing was called for, where pilots rely on cockpit instruments instead of visual cues to align with the runway.

Capt. Blair Rutherford was at the controls during the descent. The 48-year-old pilot had once lived in Yellowknife but had since moved to Edmonton.

To Rutherford's right sat co-pilot David Hare, 35, who lived in Yellowknife with his wife and three young daughters.

The plane approached the runway from the west, turning left at a height of 183 metres and travelling at approximately 340 km/h.

"As sometimes happens, the aircraft slightly overshot the centre line," MacDonald said during a press conference in Ottawa accompanying the release of the TSB report.

Normally, the autopilot would correct the route and bring the plane back in line with the runway. However, information gathered from instruments on board the aircraft shows that the pilot's control stick was moved, which served to override the autopilot. Instead of locking on the localizer - a ground-based antenna that provides runway guidance to aircraft - the autopilot mode switched to the "wings-level command" which maintains the current heading and focuses on keeping the aircraft steady in the air.

"The auto-pilot is designed to allow the pilot to override it and the amount of pressure that is required is approximately five pounds. It's possible that the pilot leaned over to reach for something and inadvertently moved the control wheel," said MacDonald.

"When the slight pressure was applied to the control wheel, it tripped (the autopilot) into sort of a default mode, for lack of a better term," he said. "It went from following the beam to maintaining a wings-level mode and maintaining its heading. So, it's just going to sit there and it's going to maintain that heading until the pilot makes another input."

Since the wind was blowing from the west, it gradually pushed the aircraft farther off course to the east, he said.

While a light showing the change in autopilot settings would have illuminated in the cockpit, it is believed neither pilot noticed the change, according to the TSB.

"It wasn't necessarily detected by the crew," said MacDonald. "And so they had a certain expectation that the plane was following the beam when it wasn't."

He pointed out that the cockpit is a very busy place in the minutes leading up to a landing, and that navigational confusion would have added more urgency to the situation.

To further complicate matters, the aircraft's compass was off by 17 degrees during the final approach.

This could have led the captain to believe that, although the GPS and course bar indicated the runway was off to the left, the plane was headed in a direction where it would eventually correct itself.

"(The compass) likely gave the crew the impression they were correcting back ... instead they were proceeding roughly parallel," said MacDonald.

The confusion over the navigation system caused a delay in normal landing procedures, and the plane entered its final descent high and fast, which in itself should have initiated a go-around, the report states.

The Canadian Armed Forces was in Resolute conducting winter military exercises under Operation Nanook, and had assumed command of the normally uncontrolled airport. Although military personnel were manning the control tower, there was no radar or way to know the plane was off course. MacDonald said the TSB's investigation cleared the military of having any fault in the crash.

In the one minute, 20 seconds before impact, Hare questioned whether the plane was on the right heading several times. Early on, the captain stated he was confident about the heading and that there was no reason to initiate a go-around.

"(Blair), I don't like this," Hare was recorded saying as the plane was on its final approach five seconds before impact.

However, Hare did not say the words "go-around" until less than two second before impact - after the ground proximity warning system had sounded.

In its findings, the TSB recommended First Air solidify procedures and language to be used in the cockpit. For example, it should be company policy that if either pilot says "go-around," a landing is automatically aborted. Further, all staff should be trained on the proper wording to use to avoid confusion when pilots are under stress.

Crew resource management (CRM) training teaches crew members situational awareness, including how to manage workload and communicate effectively in the cockpit in stressful situations. Although there is currently no minimum for how much crew resource management training a pilot receives, the norm is two days, said MacDonald. First Air staff received roughly a half-day of CRM training.

Under First Air's two-communication rule, Hare could have assumed control of the aircraft if he believed the captain had become subtly incapacitated. Rutherford was responsive to communication.

"However, his persistence in following his course of action despite the (first officer's) verbal advisories indicates that he was experiencing subtle incapacitation, which was likely due to the stress associated with the deteriorating approach parameters and associated workload," states the TSB report.

The safety board found that despite the two-communication rule, no First Air personnel were given training or guidance on how a co-pilot could force a go-around or assume control of an aircraft unless instructed to do so by the captain.

Ultimately, a go-around was called for by Hare 1.7 seconds before impact. Rutherford initiated the go-around by accelerating the engines to gain altitude 0.6 seconds before impact.

By then it was too late.

At 4:41 p.m., the plane collided with the shoulder of a hill located about one kilometre east of the runway. The plane was pointed nose up at five degrees, travelling at roughly 200 km/h. After the initial impact, the aircraft rebounded into the air and bounced over the top of the shoulder, trailing debris as it went, and landed again on the down-facing slope on the other side approximately 180 metres from the initial impact location.

Upon second impact, the plane broke into three pieces and slid along the hill.

In the weeks and months following the accident, First Air launched its own investigation and got to work re-training personnel on how to avoid similar tragedies.

"Immediately following the accident, what we did was clarify all of our call and commands and re-emphasize our no-fault go-around policy for crews," said First Air vice-president Chris Ferris. "We want our crews to be performing stabilized approaches on landings. If there are elements of the landing - be it approach speed or landing configuration - we have gateways where if they're not properly stabilized we want them to go around and try again."

The airline already had a no-fault go-around procedures and stabilized approach criteria before the crash, however, there is still work to be done to ensure crew feel empowered enough to challenge their senior officers.

"Today, obviously our thoughts are with the families and with Resolute and with Yellowknife," he said. "The North is a small community and we know this has impacted a lot of lives and our thoughts are with

those people today."

TSB board member Kathy Fox and investigator MacDonald plan to be in Resolute March 28 to answer questions from residents.

Discussion in the cockpit

4:39:13 to 4:39:30 p.m. - First officer David Hare makes five statements regarding aircraft being off course from the runway.

4:39:33 to 4:39:37 - Captain Blair Rutherford makes two statements indicating he is satisfied the autopilot is tracking properly.

4:39:46 - Hare states GPS and track deviation are showing the plane is off course and the runway is to the left.

4:39:57 to 4:40:17 - Hare states the plane is not on the localizer (an instrument that provides runway guidance), while Rutherford states the localizer is captured and a "full deflection" is unnecessary. Hare reminds captain of the hill located to the right of the runway.

4:40:30 - Hare suggests the approach be abandoned until they can solve the navigational problems.

4:40:33 - Rutherford states he plans to continue approach.

4:40:35 - Hare acknowledges plan to continue approach.

4:41:41 - Hare: "Just over the shoreline."

4:41:46.6 - Hare: "(Blair) I don't like this."

4:41:47.7 - Ground proximity warning system sounds.

4:41:49 - Hare: "Go for it."

4:41:50.1 - Hare: "Go around."

4:41:51.2 - Rutherford: "Go-around thrust."

4:41:51.8 - Impact.

Source: Transportation Safety Board aviation investigation report

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