Bradley Air Services LTD (First Air) - Boeing - B737-210C (C-GNWN) flight FAB6560

Bradley Air Services LTD (First Air) – Boeing – B737-210C (C-GNWN) flight FAB6560

Bradley Air Services LTD (First Air) - Boeing - B737-210C (C-GNWN) flight FAB6560
Impact site of Bradley Air Services LTD (First Air) B737-210C (C-GNWN) flight FAB6560

Bradley First Air flight FAB6560 , Boeing 737-210C combi 2 aircraft departed Yellowknife (CYZF), Northwest Territories, at 1440 as First Air flight 6560 (FAB6560) on a charter flight to Resolute Bay (CYRB), Nunavut, with 11 passengers, 4 crew members, and freight on board.
The crew initiated the in-range checklist at 1632 and completed it at 1637. At 1637, they began configuring the aircraft for approach and landing, and initiated the landing checklist.
At 1638:21, FAB6560 commenced a left turn just before reaching MUSAT waypoint. At the time of the turn, the aircraft was about 600 feet above the ILS glideslope at 184 knots indicated airspeed (KIAS). [ … ]

At 1640:36, FAB6560 descended through 1000 feet above field elevation. Between 1640:41 and 1641:11, the captain issued instructions to complete the configuration for landing, and the FO made several statements regarding aircraft navigation and corrective action.

At 1641:30, the crew reported 3 nm final for Runway 35T. The CYRB tower controller advised that the wind was now estimated to be 150°T at 7 knots, cleared FAB6560 to land Runway 35T [ … ] There was no further communication with the flight. The tower controller did not have visual contact with FAB6560 at any time.
At 1641:51.8, as the crew were initiating a go-around, FAB6560 collided with terrain about 1 nm east of the midpoint of the CYRB runway.

The crew’s crew resource management was ineffective

The 4 crew members and 8 passengers were fatally injured. Three passengers survived the accident and were rescued from the site by Canadian military personnel.

Findings as to causes and contributing factors

  • 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.
  • The crew’s crew resource management was ineffective. First Air’s 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.
  • Standard operating procedure adaptations on FAB6560 resulted in ineffective crew communication, escalated workload leading to task saturation, and breakdown in shared situational awareness. First Air’s supervisory activities did not detect the standard operating procedure adaptations within the Yellowknife B737 crew base.

 

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accident date: 20/08/2011
operator: BRADLEY AIR SERVICES LTD (FIRST AIR)
make: BOEING
model: B737-210C
registration: C-GNWN
msn: 21067
location: Resolute Bay, Nunavut
flight number: FAB6560

Category: Aviation Accident

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