Transportation Safety Board of Canada has issued its Progress Report on the August 20, 2011 crash of First Air Boeing 737-210C C-GNWN at Resolute Bay.
Copyright Photo: Gilbert Hechema.
Here is the full report:
First Air Flight 6560, Boeing 737 Accident, 20 August 2011, Resolute Bay (A11H0002)
On 20 August 2011, a First Air Boeing 737-210C aircraft (registration C-GNWN, serial number 21067) was being flown as a charter flight from Yellowknife, North West Territories, to Resolute Bay, Nunavut. As is often the case for aircraft operating in the arctic, the cabin was partitioned to allow a combination of cargo and passengers, this configuration is known as a combi.
At 1142 Central Daylight Time, during the approach to Runway 35T, First Air Flight 6560 impacted a hill at 396 feet above sea level (asl) and about 1 nautical mile east of the midpoint of the Resolute Bay Airport runway which, itself, is at 215 feet asl. The aircraft was destroyed by impact forces and an ensuing post-crash fire. Eight passengers and the four crew members suffered fatal injuries. Three passengers suffered serious injuries and were rescued by Canadian military personnel who were in Resolute Bay as part of a military exercise.
Investigation Team Work
The investigation team is led by the Investigator-in-Charge, Brian MacDonald. Mr. MacDonald has 31 years of aviation experience; 23 years as a pilot in the Royal Canadian Air Force and eight years with the TSB. He has been an air accident investigator for the past 15 years. Mr. MacDonald is assisted in this investigation by experts in flight operations, air traffic services, weather, aircraft structures, aircraft systems, aircraft engines, and human performance.
Some of these experts come from within the TSB, but assistance is also being provided by the following organizations: Bradley Air Services Limited (First Air), Transport Canada, NAV CANADA, the Royal Canadian Mounted Police, the Department of National Defence, The Boeing Company, Pratt and Whitney (engines), and the U.S. National Transportation Safety Board. This is a normal part of any investigation, as these experts play a key role in helping the team uncover and understand all of the underlying factors which may have contributed to the accident.
The investigation team continues its work which is in Phase 2 of this 3-phase investigation. The three phases of every investigation include: the Field Phase, the Post-Field Phase and the Report Production Phase. While continuing to gather the information it needs, the team has now begun the work of analyzing the considerable amount of data in order to determine what happened, why it happened and, what can be learned to help ensure it does not happen again.
Work Completed to Date
A significant amount of work has been completed so far, but much remains to be done. Dozens of interviews have been conducted. Hundreds of technical and operational documents, weather reports, air traffic control communications, studies and research papers have been gathered, and the analysis of this material is well underway.
A detailed survey of the accident site was completed and a comprehensive plot of the aircraft components constructed. The TSB completed an extensive study of the wreckage and removed some of the components for further laboratory analysis.
The flight recorders were located on the first day and shipped to the TSB lab for data download and analysis. The recorders contain much needed data and will assist investigators in the understanding of what happened during the approach phase of the flight.
What We Know
In the hours before the accident, the weather in Resolute Bay was variable with fluctuations in visibility and cloud ceiling. Forty minutes before the accident, the visibility was 10 miles in light drizzle with an overcast ceiling at 700 feet above ground level (agl). A weather observation taken shortly after the accident, reported visibility of 5 miles in light drizzle and mist with an overcast ceiling of 300 feet agl.
The weather conditions required the crew to conduct an instrument approach using the aircraft flight and navigation instruments. The crew planned to conduct an instrument landing system (ILS) approach to Runway 35T. This instrument approach provides guidance down to weather minimums of 1⁄2 mile visibility and a ceiling of 200 feet agl.
The crew initiated a go-around 2 seconds before impact. At this time, the flaps were set to position 40, the landing gear was down and locked, the speed was 157 knots and the final landing checklist was complete.
Another aircraft successfully completed an ILS approach to Runway 35T approximately 20 minutes after the accident. NAV CANADA conducted a flight check of the ground based ILS equipment on 22 August 2011; it was reported as serviceable.
The Resolute Bay Airport is normally an uncontrolled airport (no Air Traffic Controllers). A temporary military control zone had been established to accommodate the increase in air traffic resulting from Operation Nanook, a military exercise taking place at the time. Information from the military radars that had been installed for the exercise was retrieved for TSB analysis.
The technical examination of the aircraft at the accident site revealed no pre-impact problems. Analysis of the flight data recorder information and examination of the engines at the site indicate the engines were operating and developing considerable power at the time of the accident. Analysis of the aircraft flight and navigational instruments is ongoing.
Currently, the TSB is classifying this occurrence as a controlled flight into terrain (CFIT) accident. 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. CFIT is one of the issues identified in the TSB Watchlist.
Investigation Activities in Progress
The TSB is proceeding with several concurrent avenues of investigation in order to understand why the aircraft struck terrain 1 nautical mile east of the runway. Aircraft navigation in the final phase of flight is certainly a key area that the investigation team is pursuing. To that end, the TSB Engineering Laboratory, assisted by specialists of the aircraft and components manufacturers, is conducting exhaustive testing on the aircraft’s navigational equipment.
As with any accident investigation, investigators are looking at all aspects of training and procedures to determine if this can shed light on what may have transpired during the approach phase of the flight. Additionally, the team is studying the establishment of the temporary control zone and the coordination and operation of the airspace between civilian and military control agencies.
Communication of Safety Deficiencies
Should the investigation team uncover a safety deficiency that represents an immediate risk to aviation, the Board will communicate without delay so it may be addressed quickly and the aviation system made safer.
The Families
The TSB investigation team is mindful of the survivors and the families who lost loved ones on Flight 6560 and of their desire for answers. As we continue our work, our hope is that it will lead to the prevention of similar accidents and a safer transportation system for all Canadians.
The information posted is factual in nature and does not contain any analysis. Analysis of the accident, along with the Findings of the Board will become available when the final report is released.
The investigation is ongoing.
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