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TSB highlights worldwide problem with unstable approaches and calls for improved crew communications following 2011 crash in Resolute Bay, Nunavut

Gatineau, Quebec, 25 March 2014 – During today’s release of its investigation report (A11H0002) into the August 2011 fatal accident involving First Air flight 6560 in Resolute Bay, Nunavut, the Transportation Safety Board of Canada (TSB) called on Transport Canada and the airline industry to reduce unstable approaches that are continued to a landing, and to improve crew communications.

On 20 August 2011, a Boeing 737-210C, operated by First Air, was being flown as a charter flight from Yellowknife, Northwest Territories, to Resolute Bay, Nunavut, when it struck a hill about 1 nautical mile east of the runway. The accident claimed the lives of all 4 crew members and 8 of the passengers, and left 3 passengers seriously injured.

The investigation concluded that a combination of factors contributed to the accident. The aircraft did not intercept the runway localizer (alignment) beam, and instead diverged to the right, and ultimately hit a hill. Fundamental to the Board’s findings is the fact that an unstable approach was continued to a landing. “Too many unstable approaches continue to a landing, and this is an international problem,” said Board Member Joseph Hincke. “If we want to see fewer landing accidents, we have to tackle this issue now.”

Central to the TSB findings was that, although the 2 pilots were aware they were off course, they each had a different understanding of the situation and did not take corrective action in time. Effective crew resource management (CRM) training and procedures help crews manage workload in the cockpit and communicate effectively to make better decisions and solve problems.“Although Transport Canada is taking steps to update the CRM training standards, the Board is concerned that a comprehensive and integrated approach to monitoring and reinforcing best practices is still needed,” added Board Member Kathy Fox. “To advance aviation safety in Canada, the TSB is seeking stronger defences to reduce unstabilized approaches, and measures to improve crew communications.”

This accident involves one of the issues on the TSB Watchlist: Collisions with land and water. The Watchlist is a list of transportation safety issues that pose the greatest risk to Canadians. In each case, action to date has been inadequate, and concrete steps must be taken on the part of the regulator and industry to eliminate these risks.

An animation of the sequence of events has been released as part of this investigation. See the active investigation page for complete details of this investigation.

The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

For more information, contact:
Transportation Safety Board of Canada
Media Relations



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