Transport Canada response to Resolute crash not good enough: TSB
“Unstable approaches continue to be a high risk to safe flight operations"
The Transport Safety Board has called on Transport Canada to take action to reduce the number of unstable aircraft approaches that continue on to landing attempts.
The recommendation, released Sept. 2, is the TSB’s take on Transport Canada’s response to the August 2011 crash of First Air flight 6560.
That’s when a Boeing 737-200 en route from Yellowknife to Resolute Bay flew into a hillside about a kilometre east of the Resolute runway, killing all four crew and eight passengers, and injuring three others.
The TSB said Sept. 2 that the landing should have been aborted, noting “the aircraft arrived high and fast on final approach, was not configured for landing on a timely basis, had not intercepted the localizer, and was diverging to the right.”
And unless further action is taken to reduce the number of unstable approaches that continue on to a landing, the TSB said the risk of approach and landing accidents will persist.
In its final investigation report on the crash, released this past March, the TSB determined that an accidental change in the aircraft’s autopilot mode, a faulty compass reading and crew miscommunication led to the crash of flight 6560.
According to cockpit voice recorder data recovered from flight 6560, its captain and first officer did not display sufficient “crew resource management” or CRM skills to navigate a series of instrument conflicts and mishaps in the cockpit during landing procedure.
At 11:39 a.m. Aug. 20, during flight 6560’s approach, the flight’s first officer David Hare makes his first comment that the bearing is incorrect and then informally suggests a “go-around,” which means to abort the landing and try again.
At 11:41 a.m., when the flight’s captain Blair Rutherford finally realized while flying through a cloud of dense fog that the aircraft was not going to make a safe landing on the runway, he called for “go-around thrust,” and attempted to abort the landing, the TSB noted.
But a half-second later, the plane smashed into a hillside about a mile east of the Resolute Bay runway.
In its report, the TSB recommended that Transport Canada require operators of large commercial aircraft to monitor and cut back on unstable approaches that continue on to landing.
Instead, Transport Canada created a civil aviation safety alert that encouraged operators to identify unstable approaches.
“Unstable approaches continue to be a high risk to safe flight operations in Canada and worldwide,” said Kathy Fox, chair of the TSB, in the Sept. 2 release.
“Although [Transport Canada’s] Safety Alert is a positive step, it will be some time before the effectiveness of this voluntary approach can be validated.”
TSB’s initial report also called on Transport Canada to update and standardize its process for how flight crews manage threats (otherwise known as CRM.)
And while Transport Canada is currently upgrading its CRM training standard requirements, the TSB has already expressed concerns that it won’t be enough.