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Safety Board Report Indicates Copilot Warned Pilot Before Boeing 737 Plane Crash

March 31, 2014 - On Tuesday the Canadian Transportation Accident Investigation and Safety Board released a report in which indicated the copilot of Fight 6560 warned the captain to abort the landing which resulted in the crash of a Boeing 737-200 which killed 12 of the 15 onboard. 

On August 20, 2011, at or about 12:30 PM, the Boeing 737, Canadian registration CGNWN, operated Bradley Air Services Limited under its business name First Air, crashed into a hill impacted a hill at 396 feet above sea level while on approach for runway 35T at Resolute Bay Airport, Canada. 

At 4:38 PM the crew reported 10 nm final for Runway 35T. The captain, Blair Rutherford called for the gear to be lowered at 4:38 and for flaps 15 at 4:38. Airspeed at the time of both of these calls was 177 KIAS. At 4:38, the CYRB tower controller acknowledged the crew's report and instructed them to report 3 nm final. 


At 4:38, the copilot, David Hare (First Officer FO) requested that the tower repeat the last transmission. At 4:38, the tower repeated the request to call 3 nm final; the copilot acknowledged the call. At this point in the approach, the crew had a lengthy discussion about aircraft navigation. 

4:39 FO makes 5 statements regarding aircraft lateral displacement from desired track.
4:39 Captain makes 2 statements indicating satisfaction that the autopilot is tracking properly.
4:39 FO makes statement about track deviation displayed on GPS.
4:39 FO states they are not on auto approach, just on the flight director.
4:40 FO queries captain to confirm full deflection.
4:40 Captain concurs, and questions why full deflection when they are on the localizer.
4:40 FO states they are not on the localizer.
4:40 Captain states “It's captured; ten three is the localizer?”
4:40 FO disagrees on localizer capture and reminds the captain about the hill to the right of the runway.
4:40 FO states GPS is also showing to the right.
4:40 FO questions captain as to whether they did something wrong.
4:40 FO states opinion that they should abandon the approach and then solve the navigational problem.
4:40 Captain indicates that he plans to continue the approach.
4:40 FO acknowledges captain's plan to continue the approach.



At 4:40, FAB6560 descended through 1000 feet above field elevation. Between 4:40 and 4:41, the captain issued instructions to complete the configuration for landing, and the FO made several statements regarding aircraft navigation and corrective action.

At 4:41, 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, and added the term “check gear down” as required by the NAV CANADA Air Traffic Control Manual of Operations (ATC MANOPS) Canadian Forces Supplement.

FAB6560's response to the tower (4:41) was cut off, and the tower requested the crew to say again. There was no further communication with the flight. The tower controller did not have visual contact with FAB6560 at any time.

4:41 FO states “Just over the shoreline.”
4:41 Pitch begins to increase from −5°
4:41 FO calls captain by first name; states “I don't like this.”
4:41 GPWS: “Sink rate”
4:41 FO states “Go for it.”
4:41 GPWS: “Minimums”
4:41 FO states “Go around.”
4:41 GPWS: “Minimums”
4:41 Captain calls “Go-around thrust.” 

At 4:41, as the flight crew initiating a go-around, FAB6560 collided with terrain about 1 nm east of the midpoint of the CYRB runway. Brian MacDonald, lead investigator said “this accident was the product of a complex series of events, all of them lining up together.’ 

The reported indicated that “the captain’s mental model was likely that the approach and landing could be salvaged, and the (first officer’s) mental model was almost certainly that there was significant risk to the safety of flight and that a go-around was required.” The report also stated the copilot was not “sufficiently assertive” in making his case to abort the landing. The report went on to state “given the captain’s workload and mental model, it is likely that only clear and unambiguous information would have succeeded in changing his understanding of the situation and his course of action.”

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