Progress report: TSB Canada classifies Resolute Bay Boeing 737 accident as CFIT

January 5, 2012

In a progress report of their investigation into a fatal Boeing 737 accident at Resolute Bay, the Transportation Safety Board of Canada currently classified the accident as a Controlled Flight Into Terrain (CFIT) occurence.

On 20 August 2011, a First Air Boeing 737-210C aircraft (registration C-GNWN) was being flown as a charter flight from Yellowknife, North West Territories, to Resolute Bay, Nunavut.  At 11:42, 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.

The investigators have complete the field phase of the  investigation. With regards to the weather, it was reported that 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 12 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 technical examination of the aircraft at the accident site revealed no pre-impactproblems. 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.

More information:


VFR flight into cloud caused Indonesian DHC-6 Twin Otter CFIT accident

April 22, 2010

Indonesian accident investigators of the National Transportation Safety Committee (NTSC) have concluded that a fatal accident involving a DHC-6 Twin Otter in August 2009 has been caused by VFR flight into cloud. The airplane flew into the side of a mountain, killing all 15 on board.

Wreckage of Twin Otter PK-NVC on the mountainside

The Merpati Nusantara Airlines DHC-6 Twin Otter passenger plane flew into the side of a mountain during a domestic flight from Jayapura (DJJ) to Oksibil Airport (OKL). Merpati Flight MZ9760D took off at 10:15 with an estimated time of arrival at Oksibil of 11:05. The pilots were operating under visual flight rules (VFR) procedures. This required them to remain clear of cloud. Ten minutes before impact the pilot in command mentioned climbing to 10,000 feet, and stated “if we cannot go visual I will turn left”. The cockpit conversations did not exhibit any signs of stress or concern until two minutes before the impact, when the copilot mentioned haze and asked the captain if he could see. Fifty seconds before impact, the copilot expressed further concern and asked about the captain’s intentions, and the captain said “climb, to the left”. Forty-two seconds before impact the copilot asked if it was safe on the left.
The copilot became increasingly uncertain about the safety of the flight, specifically mentioning visibility and speed. From the recorded sounds, it is apparent that 13 seconds before impact, engine power was increased symmetrically to a high power setting. The Twin Otter struck the side of a mountain at an elevation of 9300 feet.
The wreckage was located August 4 with some difficulty because the ELT was unserviceable.

As a result of this investigation, the National Transportation Safety Committee
issued recommendations to address safety issues, specifically with respect to: maintenance procedures and maintenance inspection programs, to ensure that Emergency Locator Transmitters are serviceable; and the provision of weather information services for all civilian aircraft operations throughout Papua.


TSB Canada launches watchlist of safety issues

March 16, 2010

The Transportation Safety Board (TSB) released a “Watchlist” that points to nine critical safety issues troubling Canada’s transportation system. The TSB Watchlist took shape after analysts found troubling patterns in their work.

Three safety issues related to aviation:
Problem: There is ongoing risk that aircraft may collide with vehicles or other aircraft on the ground at Canadian airports.
Solution: Improved procedures and the adoption of enhanced collision warning systems are required at Canada’s airports.

Problem: Fatalities continue to occur when planes collide with land and water while under crew control.
Solution: Wider use of technology is needed to help pilots assess their proximity to terrain.

Problem: Landing accidents and runway overruns continue to occur at Canadian airports.
Solution: In bad weather, pilots need to receive timely information about runway surface conditions.
Airports need to lengthen the safety areas at the end of runways or install other engineered systems and structures to safely stop planes that overrun.


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