Arctic Approach: The crash of First Air flight 6560

The wreckage of First Air flight 6560 lies on Resolute Hill. (Toronto Star)

On the 20th of August 2011, a Boeing 737 carrying passengers and cargo to the remote Canadian Arctic outpost of Resolute Bay crashed into a hill on approach to the airport, killing 12 of the 15 people on board. Three survivors clung to life on a barren hillside, before they were saved by a stroke of luck: a military exercise simulating a response to a plane crash was underway in Resolute Bay at the time of the accident. The team of military personnel, firefighters, and investigators found that instead of a simulation, they were faced with a very real plane crash — the perfect test of Canada’s far northern emergency response system.

The investigation into the crash revealed a series of escalating errors that caused the plane to stray off course. There was a breakdown in communication, a subtle change in the autopilot mode, and confusion over their location. The first officer knew they were off course and that there was a hill in their path, but couldn’t convince the captain to abandon the approach. But why did the pilots keep flying when they were so hopelessly off track? Investigators ultimately discovered an unfortunate coincidence, caused by circumstances unique to the Arctic, that tricked the captain into believing everything was fine, despite mounting evidence to the contrary.

Location of Resolute Bay. (SRI International)

The Canadian Arctic is one of the harshest environments on Earth, covering millions of square kilometers of harsh tundra, swamps, rock, and ice. Only a few hardy outposts of human habitation cling to the edge of this vast wilderness. Ground transportation here is limited; unstable, swampy ground makes roads impossible to build and maintain, and some towns are located offshore on the many remote islands of the Canadian Archipelago. The only reliable way to reach most of these communities is by air, and in these isolated villages, airplanes are a way of life.

One such place is the village of Resolute Bay, located on Cornwallis Island in the center of the Archipelago. Situated at a latitude of 74 degrees north, Resolute Bay is the second most northerly town in Canada, and Canada’s fourth most northerly inhabited place. Although the main industry has historically been polar bear hunting, Resolute Bay and its unpaved airstrip also serve as a jumping off point for most scientific expeditions in the region, and the number of visitors in the town at any given moment can sometimes considerably exceed its permanent population of approximately 200.

C-GNWN, the First Air Boeing 737–200 combi involved in the accident. (CambridgeBayWeather via Wikimedia)

One of several airlines serving communities in the Canadian Arctic was First Air, which until its merger with Canadian North in 2019 offered both scheduled and charter passenger and cargo flights to a long list of scattered Inuit communities, as well as a couple of hub airports in southern Canada. Founded in 1946 as Bradley Air Services, First Air was later bought out by Makivik, a wholly Inuit-owned corporation based out of Quebec, making it one of the only airlines belonging to one of Canada’s First Nations. It operated a diverse and sometimes esoteric fleet, which at various points included the last Boeing 727 in passenger service in North America, a rare civilian version of the C-130 Hercules, and one of only two Boeing 727–200 passenger-cargo “combi” jets in existence. But like other airlines in the Canadian Arctic, one of its most stalwart workhorses was the Boeing 737–200, an early version of the popular jet produced in the 1960s and 1970s. First Air outfitted its 737–200s with gravel kits to allow them to land on dirt runways, and turned them into combination, or “combi,” aircraft by dividing the main deck into separate passenger and cargo sections. On the 737–200 combis, five cargo pallets occupied the forward two thirds of the cabin, with four rows of passenger seats located behind the cargo section.

Military personnel and helicopters take part in Operation NANOOK. (Vincent Desrosiers)

Every August between 2007 and 2017, the Canadian Arctic saw a massive increase in activity due to the annual military exercise known as Operation NANOOK. The large multi-agency exercise was aimed at training Canadian armed forces, coast guard, and police in responding to various disasters in the Arctic as well as enforcing Canadian sovereignty over the region as climate change increasingly opens it to the maritime activity. In previous years, the exercise had included responses to simulated accidents such as oil spills and sinking cruise ships, along with strategic military operations.

In 2011, Operation NANOOK was based out of Resolute Bay and included simulated responses to both maritime and air disasters. Military and civilian officials, including representatives from the Canadian Transportation Safety Board, planned to respond to a complex and realistic scenario involving a midair collision of two airliners, with rescue and recovery operations both on land and underwater. To support the operation, temporary radar and firefighting facilities had been erected at Resolute Bay Airport, which normally has neither.

An example of cargo being loaded onto a Boeing 737–200 combi. (Alex Praglowski)

On the 20th of August, in the midst of Operation NANOOK, a First Air Boeing 737–200 combi prepared to depart Yellowknife, capital of the Northwest Territories, on a charter flight to Resolute Bay. Aziz Kheraj, owner of the South Camp Inn in Resolute Bay, had hired the plane to bring in both people and supplies to the remote community. Much of the cargo consisted of food to resupply the inn, which — like all homes and businesses in Resolute Bay — has to import all of its food by air. In the cabin, 11 passengers boarded the flight in order to reach Resolute Bay, including Kheraj’s two granddaughters, 7-year-old Gabrielle Pelky and her 6-year-old sister Cheyenne Eckalook. Also among the passengers were several researchers embarking on scientific missions in the Canadian Archipelago. In command were two pilots, Captain Blair Rutherford and First Officer David Hare, who both had plenty of experience flying in the Arctic; however, Hare was inexperienced on the 737. Two flight attendants rounded out the crew, bringing the total number of people on board to 15.

The danger of flying near the North Magnetic Pole. (Own work)

At 9:40 a.m. local time, the 737 departed Yellowknife as First Air flight 6560 and proceeded northeast, deeper into the Arctic. Ten minutes after takeoff, the flight entered the Northern Domestic Airspace, or NDA, a zone encompassing high-level airspace over northern Canada where certain special flight rules apply. Flying in the NDA was made especially complex due to its proximity to the North Magnetic Pole. The North Magnetic Pole — the location to which all analog compasses naturally point — is not the same as the geographic North Pole, which lies on Earth’s axis of rotation. The North Magnetic Pole is considerably offset from true north and it tends to move around from one year to the next due to fluctuations in Earth’s magnetosphere. In 2011, the magnetic pole was located quite close to Resolute Bay, requiring pilots flying in the NDA to frequently reset their compasses to keep them pointing toward true north. If the compasses are not reset, the motion of the aircraft relative to the magnetic pole will cause the indicated compass heading to “drift” away from the true heading. To reset the compass, pilots acquire a reference heading using their GPS, then rotate the compass display so that the indicated heading corresponds to the true heading. Although the task of resetting the compass is entirely routine for First Air pilots, Rutherford and Hare apparently did a sloppy job of it, resulting in an indicated heading -8˚ off from the true heading upon entering the NDA.

As flight 6560 neared Resolute Bay, the weather began to deteriorate, with a low cloud ceiling fluctuating between 1,500 feet and 200 feet above the level of the airport. A roughly average figure of 700 feet was provided to the pilots as a reference point. Meanwhile, Captain Rutherford laid out his plan for the approach to the airport. First, they would continue on their northeasterly heading until they intercepted the extended centerline of runway 35 True, which lay on a bearing of 347˚, just slightly west of due north. The autopilot would then turn left to a heading of 347˚ to line up with the runway, and the instrument landing system (ILS) would guide them down to the threshold.

A basic outline of how the pilots of flight 6560 planned to approach the airport. (Google, own work)

When set to the appropriate mode, the autopilot tracks a radio beacon known as the localizer, which is located at the airport and sends out a concentrated signal along the extended centerline of the runway. When passing through this beam, the autopilot detects that the plane has “intercepted the localizer” and will automatically initiate a turn to follow it to its source, causing the plane to align with the runway. (The extended localizer beam, as displayed on cockpit instruments, is also referred to simply as “the localizer.”)

The description of the plan was supposed to be part of a comprehensive approach briefing, in which the pilots discuss every aspect of the approach, including safety hazards. But Captain Rutherford gave only a truncated version of the briefing, leaving out key information like which navigational aid he intended to use and what the minimum safe descent altitude was.

Due to a strong tailwind increasing their speed across the ground, Captain Rutherford planned to begin descending 105 nautical miles (194km) from the airport instead of the usual 100nm (185km), although to compensate fully for the tailwind he would have needed to start the descent even sooner. But when the pilots attempted to request descent clearance, they received no response to their first several queries. By the time flight 6560 received clearance and actually started descending, it was only 101nm (187km) away from the airport, too close given their speed. Therefore, from the very beginning, they were too high on the approach, a problem which persisted throughout the descent. In order to lose altitude quickly, Rutherford pitched the nose down, which also increased their speed even more. As it neared Resolute Bay, the plane reached speeds as high as 310 knots (574km/h), considerably faster than the local speed limit of 250kn (463km/h) imposed below 10,000 feet. Already, the workload in the cockpit was beginning to build as the pilots struggled to rein in their plane.

A timeline of events during the first phase of the approach reveals a very high cockpit workload. (TSB)

At 11:38, as the pilots hurriedly completed the landing checklist, flight 6560 arrived at the extended centerline of the runway. The autopilot detected the signal from the localizer and initiated a left turn toward a heading of 347˚, as expected. First Officer Hare called out “Localizer alive” as the plane began to turn toward the localizer heading, followed by “Glide slope alive” as the autopilot started to detect the signal from the instrument landing system. At the same time, they continued to plow through the landing checklist, selecting the landing gear down and extending the flaps.

Somewhere during this sequence of inputs, Captain Rutherford accidentally turned his control column just enough to disengage the autopilot’s heading component. The autopilot’s heading component had been in VOR/LOC mode, allowing it to track the localizer; but when roll inputs above a certain force threshold are made, it assumes that the pilot wants control and reverts to MAN, or manual mode. In manual mode, the autopilot will level the plane at its current heading and then make no further roll inputs. When the mode change occurred, several lights went out on the pilots’ displays, and the autopilot mode select knob clicked over to a different detent, but neither pilot noticed. If Rutherford had been looking away from his display when this occurred, it would have been quite hard for him to spot the difference.

The autopilot mode select switch moved from VOR/LOC to MAN without anyone noticing. (TSB)

When the autopilot’s roll component reverted to manual mode, flight 6560 had slightly overshot the localizer and was turning back toward it. The plane ended up leveling off on a heading of 346˚ — very nearly in line with the actual runway bearing of 347˚. However, with the autopilot no longer holding the plane on the selected heading, the wind pushed it toward 349˚, 2˚ right of the runway. As a result, flight 6560 steadily deviated to the right of the approach path as the descent progressed.

How the heading error tricked Captain Rutherford into thinking they were on course. (Own work, HSI image courtesy of TSB)

At this point an unfortunate set of circumstances conspired to obfuscate the fact that they were off course. The pilots hadn’t reset their compasses since entering the NDA, and by the time they turned onto final approach, magnetic drift had combined with their initial 8-degree error to skew their compass readings by -16˚ (later -17˚). Consequently, when the plane leveled out at 349˚, the heading actually displayed on their horizontal situation indicators (HSIs) was 330˚, well to the left of the runway heading. (The HSI incorporates heading information from the magnetic compass to give an overview of the plane’s position.) Captain Rutherford, believing that the autopilot was still tracking the localizer, interpreted this to mean that they had overshot the localizer and that the autopilot was turning back to the left to intercept it (see above diagram). The flight director — the overlay on his display which told him which way to fly to reach the destination — relied on the faulty compass heading, and it too indicated that the plane was on course to re-intercept the localizer. Had the compass reading been correct, the flight director would have given a “fly left” indication, but it did not.

However, First Officer Hare noticed several signs that something was wrong. First he observed that they were trending farther from the localizer on both HSIs, not closer, even though the HSIs appeared to show them on course to re-intercept the localizer. In an effort to reconcile these conflicting indications, he checked his GPS to determine their actual location. The GPS confirmed his suspicions, as it appeared to show them trending away from the localizer. Although he was unsure what had happened, he did know that they were off course and that they needed to do something about it. At 11:39, over a period of 17 seconds he made no less than five statements to the effect that they were too far to the right. Captain Rutherford acknowledged these statements but did nothing. He was well aware that they were too far to the right, although he thought they were heading back toward the correct course. As a result, he told Hare that he was confident the autopilot was tracking the localizer correctly.

How to read distance from the localizer in terms of dots on the HSI. (TSB)

But Hare wasn’t at all convinced. The HSI showed them two “dots” to the right of the localizer, the most that it could display — a highly unusual indication while on approach, and one which Hare had likely never seen in training or in line operations. He attempted to alert Rutherford to this fact, but he phrased it as a question rather than an assertion, which failed to emphasize the severity of the problem. In fact, they were required to abandon the approach and go around if the HSI showed such a large deviation, but this didn’t line up with Rutherford’s mental model of what was happening, so instead of providing an unambiguous signal to go around, it only caused further confusion. He questioned why the HSI would show such a large deviation when they were on the localizer, but instead of questioning his conception of the situation, he simply confirmed that they had selected the correct frequency for the ILS and carried on. Hare disagreed with Rutherford’s assertion that they were on the localizer, and reminded him that there was a hill to the right of the runway — an oblique reference to a danger that should have been clear and present.

Hare then pointed out that the GPS also showed them diverging from the localizer, and asked whether they had done something wrong. Finally, at 11:40, First Officer Hare suggested that they perform a go-around and circle at a safe altitude in order to sort out the problem. But he didn’t use the word “go-around” and framed the statement as an opinion; as a result, he failed to convince Rutherford, who told him that they would continue the approach.

At this time, flight 6560 descended through an altitude of 1,000 feet, the point at which the pilots are required to perform a go-around if the approach is not stabilized. Flight 6560 in fact failed to meet several of the criteria for a stabilized approach — they were off course, they were too high, their airspeed was 44 knots too fast, and they hadn’t finished the landing checklist. Hare stated that they were three miles from the runway and not configured, with the implication that they should go around because the approach was unstable. But Rutherford interpreted this statement to mean that they needed to finish configuring, and he began ordering Hare to make various configuration changes.

Timeline of events so far. (TSB)

Hare was not yet cowed, however. He again reported that the GPS showed them off course and suggested that they fly left to rejoin the localizer. Rutherford responded that he couldn’t fly left, because he thought he was already flying left and worried that if he flew left more, he wouldn’t be able to turn steeply enough to line back up with the runway. Arguing back and forth with no shared mental model of the situation, both pilots descended deeper into hopeless confusion.

Meanwhile on the ground, the military air traffic controllers based out of a pair of temporary trailers in Resolute Bay encountered a problem: the tower controller, who was responsible for planes on approach to the airport, had lost his radar display. The radar hadn’t been flight tested and was therefore not allowed to be used for controlling aircraft, but up until that moment it had nevertheless been functional. The terminal controller, who was responsible for higher level airspace, offered to come over to help fix it; however, his attempt was unsuccessful. Upon returning to the terminal control trailer, he didn’t look at his radar display because he was not actively controlling any aircraft, and he wasn’t supposed to be relying on it anyway. As a result, neither controller noticed that flight 6560’s radar return was drifting farther and farther from the correct approach path.

On board flight 6560, Captain Rutherford worked furiously to get the plane down to the glide slope and configured for landing. First Officer Hare repeatedly started trying to say something, but Rutherford interrupted him with orders to change the flap settings. At 11:41, Hare informed the tower controller that they were 3 miles out, although at that time they were actually less than one mile from the threshold. Under a crippling workload during the hopelessly unstable approach, he hadn’t had a chance to make the call until now.

Moments later, Hare caught a glimpse of what he thought was a beach through a gap in the clouds and asked, “We’re over the shoreline now?” But this only reinforced Rutherford’s expectation that they would soon descend out of the cloud layer and all would become clear. Little did he know that the real cloud base was considerably lower than the 700 feet described in the weather report they had gotten some 20 minutes earlier.

Growing increasingly agitated, First Officer Hare started to swear. By now, although neither pilot knew it, they had passed the threshold and were flying nearly parallel to runway 35 True.

“Blair, I don’t like this,” Hare said, using the captain’s first name to try to get his attention. One second later, the ground proximity warning system (GPWS) detected a dangerous closure rate with the ground, and an aural alert blared, “SINK RATE!”

“Go for it!” said Hare. “Go around!”

“MINIMUMS,” said the GPWS, alerting the crew to the fact that they were descending below the minimum safe altitude for the approach.

Timeline, extended. (TSB)

One second after Hare called for a go-around, Rutherford called out, “Go-around thrust!” He jammed the throttles forward and started to pull up, but it was too late. First Air flight 6560 slammed into the shallow slope of the hill just east of the airport, crashing belly-first onto the stony ground at more than 200 kilometers per hour. The plane slid up and over the crest of the hill, its fuselage disintegrating as it careened across the lifeless gray moonscape. The cabin split into several pieces and the floor ripped away from underneath, ejecting most of the passengers into a hail of flying debris. The center section with the wings attached burst into flames as it slid to a stop, and the cockpit was catapulted a considerable distance down into a dry ravine. After only a few terrifying seconds, the last pieces of wreckage ground to a halt, and for a moment, there was silence.

Simulation of the crash, as featured in Mayday, Season 15 episode 10: “Death in the Arctic”

Amazingly, 23-year-old graduate student Nicole Williamson survived the crash with a crushed foot and a fractured pelvis. She had remained conscious throughout the horrifying crash sequence, leaving her with unusually vivid memories of the carnage. She recalled that the plane broke apart in front of her feet, and the fuselage rolled over and over like a deadly washing machine before it eventually spit her out onto the tundra, still strapped into her seat. She came to rest dirty, disoriented, and in pain, swearing and hyperventilating as she struggled to comprehend what had happened.

Moments later, her state of shock was penetrated by a cry for help from 7-year-old Gabrielle Pelky, who had also survived the crash. Williamson had met Gabrielle at the terminal in Yellowknife and befriended her during the flight, and to hear her cry out in pain imbued her with a newfound sense of resolve. She dragged herself over to Gabrielle and found that the little girl had badly broken her leg, but was otherwise unhurt. As they huddled together for warmth, Gabrielle — with all the naïve innocence of a 7-year-old — told Williamson, “This was my first plane crash!”

Eventually they managed to drag themselves onward through the wreckage, where they stumbled upon Williamson’s colleague, 48-year-old Robin Wyllie, who had survived with several serious injuries. Unsure where they were or whether anyone was coming to save them, they banded together to survive, waiting for rescue on a bleak gray hillside at the end of the world.

An overview of the impact point. (TSB)

Meanwhile in Resolute Bay, it didn’t take long for air traffic controllers to notice that flight 6560 had not arrived and was not responding to communications. The tower controller’s initial assumption was that the plane had lost its radio and performed a missed approach, but he nevertheless alerted the firefighters to get ready for a possible emergency. The ground controller called First Air to ask if they’d heard from the plane, but they hadn’t; simultaneously, a car was sent out to survey the approach path, but no sign of the plane was found. Various efforts were made to figure out what had happened to the plane right up until 12:19 p.m., when the clouds lifted and firefighters and military personnel caught sight of smoke and flames on the hill east of Resolute Bay Airport. Rescue crews immediately headed toward the site, but due to rough terrain, they were forced to leave the fire trucks behind and proceed on foot and on ATVs. The first rescuers arrived at the crash site sometime before 12:30, where they were amazed to find Nicole Williamson, Gabrielle Pelky, and Robin Wyllie alive amid the vast trail of wreckage. A helicopter airlifted all three of them from the crash site to a temporary military hospital in Resolute Bay, where veterans of Arctic aviation expressed shock that anyone had survived. It would be some time before the survivors learned that all twelve other people on board were dead, including all four crew, and Gabrielle’s six-year-old sister Cheyenne.

First responders set up a tent to provide shelter at the crash site. (Vincent Desrosiers)

Investigators with Canada’s Transportation Safety Board were already on board a plane headed for Resolute Bay to take part in Operation NANOOK when they received word of the crash. After some initial confusion over whether this was part of the exercise, the investigators realized that this was in fact the real deal — a plane had actually crashed at Resolute Bay, and they needed to get ready to find the cause. The TSB investigators ended up arriving at the crash site in one of the most remote parts of the world before the wreckage had even gone cold.

As the survivors were flown onward to Iqaluit and eventually to Ottawa, the investigation launched into high gear. The main question that the TSB needed to answer was why First Air flight 6560 had strayed to the right of the approach path without any attempt to correct its course. An examination of the flight data recorder and cockpit voice recorder revealed that the captain had bumped the control wheel during the critical turn onto final approach and disconnected the autopilot’s heading component, allowing the wind to push them off course. But why the pilots never corrected this seemingly obvious error proved to be far more interesting.

A long distance view of the crash site under the eerie half-darkness and fog. (The Globe and Mail)

When the plane began to diverge from the approach path, each pilot latched on to a different set of clues that supported his own interpretation of what was happening. Captain Rutherford noticed the compass heading, which appeared consistent with what he would expect if the autopilot were correcting their course back toward the localizer after overshooting to the right. Supporting this interpretation was the flight director, which was instructing him to hold his current heading, as well as his expectation that they would break through the clouds at 700 feet, well above the terrain. On the other hand, First Officer Hare identified the increasing deviation shown on the HSI and on the GPS to support his conclusion that they were trending to the right of the localizer. Each pilot therefore had his own mental model of the situation, with his own expectations for what would happen next and his own assessment of the level of danger. This showed that there was no shared situational awareness in the cockpit of flight 6560. It is critical that pilots have a shared situational awareness at all times so that they are on the same page as to what needs to be done and what the risks to the flight may be. The principles of crew resource management (CRM), the guiding philosophy underlying effective cockpit communication, hold that when shared situational awareness is lost, the pilots must recognize this and work together to reconcile their mental models. But the pilots of First Air flight 6560 never did this. Instead of fully explaining his position, First Officer Hare offered up facts, such as “the HSI shows us two dots off the localizer,” “the GPS shows us off course,” and “there’s a hill to the right of the runway” without fully explaining his belief that they were trending right of track and were in danger of colliding with terrain.

The crash site overlooked Resolute Bay Airport. (CBC)

When Hare offered each of these points as a discrete piece of information, he made them easier for Rutherford to ignore. Under a high workload while trying to salvage an unstable approach, Rutherford’s attention was narrowly focused on flying the plane, leaving him vulnerable to confirmation bias — the brain’s natural tendency to tune out any information that doesn’t support its current understanding of a situation. Rutherford could also have been affected by the similar phenomenon of plan continuation bias, a tendency to reject any information which might suggest that one’s current plan is faulty and that a new plan is needed. On the cockpit voice recording, it was apparent that Rutherford was immediately dismissing the first officer’s comments without taking any time to actually evaluate them. In order to break through these biases and convince Rutherford that his interpretation was correct, Hare needed to be forceful, effectively startling the captain out of his complacency. Had Hare said something like, “The HSI and GPS show us trending to the right of the localizer and we are in danger of striking terrain,” he would almost certainly have gotten Rutherford’s attention and forced him to re-evaluate the situation. Instead, because he tried to nudge Rutherford toward the correct interpretation by hinting and hoping, he was unable to penetrate the captain’s natural resistance to changing his plan.

Smoke rises from the crash site, as seen from the airport. (Nicolas Laffont)

In theory, First Officer Hare had the right to take control and perform a go-around by himself if he believed that there was imminent danger to the flight and the captain was not responsive to that danger. To understand why he didn’t, investigators looked at how first officers at First Air were trained, and discovered that Hare was taught to apply a narrower set of criteria under which a first officer could take control from the captain. According to First Air training, a first officer could take control if the captain was obviously incapacitated, or if he appeared awake but failed to acknowledge two consecutive warnings. But on flight 6560, this threshold was never met. Captain Rutherford was awake and alert and acknowledged all of Hare’s comments, but he was afflicted by a more subtle psychological effect that suppressed his ability to assess the situation objectively. Hare was not trained to recognize this effect, nor was he under the impression that he could take control without two unacknowledged warnings, even though he technically had the right to do so. Without an unambiguous indication that he should take over, he would have been extremely reluctant to make such an unusual move. The misleading training and Rutherford’s blind confidence that he was right sowed enough doubt in Hare’s mind that he couldn’t take that crucial step. And even if he had, Rutherford might have reacted poorly — in fact, First Air captains interviewed by the TSB became visibly uncomfortable when asked about a first officer taking control when the captain is not incapacitated.

Fog surrounds the wreckage of the tail section. (TSB)

To learn why the pilots were unable to reconcile their differing mental models, the TSB examined First Air’s crew resource management training. A number of red flags immediately became apparent. First Air was still using a CRM training package provided by Transport Canada when CRM was first mandated in the 1990s, which didn’t contain the latest innovations in crew communication strategies. Furthermore, First Air’s CRM training course lasted only four hours, considerably less than the two days specified by Transport Canada, and due to the time constraint it did not cover five of the eight topics included in the training package. CRM instructors were not required to have any special knowledge of CRM. And no Transport Canada inspector had ever sat down and observed a First Air CRM training course to ensure it met regulatory requirements. To evaluate the quality of the training, TSB investigators attended a First Air CRM course, and what they found was disconcerting. Although the instructors were passionate about CRM, the class was little more than a lecture to a handful of detached students, whom the instructors struggled to get involved in the lesson. There were no example scenarios that would allow student pilots to try out the techniques for themselves, a critical aspect of any CRM course. Although some of the missing subjects were covered in recurrent training, it was clear to the TSB that First Air’s CRM course was unlikely to give new pilots any practical experience that they could apply to day-to-day operations. After attending the course, pilots would probably forget everything quickly and go back to whatever they were doing before.

Much of the cargo consisted of meat, bread, and vegetables, which lay scattered across the tundra after the crash. Guards had to be posted to keep marauding polar bears away from the rotting food. (TSB)

Some of the modern CRM strategies not covered in First Air’s training regime could have prevented the crash of flight 6560. For example, first officers at some airlines are taught the Probing, Alerting, Challenging, and Emergency (PACE) model, a technique to escalate levels of assertion as danger increases. First, in the Probing phase, a first officer asks questions intended to help the captain discover the problem independently. If this does not have the intended effect, the first officer can escalate to the Alerting phase, in which he or she specifically points out the problem. After that, they can escalate to the Challenging phase, where the first officer issues a direct statement that they are in danger and suggests a course of action. Finally, if the plane is still in danger and the captain has not taken action, the first officer can escalate to the final Emergency phase, in which he or she takes control from the captain. On flight 6560, First Officer Hare never moved past the “alerting” phase, which was insufficient to get Captain Rutherford’s attention. If he had been trained in the use of the PACE model, he would have had a road map for the further escalation of his warnings, and the crash might have been avoided.

The burnt-out remains of the center wing section. (Bureau of Aircraft Accidents Archives)

The crash also could have been prevented if the plane had been equipped with the latest ground proximity warning technology. The 737–200 involved in the accident had an older generation model that couldn’t detect rising terrain ahead of the aircraft, instead relying on closure rates derived from radio altimeter information, which resulted in an alarm that sounded too late for the pilots to save the plane. First Air was scheduled to upgrade all its planes with the more advanced system by the end of 2012, but tragically, it had not yet done so. Today, all airliners in Canada have the advanced Terrain Awareness and Warning System (TAWS), which uses a terrain database to determine when a plane is on a collision course with high ground and issues warnings well in advance.

Damage to the bottom of the tail section shows how the cabin floor was ripped out on impact. (Bureau of Aircraft Accidents Archives)

The TSB was also concerned about the fact that neither pilot suggested a go-around after the approach became unstable for reasons completely unrelated to their lateral displacement, including excessive height and speed. Although procedures require a go-around if the approach is unstable, and the guidelines for what constitutes an unstable approach are straightforward, the TSB cited a study which showed that 97% of unstable approaches (representing 3–4% of all approaches) are flown to completion. For the TSB, this represented an unacceptable level of risk, because continuation of an unstable approach is the leading cause of fatal aircraft accidents in Canada, and indeed around the world. At First Air, the natural reluctance to abandon an approach was exacerbated by a lack of clear steps that pilots could take to identify instability and call it out to the other crewmembers. When asked how they were supposed to call out an unstable approach, some First Air pilots required as much as 90 seconds to come up with an answer — an eternity during an actual approach. If the number of landing accidents was to be reduced, the percentage of unstable approaches resulting in a go-around needed to increase.

As a result of the TSB’s findings, a wide range of safety improvements were made. First Air established a policy allowing any crew member to command a go-around at any time; created standardized callouts for a wide range of situations that lacked clear guidelines; increased training on autopilot management; rewrote its training manual; provided training on risk management to company leadership; increased the length of the CRM course to a full day and incorporated the latest innovations; increased the use of CRM during simulator training; and added new emphasis on following standard operating procedures, with the goal of eliminating informal adaptations (such as abbreviated approach briefings) that pilots had incorporated into their routines. The TSB also recommended that Canadian airlines be required to monitor and reduce the number of unstable approaches that are continued to landing, and Transport Canada updated training guidelines to require some of the latest CRM techniques. Numerous other changes were made to various areas less directly related to the causes of the crash, including flight data recorder maintenance, military air traffic control procedures, and flight safety hazard reporting. Since the reforms following the First Air crash, there hasn’t been another major accident in Canada, although in many areas there remains work to be done.

The other legacy left by the crash of First Air flight 6560 is the story of its three survivors. They may have been saved by mere coincidence — in fact, almost everything and everyone that rescued them was present in Resolute Bay due to Operation NANOOK, including the firefighters, the hospital, the helicopter, and more (normally Resolute Bay relies on a small volunteer firefighting crew with no special equipment or training on aircraft fires). Furthermore, all these people and their advanced equipment were ready to go because they planned to respond to a simulated air disaster in only two days’ time. As a result, they were able to respond and rescue the survivors in record time for a crash off-airport in the Canadian Arctic. Doctors who treated the victims stated that only a couple more hours exposed to Arctic conditions could have seriously jeopardized their survival.

A memorial at the site commemorates the 12 peope who died in the crash. (Ben Larhome via flickr)

Gabrielle Pelky didn’t learn of her sister’s death for days after the crash, and according to family members it took a long time for her to truly comprehend that her sister and best friend was gone. But with time she recovered, thanks in part to her continued friendship with fellow survivor Nicole Williamson. For Williamson and Wyllie, Gabrielle’s calm demeanor and relentless energy helped them get through the ordeal as well, her innocence helping to temper the trauma of the moment. As each of the three survivors continues to live or work in the Canadian Arctic, where flying remains an essential part of everyday life, one can only hope that their “first plane crash” is also their last.

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Analyzer of plane crashes and author of upcoming book (soon™). Contact me via @Admiral_Cloudberg on Reddit or by email at kylanddempsey@gmail.com.

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