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Aviation Investigation Report A11h0002

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Aviation Investigation Report A11h0002 AVIATION INVESTIGATION REPORT A11H0002 CONTROLLED FLIGHT INTO TERRAIN BRADLEY AIR SERVICES LIMITED (FIRST AIR) BOEING 737-210C, C-GNWN RESOLUTE BAY, NUNAVUT 20 AUGUST 2011 The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. Aviation Investigation Report A11H0002 Controlled flight into terrain Bradley Air Services Limited (First Air) Boeing 737-210C, C-GNWN Resolute Bay, Nunavut 20 August 2011 Summary On 20 August 2011, the Boeing 737-210C combi aircraft (registration C-GNWN, serial number 21067), operated by Bradley Air Services Limited under its business name First Air, was being flown as First Air charter flight 6560 from Yellowknife, Northwest Territories, to Resolute Bay, Nunavut. At 1642 Coordinated Universal Time (1142 Central Daylight Time), during the approach to Runway 35T, First Air flight 6560 struck a hill about 1 nautical mile east of the runway. The aircraft was destroyed by impact forces and an ensuing post-crash fire. Eight passengers and all 4 crew members sustained fatal injuries. The remaining 3 passengers sustained serious injuries and were rescued by Canadian military personnel, who were in Resolute Bay as part of a military exercise. The accident occurred during daylight hours. No emergency locator transmitter signal was emitted by the aircraft. Ce rapport est également disponible en français. Table of contents 1.0 Factual information ................................................................................... 1 1.1 History of the flight .............................................................................................................1 1.2 Injuries to persons ................................................................................................................6 1.3 Damage to aircraft ...............................................................................................................6 1.4 Other damage .......................................................................................................................6 1.5 Personnel information .........................................................................................................7 1.5.1 Flight crew ............................................................................................................................................. 7 1.5.2 Flight attendants ................................................................................................................................... 8 1.5.3 CYRB air traffic controllers .................................................................................................................. 8 1.6 Aircraft information ............................................................................................................9 1.6.1 Aircraft maintenance ............................................................................................................................ 9 1.6.2 Aircraft performance .......................................................................................................................... 11 1.6.3 Terrain awareness devices ................................................................................................................. 11 1.6.4 C-GNWN navigation systems ........................................................................................................... 12 1.6.5 C-GNWN compass systems .............................................................................................................. 13 1.6.6 Autopilot system ................................................................................................................................. 15 1.6.7 FD-108 flight director system ............................................................................................................ 17 1.6.8 Attitude director indicator ................................................................................................................. 18 1.6.9 Approach progress display annunciators ........................................................................................ 19 1.6.10 Global positioning system ................................................................................................................. 19 1.6.11 Emergency locator transmitter .......................................................................................................... 20 1.7 Meteorological information ..............................................................................................21 1.7.1 Cloud ceiling height ........................................................................................................................... 21 1.7.2 Yellowknife weather at departure .................................................................................................... 21 1.7.3 Resolute Bay weather issued before departure ............................................................................... 21 1.7.4 Resolute Bay weather issued while FAB6560 was en route .......................................................... 22 1.7.5 Resolute Bay weather issued after the accident .............................................................................. 22 1.7.6 Upper winds ........................................................................................................................................ 23 1.7.7 Weather received by the crew ........................................................................................................... 23 1.8 Aids to navigation..............................................................................................................23 1.8.1 Navigational aids ................................................................................................................................ 23 1.8.2 Possible interference with Resolute Bay instrument landing system functionality .................. 24 1.9 Communications ................................................................................................................24 1.9.1 General ................................................................................................................................................. 24 1.9.2 Arrival and approach of KBA909 ..................................................................................................... 24 1.9.3 Communication search for FAB6560 ................................................................................................ 25 1.10 Aerodrome information ....................................................................................................26 1.10.1 Resolute Bay airport ........................................................................................................................... 26 1.10.2 Operation NANOOK additional resources ..................................................................................... 27 1.10.3 Community aerodrome radio stations ............................................................................................. 27 1.11 Flight recorders ..................................................................................................................28 1.11.1 General ................................................................................................................................................. 28 1.11.2 Flight data recorder ............................................................................................................................ 28 1.11.3 Cockpit voice recorder ....................................................................................................................... 31 1.12 Wreckage and impact information ..................................................................................32 1.12.1 Impact ................................................................................................................................................... 32 1.12.2 Wreckage .............................................................................................................................................. 33 1.13 Medical and pathological information ...........................................................................35 1.14 Fire........................................................................................................................................35 1.15 Survival aspects ..................................................................................................................36 1.15.1 Rescue response .................................................................................................................................. 36 1.15.2 Emergency locator transmitter .......................................................................................................... 36 1.15.3 Aircraft occupant seats / structural damage .................................................................................. 37 1.16 Tests and research ..............................................................................................................38 1.17 Organizational and management information ..............................................................38 1.17.1 First Air................................................................................................................................................. 38 1.17.2 Adaptations of standard operating procedures .............................................................................
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