Accident Boeing 737-210C C-GNWN,

Date:	Saturday 20 August 2011
Time:	11:42
Type:	Boeing 737-210C
Owner/operator:	First Air
Registration:	C-GNWN
MSN:	21067/414
Year of manufacture:	1975
Engine model:	Pratt & Whitney JT8D-17
Fatalities:	Fatalities: 12 / Occupants: 15
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	1,8 km E of Resolute Airport, NU (YRB) - Canada
Phase:	Approach
Nature:	Passenger - Non-Scheduled/charter/Air Taxi
Departure airport:	Yellowknife Airport, NT (YZF/CYZF)
Destination airport:	Resolute Airport, NU (YRB/CYRB)
Investigating agency:	TSB
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
A Boeing 737-200 passenger plane was destroyed when it flew into terrain while on approach to Resolute Bay Airport, NU (YRB), Canada. There were 11 passengers and four crew members on board. Eight passengers and all four crew members were killed.
The airplane had departed Yellowknife Airport, NT (YZF) on a domestic charter flight to Resolute Bay. During the approach to Runway 35T, the aircraft 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 crew had 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.

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.

TSB stated the following findings as to causes and contributing factors:

1. The late initiation and subsequent management of the descent resulted in the aircraft turning onto final approach 600 feet above the glideslope, increasing the crews workload and reducing their capacity to assess and resolve the navigational issues during the remainder of the approach.
2. When the heading reference from the compass systems was set during initial descent, there was an error of -8°. For undetermined reasons, further compass drift during the arrival and approach resulted in compass errors of at least -17° on final approach.
3. As the aircraft rolled out of the turn onto final approach to the right of the localizer, the captain likely made a control wheel roll input that caused the autopilot to revert from VOR/LOC capture to MAN and HDG HOLD mode. The mode change was not detected by the crew.
4. On rolling out of the turn, the captains horizontal situation indicator displayed a heading of 330°, providing a perceived initial intercept angle of 17° to the inbound localizer track of 347°. However, due to the compass error, the aircrafts true heading was 346°. With 3° of wind drift to the right, the aircraft diverged further right of the localizer.
5. The crews workload increased as they attempted to understand and resolve the ambiguity of the track divergence, which was incongruent with the perceived intercept angle and expected results.
6. Undetected by the pilots, the flight directors likely reverted to AUTO APP intercept mode as the aircraft passed through 2.5° right of the localizer, providing roll guidance to the selected heading (wings-level command) rather than to the localizer (left-turn command).
7. A divergence in mental models degraded the crews ability to resolve the navigational issues. The wings-level command on the flight director likely assured the captain that the intercept angle was sufficient to return the aircraft to the selected course; however, the first officer likely put more weight on the positional information of the track bar and GPS.
8. The crews attention was devoted to solving the navigational problem, which delayed the configuration of the aircraft for landing. This problem solving was an additional task, not normally associated with this critical phase of flight, which escalated the workload.
9. The first officer indicated to the captain that they had full localizer deflection. In the absence of standard phraseology applicable to his current situation, he had to improvise the go-around suggestion. Although full deflection is an undesired aircraft state requiring a go-around, the captain continued the approach.
10. The crew did not maintain a shared situational awareness. As the approach continued, the pilots did not effectively communicate their respective perception, understanding, and future projection of the aircraft state.
11. Although the company had a policy that required an immediate go-around in the event that an approach was unstable below 1000 feet above field elevation, no go-around was initiated. This policy had not been operationalized with any procedural guidance in the standard operating procedures.
12. The captain did not interpret the first officers statement of "3 mile and not configged" as guidance to initiate a go-around. The captain continued the approach and called for additional steps to configure the aircraft.
13. The first officer was task-saturated, and he thus had less time and cognitive capacity to develop and execute a communication strategy that would result in the captain changing his course of action.
14. Due to attentional narrowing and task saturation, the captain likely did not have a high-level overview of the situation. This lack of overview compromised his ability to identify and manage risk.
15. The crew initiated a go-around after the ground proximity warning system "sink rate" alert occurred, but there was insufficient altitude and time to execute the manoeuvre and avoid collision with terrain.
16. The first officer made many attempts to c

Accident investigation: