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.
A14-01
“Transport Canada require CARs Subpart 705 operators to monitor and reduce the incidence of unstable approaches that continue to a landing.”
Transport Canada Response
Since 2005, Canadian air operators operating under subpart 705 of the Canadian Aviation Regulations (CARs) must have a Safety Management System (SMS). Transport Canada has developed a Civil Aviation Safety Alert (CASA) to communicate to each air operator operating under subpart 705 of the CARs, that they should consider by using their SMS, the hazards and risks associated with unstable approaches. This CASA will inform the air operators that the Transportation Safety Board of Canada has determined that unstable approaches are a significant hazard and that Transport Canada has determined that this hazard can be mitigated through an air operator’s SMS. The CASA refers to SMS components such as safety oversight (reactive and proactive processes) and training and awareness (promotions). Additionally, the CASA will reference the voluntary use of Flight Data Monitoring (FDM) in order to gain a greater understanding of unstable approaches and the causes.
Transport Canada is committed to reviewing the effectiveness of the recommendations contained in the CASA through inspection activities. Transport Canada will determine if an air operator’s SMS is capturing all risks including unstable approaches, and if so, if this risk is being analyzed and addressed properly. This may be determined by performing a proactive assessment of unstable approach hazards (including situations where this is more likely to occur), a review of the SMS database to verify the rate of occurrence, a review of the SMS database to ensure that this is being reported and finally, follow up with the pilot community to verify that it is being reported and monitored through the SMS in order to verify a decrease in incidents and increased awareness of the hazard and attendant risks.
Canadian air operators are currently subject to a structured surveillance process described in Staff Instruction SUR-001. Transport Canada plans to direct specific surveillance activities, beginning approximately one year after the publication of the CASA, to air operators affected by the CASA. Transport Canada will begin looking for evidence of effective mitigations of this hazard through the recommended SMS processes. Alternatively, air operators that indicate that they do not have a problem with unstable approaches in their operation will be asked to demonstrate how they have reached this conclusion. Air operators with an established FDM program will have a definite advantage in gathering and analyzing this data.
Transport Canada will also conduct internal reviews to verify the effectiveness of voluntary recommendations such as those contained in the CASA.
Finally, as the safety issue may not be limited to 705 operators, the CASA will also serve to raise the concern with 703 and 704 operators and encourage them to address it voluntarily.
Safety Concern
“The Board is concerned that, without a comprehensive and integrated approach to CRM by Transport Canada and aviation operators, flight crews may not routinely practice effective CRM.”
Transport Canada Response
Crew Resource Management (CRM) remains a regulatory priority and work to consider appropriate amendments to the Canadian Aviation Regulations (CARs) continues based on the findings and recommendations of the CRM Focus Group held in 2012, and the 2010 risk assessment. As a regulatory framework that will reflect contemporary concepts is being developed, Transport Canada is now working towards engaging industry stakeholders through the Canadian Aviation Regulation Advisory Council (CARAC) to consult on proposed amendments to CARs 702, 703, 704 and 705. A Preliminary Issue and Consultation Assessment form (PICA) is being developed and will be communicated to the CARAC members in early Fall 2014. The PICA form will be followed by Notices of Proposed Amendments that will reflect the regulatory amendments that are contemplated.