Scheduled Revenue Flight

The pilot’s failure to maintain clearance from a tree during a low altitude maneuver and his failure to maintain control of the airplane. Contributing to the accident was the pilot’s use of over-the-counter sedating medications.

Findings as to Causes and Contributing Factors:
1. Airspeed fluctuations at touchdown, coupled with gusty wind conditions, caused a bounced landing.
2. Improper go-around techniques during the recovery from the bounced landing resulted in a loss of control.
3. It is possible that confused crew coordination during the attempted go-around contributed to the loss of control.

The Board of Inquiry estimated that the probable cause of this accident was the crew's decision to continue the approach and landing without carrying out the procedures (ABNORMAL AND EMERGENCY PROCEDURES) established by Embraer in the Quick Reference Handbook when a malfunction occurred with the slat/flap system, resulting in a wrong approach configuration.
The following findings were identified:
- The slats were inoperative during the approach and the crew performed five trouble shooting without success,
- Despite this situation, the crew decided to continue the approach, failed to follow the approach checklist and failed to input the reference speed and distance for landing according to circumstances,
- The aircraft landed too far down the runway, about 880 metres past the runway 35 threshold,
- The braking action was low because the runway surface was wet,
- In normal conditions, with flaps down in second position and slats out, the landing reference speed was 119 knots with a landing distance of 880 metres,
- Because the slats were inoperative, the landing reference speed should be 149 knots and a landing distance of 1,940 metres was needed,
- The aircraft passed over the runway threshold at a height of 50 feet and at an excessive speed of 163,8 knots,
- Spoilers were activated 9 seconds after touchdown, 950 metres after the runway threshold,
- Reverse thrust systems were activated 1,280 metres after the runway threshold,
- The crew started to use brakes 2,300 metres after the runway threshold (runway 35 is 3,125 metres long), with the antiskid system activated,
- Due to an excessive approach speed (15 knots above Vref), a too long flare and a too late application of the brake systems, the aircraft could not be stopped within the remaining distance,
- The slats malfunction was the consequence of the failure of several actuators which did not support negative temperatures met during the last flight,
- Since last July 19, the slats failed 53 times on this aircraft, six times during the approach and 47 times in flight,
- The crew failed to initiate a go-around procedure.

Findings as to causes and contributing factors:
1. Heavy rainfall before and during the landing resulted in a 4–6 mm layer of water contaminating the runway.
2. The occurrence aircraft’s airspeed during final approach exceeded the company prescribed limits for stabilized approach criteria. As a result, the aircraft crossed the runway threshold at a higher than recommended VREF airspeed.
3. A go-around was not performed, as per standard operating procedures, when the aircraft’s speed was greater than 5 knots above the appropriate approach speed during the stabilized portion of the approach.
4. The application of engine thrust just before touchdown caused the aircraft to touch down 3037 feet from the threshold at a higher than recommended airspeed.
5. The combination of a less than firm landing and underinflated tires contributed to the aircraft hydroplaning.
6. The emergency/parking brake was applied during the landing roll, which disabled the anti-skid braking system and prolonged the skid.
7. The aircraft lost directional control as a result of hydroplaning and veered off the runway.

Findings as to risk:
1. The typical and frequently used technique for differential braking that pilots are trained to use may not be effective when anti-skid systems require different techniques.
2. If aircraft electrical power is applied with an active fuel leak, there is a risk that an electrical spark could ignite the fuel and start a fire.
3. The use of non-grooved runways increases the risk of hydroplaning, which may result in runway excursions.
4. If there is an absence of information and training about non-grooved runways, there is a risk that crews will not carry out the appropriate landing techniques when these runways are wet.
5. The use of thrust reversers reduces the risk of runway excursions when landing on wet runways.
6. If pilots do not comply with standard operating procedures, and companies do not assure compliance, then there is a risk that occurrences resulting from such deviations will persist.

Other findings:
1. The central maintenance computer was downloaded successfully; however, there were no data present in the memory unit.
2. Although the Transportation Safety Board was able to download high-quality data from the flight data recorder, the parameters that were not recorded due to the model type and input to the flight data recorder made it more difficult to determine the sequence of events.

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 crew’s 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 captain’s 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 aircraft’s true heading was 346°. With 3° of wind drift to the right, the aircraft diverged further right of the localizer.
5. The crew’s 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 crew’s 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 crew’s 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 officer’s statement of “3 mile and not configured” 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 communicate his concerns and suggest a go-around. Outside of the two-communication rule, there was no guidance provided to address a situation in which the pilot flying is responsive but is not changing an unsafe course of action. In the absence of clear policies or procedures allowing a first officer to escalate from an advisory role to taking control, this first officer likely felt inhibited from doing so.
17. The crew’s crew resource management was ineffective. First Air’s initial and recurrent crew resource management training did not provide the crew with sufficient practical strategies to assist with decision making and problem solving, communication, and workload management.
18. Standard operating procedure adaptations on FAB6560 resulted in ineffective crew communication, escalated workload leading to task saturation, and breakdown in shared situational awareness. First Air’s supervisory activities did not detect the standard operating procedure adaptations within the Yellowknife B737 crew base.

Findings as to risk:
1. If standard operating procedures do not include specific guidance regarding where and how the transition from en route to final approach navigation occurs, pilots will adopt non-standard practices, which may introduce a hazard to safe completion of the approach.
2. Adaptations of standard operating procedures can impair shared situational awareness and crew resource management effectiveness.
3. Without policies and procedures clearly authorizing escalation of intervention to the point of taking aircraft control, some first officers may feel inhibited from doing so.
4. If hazardous situations are not reported, they are unlikely to be identified or investigated by a company’s safety management system; consequently, corrective action may not be taken.
5. Current Transport Canada crew resource management training standards and guidance material have not been updated to reflect advances in crew resource management training, and there is no requirement for accreditation of crew resource management facilitators/instructors in Canada. This situation increases the risk that flight crews will not receive effective crew resource management training.
6. If initial crew resource management training does not develop effective crew resource management skills, and if there is inadequate reinforcement of these skills during recurrent training, flight crews may not adequately manage risk on the flight deck.
7. If operators do not take steps to ensure that flight crews routinely apply effective crew resource management practices during flight operations, risk to aviation safety will persist.
8. Transport Canada’s flight data recorder maintenance guidance (CAR Standard 625, Appendix C) does not refer to the current flight recorder maintenance specification, and therefore provides insufficient guidance to ensure the serviceability of flight data recorders. This insufficiency increases the risk that information needed to identify and communicate safety deficiencies will not be available.
9. If aircraft are not equipped with newer-generation terrain awareness and warning systems, there is a risk that a warning will not alert crews in time to avoid terrain.
10. If air carriers do not monitor flight data to identify and correct problems, there is a risk that adaptations of standard operating procedures will not be detected.
11. Unless further action is taken to reduce the incidence of unstable approaches that continue to a landing, the risk of controlled flight into terrain and of approach and landing accidents will persist.

Other findings:
1. It is likely that both pilots switched from GPS to VHF NAV during the final portion of the in-range check before the turn at MUSAT.
2. The flight crew of FAB6560 were not navigating using the YRB VOR or intentionally tracking toward the VOR.
3. There was no interference with the normal functionality of the instrument landing system for Runway 35T at CYRB.
4. Neither the military tower nor the military terminal controller at CYRB had sufficient valid information available to cause them to issue a position advisory to FAB6560.
5. The temporary Class D control zone established by the military at CYRB was operating without any capability to provide instrument flight rules separation.
6. The delay in notification of the joint rescue coordination centre did not delay the emergency response to the crash site.
7. The NOTAMs issued concerning the establishment of the military terminal control area did not succeed in communicating the information needed by the airspace users.
8. The ceiling at the airport at the time of the accident could not be determined. The visibility at the airport at the time of the accident likely did not decrease below approach minimums at any time during the arrival of FAB6560. The cloud layer at the crash site was surface-based less than 200 feet above the airport elevation.

The probable causes of the accident were the failure of the crew to go around and the descent well below decision height without visual reference to landmarks when the aircraft approached the airfield in weather conditions below the captain's, aircraft's and airfield's minima and in dangerous/adverse weather phenomena like thunderstorm, heavy rain and severe turbulence as well as the lack of appropriate response and required actions following terrain awareness warning system alerts resulted in a controlled flight into terrain, collision with obstacles and the destruction of the aircraft.
Contributing factors:
- the crew underestimated the weather conditions at the destination airport thus taking an erroneous decision to attempt an approach in thunderstorm and heavy rain showers,
- unsatisfactory meteorological support of the flight, the dispatcher and later air traffic control provided information about visibility, cloud and wind data that did not correspond to actual conditions that were significantly worse than minimums required,
- clearance for the approach by air traffic control despite the presence of dangerous weather phenomena (thunderstorm, heavy rain) at the aerodrome, which did not correspond to the standard operating procedures at Blagoveshchensk,
- inadequate staffing with a first officer who was performing his first flight after a prolonged leave without proper preparation and training,
- unsatisfactory crew interaction and the failure to adhere to standard operating procedures, especially the call outs of approaching decision height, the absence of a decision by the commander to continue the landing or go-around and the lack of action to recommend/initiate a go around by the first officer.