First Air Flight 6560

Investigation

The accident was investigated by the Transportation Safety Board of Canada (TSB). In January 2012, the TSB issued an investigation update classifying the accident as a controlled flight into terrain (CFIT). It stated that the go-around manoeuvre was initiated two seconds before impact.

At that time, the crew had completed the landing checklist, the flaps were at 40, the aircraft was travelling at 157 kn and the landing gear was down and locked. Both engines were in operation and producing power. The aircraft had been following an instrument landing system (ILS) approach due to poor visibility. Post-crash investigation found the airport's ILS system to be operating normally, and was in fact used by another aircraft that successfully landed 20 minutes after the crash of Flight 6560.

In March 2014, the TSB issued the final accident report. It found that the crew's decision to initiate the descent from cruise altitude was late, and it resulted in a significantly increased workload that affected the crew's subsequent performance and ability to properly track all parameters.

The approach was entirely flown on autopilot, which was correctly set to capture the localizer signal and track along the runway centreline (VOR/LOC capture mode). However, an inadvertent movement of the control column by the captain during the turn onto the final approach track caused the autopilot to disengage from VOR/LOC mode and revert to only maintaining the current heading, resulting in the aircraft drifting out to the right (east) of the runway centreline.

The deviation was correctly shown on the onboard localizer indicator. However, for undetermined reasons, the compass system had been incorrectly set during initial descent so that it displayed a heading that was 8° to the left of the actual heading. Furthermore, the pilot did not recalibrate the compass after the initial descent, 15 minutes before the accident, though regular recalibration when so near the north magnetic pole is necessary; the magnetic influence further increased the initial mis-calibration to 17°, giving the captain the wrong impression that the aircraft was tracking towards regaining the runway centreline.

In fact the aircraft was flying roughly parallel to the runway, and a wind from the southwest was pushing it even further to the east. Under a significantly increased workload, neither pilot noticed the partial disengagement of the autopilot. First officer Hare was aware that the aircraft was off course to the right and heading for the hill east of the airport. He tried to warn Captain Rutherford 18 times, using multiple different variations of phrasing, but failed to find a way to convey the urgency of the situation and make the captain change his course of action. After the ground proximity warning system (GPWS) issued a 'sink rate' warning, Rutherford finally commanded a go-around, but there was insufficient distance from terrain to avoid the collision.

The TSB highlighted how according to First Air's own standard operation procedures, the approach was clearly unstable and should have been aborted at an early stage. The board stressed the risks posed by unstable approaches that are continued to a landing, and called for airlines and authorities to enforce standard operating procedures and crew resource management best practices, to help crews manage workload and communicate effectively in order to make better decisions.