reducing "Crew-caused"
approach and landing

Pilot-in-charge Monitored Approach

2011 B737 CFIT Resolute Bay Canada

Brief account : 

The Boeing 737-200 making an ILS approach struck a hill east of the designated landing runway in IMC and was destroyed. An off-track approach was attributed to the aircraft commander’s failure to recognise the effects of his inadvertent interference with the AP ILS capture mode and the subsequent loss of shared situational awareness on the flight deck. The approach was also continued when unstabilised and the Investigation concluded that the poor CRM and SOP compliance demonstrated on the accident flight were representative of a wider problem at the operator. 

Crew-related factors : 

The Captain was experienced on type and on the route. While the F/O was experienced he was new to the B737 (100hrs) and the specifics of the route. The aircraft was a fairly early model B737 with relatively basic automatics and instruments.  Operation to Resolute Bay poses some peculiarities due to the the high latitude necessitating changing the compass references.

The Captain (PF's) brief was incomplete and the initial approach was high and fast. The last weather reported to the crew was significantly better than that actually encountered (10 miles /700ft vs 5km / 300ft, taken 7 mins after impact).

 A number of factors including accumulated compass errors and mishandling of the autopilot resulted in the aircraft being increasingly off the actual runway centre-line. Although the First Officer had recognised the deviation and pointed out that it corresponded to the position indicated by the GPS, the PF had failed to take any notice of these observations despite having no external visual reference.

With the expected intercept angle remaining on the HIS in the presence of a significant but unappreciated compass error, the PF appeared to have an expectation that the required track would be regained. The F/O made several hints that he was unhappy implying that a go-around would be advisable. 

The investigation considered that the conversation between the two pilots during this final descent had been wholly ineffective. It was also noted that the late configuration of the aircraft and resultant failure to either stabilise the aircraft or go around was probably at least partially a result of the high speed arrival and the developing confusion on the flight deck as a shared situational awareness was lost.

The investigation commented that the 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. The standard operating procedure adaptations on this flight resulted in ineffective crew communication, escalated workload leading to task saturation, and breakdown in shared situational awareness.   

If the flight had been operated using a PicMA procedure it is likely that

1) a more thorough and interactive briefing would have taken place, particularly in the light of the F/O's low experience level on the type.

2) the descent would have commenced earlier and with more caution. 

3) if the same handling errors had been made by the F/O as PF, they would almost certainly have been picked up by the Captain. 

4) any disquiet felt by the Captain about the final approach track would have been acted upon. 

Resolute Bay, Canada
Expected weather: 
Pilot in charge: 
Early transition: 
Go-around : 
PicMA potential: 
Vert Guidance: 
Both Head Up: 
First Air
Fully prepared: 
Actual Weather: 
Low Cloud
Autopilot :