Pretty shocking reading the communication between the CPT and FO.Transportation Safety Board of Canada - Aviation Investigation Report A11H0002

 

I don't know what more that FO could have done besides say "my controls" and go around. Tough spot to be in. This should be used in CRM training.

 

My my my
That conversation is agonizing to read!

 

Agreed, USMC.... ugh.

Another example of CRM gone wrong written in blood.

 

Reading the transcript brought to mind Air Florida Flight 90.
Two FOs who got to take a death ride courtesy of their CAs' hubris.

We all get to die some time but I don't envy kinda knowing you're about to
because the guy in the seat next to you "knows better."

 

Exactly, the QH guy was a "I know everything " "I'm in charge, I'm the Captain!"

 

I guess I'm blind but I don't see a transcript of the CVR just a sequence of events.

 

At the risk of further ruffling the feathers of the (admittedly) mighty status quo and its applauders, I'd like to chime in on this with more than just the view of sympathetic but nevertheless outside observer.

This tragic event really touched me back then - and even today - because I've flown B-732 combis countless times to Arctic strips, both land and ice; have been to CYRB a thousand times and know the operational challenges it presents. But mostly because I personally know some First Air pilots and Flight Attendants. This was one of those proverbial last straws that broke the camel's back and drove me to dust off my manuscript and publish it. I could no longer just sit back and watch pilots kill their passengers, crews and themselves without at least trying to shake the captains of the industry out of their stupor. I realize I stand little chance of seeing results - if any - but hope my thoughts will catch the eyes of an energetic young hard-charger who will grab the baton and run with it.

First Air's operations, from what I saw, reflected industry standards in all respects. Its pilots were, in my esteem, a notch above their urbanized counterparts in competence, and far above them in experience with operations beyond the world of radars and concrete runways. And if they were, and yet still could not overcome the challenges of their profession, then to simply treat this tragic event as just another CFIT, to investigate only the collapse of a line of defense but not its foundation nor the method of its construction, to issue tired recommendations, lean on pilots and Air Carriers and then resume a business as usual attitude defies all logic. One doesn't have to be a dermatologist to realize that applying skin ointments will not cure, not even control, melanoma. So what's the logic behind topical treatment of a systemic disease in aviation? If pilots, "trained to standards," highly experienced and operating in their home environment can't cope with the challenges of their profession, what chance does the average "trained to standards" pilot have operating inside, or worse, outside his home environment, not to mention greenhorns released to the line?

I don't see the badly needed change in industry thinking in this report - I'm sad to say. One would think finding the cause starts by looking in the right place. The TSB failed to do that, just as its predecessor, the CASB, did following the MF1285 crash earlier. We can hope for positive change only when we see investigative Boards use such terms as airline Board of Directors Error, Management Error, CEO Error, CFO Error, and Regulator, Minister (Secretary) of Transportation and Lobbyist Error instead of Pilot Error, Human Error or its politically correct variant, Human Factors - which for some inexplicable reason always seem to exclude the above listed suspects.

Whenever the Chief Pilot or his Standards equivalent is tasked to "fix" a "Human Factors" problem, Senior Management directs him to do whatever he wants as long as it keeps the airline out of the Courts, but whatever his solution, it comes out of his budget - possibly supplemented by a token amount to give the matter the semblance of earnest intent and compliance. He can then either cut somewhere else, betray his pilots and his profession, or resign. In the vast majority of cases, he simply reaches into the magic CRM hat filled by the Regulator's or his political boss' bureaucrats who formulate recommendations in the absence of competent guidance but under overt or subtle lobby pressure. He pulls out the first rabbit from a smorgasbord of aviation-sounding concepts and psychology 101 subjects, some rational, some absurd, that bears some semblance to the problem he is tasked to fix, and tosses it to the Training Department to feed to his pilots. If he's lucky, his efforts will be rewarded. In all other cases nothing will change or worse, even more crashes.

This has been the state of the art industry mentality regarding Human Factors since deregulation whether one is ready to acknowledge it or not. This report suggests it still is. More CRM training will accomplish nothing but carries the risk of worsening the situation: CRM ought to reinvent itself. Better yet, it ought to be scrapped all together, and replaced by relevant academic subjects taught in Ground School.

If all the causes and contributing causes of this accident had to be crammed into one, it would be misguided pilot training, the product of industry delusions.

 

Its not the training, its the captain disregarding the f/o's multiple remarks regarding being off course, abandoning the approach, and terrain.
Obviously a huge CRM problem here.
The TSB is very tight with CVR transcripts, but they were shown here for a reason.

 

CRM scrapped and replaced with more ground school?
NOTHING short if physical action would have saved that crew and aircraft because the CA disregarded every clue provided.
I can give the answers for a test to a student and that student can still CHOSE to fail. This CA failed.