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First Air 737

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Hi Kasey;

Re, "What ever happened to Aviate, Navigate, Communicate...................."

Well that implies "pilot error" and usually those things are a little more complicated than that. What you think should have happened does not explain people's behaviour.

It might depend upon a number of possibilities, particularly (of course) the Navigate part. Do their a/c have GPS along with IRS (or INS?)? How was it programmed? Could this be a "true north" vs "mag north" nav or cockpit switching issue? Flight plan log-keeping (to detection of nav errors)? Cockpit conversations/distractions? Subtle equipment failure? We don't know yet.

Clearly the cause(s) need to be determined so that the error(s) can be communicated to others in order to learn (or re-learn). This is a TSB file for now so we'll see what the outcomes are before contemplating what TC might do. Scrutiny yes, but of what? We need to suspend judgement in favour of curiosity.

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"We need to suspend judgement in favour of curiosity"

Hey Don,

No judgement here, having flown the said environment for many years it came down to the skills and training of every pilot on deck! Check, double-check and be sure of adding vs subtracting when navigating in this unforgiving area.

Not saying this was not done just making an observation.

This was a very lucky outcome........

Kacey

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Kacey...sorry, that was a careless comment - I was thinking generally in terms of examining incidents, not "targeting" your observation - I've just come from the CHC Summit on Helicopter Safety and a primary theme was ensuring that one looked at all possible sources of error including the human factors ones.

Yes, very lucky outcome - it will be interesting to find out what happened and why.

Don

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.

First Air pilots suspended after flying 100s of kms off course

Boeing 737 had 19 passengers and 4 crew on board for flight from Rankin Inlet to Iqaluit


Tue Apr 08, 2014 - CBC News

First Air says the pilots of a flight that went hundreds of kilometres off course last month have been suspended with pay until an investigation is complete.

In a statement, the airline said it launched an investigation immediately after learning that a Boeing 737-200 with 19 passengers and four crew members on board went off its planned route last week.

“We have learned that there was no threat to the safety of the passengers and crew on board and the flight landed safely without further incident,” the statement reads.

First Air said it will work closely with the Transportation Safety Board on its review of the incident.

The Transportation Safety Board said the First Air flight left Rankin Inlet on Monday, March 31, headed for Iqaluit, but instead of flying there, the plane flew northeast.

“It was substantially off course,” said Peter Hildebrand, the regional manager for the TSB in Winnipeg.

Hildebrand said the aircraft was flying on auto-pilot using GPS navigation when the crew noted that they hadn’t been handed off from air traffic control in Edmonton to Montreal. They made a transmission to Montreal, but couldn’t make out the reply.

He said the crew was already reacting to the situation and was taking steps to get back on track when another aircraft relayed a message from Montreal to the flight crew.

“They reset those instruments and proceeded direct to Iqaluit,” Hildebrand said.

‘You don’t want this to be happening’

.

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http://www.cbc.ca/news/canada/north/first-air-fires-pilots-who-flew-off-course-in-nunavut-1.2605682

First Air fires pilots who flew off course in Nunavut
Flight from Rankin Inlet to Iqaluit went 100s of kilometres off course

CBC News Posted: Apr 10, 2014 11:19 AM CT Last Updated: Apr 10, 2014 12:03 PM CT


first-air-boeing-737-200.jpg

A First Air Boeing 737 flew 100s of km off course during a routine flight from Rankin Inlet to Iqaluit.

After reviewing the flight data and navigational aids on board, First Air has fired two pilots who flew a Boeing 737 hundreds of kilometres off course during a routine flight from Rankin Inlet to Iqaluit.

“During the interviews, we learned the pilots did not follow our standard operating procedures designed to eliminate navigational errors,” a news release from First Air said.

The airline company said it interviewed the pilots and received reports from the cabin crew on board before making the decision to fire the two.

“Most importantly, we have learned that there was no immediate threat to the safety of the passengers and crew,” the release says.

First Air said passenger and crew safety have always been the company’s top priority, and they have taken this incident “very seriously.”

The company said it has reinforced procedures with all crew and dispatch staff and increased in-flight oversight using data monitoring tools.

First Air said it will share the results of its investigation with the Transportation Safety Board.

On March 31, Flight 955 left Rankin Inlet for Iqaluit with 19 passengers and four crew members on board.

Instead of flying to its destination, the plane flew north.

The pilots were relying on auto-pilot using GPS navigation when the crew noticed they hadn’t been handed off from air traffic control in Edmonton to Montreal.

After making contact with Montreal, the pilots reset their course and landed without incident in Iqaluit.

Maintenance crews on the ground found no equipment problems, and cleared the plane to continue flying.

The pilots were grounded while the investigation was underway.

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Seems a touch extreme...perhaps 'demoted' Captain and FO to be held at that rank for longer than normal...., then again I guess the company felt an example had to be made..... :scratchchin:

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Wow is right. So much for a non-punitive SMS.

Having said that, what were these pilots' histories? Was this a one-off, or another of a long string of similar SOP failures?

We can't judge. We can see the extreme reaction of the company.

What will happen the next time a pilot or crewmember commits an error, of judgment or of procedure? Will they want to learn from the mistakes made ("They" being the Company), or will "they" go the antithesis route of SMS and just fire the f****ers?

This and the "other" horrible accident are nothing more than canaries in a coal mine called SMS.

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Guest longtimer

Quote from a CBC News Story:


Peter Black, chair of the First Air unit of the Air Line Pilots Association International, said in a statement that the union is "deeply disappointed" with the decision to fire the pilots "prior to a complete and thorough investigation of the incident."

“This rush to judgment has unfairly called into question the expertise and professionalism of a crew with more than 40 years of combined flight experience," Black said. "We will use all of the union’s resources to investigate this incident and support the crew.”


http://www.cbc.ca/news/canada/north/first-air-fires-pilots-who-flew-off-course-in-nunavut-1.2605682

So I imagine the terms of the collective agreement will now kick in.

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Demotion

Seems a touch extreme...perhaps 'demoted' Captain and FO to be held at that rank for longer than normal...., then again I guess the company felt an example had to be made..... :scratchchin:

Is it standard protocol to not fire pilots? Call me crazy but f#*k up bad enough and you deserve to lose your job, no?

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Many pilots have made errors of a lot more consequence and have not been fired. No one was hurt, no damage to people or aircraft, they were never in an emergency situation, (ATC/aircraft pretty much bailed them out prior to arriving at that stage).

Personally, I would think they learned their lesson and less drastic action by the company would have been in order.

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I suppose if there were no previous pilot navigational errors resulting in fatalities and haul loss at First Air, one might agree.

Both Canadian (landed in Churchill, MB) and Pacific Western (departed The Pas, MB) had similar nav problems with 737s. I know the PWA incident resulted in the Captain being fired.

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To me it indicates that First Air has a great deal to learn still.

Beyond that it is none of our business. The union must do as it must according to Canadian Labour law. I will say that it is unfortunate to place the issue in this old-fashioned discourse for they may have others who "do not adhere to SOPs" and now that door to a change-of-cutlure is being shut.

CanadaEH - this isn't McDonalds where if you screw up the order or the management of the store you're out the door.

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Rich, the captain who landed the Southwest 737 so hard that the nose gear collapsed is probably never going to make that level of income again, should that enter into management's decision making process when terminating an employee? IMO, I don't think so. There are professions that should be held to a higher level than a McDonalds employee, and this is one of them.

IMO, there are two possible reasons why this pair was fired so quickly:

1. Safety theater: management is trying to save face after the Resolute accident.

2. Management listened to the CVR tapes, interviewed the pilots, and reviewed their training files, and decided that their actions were negligent and/or incompetent and a safety issue.

If it's #1, well that's just plain wrong, and hopefully the union will be able to successfully defend them. If it's #2, maybe a change of career is in order, to something with a lesser degree of responsibility.

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Not so much a "higher standard" than other professions but crews have to be held to an examination process that is focussed on "what" not who to begin with.

The assumption behind the notion, "higher standard" is that of "the bad apple". That notion automatically sets up the paired-opposite concept of "the good apple". Do any of us really believe that human beings and human factors can be understood this way and do we expect that "once those bad apples are weeded out (fired), things will be different?

While I understand and know that fundamental competency can be an issue in rare cases, (the Southwest nosewheel landing...), this doesn't feel like a case of crew/pilot incompetence or negligence. The TSB may not have said so directly, but the the Board's Report into First Air's Resolute Bay fatal accident made it abundantly clear enough:

“People rarely follow rules or instructions precisely. They do so for reasons and in ways that make sense to them given their circumstances, knowledge and goals.”

“While policies and SOPs are prescribed by a company to set boundaries for safe operations, individuals may experiment with the boundaries in order to become more productive or obtain some other benefit. This experimentation leads to adaptations of procedures and to a shift beyond the prescribed boundaries described in the SOPs, toward unsafe practices.“

. . .

“Such adaptations are unlikely to be recognized as deviations by those within the group employing them. The adaptations slowly become normal behaviour, and the risk associated with them is unlikely to be recognized. This tendency has been described as the ‘normalization of deviance’.

Using these non-SMS, traditional tools (discipline, two-weeks-off, firing, etc), to correct what appears to be operational culture problems inevitably means that the wrong solutions will be arrived at and the same outcomes are going to occur again, just with different "bad apples".

Two serious events, one fatal, appear to indicate that there are cockpit discipline / CRM issues here. If so, where does that come from? Numerous flight safety conferences wrestle with these questions constantly.

We know that both the fatal accident and this navigation incident were easily preventable. How does firing the crew solve the obviously-larger problem? People cannot be frightened or threatened into not making mistakes. I doubt very much whether these guys started out anticipating the outcomes that occurred. Was this because the causes of both were invisible due to the normalization of deviance? Is it a coincidence or a place to begin that both these serious/fatal events were SOP and navigation related? If two crews, then what of others? That is the question to ask, I think - not "Why were these guys fired?"

The other issue that comes up in these discussions is, "Compliance". Human beings, very capable, earnest, intelligent human beings with stellar reputations as pilots are going to make mistakes. Is that "non-compliance" or "human error"? How do we decide which is which, and why?

It does no good to just say "follow SOPs" or else, and achieving 100% compliance under any circumstances is not possible. So finding out why people are making mistakes is part of the flight safety / investigative process.

It is very unlikely that a fired crew and a union forced into a defence position is going to be part of that process of change. What conclusions may we draw concerning outcomes?

This approach does not mean there are no consequences for crews or for an airline's management. Consequences come in the form of due diligence for both the airline, and pilot representatives as constituted at the airline. Check rides, extra simulator sessions, being placed in the right seat for a period of time or being placed on probabation for a period of time is not punishment, it is due diligence. This is what a Safety Reporting culture is under SMS. edit: Under SMS, a crew finding themselves to have made an error must self-report no matter how minor or serious the event. A crew cannot for example overspeed flaps or gear and neither log the event nor self-report. Such actions may place others who fly the airplane next at risk and may even place one's company at risk.

And if a flight data analysis program shows events or a violation (small 'v') of SOPs or operational handling of the airplane or a serious event such as an EGPWS/TCAS/Stick shaker, airspeed/structural limit exceedence or 'g' exeedence then the crew must be contacted by their flight data representative to understand what occurred and why so that de-identified information may be passed on to the appropriate management (ops, training, standards, regulatory) and also to the pilots in regular reports, for their awareness and learning. In such a process there is no good reason to refuse to participate in the safety process.

It is only at the end of that process where it is concluded that either a pilot is unable or unwilling to address the issues that have led to these initial processes, that "another line of work" may be in order.

Firing a pilot perhaps means that little or none of this initial work would have been done, or if done was box-ticking and ineffective in handling the precursors that inevitably are there but the processes or culture aren't in place to make such signs visible. It is a variation on the notion that "I'll see it when I believe it".

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From Flight Global:

http://www.flightglobal.com/news/articles/first-air-to-equip-fleet-with-automatic-black-box-streaming-398614/?cmpid=NLC|FGFG|FGFIN-2014-0506-GLOB&sfid=70120000000taAh

First Air to equip fleet with automatic black box streaming
Washington DC
Source: pro.png
22:05 25 Apr 2014

Canadian carrier First Air is equipping its fleet with a new capability that allows for automatic streaming of aircraft black box data, says the carrier.

The airline, which specialises in passenger and cargo flights to remote areas in Northern Canada, says it expects its entire fleet to be outfitted with the capability to start automatic black box streaming and downloading by “the middle to the end of May,” says Vic Charlebois, First Air’s vice-president, flight operations.

First Air will add the function, called FLYHTStream, to its Automated Flight Information Reporting System (AFIRS) provided by Calgary-based FLYHT Aerospace Solutions. The airline finished installing the system on its fleet of 22 aircraft in January, says Charlebois. It has been using the AFIRS system for tasks including tracking flights and monitoring engine trends since first rolling out the system about 18 months ago.

First Air will be the first of about 40 airlines using the AFIRS system for performing real time data downloads of the black box data while the aircraft is flying, says FLYHT. The streaming would only begin if the AFIRS system receives alerts from aircraft systems that there could be an emergency, which is another function that FLYHT is working to provide.

(FLYHTStream)

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