"Blair, I don't like this."
Those were the last words First Air co-pilot David Hare spoke to pilot Blair Rutherford. Five seconds later, both were dead, along with 10 others on the airplane
A Transportation Safety Board report into the crash detailed Tuesday how it took just 2 1/2 minutes for a combination of human and technical mistakes to turn a passenger and supply flight to a remote Arctic community from routine to calamitous.
The investigation into the crash of First Air Flight 6560 blames an undetected autopilot change, a faulty compass reading and disagreement between the two pilots about whether to abort the landing.
"This accident was the product of a complex series of events, all of them lining up together," lead investigator Brian MacDonald said Tuesday as the report was released. "But what ultimately tied all these things together was that as the flight progressed each pilot developed a different understanding of the situation and they were unable to reconcile that difference."
The chartered plane was on a regular run to Resolute from Yellowknife on Aug. 20, 2011. There were scientists on the plane, along with staff heading back to work at a local inn and the inn owner's two young granddaughters.
The crash killed all four crew members and eight passengers. Three passengers miraculously survived.
In cool, technical language, the board's report provides a second-by-second breakdown of what probably happened in the cockpit as the pilots crashed the Boeing 737 into a hillside a kilometre from the runway.
Problems began because on-board compasses were incorrectly adjusted by 17 degrees. That error was compounded when the captain turned into the final approach and unwittingly changed the operational mode of the plane's autopilot. Busy with the landing checklist, in weather obscured by cloud, mist and light rain, neither he nor the co-pilot picked up the change.
Within seconds after that final turn, the co-pilot realized the plane was off course and repeatedly told the pilot, reminding him about the large hill to the right of the runway. Rutherford replied that the autopilot was working fine.
Puzzled as to why the plane's navigational instruments weren't lining up with ground-based systems, Hare asked if they'd done something wrong. Five seconds later, he suggested they pull up and go around for another approach.
Rutherford, fully focused on landing the plane and on figuring out why his instruments were giving confusing readings, refused.
"It is likely that the captain did not fully comprehend information that indicated that his original plan was no longer viable," says the report.
Less than 10 seconds after first suggesting they pull up, Hare asked again, pointing out that the plane wasn't configured for a landing so close to the landing strip. The report suggests Rutherford is likely to have understood the remark as a request to prepare the plane for landing.
Cockpit communication had broken down.
"The captain's mental model was likely that the approach and landing could be salvaged, and the (co-pilot's) mental model was almost certainly that there was significant risk to the safety of flight and that a go-around was required. These divergent mental models compromised the pilots' ability to communicate and work together."
Four seconds after his second request to pull up, Hare asked Rutherford to bank to the left. Their navigational confusion was evident when Hare confused the shoreline of a small lake with the seashore.
A couple of seconds later, Hare swore, then told his colleague: "Blair, I don't like this."
Almost immediately after, the plane's ground position systems began to sound alarms. About 2 1/2 minutes after making the final turn, Rutherford tried to pull up and go around.
"There was insufficient altitude and time to execute the manoeuvre and avoid collision with terrain."
The plane smashed into the hill and broke into three pieces. Flaming wreckage was strewn around the tundra.
Federal Transport Minister Lisa Raitt said she hadn't yet had a chance to read the crash report but her officials were examining it. "It's a very tragic accident that happened and of course we always want to make sure we do the best we can with respect to safety."