BRADLEY AIR SERVICES LIMITED

BRADLEY AIR SERVICES LIMITED (FIRST AIR) CRASH, NUNAVUT
On 20 th August 2011, First Air 6560 then operated by Bradley Air Services
Limited crashed their Boeing 737-210C aircraft carrying 11 passengers and 4 crew
members into a hill which was also proceeded by a post-crash fire. The aircraft
departed Yellowknife, Northwest Territories heading to Resolute Bay, Nunavut. During
the approach towards Runway 35T, the plane crashed into a hill approximately 1
nautical mile east of the Runway 35T killing 8 passengers and all 4 crew members. The
aircraft was completely destroyed and there were only 3 survivors but with serious
injuries.
WHAT STORY DID WRECKAGE TELL?

Figure 3:-
Wreckage
Distribution.

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The
wreckage was scattered into many little pieces across a vast area which implies the
aircraft crashed at a very low angle but high velocity which was a result of the aircraft
stalling and the pilots losing control of the aircraft. The aircraft initially crashed at a 5°

nose up angle before rebounding and finally crashing at a second location
approximately 590 feet from initial impact location.
Fortunately for the investigators, the most of flight instruments in the cockpit were
recovered and it was discovered the aircraft’s heading was set on 29°T instead of 37°T,
an error of 8°. Also factoring in wind triangle calculation for the region at the time, an
offset of about 4° is required to compensate for the wind, however these calculations
were not included in the pilot’s decision making taking the heading error to at least 12°.
HOW HUMAN FACTORS LED TO THE CRASH OF THE AIRPLANE?
During the approach, the first officer expressed his concerns repeatedly about
the risk of an unstable approach but the captain brushed off the complaint and
proceeded with the risky approach which was one of the main causes of the crash.
The investigation revealed that the captain said he recalled an occurrence of a
similar situation on the same aircraft operated by a different pilot where the indicators
implied the aircraft position was drifted away from the localizer centreline but that pilot
managed to land safely. This most likely influenced the captain’s decision to continue
the approach rather than the standard procedure of returning to a stable attitude and re-
attempting the approach. The several human factors that affected the accident include
behavioural bias, expectation bias of the captain and the unhealthy corporate culture of
the airline which encouraged crew members to continuously bend from the standard
operating procedures.
The company’s policy and training suggested that the first officer can only take
control of the aircraft ONLY when the captain was incapacitated. However, the first
officer should have been trained in situational awareness to deal with occasions where
the captain is proceeding with an unsafe course of action when the risk can be easily
avoided. The plane would not have crashed if the captain listened to the advice of the
first officer to re-attempt the approach or if the first officer took control of the aircraft
when the captain was experiencing “subtle incapacitation”.