Investigation Summary
The accident was driven by a breakdown in Crew Resource Management (CRM) under high workload. During the turn onto final approach, the Captain inadvertently bumped the control column, which caused the autopilot to switch from 'VOR/LOC' capture mode to 'HDG SEL' (heading select) mode. Because the aircraft was operating near the North Magnetic Pole, the compass system required frequent manual recalibration. The investigation found that the compass was already mis-set by 8 degrees during the initial descent; uncorrected magnetic drift during the remainder of the flight increased this to a 17-degree directional error. This error coincidentally made the heading indicator appear to show the aircraft was intercepting the localizer, even as it was actually flying parallel to it and drifting further east due to a southwest wind. The First Officer identified the deviation using GPS data and visual cues, but his 18 attempts to intervene were not assertive enough to overcome the Captain's confirmation bias.
Final Conclusions
The TSB concluded that the late initiation of descent increased crew workload, leading to the undetected autopilot mode change. The compass drift provided misleading information that supported the Captain's belief they were on course. Ineffective CRM prevented the First Officer from successfully challenging the Captain's decision to continue an unstable approach. The aircraft impacted a hill 1 nm east of the runway midpoint. The proximity of a military exercise (Operation Nanook) allowed for an immediate rescue response, which saved the three survivors.
Photographic Evidence (1)
Video Analysis
Wrong Course Air Crash Boeing 737 First Air Flight 6560 — A detailed look at the navigation errors and CRM breakdown that led to the crash of First Air 6560 in the Canadian Arctic.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
First Officer
Systems & Failure Modes
Autopilot (SP-77)
Reverted from VOR/LOC to HDG mode after an inadvertent control column input, causing the plane to stop tracking the localizer.
Compass System
Experienced significant gyro drift due to high latitude; the crew failed to recalibrate it, leading to a 17 degree error.
GPWS
Provided 'Sink Rate' and 'Minimums' alerts, but the crew's response was too late to avoid terrain.
Interesting Facts
- 01The aircraft was a 'combi' model, carrying 5 cargo pallets in the front and 4 rows of passengers in the rear.
- 02The crash occurred during Operation Nanook, a military exercise that coincidentally included a simulated plane crash scenario.
- 03The First Officer attempted to warn the Captain 18 times about the navigation deviation.
- 04The aircraft compass was found to be 17 degrees out of alignment due to a combination of an initial mis-setting and uncorrected magnetic drift.
- 05The aircraft impacted a hill 396 feet above mean sea level, located approximately 1 nm east and abeam the runway midpoint.
- 06Three passengers survived the impact and were rescued by Canadian military personnel already on site for the exercise; they were evacuated via a CC-177 aircraft.
Safety Actions & Advisories
CRM Training Standards
The TSB recommended that Transport Canada develop contemporary CRM training standards for all Part VII commercial operators to include threat and error management.
Unstable Approach Policies
The investigation highlighted the need for airlines to enforce strict 'go-around' policies when approach parameters (like lateral deviation) are exceeded.