03/25/2014 04:00 EDT | Updated 05/24/2014 05:59 EDT

First Air Crash Report Complete Years After 12 Killed In Arctic Disaster

"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. It was about 2 1/2 minutes since Rutherford had made the final turn. He tried to pull up and go around, but it was too late.

"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.

Resolute residents and soldiers from a Canadian Forces exercise which happened to be underway nearby rushed to the scene. The military had established a temporary air traffic control tower at the airport that day and were guiding in all planes.

Several lawsuits filed over the disaster cast partial blame on the military presence, but MacDonald said it was in no way to blame for the crash.

The board earlier revealed that another plane was in the same area at the time and posed the risk of a mid-air collision. MacDonald said further investigation showed both were aware of each other and the other aircraft landed safely.

The report made one main recommendation: improving communication between crew members on all planes. Blair and Rutherford had received outdated crew management training in a two-day course that was compressed into four hours.

"The first officer's suggestions weren't compelling enough to alter the captain's mindset and the first officer likely felt inhibited from taking control of the aircraft from the captain," board member Kathy Fox told reporters in Ottawa. "Crew resource management is supposed to help flight crews in exactly these kinds of situations."

Fox said Transport Canada is updating its training, but she warned there will be "gaps" unless all airlines are required to apply the standards on a daily basis.

Daniel Slunder, president of the Canadian Federal Pilots Association, said Transport Canada used to have pilot inspectors or check pilots who sat on flights to test crews. In 2007, the government made airlines responsible for hiring their own check pilots.

Slunder suggested those private checks aren't always up to snuff and are often scheduled when they used to be unannounced.

Board member Joseph Hincke also said planes around the world are landing when they shouldn't. About four per cent of approaches are unstable, he said, and in those cases nearly all pilots proceed anyway.

"Most of the time everything works out just fine but sometimes there are consequences — a runway overrun, tail strike or, in this case, a fatal crash," Hincke said. "To improve airline safety in Canada, this needs to change"

Airlines need to further enshrine procedures about aborting landings and use technology to track the results, he said.

Chris Ferris, executive vice-president with First Air, said the airline has written new flight manuals and increased crew training. It's also encouraging pilots to perform more stablized approaches.

"We've definitely taken lessons from this investigation and strengthened and become a much safer airline," he said.

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."

— With files from Chris Purdy

Note to readers: This is a corrected story. An earlier version said the flight number was 6550.