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The wreckage of First Air Flight 6560 is pictured in Resolute Bay, Nunavut, Aug. 23, 2011.Chris Wattie/Reuters

First Air Flight 6560 was flying smoothly, nearing the end of its summertime journey from the Northwest Territories to a remote Nunavut hamlet. There was even some "normal banter" among the crew, as the lead investigator put it.

Moments later, as the plane descended for landing, the first officer said to the captain: "I don't like this."

That 2011 flight in Resolute Bay is outlined in a 215-page Transportation Safety Board report released Tuesday that details the 18 human, technical and organizational factors that combined to spell tragedy. Despite some speculation, the Operation Nanook military exercise nearby was not among the causes.

"We call it, 'lining up the holes in Swiss cheese,' " Brian MacDonald, the TSB investigator-in-charge, said in an interview in Ottawa. "When the safety barriers are no longer in place, you can run an arrow through all the holes … Normally, there's some cheese blocking some of those holes – the cheese could be a regulation or a training procedure. So when you get that many factors coming together, you're inevitably going to get an accident."

Mr. MacDonald branded the investigation the "most complex and lengthy" in his 18 years of probing accidents. In issuing its detailed report, the board, an independent government agency that doesn't lay blame, brought readers into the First Air cockpit for a gripping glimpse into the flight's final minutes.

The autopilot failed to align the aircraft with the runway and then went into a different mode. Wind pushed the plane even further to the right. The compass, for still undetermined reasons, was off by 17-degrees, likely leading the crew to believe they could realign the plane in time.

Over the course of 17 seconds at 4:39 p.m., the first officer five times stated the plane was off course. The captain twice said he was satisfied the autopilot was tracking properly. At 4:40, the first officer reminded the captain about a hill to the right of the runway and questioned whether they had done something wrong.

The first officer then said, in less explicit terms, that he thought they should abort the landing. The captain said he planned to continue the approach. Then, at 4:41, the first officer, David Hare, called Captain Blair Rutherford by first name and said he didn't like what was happening. Within seconds, the plane struck the hill, killing 12 of 15 people on board – including the two pilots.

"Today's report makes it clear that the accident was the culmination of a complex chain of unfortunate events," the Rutherford family said in a statement provided by the captain's wife, Tatiana. "Our hearts are with everyone whose life has been forever changed because of this tragic incident, and of course are with our beloved Blair."

The statement also said the family hopes the aviation industry will learn from the accident so "such a tragedy never happens again."

The head of the Canadian Federal Pilots Association, which represents the licensed pilots who work for Transport Canada as aviation inspectors, said the government needs a more hands-on approach when it comes to mandating and monitoring training. Still, Captain Daniel Slunder said he is "loathe" to blame anyone in particular since "the circumstances conspired to set the pilots up for the accident."

The First Air pilots received crew resource management (CRM) training, which focuses on communication and decision-making, but that training was outdated and lasted just a quarter of Transport Canada's recommended time. First Air said in a statement it has already taken steps to enhance pilot training.

Transport Canada is updating its CRM training standard, but the board noted there aren't plans to mandate a certain amount of training or require instructor accreditation. The TSB also called on the government to reduce the number of unstable approaches that continue to a landing.

Federal Transport Minister Lisa Raitt thanked the board for its work and said she has asked her ministry to examine the report on an "expedited basis."