Air Ontario Flight 1363

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Air Ontario Flight 1363
C-FONF (Air Ontario) C-FONF - Fokker F-28-1000 - Air Ontario at Toronto Lester B. Pearson Airport (YYZ).jpg
C-FONF, the Fokker F28 involved in the accident
Accident
Date10 March 1989 (10 March 1989)
SummaryCrashed on take-off in icing conditions
Site Dryden Regional Airport, Dryden, Ontario, Canada
49°50′20″N92°46′01″W / 49.83889°N 92.76694°W / 49.83889; -92.76694
Aircraft
Aircraft type Fokker F28-1000 Fellowship
Operator Air Ontario
IATA flight No.AE1363
ICAO flight No.MDA1363
Call signONTARIO 1363
Registration C-FONF
Flight origin Thunder Bay Int'l Airport
Stopover Dryden Regional Airport
Destination Winnipeg James Armstrong Richardson Int'l Airport
Occupants69
Passengers65
Crew4
Fatalities24 (21 passengers; 3 crew members)
Injuries37
Survivors45

Air Ontario Flight 1363 was a scheduled Air Ontario passenger flight which crashed near Dryden, Ontario, on 10 March 1989 shortly after takeoff from Dryden Regional Airport. [1] The aircraft was a Fokker F28-1000 Fellowship twin jet. [2] It crashed after only 49 seconds because it was not able to attain sufficient altitude to clear the trees beyond the end of the runway, due to ice and snow on the wings. [3]

Contents

A similar accident happened in 1992 when USAir Flight 405 crashed into Flushing Bay on takeoff at LaGuardia Airport, after ice had accumulated on the wings during taxi.

Aircraft and crew

The aircraft, a Fokker F28-1000, had been manufactured in 1972 and had been in service for Turkish Airlines from 1973 to 1987. The aircraft had been used by Air Ontario since November 1987. It was one of two F28-1000s operated by the airline. [4] : 8 

The flight was under the command of veteran pilot Captain George Morwood (52). He was an experienced airman who had been flying for approximately 34 years with Air Ontario. He had roughly 24,100 flying hours. His first officer was Keith Mills (35). Mills was also a highly experienced pilot with Air Ontario for 10 years, having accrued more than 10,000 hours of flying time. [5] Both pilots were new to the F28-1000, having fewer than 150 hours between them on the aircraft type. [4]

Accident

The flight had departed from Thunder Bay bound for Winnipeg with an intermediate stop in Dryden, where the aircraft struck trees shortly after takeoff and then disintegrated on impact. The accident caused the deaths of 21 of the 65 passengers and three of the four crew members on board, including both pilots. [6]

Investigation

Wreckage of Air Ontario Flight 1363 Air Ontario Flight 1363 wreckage.jpg
Wreckage of Air Ontario Flight 1363

The fierce post-crash fire resulted in severe damage to both the cockpit voice recorder and the flight data recorder; neither of these units could be read as a result. Because of this, the investigative effort relied almost entirely on witness statements regarding the crash and the events leading up to it.

The investigation revealed that an unserviceable auxiliary power unit (APU), and no available external power unit at Dryden Regional Airport, led to questionable decision-making, which was a critical factor leading to the crash of Flight 1363. If the engines had been turned off, they could not have been restarted again due to the unserviceability of the APU and lack of external power. Therefore, the port engine was left running during the stopover in Dryden.

Snow was falling gently that afternoon and a layer of 0.6 to 1.3 cm (0.24 to 0.51 in) of snow had accumulated on the wings. The wings needed to be deiced before takeoff, but the Fokker F28 aircraft is never supposed to be deiced while the engines are running because of a risk of toxic fumes entering the cabin of the aircraft. The pilot, therefore, did not request to have the wings deiced; at the time, airline instructions were unclear on this point, but the subsequent report was very critical of this decision.

Injury map of Air Ontario Flight 1363 Ao1363injurymap.png
Injury map of Air Ontario Flight 1363

Fuel needed to be loaded and was done with the engine running while passengers were on board (known as a hot refuel). Off-loading and reloading passengers would have taken considerable time, and the longer the aircraft stayed on the ground, the greater was the need for the wings to be sprayed with deicing fluid. To prevent further delay and a greater possibility of a buildup on the wings, Captain Morwood decided to have the aircraft fueled while the engine was running and with passengers on board. This procedure was not then, and is not now, prohibited by Transport Canada. Airline instructions were also inconsistent.[ citation needed ]

Result

The accident investigation was subsumed into a judicial inquiry under a judge, Virgil P. Moshansky. His report showed that competitive pressures caused by commercial deregulation cut into safety standards and that many of the industry's sloppy practices and questionable procedures placed the pilot in a very difficult situation. The report also stated that the aircraft should not have been scheduled to refuel at an airport that did not have proper equipment, and that neither training nor manuals had sufficiently warned the pilot of the dangers of ice on the wings. [7] Moshansky blamed Transport Canada for letting Air Ontario expand into the operation of bigger, more complicated aircraft without detecting the deficiencies of their existing aircraft.

After the crash of Air Ontario Flight 1363, many significant changes were made to the Canadian Aviation Regulations. These included new procedures regarding refueling and deicing, as well as many new regulations intended to improve the general safety of all future flights in Canada. [8] Specifically, these referred to the effectiveness of certain deicing fluids over time and the increased use of Type II fluid. This mixture includes polymerising agents, which make the deicing effect last longer.

Another cause of the crash of Flight 1363 was delays in changes to deicing procedures from the Canadian Aviation Safety Board's (CASB) dissenting report on the 1985 crash of Arrow Air Flight 1285, which may have also involved ice, but a separate minority report stated that an explosion occurred. [9] [10] Both crashes undermined confidence in the CASB's investigations and led to the Canadian government shutting down the CASB one year after the Flight 1363 accident. The CASB was replaced by the Transportation Safety Board of Canada (TSB), a more independent and multimodal investigative agency.

Air Ontario 1363 Memorial Site Air Ontario 1363 Memorial Site.jpg
Air Ontario 1363 Memorial Site

Memorial

A memorial is located on MacArthur Road. [11]

The Discovery Channel Canada / National Geographic TV series Mayday featured the incident in a season-9 episode titled "Cold Case". [12] TLC also aired a segment on the crash in the 1990's special called Terror in the Sky. It featured interviews with passengers and footage from the investigation hearing. [13]

See also

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References

  1. ↑ Maclean's: Pointing the finger. Vol. 105. Rogers Publishing Limited. p. 15.
  2. ↑ Tolleson, Terry. The Curse of Complacency. Vol. 18. Aircraft Maintenance Technology. pp. 74–76.
  3. ↑ "Disclaimer - Electronic Collection" (PDF).
  4. 1 2 Disclaimer – Electronic Collection. Epe.lac-bac.gc.ca.
  5. ↑ "95.1". www.crm-devel.org. Retrieved 1 January 2021.
  6. ↑ Ranter, Harro. "ASN Aircraft accident Fokker F-28 Fellowship 1000 C-FONF Dryden Municipal Airport, ON (YHD)". aviation-safety.net. Aviation Safety Network . Retrieved 2 February 2014.
  7. ↑ "Accident Descriptions". Aviation Safety Network. Flight Safety Foundation. Retrieved 10 April 2015.
  8. ↑ Hughes. Aviation Week & Space Technology (School ed.). MAS Ultra. p. 136.
  9. ↑ "Aviation Occurrence Report, Arrow Air Inc. Douglas DC-8-63 N950JW, Gander International Airport, Newfoundland, 12 December 1985" (PDF). Canadian Aviation Safety Board. 14 November 1988. Retrieved 11 September 2017.
  10. ↑ Dissenting Opinion, Arrow Air Inc. Douglas DC-8-63 N950JW, Gander International Airport, Newfoundland, 12 December 1985 (PDF). Canadian Aviation Safety Board. 14 November 1988. Retrieved 11 September 2017.
  11. ↑ "Dryden observes anniversary of Air Ontario crash" . Retrieved 29 June 2016.
  12. ↑ "Cold Case". Mayday . Season 9. 2010. Discovery Channel Canada / National Geographic Channel.
  13. ↑ "Terror in the Sky" on YouTube
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