Flight 1363 Sparks Biggest Investigation In Canadian History | Mayday: Air Disaster

emergency crews rush to the crash site deep in the woods the injured are taken to hospital in driving i was very concerned because i kept looking at the wing all the time i thought it was a lot of snow i didn't notice anything wrong going down the runway like i said it was just when i we started hitting the trees i knew there's something wrong within 24 hours a team of investigators from the canadian aviation safety board arrives at the scene you're going there hopefully with the idea that you can find out what happened why it happened and how do you prevent it from happening in the future we walked the entire path of the airplane to the threshold of the runway and then we walked the flight path of the airplane right to the crash site that was the first thing that i did i wanted to document what i was seeing by photographing when you walk in on an accident site like that there are two things that overwhelm you the smell of aviation jet fuel and the smell of death the trees just past the end of runway 29 give investigator david rower and his team vital clues about the f-28s failed flight what happened was the airplane went off the end of the runway in what we would call ground effect and just stayed at that height simply clipping the tops of the trees look at how these treetops have been clipped off it didn't ever fly [Music] you've got 24 people that died you've got two pilots that died and a flight attendant that died and they died for the most part trying to do their job so you really want to do them justice but you also have to be fair and if there were mistakes made mistakes have to be fixed from the rear of the fuselage investigators recover the f-28s two black boxes the flight data recorder and the cockpit voice recorder the devices are designed to withstand temperatures of 1100 degrees celsius for up to 30 minutes investigators are frustrated to learn that the mylar tape from the recorders has suffered extreme heat damage it's estimated the black boxes were scorched by an 1100 degree inferno for at least 90 minutes far beyond their limit the data is unrecoverable that was a big blow to us because now you have to try and gather information and try and establish that is factual by independent roots we were just about to leave thunder bay and they gave us 10 new passengers investigators must now rely heavily on eyewitness reports to reconstruct the events leading up to the doomed takeoff they learned that the f-28 began its day in winnipeg and was scheduled to fly a return route to thunder bay and back with a stopover in dryden but in thunder bay plans changed the cancellation of another flight forced the crew to pick up 10 additional passengers and when they did their calculations they realized that we were overloaded and something had to come off all right let's um offload some fuel then they ended up removing fuel in order to be within the proper weight dispatch ontario 363. so the flight was delayed an hour the extra weight of the new passengers left the crew no choice they had to unload fuel to lighten their load that meant when they arrived in dryden they needed to pump in more than the usual amount of fuel for the final leg back to winnipeg rower wonders if the change in plans somehow led to a miscalculation of the weight and balance was the f-28 too heavy for takeoff then uncovers a puzzling detail the plane's weight and balance form for the take-off from dryden was never collected as required it burned in the fire rower is forced to use air ontario's standard averages to calculate passenger and baggage weights the data combined with the airport's fuel records allows him to estimate the plane's gross takeoff weight we knew how many people we had on board we knew how many bags we had on the airplane and we knew what our fuel load was he estimates the f-28 weighed between 62 thousand and sixty four thousand pounds [Music] and the airplane's max takeoff weight was sixty five thousand pounds and so we came to the conclusion that the airplane was not overweight the cause of the crash remains a mystery 18 days into the investigation the canadian government appoints justice virgil mashansky to lead a more wide-ranging inquiry into all aspects of the aviation system that might have contributed to the air ontario tragedy the government was looking for an experienced trial judge and preferably one with an aviation background moshansky is an experienced pilot with 13 years on the bench he will work closely with crash investigator david rower and aviation consultant frank black the new team's first step assessing the plane's technical systems the electrical system the hydraulic system the fuel system all of these systems are looked at both in terms of what is their history leading up to the accident and what remnants are remaining at the crash site that can be examined clues to a possible system failure arise when sonja hartwick recalls a troubling event aboard the same plane just days before the fatal crash i think it was monday or tuesday when we took off there was a smoke that filled the aircraft and there was this horrible smell i thought oh my god we have a fire in the lab but there was no fire in the lavatory or anywhere else in the cabin they told us that apparently it had something to do with oil sitting in the apu system so every takeoff that day this would happen the auxiliary power unit is a generator that provides the power needed to start the engines did burning oil in the apu somehow cause a fire and ultimately doom flight 1363 rower searches the week's journey log for any mention of the auxiliary power unit he makes a surprising discovery the apu wasn't working on the day of the crash it couldn't possibly have caused the fire but the inoperative power unit may still have played a role in the tragedy investigators learned that it forced the crew to make a risky decision in driving to the connectors let's hope it holds normally the captain would rely on the apu to restart his engines after shutting them both down for refueling but if he couldn't use his apu he couldn't shut his engines though that meant flight 1363 had to be refueled with one engine still running captain moorwood is in a situation where he's got a hot refuel with passengers on board the aircraft he's got to keep an engine running to refuel the airplane hot refueling isn't against regulations but the risk of a fuel spill makes it potentially dangerous in toronto in 1973 a maintenance person was killed when an air canada dc-8 jet was consumed by fire during refueling [Music] heart refueling is not a normal practice could the hot refueling have caused some kind of damage to the engines the dryden airport manager a former military pilot suspects there was trouble with the plane's engines he tells rower he saw the takeoff from his office and heard a sharp explosive noise just as it disappeared from view to him it signified a flame-out or engine failure i thought this is going to be a high profile and potentially controversial investigation and the only way to ensure that the truth stands up is to have hard evidence from the aircraft accident and so we took the airplane completely and we put it in our lab in ottawa anything with signs pointing to engine failure as the cause of the crash strip it down rower orders extensive engine testing those engines were examined in detail for damage rower finds the f-28s two rolls-royce engines suffered only minor structural damage there's no evidence of an engine fire nothing at all to suggest the engines had failed with little physical evidence to explain the failed takeoff investigators are back to square one to solve the mystery they comb through survivor and eyewitness statements a common thread emerges they said in their witness statements there was snow and ice on the wings when the airplane attempted to take off rowers studies weather charts for clues we had very good meteorological information the charts show that during the half hour the f-28 was on the ground at dryden airport visibility shrank from four kilometers to less than one kilometer because of the snow storm and all we may find other reasons for sure snow and ice on the wings was a factor in this act sonja hartwick tells investigators about an unusual sight during takeoff as we took off i noticed that the wings just became a solid sheen of gray shiny ice investigators consult the f-28s manuals to study its anti-icing systems they find that only the wings leading edges are protected the aircraft had heated leading edges on the wings i wonder if the anti-icing system was working and the heat was provided by bleed air from the compressors on the engine they found the valves that allow the compressed air access to the leading edges and they tested the valve to see if it functioned than it did the anti-icing system was working but since it only heats the leading edge it likely didn't clear ice that formed on the surface of flight 1363's wings investigators suspect that snow and ice build up what experts call wing contamination may have played a major role in the crash to verify that suspicion rower and his team meet with engineers from focker thanks for coming curious to see what you have jack van hanks who was the chief engineer had the extensive aerodynamic studies and data on the effects of contamination on an f-28 airplane fokker engineers have run simulations of the crash they were able to get some very good data in terms of the performance of the airplane simulating the type of loads temperatures etc that the dryden aircraft would would have been exposed to investigators make a crucial discovery about the design of the f-28 because of the angle of the wings a very small amount of ice makes the plane susceptible to stalling they concluded that even the most minute bit of contamination in the wing would disrupt the airflow and cause a loss of lift that answers a lot of questions the simulations support what witnesses saw it just barely got airborne dropping wings losing lift and then hitting trees decelerating to the point where it broke up investigators are now certain that contaminated wings caused the crash but what's still unclear is why the plane was not de-iced before takeoff almost all airports in cold climates including dryden are equipped with the technology to remove ice from a plane but captain moorwood never requested de-icing it's getting worse what's the latest investigators need to figure out why they want to understand what made him risk his own life the torton halls and the lives of the 68 other people on board flight 1363 investigators dig through captain george morwood's flight records and work history they interview crew members searching for clues to his behavior captain warwick was a very very professional very old-school pilot he had his view on how things should be done properly and what his definition of proper and professional would be he also was very concerned about his passengers he enjoyed making sure that they got on their flights on time and got to their destinations on time you know air ontario was a growing company it was their first foray into the jet operations i'm sure that there were many things that cap moorwood would have thought in his own mind but this is not how he would do it and i'm sure at times he probably let the superiors know that morwood's history shows he's delayed and cancelled flights in the past because of icing concerns is stumped why didn't he request de-icing in dryden another pilot who was at dryden airport that day provides part of the answer he heard morwood on the phone to air ontario that is what i have been trying to tell you he was very frustrated and he was really concerned about his passengers moore would complain to the off-duty pilot about the company these guys you want to guess my weight before i left thunder bay 66 and change i had to offload fuel now that right so now what am i supposed to do no you figure it out when he left the terminal he was observed by witnesses to appear to be very upset and very angry investigators wonder what set morwood off they try to piece together the pilot's day on march the 10th this was the fifth day of a very long week for captain morwood and he was the next day leaving with his family on a ski vacation before his first flight of the day he'd learned the plane's apu still wasn't working and then once in thunder bay more bad news after refueling the dispatcher forces morwood to take on 10 extra passengers now he must offload fuel and lose more time there goes the schedule let's um offload some fuel then this meant more wood would leave thunder bay behind schedule dispatch ontario 363. and captain morwood is the type of captain who didn't want to be late now on route to dryden and an hour behind schedule the weather forecast the crew was given of light rain and fog is no longer accurate and captain morwood didn't get the forecast of freezing rain coming into dryden which he should have had as flight 1363 lands in dryden the weather was getting worse by the minute the plane sat there for half an hour while snow built up on the wings i gotta talk to somebody about this investigators may never know how concerned morwood was about the weather but there is evidence that it was on his mind when rower questions the fuelling agent he learns that morwood did ask about de-icing moments before takeoff is there de-icing available the fueling agent says he pointed out the de-icing ground crew to moorwood the agent then offers a compelling reason that could explain why the captain didn't de-ice air ontario had a policy prohibiting him from de-icing with an engine running the fluid can be ingested in the engines and then find its way from there to the air conditioning on the airplane and make it extremely noxious in the cabin portion of the airplane but if moorwood had shut down both engines he wouldn't have been able to restart his plane now the only other way to start the airplane on the ground is with a ground-based aircart that can provide the compressed air and dryden did not have the capability to start the airplane the equipment would have had to be flown in from winnipeg it would have been a costly decision if he shut it down he would ground the aircraft there effectively requiring the billeting of passengers and hotels and at an expense to the airline for which he would be answerable right so now so he was under a great deal of pressure no you figure it out and i believe that the conversation on the phone would have been about that scenario and his displeasure with it but he didn't have any other chance it's getting worse what's the latest quite heavy snow looks like it's gonna be a bad one still within our takeoff limits well that's good we got a lot of people who want to make their connectors let's hope it holds though the amount of snow on the wings was still within limits it's what lay under the snow that doomed the flight the fuel in a plane's wing can get as cold as -40 degrees celsius the frigid fuel cools the metal surface of the wing when snow hits this supercooled surface it freezes instantly into a barely visible layer of ice it's a process called cold soaking and this of course that's what's disrupting the airflow on the wing and destroying the lifting capabilities tell them we're going immediately kenora ontario we're taxiing out at this time the only reason that i can possibly think of that led to his decision to execute the takeoff was the fact that he didn't consider the cold soaking phenomena and the fact that those wings could still have ice on the glass kenora we're ready to proceed and kenora driving on perhaps not wanting to face the consequences of shutting down his engines moore would opted to take off for winnipeg without de-icing his plane he must have concluded that the ice won't blow off on takeoff that is where he made a mistake a tragic mistake but mashansky concludes that despite his mistake captain moorwood is not solely responsible for the crash it wasn't simply pilot error there were myriad of factors which was the cause of the accident one of the most important factors air ontario's decision to let the plane fly with a broken apu they were deferring a lot of the maintenance that should have been done because of a shortage of parts and then they had to scrounge around all across canada with various f28 operators to borrow parts from them and this this was a very bad move on the part of air ontario management the investigation determines that by cutting corners and focusing too much on the bottom line the airline was putting all their passengers and employees at risk because the f-28 is renewed to air ontario there was this urgency to get one crew off and get the next crew on flying this urgency to have them in the air producing money i came to the conclusion after a lot of thought about this accident that there were a lot of other hands on those throttles pushing those throttles forward [Music] there were a lot of people that were involved in the sequence of events that led to this tragic outcome this was a preventable accident but everything conspired against the pilots i gotta talk to somebody about this because air ontario management did not have a safety culture and you have to have a safety culture from the top management down knowing there are dozens of fokker f-28s flying around the world justice mashansky takes an unusual step he releases a report well before his inquiry concludes it warns of the plane's vulnerability to ice build-up and stresses the need for frequent de-icing in winter conditions even a small amount of icing would be disastrous on an f-28 but 15 months later it becomes clear that mushansky's warnings have not been heard us air flight 405 is preparing to fly from new york to cleveland on march the 22nd 1992 the plane is a focker f-28 and it's snowing it's one degree below freezing at 9 pm the jet is being de-iced for a second time since its arrival from florida [Music] in the past hour an inch of snow has fallen and shows no signs of stopping us the crew prepares for takeoff flight 405 is an hour and 45 minutes behind schedule when captain wallace monsieur starts taxiing to runway 13. then unexpectedly left on the inner to hold short of echo at 907 pm flight 405 is forced to wait on the taxiway near runway 13. another 23 minutes pass first officer john rashuber turns on a light that illuminates his wings he checks the right wing for ice he sees none looks pretty good to me as far as i can see user 405 runway 1-3 clear for takeoff even though it's now been 35 minutes since their last de-icing the crew does not request another take off thrusts set [Music] just after the f-28 begins its rotation the aircraft had enough flying speed to to lift off barely lift up the wings just could not support the airplane they knew they were in trouble 13 seconds after lifting off flight 405 crashes on the shore of flushing bay i don't think any pilot really thinks he's going to crash they were they were trying to save the airplane right to the end 27 of the 51 people on board are killed another fokker f-28 has crashed with tragic consequences my reaction when i heard about it was my god is dried all over again within days investigator in charge robert benson suspects that ice on the wings was the major cause it would be very very difficult for either of the pilots to really detect ice on the wings looking backwards over their shoulders through the side windows of the airplane looks pretty good to me as far as i can see so the captain was faced with quite a problem if he wanted to be de-iced a third time he would have had to get out of the lines taxi all the way back into the parking area and meet up with a de-icing truck again take off thrust that would have put them very very late and it may have even caused the cancellation of the flight after all of this work after all of the efforts to see it happen again was extremely frustrating there were no regulations in place requiring the crew to seek another de-icing after their extended delay but justice mashansky had called attention to the dangers of long wait times when he issued his interim report if they had followed the recommendations in my second interim report this accident certainly could have been averted [Music] he also had drawn attention to the limitations of the de-icing fluid being used at the time called type 1 fluid it's a mixture of antifreeze and water those chemicals are designed that as you accelerate down the runway that they'll actually shed off your wing so that when you actually want the wing to lift and produce lift that it's not contaminated type 1 fluid is applied hot to de-ice the plane's surfaces but it doesn't last long type 1 fluid had hold over time in their best conditions of about 15 minutes under poor conditions such as freezing rain it could be as low as six minutes during the air ontario investigation mushansky's team reached a stark conclusion about the effectiveness of type 1 fluid even if captain morwood could have de-iced his plane in dryden we're fired up taxing for departure requesting airways to win it may have made no difference flight 1363 had to wait for the troubled cessna 150 to land by the time he waited for this 150 aircraft and pilot to land and then they backtracked and got into position now they're in a serious small storm and they are getting contaminated even if morwood had de-iced during his 30 minutes on the ground the delay may have been enough for the fluid to stop working the plane's wings may once again have become coated in ice it came out in the examination of air ontario pilots that there was a dire need for training in terms of how the de-icing anti-icing systems worked and how long your aircraft was protected as soon as our accident occurred up in new york we of course understood that it was a similar aircraft in fact a nearly identical aircraft to the dryden accident airplane the circumstances were similar in both accidents and uh the dryden report was a tour de force which helped us focus our investigation quite a bit justice mashansky had released his interim report more than a year before the crash of flight 405. his recommendations could have prevented it machansky would soon discover that a breakdown in communication had cost the lives of 27 people in new york during his inquiry justice mashansky learned that there was another type of de-icing fluid available to the airline industry it's called type 2 fluid it's thicker than type 1 which prevents it from immediately flowing off an aircraft a type 2 fluid is a much more gooey substance i've heard it referred to as almost mucus-like with holdover times of up to 45 minutes it keeps ice from accumulating then blows off the plane's surfaces at takeoff 15 months before the u.s air crash machansky recommended greater use of the thicker type 2 fluid mushansky's investigators also studied de-icing practices at toronto's pearson airport we got a hold of a film crew and we waited and watched the weather very carefully until we found a forecast of freezing rain and we've tracked one aircraft which was heading for the caribbean the investigators discovered an alarming gap in the time between de-icing and takeoff and from the time the aircraft was de-iced on the gate until the time the aircraft took off was somewhere in the order of 41 minutes so there was no doubt that aircraft were departing pearson airport with a partially or largely contaminated wing surface we then went to chicago o'hare this was the first airport to actually put in place runway and the icing pads and it was very useful in terms of explaining to us how these had evolved what type of de-icing equipment they were using on them how they worked at the time of the u.s air crash laguardia did not offer de-icing at the runway only at the gate again 15 months before the crash justice mashansky recommended the placement of de-icing facilities at runways instead of terminal gates mushansky also recommended that pilots not only inspect their wings from the cockpit looks pretty good to me as far as i can see but also from the cabin runway claims that his report could have prevented the crash at laguardia but the federal aviation administration claims it never received his report in 1990 and therefore couldn't pass the information along to airlines and pilots but justice mashansky doesn't accept that my second interim report went out in december of 1990. about a year and a half before the laguardia crash occurred so i i think probably sat on somebody's desk [Music] the crash of flight 1363 resulted in dozens of recommendations that could save lives the crash of flight 405 ensured those recommendations were widely implemented well there was a lot that came out at dryden i mean the commission came up with 192 recommendations it changed the whole nature of how we approach contamination we now have runway and de-icing pads so they can get a final de-icing before they take off this was something directly the result of the dryden commission inquiry today most airlines use a new type of de-icing fluid type 4 de-icing fluid lasts longer it will stick to a wing for up to two hours as well air traffic controllers must now be able to tell flight crews how long they will be delayed at the runway after being de-iced [Music] trident is really the first accident that explored not only what happens in the pointed end of an airplane but what happens within a corporate culture it puts ceos on notice that they can't hide in the woodwork when an accident occurs [Music] dutch manufacturer focker went bankrupt in 1996 despite this in 2009 there were still 55 fokker f-28 jets in operation worldwide mostly in warmer climates nobody should ever lose their life due to contamination accident again in commercial aviation anywhere in a snow and ice environment we've learned all the lessons you

Channel: Mayday: Air Disaster

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Id: r33ddsjmmUw

Length: 36min 30sec (2190 seconds)

Published: Wed Jul 14 2021