The Disastrous Crash Of Flight 1363 That Took Years To Solve | Mayday: Air Disaster

thank you New York City's LaGuardia Airport March the 22nd 1992. a commuter plane with 51 people on board tries to lift off the Runway rotate but the pilots can't get it to climb they knew they were in trouble but they were fighting all the way to the end U.S Air flight 405 plunges into the icy waters of flushing Bay 27 people die for U.S investigators it's an open and shut case this accident was not a huge surprise to us but Canadian investigators are stunned they know the New York accident should never have happened my reaction when I heard about it was my God is driving all over again three years earlier an exhaustive investigation into a crash at a remote northern airport had identified a killer and spelled out ways to keep it from striking again certainly if they had followed the recommendations in my report the f-28 crash at LaGuardia could have been averted the LaGuardia accident makes one thing clear the right people never got the warning amazing March the 10th 1989 it's 11 39 a.m at Dryden Ontario's Airport like snowfalls as air Ontario flight 1363 stops in the remote Northern community on its way from Thunder Bay to Winnipeg the passengers stay on board while the plane is refueled [Music] for flight attendant Sonja Hartwick and the crew aboard the fokka f-28 it's been a frustrating day of delays big fluffy white snowflakes at this time we're falling gently to the ground and it was very very gray and I thought hmm I guess this means we're going to be delayed again I can't see us making it to Winnipeg on time it's Friday the beginning of March break already an hour behind schedule another delay could jeopardize the vacation plans of many of the 69 passengers and crew there is a lot of families traveling on board with plans most of them were going skiing and so they were very concerned about meeting their connections in Winnipeg Kenora Dryden it's Ontario 363 first officer Keith Mills checks on weather conditions Captain George morward returns from making a phone call inside the airport late afternoon check that quite heavy snow looks like it's going to be a bad one it's 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 temperatures hover around freezing visibility is decreasing if the flight doesn't leave soon it could be grounded indefinitely Dryden is a very small City it's a very remote part of Ontario with a population of about 6 500 the isolated Community lies halfway between Thunder Bay and Winnipeg harsh Canadian Winters with bitter cold reaching -35 degrees Celsius are the norm here it's not the place to be stranded in the middle of a snowstorm [Music] Royal Canadian Mounted Police Officer Don crawshaw and his partner are escorting a prisoner to Winnipeg when we did a criminal check on the prisoner who before we left he came up as a violent person so two of us have to go with him he was wanted him Banff on a fraud charge and that's what he was being brought back to Alberta for okay no smoking and seat belts what instruments sinks cross check Captain more wood uses the power of engine number two already running to fire engine number one more wooden Mills are both highly experienced Pilots however they've each flown fewer than 100 hours in the fokka f-28 the multi-million dollar aircraft is the first air Ontario jet to serve the remote Northern Ontario region [Music] 24 minutes after landing in Dryden flight 1363 is ready to leave foreign we're fired up taxi for departure requesting Airways to Winnipeg we're having some bad weather over here an approaching aircraft's urgent request to land unbelievable gives Captain more wood little choice he delays takeoff okay 363 is holding short of the active we are going to be a few moments until a small plane lands safely I'm sorry folks this just isn't our day in the two years that I had flown with near Ontario I'd never come across anything like this before the Cessna 150 lands safely clearing the runway for flight 1363's departure tell them we're going immediately Kenora Ontario we're taxiing out at this time 363 driving finally an hour behind schedule the plane taxis to Runway 29. [Music] as we're going down the the runway to position for takeoff the blanket of Snows falling and I couldn't see the tree line anymore it was like looking through a sheer folks we're sorry for the delay flight attendants please be seated for takeoff at 1209 PM flight 1363 is ready for takeoff advise Kenora we're ready to proceed and Kenora Drive in Ontario 363 is about to roll 29 at Dryden Roger Captain more wood performs a brief engine run-up beating the engines to rid them of any accumulated snow and ice then he begins his role down the runway when we're taking off I'm usually very quiet and focused meticulously going through a checklist in my own mind what would I do in the case of an emergency one the f-28 reaches its takeoff speed rotate 80 knots our takeoff was very slow and sluggish like a slow sluggish person running up the hill clearly there's something wrong the f-28 struggles to get airborne cleared the trees the plane started shaking I thought oh my God we're in a crash that's when we all hell broke please if you can equate to being in a mix master that's what the plane felt like at the time there's this dip to the left and then dipped to the right the Pilot's trying to get this plane up then all of a sudden there was a Power Burst the plane seemed to stabilize itself you could feel like the Pilot's trying to get control of it but a few seconds later it became a Knicks Master again I yelled out the emergency grab your ankles get your hands done [Music] and I kept yelling that and then I assumed my brace position you could hear people screaming and yelling there's loud horrible sounds we are clearly crashing the pilots are helpless 49 seconds after lifting off air Ontario flight 1363 crash lands in the bush 950 meters west of Runway 29. there is Carnage of the aircraft all over the place I didn't know where I was and at that point I thought oh my gosh I'm a lie I'm still alive that this is all happening so quickly when we trashed we came down on an angle it ripped the right side of the plane open and that's how we got out our odd sweep probably would have never gone out now the prisoner was selling handcuffs so I reached over and I took the Cuffs off of him there but he never left me and then we exited the aircraft there's fire all around there's explosions I'm thinking oh my God we're full of fuel and I started yelling come this way come this way for people to follow my voice come this way passengers Scramble for safety before the fire spreads 45 people survived the accident but 24 people do not including Captain more wood and first officer Mills foreign rushed to the crash site deep in the woods [Music] the injured are taken to hospital in Dryden I was very concerned because I kept looking at doing all the time I thought it was a lot of snow I didn't notice anything wrong going down the run me 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 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 Rowe and his team vital clues about the f-28's 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 you've got 24 people that died you've got two pilots that died in 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 uh if there were mistakes made mistakes have to be fixed from the rear of the fuselage investigators recover the f-28's two black boxes the flight data recorder and the cockpit voice recorder [Music] 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 it's factual by independent routes 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 way 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 he then uncovers a puzzling detail planes Weight and Balance form for the takeoff 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 [Music] 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 62 064 000 pounds and the airplanes Max takeoff weight was 65 000 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 machansky 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 moshanski 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 foreign Clues to a possible system failure arise when Sonia Hartwig 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. Roa 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 Dryden one of the connectors let's orbit hole 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 down Batman flight 1363 had to be refueled with one engine still running that more wood is in a situation where he's got a heart 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 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 [Applause] 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 Roa finds the f-28's 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 Common Thread emerges they've said in their witness statements there were snow and ice on the wings when the airplane attempted to take off [Music] Roa 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 snowstorm in all we may find other reasons for sure snow and ice on the wings was a factor in this act Sonia Hartwig tells investigators about an unusual sight during takeoff notice that the wings this became a solid Sheen a gray shiny ice investigators consult the f-28's manuals to study its anti-icing systems they find that only the Wing's leading edges are protected head heated leading edges on the wings I wonder if the anti-acing 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 save it function then 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 fokka 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 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 [Music] 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 the concluded that even the most minute of contamination of the wing would disrupt the airflow and cause a loss of lift well 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 cause 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 moorewood 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 let's hope it holds and the lives of the 68 other people on board flight 1363. investigators dig through Captain George morward's flight records and work history they interview crew members searching for Clues to his behavior Captain Warwood 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 Captain Morgan 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 canceled flights in the past because of icing concerns Roa 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 morewood 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 complained to the off-duty pilot about the company 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 more wood 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 more wood 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 more wood 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 more wood 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 planes 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 more wood was about the weather but there is evidence that it was on his mind when Roa questions the fueling agent he learns that morewood did ask about de-icing moments before takeoff is there de-icing available fueling agent says he pointed out the de-icing ground crew to more wood 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 more wood had shot down both engines he wouldn't have been able to restart his plane the only other way to start the airplane on the ground is with a ground-based air cart 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 out of the 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 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 going to be a bad one it's still within our takeoff limits well that's good we've got a lot of people who want to make their connectors let's hope 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 minus 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 is what's disrupting the airflow on the wing and destroying the lifting capabilities tell them we're going immediately kenoir 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 a cold soaking phenomena and the fact that those wings could still have ice on them advise Kenora we're ready to proceed and Kenora Drive in Ontario perhaps not wanting to face the consequences of shutting down his engines Moore adopted 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 machansky concludes that despite his mistake Captain more wood is not solely responsible for the crash it wasn't simply pilot error there were many other factors which the words this 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-28s were new 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 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 foka f-28s flying around the world Justice machansky 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 a disastrous on an f-28 [Music] in months later it becomes clear that machansky's warnings have not been heard U.S Air flight 405 is preparing to fly from New York to Cleveland on March the 22nd 1992. the plane is a fokka f-28 and it's snowing it's one degree below freezing at 9pm the jet is being de-iced for a second time since its arrival from Florida in the past hour an inch of snow has fallen and shows no signs of stopping [Music] the crew prepares for takeoff flight 405 is an hour and 45 minutes behind schedule when Captain Wallace Majora starts taxiing to Runway 13. then unexpectedly [Music] 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 you're there 405 Runway one three clear for takeoff even though it's now been 35 minutes since their last de-icing the crew does not request another pick up thrusts set temps okay everything proceeds as it should until the one rotate 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 foreign 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 fokka f-28 has crashed with tragic consequences my reaction when I heard about it was my God is driving 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 it's pretty good to me so the captain was faced with quite a problem if you wanted to be de-iced a third time he would have had to get out on the lines taxi all the way back into the parking area and meet up with a deicing truck again take off thrusts that would have put him 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 machansky 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] 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 wrong way 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 surfaces but it doesn't last long topon 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 machansky's team reached a stark conclusion about the effectiveness of type 1 fluid even if Captain more wood could have de-iced his plane in Dryden we're fired up taxing for departure requesting Airways to Winnipeg 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 start and they are getting contaminated even if more wood had dis during his 30 minutes on the ground rotate the delay may have been enough for the fluid to stop working the plane's wings May once again have become coated in ice [Music] 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 uh 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 The Dryden report was a tour de force which helped us focus our investigation quite a bit Justice machansky had released his interim report more than a year before the crash of flight 405. his recommendations could have prevented it moshansky would soon discover that a breakdown in communication had cost the lives of 27 people in New York during his inquiry Justice machansky 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 moshansky recommended greater use of the thicker type 2 fluid moshansky's investigators also studied de-icing practices at Toronto's Pearson Airport we got 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-ice 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-acing 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 machansky recommended the placement of de-icing facilities at runways instead of terminal Gates moshanski also recommended that Pilots not only inspect their wings from the cockpit pretty good to me as far as I could see but also from the cabin ET claims that his report could have prevented the crash at LaGuardia Federal Aviation Administration claims it never received his report in 1990 and therefore couldn't pass the information along to Airlines and Pilots but just as machansky doesn't accept that my second interim report went out in December of 1990. it's about a year and a half before the LaGuardia crash occurred so I I think uh 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 of Dryden I mean the commission came out with 192 recommendations it changed the whole nature of how we approached contamination we now have a Runway and de-icing paths 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 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 Dutch manufacturer Hawker went bankrupt in 1996. despite this in 2009 there was still 55 fokka f-28 jets in operation worldwide mostly in warmer climates nobody should ever lose their life during a contamination accident again in commercial Aviation anywhere in a snow and ice environment we've learned all the lessons [Music] thank you [Music]

Channel: Curious?: Science and Engineering

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Id: JXWK535LGBk

Length: 47min 3sec (2823 seconds)

Published: Fri Mar 17 2023