Mayday (2013) s09e06 Episode Script
Cold Case
JONATHAN ARIS: New York City's LaGuardia Airport - March 22, 1992.
USAir Flight 405 plunges into the icy waters of Flushing Bay.
27 people die.
For US investigators, it's an open-and-shut case.
But Canadian investigators are stunned.
They know the New York accident should never have happened.
If they had followed the recommendations in my report, the F28 crash at LaGuardia could have been averted.
The LaGuardia accident makes one thing clear - the right people never got the warning.
March 10, 1989.
It's 11:39am at Dryden, Ontario's airport.
Light snow falls as Air Ontario Flight 1363 stops in the remote northern community on its way from Thunder Bay to Winnipeg.
The passengers stay onboard while the plane is refuelled.
WOMAN: Big, fluffy white snowflakes at this time were falling gently to the ground and it was very, very grey, 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.
There was a lot of families travelling onboard 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.
MAN: (OVER RADIO) Ontario 363.
Kenora.
As first officer Keith Mills checks on weather conditions, captain George Morwood returns from making a phone call inside the airport.
It's getting worse.
What's the latest? MAN: (OVER RADIO) It won't clear till late afternoon.
Check that.
Quite heavy snow.
Looks like it's gonna be a bad one - but still within our take-off limits.
Well, that's good.
We've 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.
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.
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 before we left, he came up as a violent person, so two of us have to go with him.
He was wanted in Banff on a fraud charge and that's what he was being brought back to Alberta for.
OK, no smoking and seatbelts.
On.
- Instruments.
- Synched.
Cross check.
Captain Morwood uses the power of engine number two, already running, to fire engine number one.
(ENGINE WHINES) Morwood and Mills are both highly experienced pilots.
However, they've each flown fewer than 100 hours in the Fokker F28.
The multimillion-dollar aircraft is the first Air Ontario jet to serve the remote northern Ontario region.
Inform Kenora we're rolling.
We're fired up.
Taxiing for departure.
Requesting airways to Winnipeg.
MAN: (OVER RADIO) Hang on a sec, guys.
Is there a chance that plane can hold? We're having some bad weather up here.
An approaching aircraft's urgent request to land Unbelievable.
.
.
gives Captain Morwood little choice.
He delays take-off.
OK, 363's holding short of the active.
In the two years that I had flown with Air 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 Dryden.
Finally, an hour behind schedule, the plane taxis to runway 29.
As we were going down the runway to position for take-off, the blanket of snow was falling and I couldn't see the treeline anymore.
It was like looking through a sheer.
Flight attendants, please be seated for take-off.
At 12:09pm, Flight 1363 is ready for take-off.
Advise Kenora, we're ready to proceed.
And Kenora, Dryden, Ontario 363 is about to roll 29 at Dryden.
MAN: (OVER RADIO) Securing 363 Kenora - roger.
Captain Morwood performs a brief engine run-up, heating the engines to rid them of any accumulated snow and ice.
Then he begins his roll 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?" The F28 reaches its take-off speed Rotate.
.
.
80 knots.
Our take-off was very slow and sluggish, like a slow, sluggish person running up a hill.
Clearly, there's something wrong.
The F28 struggles to get airborne.
It cleared the trees.
The plane started shaking.
(SCREAMING) I thought, "Oh, my God, we're going to crash.
" That's when all hell broke loose.
If you can equate to being in a Mixmaster, that's what the plane felt like at the time.
There was this dip to the left and then dip 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 stabilise itself.
You could just feel that the pilot is trying to get control of it.
But a few seconds later, it became a Mixmaster again.
I yelled out, "Emergency! "Grab your ankles.
Get your heads down.
" Grab your ankles! Get your heads down! I kept yelling that and then I assumed my brace position.
The pilots are helpless.
49 seconds after lifting off .
.
Air Ontario Flight 1363 crash-lands in the bush, 950 metres 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 alive! I'm still alive!" That this is all happening so quickly.
Now, the prisoner was still in handcuffs so I reached over and I took the cuffs off of him but he never left me and then we exited the aircraft.
There was fire all around.
There was explosions.
I'm thinking, "Oh, my God - we're full of fuel.
" Guys, come this way.
I started yelling, "Come this way! Come this way!" for people to follow my voice.
Come this way! Come on.
Passengers scramble for safety before the fire spreads.
45 people survive the accident.
But 24 people do not, including Captain Morwood and First Officer Mills.
Emergency crews rush to the crash site deep in the woods.
The injured are taken to hospital in Dryden.
I was very concerned, because I kept looking out the window and at the time, I thought there was a lot of snow.
I didn't notice anything wrong going down the runway.
It was just when we started hitting trees I knew something was wrong.
Within 24 hours, a team of investigators from the Canadian Aviation Safety Board arrives at the scene.
You go in there hopefully with the idea that you can find out what happened, why it happened and how you prevent it from happening in the future.
We walked the entire path of the airplane from 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.
The trees just past the end of runway 29 give investigator David Rohrer and his team vital clues about the F28'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.
It didn't ever fly.
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 F28's two black boxes.
The devices are designed to withstand temperatures of 1,100 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 1,100-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.
They learn that the F28 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 realised that we were overloaded and something had to come off.
Alright.
Let's offload some fuel, then.
They ended up removing fuel in order to be within the proper weight.
Despatch - 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.
Rohrer wonders if the change in plans somehow led to a miscalculation of the weight and balance.
Was the F28 too heavy for take-off? He 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.
Rohrer is forced to use Air Ontario's standard averages to calculate passenger and baggage weights.
ROHRER: 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 F28 weighed between 62,000 and 64,000 pounds.
And the airplane's max take-off weight was 65,000 pounds.
So we came to the conclusion that the airplane was not overweight.
18 days into the investigation, the Canadian government appoints Justice Virgil Moshansky 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 who had an aviation background.
Moshansky is an experienced pilot with 13 years on the bench.
He will work closely with crash investigator David Rohrer 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 Sonia 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 this smoke that filled the aircraft, and there was this horrible smell.
I thought, "Oh, my God.
We have a fire in the lav.
" 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 take-off 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? Rohrer 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 learn that it forced the crew to make a risky decision in Dryden.
Go on to the connectors.
Let's hope it holds.
Normally the captain would rely on the APU to re-start his engines after shutting them both down for re-fuelling.
But if he couldn't use his APU, he couldn't shut his engines down.
That meant Flight 1363 had to be re-fuelled with one engine still running.
Captain Morwood is in a situation where he's got a hot re-fuel with passengers onboard the aircraft.
He's got to keep an engine running to re-fuel the airplane.
Hot re-fuelling 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 re-fuelling.
Hot re-fuelling is not a normal practice.
Could the hot re-fuelling have caused some kind of damage to the engines? I thought, "This is gonna 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.
.
.
Rohrer orders extensive engine testing.
Those engines were examined in detail for damage.
Rohrer finds the F28'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 take-off, investigators are back to square one.
To solve the mystery, they comb through survivor and eyewitness statements.
A common thread emerges.
They've said in their witness statements, there was snow and ice on the wings when the airplane attempted to take off.
Rohrer studies weather charts for clues.
We had very good meteorological information.
The charts show that during the half-hour the F28 was on the ground at Dryden Airport, visibility shrank from four kilometres to less than one kilometre because of the snowstorm.
And we need to find other reasons.
For sure, snow and ice on the wings was a factor in this accident.
Sonia Hartwick tells investigators about an unusual sight during take-off.
As we took off, I noticed that the wings just became a solid sheen of grey, shiny ice.
Investigators consult the F28's manuals to study its anti-icing systems.
They find that only the wing's leading edges are protected.
BLACK: 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 and 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, Rohrer and his team meet with engineers from Fokker.
Thanks for coming.
Curious to see what you have.
Jack van Hengst, who was the chief engineer, had extensive aerodynamic studies and data on the effects of contamination on an F28 airplane.
Fokker engineers have run simulations of the crash.
BLACK: They were able to get some very good data in terms of the performance of the airplane, simulating the type of loads, temperatures et cetera, that the Dryden aircraft would have been exposed to.
Investigators make a crucial discovery about the design of the F28.
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 on 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 and decelerating to the point where it broke up.
Investigators are now certain that contaminated wings caused the crash.
But what is still unclear is why the plane was not de-iced before take-off.
Almost all airports in cold climates, including Dryden, are equipped with the technology to remove ice from a plane.
But Captain Morwood never requested de-icing.
It's getting worse.
What's the latest? MAN: (OVER RADIO) It won't clear till late afternoon.
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 Morwood's flight records and work history.
They interview crew members, searching for clues to his behaviour.
Captain Morwood 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.
You know, Air Ontario was a growing company.
It was their first foray into jet operations.
I'm sure that there were many things that Captain Morwood would have thought in his own mind, that 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.
Rohrer 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.
Morwood complained 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.
HON.
MOSHANSKY: 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 10.
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 refuelling, the dispatcher forces Morwood to take on 10 extra passengers.
(SIGHS) Now he must offload fuel and lose more time.
There goes the schedule.
Let's, umoffload some fuel, then.
This meant Morwood would leave Thunder Bay behind schedule.
Dispatch.
And Captain Morwood is the type of captain who didn't want to be late.
Now en route to Dryden, and an hour behind schedule, the weather forecast the crew was given of light rain and fog is no longer accurate.
BLACK: 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've 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 Rohrer questions the fuelling agent, he learns that Morwood did ask about de-icing moments before take-off.
Is there de-icing available? The fuelling agent says he pointed out the de-icing ground crew to Morwood.
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.
BLACK: 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 Morwood had shut 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 in hotels and added expense to the airline for which he would be answerable.
Right.
So now what am I gonna do? So he was under a great deal of pressure.
No.
You figure it out.
ROHRER: 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.
It's still within our take-off limits.
That's good.
We've got lots of people who want to make 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 super-cool 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 air flow 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 take-off was the fact that he didn't consider the cold soaking phenomena and the fact that those wings could still have ice on them.
Advise Kenora we're ready to proceed.
Perhaps not wanting to face the consequences of shutting down his engines, Morwood opted to take-off for Winnipeg without de-icing his plane.
HON.
MOSHANSKY: He must have concluded that the ice would blow off on take-off.
That is where he made a mistake - a tragic mistake.
But Moshansky concludes that despite his mistake, Captain Morwood is not solely responsible for the crash.
It wasn't simply pilot error.
There were a myriad of factors which were 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 round all across Canada with various F28 operators to borrow parts from them, and 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.
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've got to 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 of management down.
Knowing there are dozens of Fokker F28s flying around the world, Justice Moshansky 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 F28.
But 15 months later, it becomes clear that Moshansky's warnings have not been heard.
USAir Flight 405 is preparing to fly from New York to Cleveland on March 22, 1992.
The plane is a Fokker F28.
It's one degree below freezing.
At 9:00pm, 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.
MAN: (OVER RADIO) USAir 405 - clear for taxi runway 13.
The crew prepares for take-off.
Flight 405 is an hour and 45 minutes behind schedule when Captain Wallace Majure starts taxiing to runway 13.
Then, unexpectedly MAN: (OVER RADIO) USAir 405, turn left, and hold short of Echo.
Left on the inner.
Hold short of Echo.
Another 23 minutes pass.
First Officer John Rachuba 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.
MAN: (OVER RADIO) USAir 405, runway 13 clear for take-off.
Even though it's now been 35 minutes since their last de-icing, the crew does not request another.
Take-off, thrusts.
Set.
Temps OK.
Everything proceeds as it should.
- Until - V1.
Rotate.
.
.
just after the F28 begins its rotation.
The aircraft had enough flying speed to lift off - barely lift off.
The wings just could not support the airplane.
13 seconds after lifting off, Flight 405 crashes on the shore of Flushing Bay.
I don't think any pilot really thinks he's gonna crash.
They were trying to save the airplane right till the end.
(SIRENS WAIL) 27 of the 51 people onboard are killed.
Another Fokker F28 has crashed with tragic consequences.
My reaction when I heard about it was, "My God - it's Dryden all over again!" Within days, investigator-in-charge Robert Benzon 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 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, thrusts.
That would have put him very, very late and it may have even caused the cancellation of the flight.
BLACK: 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 Moshansky 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.
He also had drawn attention to the limitations of the de-icing fluid being used at the time.
Called 'Type I fluid', it's a mixture of antifreeze and water.
ROHRER: Those chemicals are designed that as you accelerate down a runway, that they will actually shed off your wing, so that when you actually want the wing to lift and produce lift, that it's not contaminated.
Type I fluid is applied hot to de-ice the plane's surfaces .
.
but it doesn't last long.
Type I fluid had a hold-over time in the 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, Moshansky's team reached a stark conclusion about the effectiveness of Type I fluid.
Even if Captain Morwood could have de-iced his plane in Dryden We're fired up.
Taxiing for departure.
Requesting airways to Winnipeg.
.
.
it may have made no difference.
MAN: (OVER RADIO) Hang on a sec, guys.
Is there a chance that plane can hold? We're having some bad weather up here.
Unbelievable.
Flight 1363 had to wait for the troubled Cessna 150 to land.
ROHRER: 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 snowstorm and they are getting contaminated.
Even if Morwood had de-iced 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.
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 the Dryden report was a tour de force which helped us focus our investigation quite a bit.
Justice Moshansky 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 Moshansky learned that there was another type of de-icing fluid available to the airline industry.
It's called Type II fluid.
A Type II fluid is a much more gooey substance.
I've heard it referred to as almost mucus-like.
With hold-over times of up to 45 minutes, it keeps ice from accumulating, then blows off the plane's surfaces at take-off.
15 months before the USAir crash, Moshansky recommended greater use of the thicker Type II fluid.
Moshansky's investigators also studied de-icing practices at Toronto's Pearson Airport.
BLACK: 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 tracked one aircraft which was heading for the Caribbean 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 aircrafts 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 de-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 USAir crash, LaGuardia did not offer de-icing at the runway - only at the gate.
Again, 15 months before the crash, Justice Moshansky recommended the placement of de-icing facilities at runways instead of terminal gates.
Moshansky also recommended that pilots not only inspect their wings from the cockpit It looks pretty good to me as far as I can see.
.
.
but also from the cabin.
MAN: (OVER RADIO) USAir 405.
Runway 13 clear for take-off.
Moshansky 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 Moshansky doesn't accept that.
My second interim report went out in December of 1990.
It was about a year and a half before the LaGuardia crash occurred.
So I think it probably sat on somebody's desk.
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 up with 192 recommendations.
It changed the whole nature of how we approach contamination.
JUSTICE MOSHANSKY: We now have runway and the 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 IV 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.
BLACK: Dryden 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 the EOs on notice that they can't hide in the woodwork when an accident occurs.
Dutch manufacture Fokker went bankrupt in 1996.
Despite this, in 2009, there were still 55 Fokker F28 jets in operation worldwide, mostly in warmer climates.
Nobody should ever lose their life due to a contamination accident again in commercial aviation - anywhere in a snow and ice environment.
We've learned all the lessons.
Supertext Captions by Red Bee Media Australia
USAir Flight 405 plunges into the icy waters of Flushing Bay.
27 people die.
For US investigators, it's an open-and-shut case.
But Canadian investigators are stunned.
They know the New York accident should never have happened.
If they had followed the recommendations in my report, the F28 crash at LaGuardia could have been averted.
The LaGuardia accident makes one thing clear - the right people never got the warning.
March 10, 1989.
It's 11:39am at Dryden, Ontario's airport.
Light snow falls as Air Ontario Flight 1363 stops in the remote northern community on its way from Thunder Bay to Winnipeg.
The passengers stay onboard while the plane is refuelled.
WOMAN: Big, fluffy white snowflakes at this time were falling gently to the ground and it was very, very grey, 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.
There was a lot of families travelling onboard 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.
MAN: (OVER RADIO) Ontario 363.
Kenora.
As first officer Keith Mills checks on weather conditions, captain George Morwood returns from making a phone call inside the airport.
It's getting worse.
What's the latest? MAN: (OVER RADIO) It won't clear till late afternoon.
Check that.
Quite heavy snow.
Looks like it's gonna be a bad one - but still within our take-off limits.
Well, that's good.
We've 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.
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.
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 before we left, he came up as a violent person, so two of us have to go with him.
He was wanted in Banff on a fraud charge and that's what he was being brought back to Alberta for.
OK, no smoking and seatbelts.
On.
- Instruments.
- Synched.
Cross check.
Captain Morwood uses the power of engine number two, already running, to fire engine number one.
(ENGINE WHINES) Morwood and Mills are both highly experienced pilots.
However, they've each flown fewer than 100 hours in the Fokker F28.
The multimillion-dollar aircraft is the first Air Ontario jet to serve the remote northern Ontario region.
Inform Kenora we're rolling.
We're fired up.
Taxiing for departure.
Requesting airways to Winnipeg.
MAN: (OVER RADIO) Hang on a sec, guys.
Is there a chance that plane can hold? We're having some bad weather up here.
An approaching aircraft's urgent request to land Unbelievable.
.
.
gives Captain Morwood little choice.
He delays take-off.
OK, 363's holding short of the active.
In the two years that I had flown with Air 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 Dryden.
Finally, an hour behind schedule, the plane taxis to runway 29.
As we were going down the runway to position for take-off, the blanket of snow was falling and I couldn't see the treeline anymore.
It was like looking through a sheer.
Flight attendants, please be seated for take-off.
At 12:09pm, Flight 1363 is ready for take-off.
Advise Kenora, we're ready to proceed.
And Kenora, Dryden, Ontario 363 is about to roll 29 at Dryden.
MAN: (OVER RADIO) Securing 363 Kenora - roger.
Captain Morwood performs a brief engine run-up, heating the engines to rid them of any accumulated snow and ice.
Then he begins his roll 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?" The F28 reaches its take-off speed Rotate.
.
.
80 knots.
Our take-off was very slow and sluggish, like a slow, sluggish person running up a hill.
Clearly, there's something wrong.
The F28 struggles to get airborne.
It cleared the trees.
The plane started shaking.
(SCREAMING) I thought, "Oh, my God, we're going to crash.
" That's when all hell broke loose.
If you can equate to being in a Mixmaster, that's what the plane felt like at the time.
There was this dip to the left and then dip 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 stabilise itself.
You could just feel that the pilot is trying to get control of it.
But a few seconds later, it became a Mixmaster again.
I yelled out, "Emergency! "Grab your ankles.
Get your heads down.
" Grab your ankles! Get your heads down! I kept yelling that and then I assumed my brace position.
The pilots are helpless.
49 seconds after lifting off .
.
Air Ontario Flight 1363 crash-lands in the bush, 950 metres 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 alive! I'm still alive!" That this is all happening so quickly.
Now, the prisoner was still in handcuffs so I reached over and I took the cuffs off of him but he never left me and then we exited the aircraft.
There was fire all around.
There was explosions.
I'm thinking, "Oh, my God - we're full of fuel.
" Guys, come this way.
I started yelling, "Come this way! Come this way!" for people to follow my voice.
Come this way! Come on.
Passengers scramble for safety before the fire spreads.
45 people survive the accident.
But 24 people do not, including Captain Morwood and First Officer Mills.
Emergency crews rush to the crash site deep in the woods.
The injured are taken to hospital in Dryden.
I was very concerned, because I kept looking out the window and at the time, I thought there was a lot of snow.
I didn't notice anything wrong going down the runway.
It was just when we started hitting trees I knew something was wrong.
Within 24 hours, a team of investigators from the Canadian Aviation Safety Board arrives at the scene.
You go in there hopefully with the idea that you can find out what happened, why it happened and how you prevent it from happening in the future.
We walked the entire path of the airplane from 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.
The trees just past the end of runway 29 give investigator David Rohrer and his team vital clues about the F28'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.
It didn't ever fly.
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 F28's two black boxes.
The devices are designed to withstand temperatures of 1,100 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 1,100-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.
They learn that the F28 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 realised that we were overloaded and something had to come off.
Alright.
Let's offload some fuel, then.
They ended up removing fuel in order to be within the proper weight.
Despatch - 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.
Rohrer wonders if the change in plans somehow led to a miscalculation of the weight and balance.
Was the F28 too heavy for take-off? He 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.
Rohrer is forced to use Air Ontario's standard averages to calculate passenger and baggage weights.
ROHRER: 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 F28 weighed between 62,000 and 64,000 pounds.
And the airplane's max take-off weight was 65,000 pounds.
So we came to the conclusion that the airplane was not overweight.
18 days into the investigation, the Canadian government appoints Justice Virgil Moshansky 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 who had an aviation background.
Moshansky is an experienced pilot with 13 years on the bench.
He will work closely with crash investigator David Rohrer 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 Sonia 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 this smoke that filled the aircraft, and there was this horrible smell.
I thought, "Oh, my God.
We have a fire in the lav.
" 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 take-off 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? Rohrer 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 learn that it forced the crew to make a risky decision in Dryden.
Go on to the connectors.
Let's hope it holds.
Normally the captain would rely on the APU to re-start his engines after shutting them both down for re-fuelling.
But if he couldn't use his APU, he couldn't shut his engines down.
That meant Flight 1363 had to be re-fuelled with one engine still running.
Captain Morwood is in a situation where he's got a hot re-fuel with passengers onboard the aircraft.
He's got to keep an engine running to re-fuel the airplane.
Hot re-fuelling 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 re-fuelling.
Hot re-fuelling is not a normal practice.
Could the hot re-fuelling have caused some kind of damage to the engines? I thought, "This is gonna 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.
.
.
Rohrer orders extensive engine testing.
Those engines were examined in detail for damage.
Rohrer finds the F28'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 take-off, investigators are back to square one.
To solve the mystery, they comb through survivor and eyewitness statements.
A common thread emerges.
They've said in their witness statements, there was snow and ice on the wings when the airplane attempted to take off.
Rohrer studies weather charts for clues.
We had very good meteorological information.
The charts show that during the half-hour the F28 was on the ground at Dryden Airport, visibility shrank from four kilometres to less than one kilometre because of the snowstorm.
And we need to find other reasons.
For sure, snow and ice on the wings was a factor in this accident.
Sonia Hartwick tells investigators about an unusual sight during take-off.
As we took off, I noticed that the wings just became a solid sheen of grey, shiny ice.
Investigators consult the F28's manuals to study its anti-icing systems.
They find that only the wing's leading edges are protected.
BLACK: 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 and 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, Rohrer and his team meet with engineers from Fokker.
Thanks for coming.
Curious to see what you have.
Jack van Hengst, who was the chief engineer, had extensive aerodynamic studies and data on the effects of contamination on an F28 airplane.
Fokker engineers have run simulations of the crash.
BLACK: They were able to get some very good data in terms of the performance of the airplane, simulating the type of loads, temperatures et cetera, that the Dryden aircraft would have been exposed to.
Investigators make a crucial discovery about the design of the F28.
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 on 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 and decelerating to the point where it broke up.
Investigators are now certain that contaminated wings caused the crash.
But what is still unclear is why the plane was not de-iced before take-off.
Almost all airports in cold climates, including Dryden, are equipped with the technology to remove ice from a plane.
But Captain Morwood never requested de-icing.
It's getting worse.
What's the latest? MAN: (OVER RADIO) It won't clear till late afternoon.
Investigators need to figure out why.
They want to understand what made him risk his own life Let's hope it holds.
.
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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 behaviour.
Captain Morwood 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.
You know, Air Ontario was a growing company.
It was their first foray into jet operations.
I'm sure that there were many things that Captain Morwood would have thought in his own mind, that 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.
Rohrer 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.
Morwood complained 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.
HON.
MOSHANSKY: 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 10.
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 refuelling, the dispatcher forces Morwood to take on 10 extra passengers.
(SIGHS) Now he must offload fuel and lose more time.
There goes the schedule.
Let's, umoffload some fuel, then.
This meant Morwood would leave Thunder Bay behind schedule.
Dispatch.
And Captain Morwood is the type of captain who didn't want to be late.
Now en route to Dryden, and an hour behind schedule, the weather forecast the crew was given of light rain and fog is no longer accurate.
BLACK: 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've 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 Rohrer questions the fuelling agent, he learns that Morwood did ask about de-icing moments before take-off.
Is there de-icing available? The fuelling agent says he pointed out the de-icing ground crew to Morwood.
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.
BLACK: 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 Morwood had shut 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 in hotels and added expense to the airline for which he would be answerable.
Right.
So now what am I gonna do? So he was under a great deal of pressure.
No.
You figure it out.
ROHRER: 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.
It's still within our take-off limits.
That's good.
We've got lots of people who want to make 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 super-cool 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 air flow 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 take-off was the fact that he didn't consider the cold soaking phenomena and the fact that those wings could still have ice on them.
Advise Kenora we're ready to proceed.
Perhaps not wanting to face the consequences of shutting down his engines, Morwood opted to take-off for Winnipeg without de-icing his plane.
HON.
MOSHANSKY: He must have concluded that the ice would blow off on take-off.
That is where he made a mistake - a tragic mistake.
But Moshansky concludes that despite his mistake, Captain Morwood is not solely responsible for the crash.
It wasn't simply pilot error.
There were a myriad of factors which were 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 round all across Canada with various F28 operators to borrow parts from them, and 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.
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've got to talk to somebody about this.
.
.
because Air Ontario management did not have a safety culture .
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and you have to have a safety culture from the top of management down.
Knowing there are dozens of Fokker F28s flying around the world, Justice Moshansky 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 F28.
But 15 months later, it becomes clear that Moshansky's warnings have not been heard.
USAir Flight 405 is preparing to fly from New York to Cleveland on March 22, 1992.
The plane is a Fokker F28.
It's one degree below freezing.
At 9:00pm, 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.
MAN: (OVER RADIO) USAir 405 - clear for taxi runway 13.
The crew prepares for take-off.
Flight 405 is an hour and 45 minutes behind schedule when Captain Wallace Majure starts taxiing to runway 13.
Then, unexpectedly MAN: (OVER RADIO) USAir 405, turn left, and hold short of Echo.
Left on the inner.
Hold short of Echo.
Another 23 minutes pass.
First Officer John Rachuba 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.
MAN: (OVER RADIO) USAir 405, runway 13 clear for take-off.
Even though it's now been 35 minutes since their last de-icing, the crew does not request another.
Take-off, thrusts.
Set.
Temps OK.
Everything proceeds as it should.
- Until - V1.
Rotate.
.
.
just after the F28 begins its rotation.
The aircraft had enough flying speed to lift off - barely lift off.
The wings just could not support the airplane.
13 seconds after lifting off, Flight 405 crashes on the shore of Flushing Bay.
I don't think any pilot really thinks he's gonna crash.
They were trying to save the airplane right till the end.
(SIRENS WAIL) 27 of the 51 people onboard are killed.
Another Fokker F28 has crashed with tragic consequences.
My reaction when I heard about it was, "My God - it's Dryden all over again!" Within days, investigator-in-charge Robert Benzon 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 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, thrusts.
That would have put him very, very late and it may have even caused the cancellation of the flight.
BLACK: 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 Moshansky 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.
He also had drawn attention to the limitations of the de-icing fluid being used at the time.
Called 'Type I fluid', it's a mixture of antifreeze and water.
ROHRER: Those chemicals are designed that as you accelerate down a runway, that they will actually shed off your wing, so that when you actually want the wing to lift and produce lift, that it's not contaminated.
Type I fluid is applied hot to de-ice the plane's surfaces .
.
but it doesn't last long.
Type I fluid had a hold-over time in the 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, Moshansky's team reached a stark conclusion about the effectiveness of Type I fluid.
Even if Captain Morwood could have de-iced his plane in Dryden We're fired up.
Taxiing for departure.
Requesting airways to Winnipeg.
.
.
it may have made no difference.
MAN: (OVER RADIO) Hang on a sec, guys.
Is there a chance that plane can hold? We're having some bad weather up here.
Unbelievable.
Flight 1363 had to wait for the troubled Cessna 150 to land.
ROHRER: 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 snowstorm and they are getting contaminated.
Even if Morwood had de-iced during his 30 minutes on the ground Rotate.
.
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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 the Dryden report was a tour de force which helped us focus our investigation quite a bit.
Justice Moshansky 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 Moshansky learned that there was another type of de-icing fluid available to the airline industry.
It's called Type II fluid.
A Type II fluid is a much more gooey substance.
I've heard it referred to as almost mucus-like.
With hold-over times of up to 45 minutes, it keeps ice from accumulating, then blows off the plane's surfaces at take-off.
15 months before the USAir crash, Moshansky recommended greater use of the thicker Type II fluid.
Moshansky's investigators also studied de-icing practices at Toronto's Pearson Airport.
BLACK: 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 tracked one aircraft which was heading for the Caribbean 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 aircrafts 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 de-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 USAir crash, LaGuardia did not offer de-icing at the runway - only at the gate.
Again, 15 months before the crash, Justice Moshansky recommended the placement of de-icing facilities at runways instead of terminal gates.
Moshansky also recommended that pilots not only inspect their wings from the cockpit It looks pretty good to me as far as I can see.
.
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but also from the cabin.
MAN: (OVER RADIO) USAir 405.
Runway 13 clear for take-off.
Moshansky 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 Moshansky doesn't accept that.
My second interim report went out in December of 1990.
It was about a year and a half before the LaGuardia crash occurred.
So I think it probably sat on somebody's desk.
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 up with 192 recommendations.
It changed the whole nature of how we approach contamination.
JUSTICE MOSHANSKY: We now have runway and the 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 IV 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.
BLACK: Dryden 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 the EOs on notice that they can't hide in the woodwork when an accident occurs.
Dutch manufacture Fokker went bankrupt in 1996.
Despite this, in 2009, there were still 55 Fokker F28 jets in operation worldwide, mostly in warmer climates.
Nobody should ever lose their life due to a contamination accident again in commercial aviation - anywhere in a snow and ice environment.
We've learned all the lessons.
Supertext Captions by Red Bee Media Australia