Mayday 2025 | US Flight 405, The Dryden Ontario Plane Crash, Mayday Air Disaster, National Geographic Documentary, Mayday 2025: Air Crash Investigation
#mayday #air_crash #mid_air_collision #lose_power #american_airline #explore #trend #fyp
Mayday: Air Disaster is a dramatic non-fiction series that investigates high-profile air disasters to uncover how and why they happened. Mayday: Air Disaster follows survivors, family members of crash victims and transportation safety investigators as they piece together the evidence of the causes of major accidents. So climb into the cockpit for an experience you won't soon forget.
#mayday
#air_disaster
#airline
#crash_on_maoten
#plane_crashs
#maday_episodes
#air_crash_investigation
#mayday #air_crash #mid_air_collision #lose_power #american_airline #explore #trend #fyp
Mayday: Air Disaster is a dramatic non-fiction series that investigates high-profile air disasters to uncover how and why they happened. Mayday: Air Disaster follows survivors, family members of crash victims and transportation safety investigators as they piece together the evidence of the causes of major accidents. So climb into the cockpit for an experience you won't soon forget.
#mayday
#air_disaster
#airline
#crash_on_maoten
#plane_crashs
#maday_episodes
#air_crash_investigation
Category
🗞
NewsTranscript
00:00New York City's LaGuardia Airport, March the 22nd, 1992.
00:07A commuter plane with 51 people on board tries to lift off the runway.
00:12Rotate.
00:12But the pilots can't get it to climb.
00:15They knew they were in trouble, but they were fighting all the way to the end.
00:20U.S. Air Flight 405 plunges into the icy waters of Flushing Bay.
00:2627 people die.
00:28For U.S. investigators, it's an open and shut case.
00:32This accident was not a huge surprise to us.
00:36But Canadian investigators are stunned.
00:38They know the New York accident should never have happened.
00:41My reaction when I heard about it was, my God, it's driving all over again.
00:46Three years earlier, an exhaustive investigation into a crash at a remote northern airport had identified a killer
00:52and spelled out ways to keep it from striking again.
00:55Certainly, if they had followed the recommendations in my report,
01:00the F-28 crash at LaGuardia could have been averted.
01:03The LaGuardia accident makes one thing clear.
01:06The right people never got the warning.
01:08March 10th, 1989.
01:35It's 11.39 a.m. at Dryden, Ontario's airport.
01:41Light snow falls as Air Ontario Flight 1363 stops in the remote northern community on its way from Thunder Bay to Winnipeg.
01:49The passengers stay on board while the plane is refuelled.
02:03For flight attendant Sonia Hartwick and the crew aboard the Fokker F-28,
02:07it's been a frustrating day of delays.
02:10Big, fluffy, white snowflakes.
02:13At this time, we're falling gently to the ground.
02:17And it was very, very grey.
02:20And I thought, hmm, I guess this means we're going to be delayed again.
02:24I can't see us making it to Winnipeg on time.
02:26It's Friday, the beginning of March break.
02:33Already an hour behind schedule,
02:35another delay could jeopardise the vacation plans of many of the 69 passengers and crew.
02:41There was a lot of families travelling on board with plans.
02:45Most of them were going skiing.
02:48And so they were very concerned about meeting their connections in Winnipeg.
02:53Kenora Dryden, it's Ontario 363.
02:56Ontario 363, Kenora.
02:59As First Officer Keith Mills checks on weather conditions,
03:03Captain George Moorwood returns from making a phone call inside the airport.
03:07It's getting worse.
03:08It's the latest.
03:09And it won't clear until late afternoon.
03:11Check that.
03:12Quite heavy snow.
03:13Looks like it's going to be a bad one.
03:15It's still within our take-off limits.
03:17Well, that's good.
03:18We've got a lot of people who want to make their connectors.
03:20Let's hope it holds.
03:23Temperatures hover around freezing.
03:26Visibility is decreasing.
03:28If the flight doesn't leave soon, it could be grounded indefinitely.
03:33Dryden is a very small city.
03:35It's a very remote part of Ontario.
03:38With a population of about 6,500,
03:41the isolated community lies halfway between Thunder Bay and Winnipeg.
03:47Harsh Canadian winters with bitter cold reaching minus 35 degrees Celsius are the norm here.
03:53It's not the place to be stranded in the middle of a snowstorm.
03:57Royal Canadian Mounted Police Officer Don Crawshaw and his partner are escorting a prisoner to Winnipeg.
04:09When we did a criminal check on the prisoner before we left,
04:15he came up as a violent person.
04:17So two of us have to go with him.
04:19He was wanted in Banff on a fraud charge.
04:21And that's what he was bringing back to Alberta for.
04:27Hey, no smoking and seatbelts.
04:31All right.
04:32Instruments.
04:34Sinks.
04:36Cross check.
04:39Captain Moorwood uses the power of engine number two, already running, to fire engine number one.
04:48Moorwood and Mills are both highly experienced pilots.
04:52However, they've each flown fewer than 100 hours in the Fokker F-28.
04:57The multi-million dollar aircraft is the first Air Ontario jet to serve the remote northern Ontario region.
05:0624 minutes after landing in Dryden, flight 1363 is ready to leave.
05:12Informed, Canora, we're rolling.
05:15We're fired up, taxiing for departure, requesting airways to Winnipeg.
05:19Hang on a sec, guys.
05:20Is there a chance that plane can hold?
05:22We're having some bad weather up here.
05:24An approaching aircraft's urgent request to land.
05:27Unbelievable.
05:28Gives Captain Moorwood little choice.
05:31He delays takeoff.
05:32Okay, 363 is holding short of the active.
05:35We are going to be a few moments until a small plane lands safely.
05:41We're sorry, folks.
05:41This just isn't our day.
05:45In the two years that I had flown with Air Ontario, I'd never come across anything like this before.
05:50The Cessna 150 lands safely, clearing the runway for flight 1363's departure.
06:00Tell them we're going immediately.
06:03Canora, Ontario, we're taxiing out at this time.
06:05We have 363 drive.
06:08Finally, an hour behind schedule, the plane taxis to runway 29.
06:15As we're going down the runway to position for takeoff, the blanket of snow was falling, and I couldn't see the tree line anymore.
06:25It was like looking through a shear.
06:28Folks, we're sorry for the delay.
06:31Flight attendants, please be seated for takeoff.
06:36At 12.09 p.m., flight 1363 is ready for takeoff.
06:41Advise Canora, we're ready to proceed.
06:46And Canora, Dryden, Ontario, 363 is about to roll 29 at Dryden.
06:51Carry on 363, Canora, roger.
06:55Captain Moorwood performs a brief engine run-up, heating the engines to rid them of any accumulated snow and ice.
07:03Then he begins his roll down the runway.
07:08When we're taking off, I'm usually very quiet and focused, meticulously going through a checklist in my own mind,
07:14what would I do in the case of an emergency?
07:19V1.
07:20The F28 reaches its takeoff speed.
07:22Rotate.
07:2380 knots.
07:25Our takeoff was very slow and sluggish.
07:34Like a slow, sluggish person running up a hill.
07:39Clearly, there's something wrong.
07:42The F28 struggles to get airborne.
07:44We cleared the trees.
07:47The plane started shaking.
07:53I thought, oh my God, we're going to crash.
07:56That's when all hell broke loose.
07:57If you can equate to being in a mixmaster, that's what the plane felt like at the time.
08:06There's this dip to the left and then dip to the right.
08:09The pilot's trying to get this plane up.
08:11Then all of a sudden, there was a power burst.
08:15The plane seemed to stabilize itself.
08:17You could feel that the pilot's trying to get control of it.
08:20But a few seconds later, it became a mixmaster again.
08:29I yelled out, emergency, grab your ankles, get your heads down.
08:33Grab your ankles, get your heads down.
08:35And I kept yelling that, and then I assumed my brace position.
08:39You could hear people screaming and yelling.
08:41There's loud, horrible sounds.
08:44We are clearly crashing.
08:47The pilots are helpless.
08:5149 seconds after lifting off,
08:56Air Ontario Flight 1363 crash lands in the bush,
09:01950 meters west of runway 29.
09:05There was carnage of the aircraft all over the place.
09:19I didn't know where I was.
09:21And at that point, I thought, oh my gosh, I'm alive.
09:23I'm still alive that this is all happening so quickly.
09:28When we crashed, we came down on an angle.
09:32It ripped the right side of the plane open.
09:35And that's how we got out.
09:37Or else we probably would have never have gotten out.
09:40Now, the prisoner was still in handcuffs.
09:43So I reached over, and I took the cuffs off of him there.
09:47But he never left me.
09:48And then we exited the aircraft.
09:52There's fire all around.
09:54There's explosions.
09:56I'm thinking, oh my God, we're full of fuel.
09:58Guys, come this way.
10:00And I started yelling, come this way, come this way,
10:03for people to follow my voice.
10:04Come this way.
10:06Passengers scramble for safety before the fire spreads.
10:1245 people survived the accident.
10:16But 24 people do not,
10:19including Captain Moorwood and First Officer Mills.
10:22Emergency crews rush to the crash site deep in the woods.
10:42The injured are taken to hospital in Dryden.
10:55I was very concerned because I kept looking at the wing all the time.
10:57I thought there was a lot of snow.
10:59I didn't notice anything wrong going down the runway.
11:01Like I said, it was just when we started hitting the trees,
11:03I knew there was something wrong.
11:03Within 24 hours,
11:11a team of investigators from the Canadian Aviation Safety Board arrives at the scene.
11:22You're going there,
11:23hopefully with the idea that you can find out what happened,
11:25why it happened,
11:26and how do you prevent it from happening in the future.
11:29We walked the entire path of the airplane to the threshold of the runway,
11:33and then we walked the flight path of the airplane right to the crash site.
11:37That was the first thing that I did.
11:40I wanted to document what I was seeing by photographing.
11:45When you walk in on an accident site like that,
11:47there are two things that overwhelm you.
11:49The smell of aviation jet fuel
11:51and the smell of death.
12:03The trees just past the end of runway 29
12:09give investigator David Rohr and his team vital clues
12:12about the F-28's failed flight.
12:16What happened was the airplane went off the end of the runway
12:19in what we would call ground effect
12:21and just stayed at that height,
12:22simply clipping the tops of the trees.
12:25Look at how these treetops have been clipped off.
12:27It didn't ever fly.
12:34You've got 24 people that died.
12:37You've got two pilots that died
12:38and a flight attendant that died.
12:40And they died, for the most part, trying to do their job.
12:43So you really want to do them justice,
12:46but you also have to be fair.
12:49And if there were mistakes made,
12:51mistakes have to be fixed.
12:52From the rear of the fuselage,
12:56investigators recover the F-28's two black boxes,
13:01the flight data recorder
13:02and the cockpit voice recorder.
13:11The devices are designed to withstand temperatures
13:14of 1,100 degrees Celsius for up to 30 minutes.
13:18Investigators are frustrated to learn
13:20that the mylar tape from the recorders
13:22has suffered extreme heat damage.
13:26It's estimated the black boxes
13:28were scorched by an 1,100-degree inferno
13:30for at least 90 minutes,
13:32far beyond their limit.
13:34The data is unrecoverable.
13:36That was a big blow to us
13:38because now you have to try
13:40and gather information
13:42and try and establish
13:45that it's factual by independent routes.
13:48We were just about to leave Thunder Bay
13:51and they gave us 10 new passengers.
13:55Investigators must now rely heavily
13:57on eyewitness reports
13:58to reconstruct the events
13:59leading up to the doomed takeoff.
14:02They learned that the F-28
14:04began its day in Winnipeg
14:05and was scheduled to fly a return route
14:08to Thunder Bay and back
14:09with a stopover in Dryden.
14:14But in Thunder Bay, plans changed.
14:18The cancellation of another flight
14:19forced the crew to pick up
14:2110 additional passengers.
14:23And when they did their calculations,
14:26they realized that we were overloaded
14:29and something had to come off.
14:30All right, let's offload some fuel then.
14:34They ended up removing fuel
14:36in order to be within the proper weight.
14:39Dispatch, Ontario 363.
14:41So the flight was delayed an hour.
14:44The extra weight of the new passengers
14:45left the crew no choice.
14:48They had to unload fuel
14:49to lighten their load.
14:51That meant when they arrived in Dryden,
14:54they needed to pump in
14:55more than the usual amount of fuel
14:57for the final leg back to Winnipeg.
14:59Rhoa wonders if the change in plans
15:04somehow led to a miscalculation
15:06of the weight and balance.
15:09Was the F-28 too heavy for takeoff?
15:14He then uncovers a puzzling detail.
15:17The plane's weight and balance form
15:19for the takeoff from Dryden
15:20was never collected as required.
15:23It burned in the fire.
15:24Rhoa is forced to use
15:29Air Ontario's standard averages
15:31to calculate passenger and baggage weights.
15:35The data, combined with the airport's fuel records,
15:39allows him to estimate
15:40the plane's gross takeoff weight.
15:42We knew how many people we had on board.
15:46We knew how many bags we had on the airplane.
15:49And we knew what our fuel load was.
15:53He estimates the F-28 weighed
15:55between 62,000 and 64,000 pounds.
16:00And the airplane's max takeoff weight
16:02was 65,000 pounds.
16:04And so we came to the conclusion
16:05that the airplane was not overweight.
16:07The cause of the crash remains a mystery.
16:1418 days into the investigation,
16:17the Canadian government appoints
16:19Justice Virgil Moshansky
16:20to lead a more wide-ranging inquiry
16:22into all aspects of the aviation system
16:25that might have contributed
16:26to the Air Ontario tragedy.
16:29The government was looking for
16:31an experienced trial judge
16:32and preferably one who had
16:34an aviation background.
16:35Moshansky is an experienced pilot
16:38with 13 years on the bench.
16:41He will work closely
16:42with crash investigator David Rohrer
16:44and aviation consultant Frank Black.
16:47The new team's first step,
16:49assessing the plane's technical systems.
16:51The electrical system,
16:52the hydraulic system,
16:53the fuel system,
16:55all of these systems
16:56are looked at both in terms
16:58of what is their history
17:00leading up to the accident
17:01and what remnants are remaining
17:03at the crash site
17:04that can be examined.
17:05Clues to a possible system failure
17:12arise when Sonia Hartwick
17:14recalls a troubling event
17:15aboard the same plane
17:16just days before the fatal crash.
17:19I think it was Monday or Tuesday.
17:22When we took off,
17:23there was a smoke
17:24that filled the aircraft
17:25and there was this horrible smell.
17:27I thought, oh my God,
17:29we have a fire in the lab.
17:34But there was no fire
17:35in the lavatory
17:36or anywhere else in the cabin.
17:39They told us
17:41that apparently it had something
17:42to do with oil
17:43sitting in the APU system.
17:45So every takeoff that day,
17:48this would happen.
17:51The auxiliary power unit
17:53is a generator
17:54that provides the power
17:55needed to start the engines.
17:58Did burning oil in the APU
18:00somehow cause a fire
18:01and ultimately doom flight 1363?
18:06Rohr searches the week's journey log
18:08for any mention
18:09of the auxiliary power unit.
18:11He makes a surprising discovery.
18:14The APU wasn't working
18:16on the day of the crash.
18:17It couldn't possibly
18:19have caused the fire.
18:20But the inoperative power unit
18:22may still have played
18:23a role in the tragedy.
18:27Investigators learned
18:28that it forced the crew
18:29to make a risky decision
18:30in Dryden.
18:31Let's hope it holds.
18:33Normally,
18:34the captain would rely
18:35on the APU
18:36to restart his engines
18:37after shutting them
18:38both down for refueling.
18:40But if he couldn't use his APU,
18:42he couldn't shut his engines down.
18:44That meant flight 1363
18:46had to be refueled
18:48with one engine still running.
18:50Captain Warwood
18:51is in a situation
18:52where he's got to hot refuel
18:53with passengers
18:54on board the aircraft.
18:56He's got to keep
18:56an engine running
18:57to refuel the airplane.
19:00Hot refueling
19:02isn't against regulations,
19:03but the risk of a fuel spill
19:05makes it potentially dangerous.
19:10In Toronto in 1973,
19:13a maintenance person
19:14was killed
19:15when an Air Canada DC-8 jet
19:17was consumed by fire
19:18during refueling.
19:20Hot refueling
19:22is not a normal practice.
19:25Could the hot refueling
19:26have caused
19:27some kind of damage
19:28to the engines?
19:29The Dryden airport manager,
19:36a former military pilot,
19:37suspects there was trouble
19:39with the plane's engines.
19:41He tells Rower
19:42he saw the take-off
19:43from his office
19:43and heard a sharp,
19:45explosive noise
19:46just as it disappeared
19:47from view.
19:48To him,
19:49it signified a flame-out
19:50or engine failure.
19:51I thought this is going
20:00to be a high-profile
20:01and potentially
20:02controversial investigation,
20:04and the only way
20:05to ensure that the truth
20:06stands up
20:08is to have hard evidence
20:09from the aircraft accident.
20:12And so we took the airplane
20:13completely,
20:14and we put it in our lab
20:16in Ottawa.
20:17with signs pointing
20:21to engine failure
20:22as the cause
20:22of the crash,
20:24Rower orders
20:26extensive engine testing.
20:28Those engines
20:29were examined
20:30in detail for damage.
20:33Rower finds
20:34the F-28's
20:35two Rolls-Royce engines
20:36suffered only
20:37minor structural damage.
20:38There's no evidence
20:40of an engine fire,
20:41nothing at all
20:42to suggest
20:43the engines had failed.
20:50With little physical evidence
20:52to explain
20:53the failed take-off,
20:54investigators are back
20:55to square one.
20:59To solve the mystery,
21:01they comb through
21:02survivor and eyewitness statements.
21:05A common thread emerges.
21:06They've said
21:07in their witness statements,
21:08there was snow and ice
21:09on the wings
21:10when the airplane
21:11attempted to take off.
21:18Rower studies
21:19weather charts
21:19for clues.
21:21We had very good
21:21meteorological information.
21:24The charts show
21:25that during the half hour
21:26the F-28 was on the ground
21:28at Dryden Airport.
21:29Visibility shrank
21:30from four kilometers
21:31to less than one kilometer
21:33because of the snowstorm.
21:35And we may find
21:36other reasons
21:37for sure
21:38snow and ice
21:39on the wings
21:40was a factor
21:41in this action.
21:43Sonia Hartwick
21:44tells investigators
21:45about an unusual sight
21:46during take-off.
21:48As we took off,
21:49I noticed
21:50that the wings
21:51just became
21:52a solid sheen
21:53of gray,
21:54shiny ice.
21:59Investigators
22:00consult the F-28's manuals
22:02to study its anti-icing systems.
22:04They find that only
22:05the wings' leading edges
22:07are protected.
22:08The aircraft
22:09had heated leading edges
22:11on the wings.
22:12I wonder if the anti-icing system
22:14was working.
22:15And the heat
22:16was provided by bleed air
22:17from the compressors
22:18on the engine.
22:20They found the valves
22:21that allow the compressed air
22:24access to the leading edges.
22:26and they tested the valve
22:32to see if it functioned
22:33and it did.
22:35The anti-icing system
22:36was working.
22:38But since it only
22:39heats the leading edge,
22:41it likely didn't clear ice
22:43that formed on the surface
22:44of Flight 1363's wings.
22:50Investigators suspect
22:51that snow and ice buildup,
22:53what experts call
22:54wing contamination
22:55may have played
22:57a major role
22:57in the crash.
23:01To verify that suspicion,
23:04Roha and his team
23:05meet with engineers
23:06from Fokker.
23:08Thanks for coming.
23:09Curious to see
23:10what you have.
23:12Jack Van Hengst,
23:13who was the chief engineer,
23:14had extensive
23:16aerodynamic studies
23:17and data
23:18on the effects
23:18of contamination
23:19on an F-28 airplane.
23:22Fokker engineers
23:23have run simulations
23:24of the crash.
23:26They were able
23:27to get some
23:28very good data
23:29in terms of
23:30the performance
23:31of the airplane,
23:32simulating the type
23:33of loads,
23:34temperatures, etc.,
23:36that the Dryden aircraft
23:37would have been exposed to.
23:42Investigators
23:42make a crucial discovery
23:44about the design
23:44of the F-28.
23:46Because of the angle
23:47of the wings,
23:49a very small amount
23:50of ice makes the plane
23:51susceptible to stalling.
23:54They concluded
23:55that even the most
23:57minute bit of
23:58contamination
24:00on the wing
24:00would disrupt
24:02the airflow
24:03and cause
24:04a loss of lift.
24:06Well, that answers
24:07a lot of questions.
24:09The simulations
24:09support what witnesses
24:11saw.
24:11It just barely
24:13got airborne,
24:15dropping wings,
24:16losing lift,
24:17and then hitting trees,
24:19decelerating to the point
24:20where it broke up.
24:26Investigators
24:26are now certain
24:27that contaminated wings
24:29caused the crash.
24:31But what's still unclear
24:32is why the plane
24:34was not de-iced
24:35before take-off.
24:35almost all airports
24:39in cold climates,
24:40including Dryden,
24:42are equipped
24:42with the technology
24:43to remove ice
24:44from a plane.
24:49But Captain Morwood
24:51never requested
24:52de-icing.
24:52It's getting worse.
24:55What's the latest?
24:58Investigators
24:59need to figure out
25:00why.
25:01They want to understand
25:02what made him risk
25:03his own life.
25:04Let's hope it holds.
25:05and the lives
25:07of the 68 other people
25:09on board
25:09flight 1363.
25:16Investigators
25:17dig through
25:17Captain George Morwood's
25:19flight records
25:20and work history.
25:21They interview
25:22crew members
25:22searching for clues
25:24to his behavior.
25:25Captain Morwood
25:26was a very,
25:27very professional,
25:29very old school pilot.
25:31He had his view
25:32on how things
25:32should be done properly
25:34and what his definition
25:35of proper
25:35and professional
25:36would be.
25:38He also was very
25:39concerned about
25:40his passengers.
25:41He enjoyed making sure
25:43that they got
25:43on their flights
25:44on time
25:45and got to their
25:45destinations on time.
25:47You know,
25:48Air Ontario
25:48was a growing company.
25:50It was their first
25:51foray into jet operations.
25:54I'm sure that there
25:55were many things
25:57that Captain Morwood
25:58would have thought
25:58in his own mind.
26:00This is not how
26:01he would do it.
26:02And I'm sure at times
26:03he probably let
26:04the superiors
26:05know that.
26:06Morwood's history
26:07shows he's delayed
26:08and canceled flights
26:09in the past
26:10because of icing concerns.
26:13Rohwer is stumped.
26:14Why didn't he request
26:15de-icing in Dryden?
26:19Another pilot
26:20who was at Dryden
26:21Airport that day
26:22provides part
26:23of the answer.
26:25He heard Morwood
26:26on the phone
26:26to Air Ontario.
26:27That is what I have
26:31been trying
26:32to tell you.
26:33He was very frustrated
26:35and he was really
26:36concerned about
26:37his passengers.
26:38Morwood complained
26:39to the off-duty pilot
26:41about the company.
26:42These guys.
26:44You want to guess
26:44my weight
26:45before I left
26:45Thunder Bay?
26:4666 and change.
26:48I had to offload fuel.
26:50Now that...
26:50Right.
26:53So now
26:54what am I supposed
26:54to do?
26:56No.
26:57You figure it out.
27:00When he left
27:01the terminal
27:02he was observed
27:03by witnesses
27:04to appear
27:05to be very upset
27:07and very angry.
27:11Investigators wonder
27:12what set Morwood off.
27:14They try to piece
27:15together the pilot's day
27:16on March the 10th.
27:17This was the fifth day
27:19of a very long week
27:20for Captain Morwood
27:21and he was the next day
27:23leaving with his family
27:24on a ski vacation.
27:27Before his first
27:28flight of the day
27:29he'd learned
27:30the plane's APU
27:31still wasn't working.
27:36And then
27:37once in Thunder Bay
27:38more bad news.
27:41After refueling
27:42the dispatcher
27:42forces Morwood
27:43to take on
27:4410 extra passengers.
27:47now he must
27:48offload fuel
27:49and lose more time.
27:51There goes the schedule.
27:53Let's um
27:54offload some fuel then.
27:56This meant
27:57Morwood would leave
27:57Thunder Bay
27:58behind schedule.
27:59Dispatch.
28:00Ontario 363.
28:01And Captain Morwood
28:02is the type of captain
28:03who didn't want
28:04to be late.
28:07Now en route
28:08to Dryden
28:09and an hour
28:09behind schedule
28:10the weather forecast
28:11the crew was given
28:12of light rain
28:13and fog
28:13is no longer accurate.
28:15and Captain
28:17Morwood
28:17didn't get
28:19the forecast
28:19of freezing rain
28:21coming into Dryden
28:22which he should have had.
28:24As flight 1363
28:26lands in Dryden
28:27the weather
28:27was getting worse
28:28by the minute.
28:30The plane
28:31sat there
28:32for half an hour
28:33while snow
28:34built up on the wings.
28:37I gotta talk
28:38to somebody
28:39about this.
28:40Investigators
28:41may never know
28:42how concerned
28:43Morwood was
28:43about the weather.
28:48But there is evidence
28:49that it was
28:50on his mind.
28:52When Rohr
28:53questions the
28:54fueling agent
28:54he learns
28:55that Morwood
28:56did ask
28:57about de-icing
28:57moments
28:58before take-off.
29:00Is there
29:01de-icing available?
29:05The fueling agent
29:06says he pointed
29:07out the de-icing
29:08ground crew
29:09to Morwood.
29:09The agent
29:14then offers
29:14a compelling
29:15reason
29:15that could explain
29:16why the captain
29:17didn't de-ice.
29:21Air Ontario
29:22had a policy
29:23prohibiting him
29:24from de-icing
29:25with an engine running.
29:26The fluid
29:29can be ingested
29:30in the engines
29:31and then find
29:32its way
29:32from there
29:32to the air
29:33conditioning
29:33on the airplane
29:34and make it
29:36extremely noxious
29:37in the cabin
29:38portion of the airplane.
29:40But if Morwood
29:41had shut down
29:42both engines
29:42he wouldn't have
29:43been able
29:44to restart
29:44his plane.
29:45The only other
29:47way to start
29:47the airplane
29:48on the ground
29:49is with a
29:50ground-based
29:51air cart
29:52that can provide
29:53the compressed air
29:54and Dryden
29:56did not have
29:57the capability
29:58to start the airplane.
30:00The equipment
30:00would have had
30:01to be flown in
30:02from Winnipeg.
30:03It would have been
30:04a costly decision.
30:06If he shut it down
30:07he would ground
30:08the aircraft there
30:09effectively
30:09requiring the
30:12billeting
30:13of passengers
30:14and hotels
30:15and out of the
30:16expense to the
30:17airline for which
30:17he would be
30:18answerable.
30:19Right.
30:19So now what I'm
30:20So he was under
30:20a great deal
30:21of pressure.
30:22No.
30:23You figure it out.
30:25And I believe
30:26that the conversation
30:27on the phone
30:28would have been
30:29about that scenario
30:30and his displeasure
30:31with it.
30:32But he didn't
30:33have any other chance.
30:35It's getting worse.
30:36What's the latest?
30:37Quite heavy snow.
30:38Looks like it's
30:38going to be a bad one.
30:40It's still within
30:40our takeoff limits.
30:41Well that's good.
30:42We've got a lot of people
30:43who want to make
30:43their connectors.
30:44Let's hope it holds.
30:46Though the amount of snow
30:47on the wings
30:47was still within limits,
30:49it's what lay under
30:50the snow that doomed
30:51the flight.
30:53The fuel in a plane's
30:54wing can get as cold
30:55as minus 40 degrees
30:57Celsius.
30:58The frigid fuel
30:59cools the metal surface
31:01of the wing.
31:02When snow hits
31:03this supercooled surface,
31:05it freezes instantly
31:06into a barely visible
31:07layer of ice.
31:09It's a process
31:10called cold soaking.
31:11And this, of course,
31:12is what's disrupting
31:13the airflow on the wing
31:14and destroying
31:15the lifting capabilities.
31:16Tell them we're going
31:17immediately.
31:19Canora and Terra,
31:20we're taxiing out
31:20at this time.
31:21The only reason
31:23that I can possibly
31:25think of that led
31:26to his decision
31:27to execute
31:28the takeoff
31:29was the fact
31:30that he didn't consider
31:31the cold soaking
31:32phenomena
31:33and the fact
31:34that those wings
31:35could still have ice
31:36on them.
31:37Advise Canora,
31:38we're ready to proceed.
31:40And Canora,
31:40drive in Ontario.
31:41Perhaps not wanting
31:42to face the consequences
31:43of shutting down
31:44his engines,
31:46Morwood opted
31:46to take off
31:47for Winnipeg
31:47without de-icing
31:48his plane.
31:51He must have concluded
31:52that the ice
31:53would blow off
31:54on takeoff.
31:56That is where
31:57he made a mistake,
31:59a tragic mistake.
32:00But Mashansky
32:02concludes that
32:03despite his mistake,
32:05Captain Morwood
32:06is not solely
32:07responsible for the crash.
32:09It wasn't simply
32:09pilot error.
32:11There were a myriad
32:11of factors,
32:12which were the cause
32:14of the accident.
32:20One of the most
32:21important factors,
32:23Air Ontario's decision
32:24to let the plane
32:25fly with a broken APU.
32:27They were deferring
32:29a lot of the maintenance
32:30that should have been done
32:31because of a shortage
32:33of parts.
32:34And then they had
32:35to scrounge around
32:36all across Canada
32:37with various F-28 operators
32:40to borrow parts from them.
32:43And this was a very bad move
32:47on the part
32:47of Air Ontario management.
32:49The investigation determines
32:51that by cutting corners
32:52and focusing too much
32:54on the bottom line,
32:56the airline was putting
32:57all their passengers
32:58and employees at risk.
32:59Because the F-28s
33:01were new to Air Ontario,
33:02there was this urgency
33:03to get one crew off
33:04and get the next crew on flying.
33:06This urgency to have them
33:08in the air
33:08producing money.
33:11I came to the conclusion
33:13after a lot of thought
33:15about this accident
33:15that there were a lot
33:17of other hands
33:17on those throttles,
33:20pushing those throttles forward.
33:21There were a lot of people
33:26that were involved
33:29in the sequence of events
33:31that led to this tragic outcome.
33:35This was a preventable accident,
33:38but everything conspired
33:39against the pilots.
33:41I've got to talk to somebody
33:42about this.
33:43Because Air Ontario management
33:45did not have a safety culture.
33:49And you have to have
33:50a safety culture
33:51from the top management down.
34:01Knowing there are dozens
34:02of Fokker F-28s
34:04flying around the world,
34:05Justice Mashansky
34:06takes an unusual step.
34:09He releases a report
34:10well before his inquiry concludes.
34:13Good afternoon.
34:15It warns of the plane's
34:16vulnerability to ice buildup
34:17and stresses the need
34:19for frequent de-icing
34:20in winter conditions.
34:23Even a small amount of icing
34:24would be disastrous
34:25on an F-28.
34:32But 15 months later,
34:34it becomes clear
34:35that Mashansky's warning
34:36have not been heard.
34:39U.S. Air Flight 405
34:41is preparing to fly
34:42from New York to Cleveland
34:44on March 22, 1992.
34:48The plane is a Fokker F-28
34:50and it's snowing.
34:55It's one degree below freezing.
34:58At 9 p.m.,
34:59the jet is being de-iced
35:01for a second time
35:02since its arrival from Florida.
35:05In the past hour,
35:06an inch of snow has fallen
35:08and shows no signs of stopping.
35:11U.S. Air 405
35:12cleared to taxi
35:12runway 13.
35:14The crew prepares for takeoff.
35:18Flight 405
35:20is an hour and 45 minutes
35:21behind schedule
35:22when Captain Wallace Majeure
35:24starts taxiing
35:25to runway 13.
35:25to runway 13.
35:28Then,
35:29unexpectedly,
35:30U.S. Air 405,
35:32turn left in the whole
35:33short of echo.
35:37Left on the inner
35:38to hold short of echo.
35:39At 9.07 p.m.,
35:41flight 405
35:42is forced to wait
35:43on the taxiway
35:44near runway 13.
35:47Another 23 minutes pass.
35:51First officer
35:52John Raschuba
35:52turns on a light
35:53that illuminates his wings.
35:55He checks the right wing
35:56for ice.
35:58He sees none.
35:59Looks pretty good to me
36:00as far as I can see.
36:01U.S. Air 405
36:04runway 13
36:05clear for takeoff.
36:07Even though
36:08it's now been
36:0935 minutes
36:10since their last de-icing,
36:12the crew does not
36:13request another.
36:14Takeoff thrust set.
36:16Temps okay.
36:18Everything proceeds
36:19as it should
36:20until
36:23V1
36:23rotate.
36:27Just after the F-28
36:29begins its rotation.
36:31The aircraft
36:33had enough
36:34flying speed
36:35to lift off.
36:38Barely lift off.
36:40The wings
36:41just could not
36:41support the airplane.
36:43They knew
36:43they were in trouble.
36:4513 seconds
36:46after lifting off,
36:47flight 405
36:48crashes
36:49on the shore
36:50of Flushing Bay.
36:56I don't think
36:57any pilot
36:58really
36:59thinks he's
37:00going to crash.
37:01They were trying
37:02to save the airplane
37:03right to the end.
37:0827 of the 51
37:09people on board
37:10are killed.
37:13Another Fokker F-28
37:15has crashed
37:16with tragic consequences.
37:18My reaction
37:19when I heard
37:20about it was,
37:21my God,
37:22it's dried
37:22all over again.
37:24Within days,
37:25investigator in charge
37:27Robert Benzen
37:27suspects that ice
37:28on the wings
37:29was the major cause.
37:31It would be very,
37:31very difficult
37:32for either of the pilots
37:33to really detect
37:34ice on the wings
37:36looking backwards
37:37over their shoulders
37:37through the side windows
37:39of the airplane.
37:40It's pretty good to me
37:41as far as I can see.
37:41So the captain
37:43was faced with
37:43quite a problem.
37:45If he wanted
37:46to be de-iced
37:46a third time,
37:47he would have had
37:47to get out
37:48on the lines,
37:49taxi all the way
37:49back into the
37:50parking area
37:51and meet up
37:52with a de-icing truck
37:53again.
37:54Takeoff thrusts.
37:55That would have
37:55put him very,
37:56very late
37:57and it may have
37:58even caused
37:59the cancellation
37:59of the flight.
38:02After all
38:03of this work,
38:04after all
38:05of the efforts
38:06to see it
38:07happen again
38:09was extremely
38:10frustrating.
38:16There were
38:17no regulations
38:17in place
38:18requiring the crew
38:19to seek another
38:20de-icing
38:20after their
38:21extended delay.
38:23But Justice
38:24Mashansky
38:25had called
38:25attention
38:26to the dangers
38:26of long wait times
38:27when he issued
38:28his interim report.
38:30If they had
38:31followed the
38:32recommendations
38:32in my second
38:34interim report,
38:35this accident
38:36certainly could
38:37have been averted.
38:43He also
38:44had drawn attention
38:45to the limitations
38:46of the de-icing fluid
38:48being used
38:48at the time.
38:50Called type 1
38:51fluid,
38:52it's a mixture
38:52of antifreeze
38:53and water.
38:54Those chemicals
38:55are designed
38:56that as you
38:56accelerate down
38:57the runway
38:58that they'll
38:59actually shed
38:59off your wing
39:00so that when
39:01you actually
39:02want the wing
39:03to lift
39:03and produce lift
39:04that it's not
39:05contaminated.
39:07Type 1 fluid
39:08is applied hot
39:09to de-ice
39:10the plane's
39:10surfaces.
39:12But it doesn't
39:13last long.
39:14Type 1 fluid
39:15had a hold
39:16over time
39:17in their best
39:18conditions
39:19of about 15 minutes.
39:22Under poor
39:23conditions such
39:24as freezing rain
39:24it could be
39:25as low as 6 minutes.
39:27During the Air
39:28Ontario investigation,
39:30Mashansky's team
39:31reached a stark
39:32conclusion
39:32about the
39:33effectiveness
39:33of type 1
39:34fluid.
39:35Even if
39:36Captain Moorwood
39:37could have
39:37de-iced his
39:38plane in Dryden,
39:39We're fired up
39:40taxing for departure
39:41requesting airways
39:42to Winnipeg.
39:43It may have
39:44made no difference.
39:48Hang on a sec guys,
39:49is there a chance
39:49that plane can hold?
39:50We're having
39:51some bad weather
39:51up here.
39:52Unbelievable.
39:53Flight 1363
39:54had to wait
39:55for the troubled
39:56Cessna 150
39:57to land.
39:58By the time
39:59he waited
39:59for this 150
40:00aircraft and pilot
40:01to land
40:02and then they
40:02backtracked
40:03and got into
40:03position.
40:04Now they're
40:05in a serious
40:06small storm
40:07and they are
40:08getting contaminated.
40:12Even if
40:13Moorwood had
40:13de-iced during
40:14his 30 minutes
40:15on the ground,
40:16rotate.
40:17The delay
40:18may have been
40:19enough for the
40:19fluid to stop
40:20working.
40:21The plane's
40:22wings may once
40:22again have
40:23become coated
40:24in ice.
40:32It came out
40:34in the examination
40:36of Air
40:37Ontario pilots
40:38that there was
40:39a dire need
40:40for training
40:41in terms of
40:43how the
40:43de-icing,
40:44anti-icing
40:45systems worked
40:46and how long
40:47your aircraft
40:48was protected.
40:50As soon as
40:51our accident
40:53occurred up
40:54in New York,
40:55we of course
40:55understood that
40:56it was a similar
40:57aircraft,
40:57in fact,
40:58a nearly identical
40:58aircraft to the
40:59Dryden accident
41:00airplane.
41:01The circumstances
41:02were similar
41:03in both accidents
41:05and the Dryden
41:06report was a
41:07tour de force
41:08which helped us
41:09focus our
41:10investigation
41:10quite a bit.
41:13Justice
41:13Moschansky
41:14had released
41:14his interim
41:15report more
41:16than a year
41:17before the
41:17crash of
41:18Flight 405.
41:20His
41:20recommendations
41:21could have
41:22prevented it.
41:25Moschansky
41:26would soon
41:26discover that
41:27a breakdown
41:28in communication
41:29had cost
41:30the lives
41:30of 27 people
41:32in New York.
41:40During his
41:41inquiry,
41:42Justice
41:42Moschansky
41:43learned that
41:43there was
41:43another type
41:44of de-icing
41:45fluid available
41:45to the
41:46airline industry.
41:49It's called
41:51Type 2
41:51fluid.
41:53It's thicker
41:54than Type 1
41:55which prevents
41:56it from
41:56immediately
41:56flowing off
41:57an aircraft.
41:59A Type 2
42:00fluid is a
42:02much more
42:03gooey substance.
42:04I've heard it
42:05referred to
42:05as almost
42:06mucus-like.
42:08With holdover
42:08times of up
42:09to 45 minutes,
42:10it keeps ice
42:11from accumulating,
42:13then blows off
42:14the plane's
42:14surfaces at
42:15takeoff.
42:17Fifteen months
42:18before the
42:18U.S. air crash,
42:20Moschansky
42:20recommended greater
42:21use of the
42:22thicker Type 2
42:23fluid.
42:26Moschansky's
42:27investigators also
42:28studied de-icing
42:29practices at
42:30Toronto's
42:30Pearson Airport.
42:32We got a hold
42:33of a film crew
42:34and we waited
42:36and watched the
42:36weather very
42:37carefully until
42:38we found a
42:40forecast of
42:40freezing rain.
42:42And we tracked
42:43one aircraft
42:44which was heading
42:46for the Caribbean.
42:46The investigators
42:48discovered an
42:49alarming gap in
42:50the time between
42:51de-icing and
42:52takeoff.
42:53And from the
42:54time the aircraft
42:55was de-icing on
42:56the gate until
42:57the time the
42:58aircraft took
42:59off was
43:00somewhere in
43:00the order of
43:0041 minutes.
43:01So there was
43:02no doubt that
43:04aircraft were
43:04departing Pearson
43:06Airport with a
43:08partially or
43:09largely contaminated
43:11wing surface.
43:14We then went to
43:16Chicago O'Hare.
43:18This was the
43:19first airport to
43:20actually put in
43:22place runway and
43:23de-icing pads.
43:25And it was very
43:26useful in terms of
43:28explaining to us
43:28how these had
43:29evolved, what type
43:30of de-icing equipment
43:32they were using on
43:33them, how they
43:34worked.
43:35At the time of
43:36the U.S. air
43:36crash, LaGuardia
43:38did not offer
43:39de-icing at the
43:39runway, only at
43:41the gate.
43:44Again, 15 months
43:45before the crash,
43:47Justice Mashansky
43:48recommended the
43:48placement of de-icing
43:50facilities at
43:50runways instead of
43:52terminal gates.
43:55Mashansky also
43:56recommended that
43:56pilots not only
43:57inspect their wings
43:58from the cockpit,
44:00Looks pretty good
44:00to me as far as I
44:01can see, but also
44:03from the cabin.
44:04U.S. air 405,
44:06runway 13,
44:07clear for takeoff.
44:08Mashansky claims
44:09that his report
44:10could have prevented
44:10the crash at LaGuardia.
44:15But the Federal
44:16Aviation Administration
44:17claims it never
44:18received his report
44:19in 1990, and
44:21therefore couldn't
44:21pass the information
44:22along to airlines
44:23and pilots.
44:25But Justice
44:26Mashansky doesn't
44:26accept that.
44:28My second interim
44:29report went out
44:29in December of
44:321990.
44:35It was about a year
44:36and a half before
44:37the LaGuardia crash
44:39occurred.
44:41So I think
44:43probably sat on
44:44somebody's desk.
44:48The crash of
44:49Flight 1363
44:51resulted in dozens
44:52of recommendations
44:52that could save
44:54lives.
44:56The crash of
44:57Flight 405
44:58ensured those
44:59recommendations were
45:00widely implemented.
45:02Well, there was a
45:03lot that came out
45:04of Dryden.
45:04I mean, the
45:05commission came out
45:06with 192
45:07recommendations.
45:08It changed the
45:10whole nature of
45:12how we approach
45:12contamination.
45:16We now have
45:18runway and
45:19de-icing pads
45:20so they can get
45:21a final de-icing
45:23before they take
45:24off.
45:26This was
45:26something directly
45:28the result of the
45:29Dryden commission
45:29inquiry.
45:32Today, most
45:33airlines use a new
45:34type of de-icing
45:35fluid.
45:36Type 4 de-icing fluid
45:38lasts longer.
45:40It will stick to a
45:41wing for up to
45:42two hours.
45:44As well, air traffic
45:46controllers must now
45:47be able to tell
45:47flight crews how long
45:49they will be delayed
45:50at the runway after
45:51being de-iced.
45:54Dryden is really the
45:55first accident that
45:56explored not only what
45:59happens in the pointed
46:00end of an airplane,
46:00plane, but what
46:02happens within a
46:04corporate culture, it
46:05puts CEOs on notice
46:07that they can't hide in
46:09the woodwork when an
46:11accident occurs.
46:15Dutch manufacturer Fokker
46:17went bankrupt in 1996.
46:19Despite this, in 2009,
46:22there were still 55 Fokker F-28
46:24jets in operation
46:25worldwide, mostly in
46:28warmer climates.
46:30Nobody should ever
46:31lose their life due to
46:32contamination accident
46:33again in commercial
46:34aviation, anywhere in a
46:37snow and ice
46:37environment.
46:38We've learned all the
46:39lessons.
46:39Transondenation
46:41rutory
46:41is a