Ramesh Lutchmedial
On March 10, 1989, a Fokker F28-1000 Fellowship twin jet operating Air Ontario Flight 1363 crashed shortly after takeoff from Dryden Regional Airport in Ontario, Canada.
The aircraft was unable to attain sufficient altitude to clear the trees beyond the runway, owing to a buildup of ice and snow on the wings.
Three of the four crew members, including both pilots, and 21 of the 65 passengers died.
The flight was under the command of Captain George Morwood, an experienced airman with 24,100 hours of flying time who had flown for approximately 34 years with Air Ontario. The first officer was Keith Mills, a highly experienced pilot with more than 10,000 hours' flying time and who had been with Air Ontario for ten years.
However, both pilots were new to the F28-1000, having flown fewer than 150 hours between them on the aircraft type.
The flight had departed from Thunder Bay, Ontario, bound for Winnipeg, Manitoba, with a stop in Dryden.
The Canadian Aviation Safety Board (CASB) immediately undertook an investigation into the crash, pursuant to the Canadian Aviation Safety Board Act.
The investigator in charge arrived at Dryden on March 11, 1989, with a team of 21 CASB investigators. The CASB team began its investigation as it would in any major accident investigation, interviewing witnesses and analysing the aircraft wreckage.
On March 29, 1989, under mounting public pressure, the investigation was suspended and the Canadian government appointed a royal commission to inquire into the contributing factors and causes of the crash, headed by Virgil P Moshansky, a former judge. The commission was authorised to make recommendations it deemed appropriate in the interests of aviation safety.
Immediate steps were taken to reactivate the investigation. The chairman of CASB was asked to second certain CASB aviation accident investigators to the commission to assist, and with the complete co-operation of CASB, the investigation was transferred to the Moshansky Commission.
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Moshansky adopted a systems-analysis approach and delved deeply into the operations of Air Ontario, Transport Canada and the larger Canadian air transport industry.
This approach identified numerous safety-related deficiencies in the operations of Air Ontario and Transport Canada’s regulatory functions.
The post-crash fire severely damaged both the cockpit voice recorder and the flight data recorder, leaving both unreadable. So the investigative effort relied almost entirely on witness statements about the crash and the events leading up to it.
The investigation revealed an unserviceable auxiliary power unit (APU), and no available external power unit at Dryden Regional Airport, led to questionable decision-making – a critical factor leading to the crash. If the engines had been turned off, they could not have been restarted, owing to the unserviceability of the APU and lack of external power. So the left engine remained running during th
