1 00:00:01,689 --> 00:00:05,689 New York City's LaGuardia Airport, March the 22nd, 1992. 2 00:00:07,344 --> 00:00:11,379 A commuter plane with 51 people on board tries to lift off the runway. 3 00:00:11,448 --> 00:00:14,896 Rotate. But the pilots can't get it to climb. 4 00:00:14,965 --> 00:00:16,413 They knew they were in trouble, 5 00:00:16,482 --> 00:00:19,103 but they were fighting all the way to the end. 6 00:00:20,241 --> 00:00:25,413 USAir Flight 405 plunges into the icy waters of Flushing Bay. 7 00:00:26,206 --> 00:00:28,758 Twenty-seven people die. 8 00:00:28,827 --> 00:00:31,689 For U.S. investigators, it's an open-and-shut case. 9 00:00:32,517 --> 00:00:35,379 This accident was not a huge surprise to us. 10 00:00:35,448 --> 00:00:37,793 But Canadian investigators are stunned. 11 00:00:38,448 --> 00:00:41,275 They know the New York accident should never have happened. 12 00:00:41,344 --> 00:00:43,620 My reaction when I heard about it was: 13 00:00:43,689 --> 00:00:45,896 My god, it's Dryden all over again. 14 00:00:45,965 --> 00:00:47,517 Three years earlier, 15 00:00:47,586 --> 00:00:50,724 an exhaustive investigation into a crash at a remote northern airport 16 00:00:50,793 --> 00:00:52,724 had identified a killer 17 00:00:52,793 --> 00:00:56,000 and spelled out ways to keep it from striking again. 18 00:00:56,068 --> 00:00:59,896 Certainly if they had followed the recommendations in my report, 19 00:00:59,965 --> 00:01:02,862 the F-28 crash at La Guardia could've been averted. 20 00:01:02,931 --> 00:01:05,862 The La Guardia accident makes one thing clear: 21 00:01:05,931 --> 00:01:08,068 The right people never got the warning. 22 00:01:12,344 --> 00:01:14,551 Mayday, mayday. 23 00:01:33,137 --> 00:01:35,310 March the 10th, 1989. 24 00:01:36,827 --> 00:01:40,517 It's 11:39 a.m. at Dryden Ontario's Airport. 25 00:01:41,275 --> 00:01:46,793 Light snow falls as Air Ontario Flight 1363 stops in the remote northern community 26 00:01:46,862 --> 00:01:49,241 on its way from Thunder Bay to Winnipeg. 27 00:01:52,206 --> 00:01:55,310 The passengers stay on board while the plane is refuelled. 28 00:02:03,379 --> 00:02:07,793 For Flight Attendant Sonia Hartwick and the crew aboard the Fokker F-28, 29 00:02:07,862 --> 00:02:09,931 it's been a frustrating day of delays. 30 00:02:10,965 --> 00:02:14,206 Big, fluffy, white snowflakes, at this time, 31 00:02:14,275 --> 00:02:17,137 were falling gently to the ground, 32 00:02:17,206 --> 00:02:19,965 and it was very, very grey. 33 00:02:20,034 --> 00:02:24,724 And I thought: Hmm, I guess this means we're going to be delayed again. 34 00:02:24,793 --> 00:02:27,724 I can't see us making it to Winnipeg on time. 35 00:02:29,862 --> 00:02:32,172 It's Friday, the beginning of March break. 36 00:02:33,137 --> 00:02:35,034 Already an hour behind schedule, 37 00:02:35,103 --> 00:02:40,931 another delay could jeopardize the vacation plans of many of the 69 passengers and crew. 38 00:02:41,724 --> 00:02:45,241 There was a lot of families travelling on board with plans. 39 00:02:45,310 --> 00:02:47,172 Most of them were going skiing. 40 00:02:47,482 --> 00:02:49,034 And, uh... 41 00:02:49,103 --> 00:02:53,379 so they were very concerned about meeting their connections in Winnipeg. 42 00:02:53,448 --> 00:02:56,068 Kenora, Dryden, it's Ontario 363. 43 00:02:56,724 --> 00:02:58,689 Ontario 363, Kenora. 44 00:02:59,655 --> 00:03:03,206 As First Officer Keith Mills checks on weather conditions, 45 00:03:03,275 --> 00:03:07,241 Captain George Morwood returns from making a phone call inside the airport. 46 00:03:07,310 --> 00:03:09,689 It's getting worse. What's the latest? 47 00:03:09,758 --> 00:03:13,172 ...and it won't clear till late afternoon. - Check that. Quite heavy snow. 48 00:03:13,241 --> 00:03:15,448 Looks like it's gonna be a bad one. 49 00:03:15,517 --> 00:03:17,103 It's still within our takeoff limits. 50 00:03:17,172 --> 00:03:20,137 Well, that's good. We got a lot of people who want to make their connectors. 51 00:03:20,206 --> 00:03:21,724 Let's hope it holds. 52 00:03:23,137 --> 00:03:25,137 Temperatures hover around freezing. 53 00:03:26,172 --> 00:03:27,931 Visibility is decreasing. 54 00:03:28,655 --> 00:03:30,724 If the flight doesn't leave soon, 55 00:03:30,793 --> 00:03:32,724 it could be grounded indefinitely. 56 00:03:33,827 --> 00:03:35,482 Dryden is a very small city. 57 00:03:35,551 --> 00:03:38,241 It's a very remote part of Ontario. 58 00:03:39,068 --> 00:03:41,586 With a population of about 6,500, 59 00:03:41,655 --> 00:03:46,241 the isolated community lies halfway between Thunder Bay and Winnipeg. 60 00:03:47,241 --> 00:03:49,827 Harsh Canadian winters with bitter cold 61 00:03:49,896 --> 00:03:53,034 reaching -35° Celsius are the norm here. 62 00:03:54,137 --> 00:03:57,034 It's not the place to be stranded in the middle of a snowstorm. 63 00:04:03,793 --> 00:04:07,793 Royal Canadian Mounted Police Officer Don Crawshaw and his partner 64 00:04:07,862 --> 00:04:10,068 are escorting a prisoner to Winnipeg. 65 00:04:10,137 --> 00:04:14,965 When we did a criminal check on the prisoner before we left, 66 00:04:15,034 --> 00:04:17,689 he came up as a violent person, so... 67 00:04:17,758 --> 00:04:19,517 two of us had to go with him. 68 00:04:19,586 --> 00:04:21,862 He was wanted in Banff on a fraud charge, 69 00:04:21,931 --> 00:04:25,344 and that's what he was being brought back to Alberta for. 70 00:04:27,758 --> 00:04:29,931 Okay, no smoking and seatbelts. 71 00:04:31,172 --> 00:04:33,482 - On. - Instruments. 72 00:04:33,551 --> 00:04:35,068 Synced. 73 00:04:35,758 --> 00:04:37,275 Crosschecked. 74 00:04:39,793 --> 00:04:42,793 Captain Morwood uses the power of engine 75 00:04:42,862 --> 00:04:45,310 already running, to fire engine 76 00:04:48,379 --> 00:04:51,241 Morwood and Mills are both highly experienced pilots. 77 00:04:52,448 --> 00:04:56,344 However, they've each flown fewer than 100 hours in the Fokker F-28. 78 00:04:57,206 --> 00:05:00,137 The multimillion-dollar aircraft is the first Air Ontario jet 79 00:05:00,206 --> 00:05:03,034 to serve the remote Northern Ontario region. 80 00:05:06,206 --> 00:05:08,896 Twenty-four minutes after landing in Dryden, 81 00:05:08,965 --> 00:05:11,586 Flight 1363 is ready to leave. 82 00:05:12,344 --> 00:05:14,103 Inform Kenora we're rolling. 83 00:05:15,379 --> 00:05:18,862 We're fired up, taxiing for departure, requesting airways to Winnipeg. 84 00:05:19,551 --> 00:05:21,965 Hang on a sec, guys. Is there a chance that plane can hold? 85 00:05:22,034 --> 00:05:24,413 We're having some bad weather up here. 86 00:05:24,482 --> 00:05:27,379 An approaching aircraft's urgent request to land... 87 00:05:27,448 --> 00:05:28,724 Unbelievable. 88 00:05:28,793 --> 00:05:30,655 ...gives Captain Morwood little choice. 89 00:05:31,206 --> 00:05:32,655 He delays takeoff. 90 00:05:32,724 --> 00:05:35,310 Okay, 363's holding short of the active. 91 00:05:37,344 --> 00:05:40,793 We are gonna be a few moments until a small plane lands safely. 92 00:05:40,862 --> 00:05:43,413 Sorry, folks. This just isn't our day. 93 00:05:44,689 --> 00:05:47,896 In the two years that I had flown with Air Ontario, 94 00:05:47,965 --> 00:05:50,448 I'd never come across anything like this before. 95 00:05:52,931 --> 00:05:55,620 The Cessna 150 lands safely, 96 00:05:55,689 --> 00:05:59,137 clearing the runway for Flight 1363's departure. 97 00:06:00,000 --> 00:06:02,172 Tell them we're going immediately. 98 00:06:03,206 --> 00:06:06,862 Kenora, Ontario, we're taxiing out at this time. 363, Dryden. 99 00:06:08,413 --> 00:06:11,793 Finally, an hour behind schedule, 100 00:06:11,862 --> 00:06:14,137 the plane taxis to Runway 29. 101 00:06:16,034 --> 00:06:20,379 As we were going down the runway to position for takeoff... 102 00:06:21,448 --> 00:06:25,103 ...a blanket of snow was falling and I couldn't see the treeline anymore. 103 00:06:25,172 --> 00:06:27,103 It was like looking through a sheer. 104 00:06:28,689 --> 00:06:31,206 Folks, we're sorry for the delay. 105 00:06:31,275 --> 00:06:32,758 Flight attendants, 106 00:06:32,827 --> 00:06:34,413 please be seated for takeoff. 107 00:06:36,655 --> 00:06:38,517 At 12:09 p.m., 108 00:06:38,586 --> 00:06:41,000 Flight 1363 is ready for takeoff. 109 00:06:41,517 --> 00:06:44,000 Advise Kenora, we're ready to proceed. 110 00:06:46,448 --> 00:06:50,965 And Kenora, Dryden, Ontario, 363 is about to roll 29 at Dryden. 111 00:06:51,620 --> 00:06:53,689 Ontario 363 Kenora, roger. 112 00:06:54,517 --> 00:06:57,931 Captain Morwood performs a brief engine run-up, 113 00:06:58,000 --> 00:07:01,551 heating the engines to rid them of any accumulated snow and ice. 114 00:07:03,620 --> 00:07:05,965 Then he begins his roll down the runway. 115 00:07:08,517 --> 00:07:11,862 When we're taking off, I'm usually very quiet and focused, 116 00:07:11,931 --> 00:07:14,689 meticulously going through a checklist in my own mind: 117 00:07:14,758 --> 00:07:17,275 What would I do in the case of an emergency? 118 00:07:19,000 --> 00:07:20,275 V1. 119 00:07:20,344 --> 00:07:23,068 The F-28 reaches its takeoff speed: - Rotate. 120 00:07:23,137 --> 00:07:24,448 ...80 knots. 121 00:07:31,965 --> 00:07:34,896 Our takeoff was very slow and sluggish, 122 00:07:34,965 --> 00:07:38,206 like a slow, sluggish person running up a hill. 123 00:07:39,517 --> 00:07:41,620 Clearly, there's something wrong. 124 00:07:42,172 --> 00:07:44,517 The F-28 struggles to get airborne. 125 00:07:45,655 --> 00:07:47,551 We cleared the trees, uh... 126 00:07:47,620 --> 00:07:50,344 the plane... started shaking. 127 00:07:53,310 --> 00:07:55,379 I thought: Oh, my God, we're gonna crash. 128 00:07:56,137 --> 00:07:57,896 That's when all hell broke loose. 129 00:08:00,758 --> 00:08:03,310 If you can equate to being in a Mixmaster, 130 00:08:03,379 --> 00:08:05,344 that's what the plane felt like at the time. 131 00:08:06,068 --> 00:08:09,103 There's this dip to the left and then dip to the right. 132 00:08:09,172 --> 00:08:11,448 The pilot's trying to get this plane up. 133 00:08:12,827 --> 00:08:15,413 Then all of a sudden, there was a power burst. 134 00:08:15,482 --> 00:08:17,172 The plane seemed to stabilize itself. 135 00:08:17,896 --> 00:08:20,724 You could feel the pilots trying to get control of it. 136 00:08:21,862 --> 00:08:25,448 But a few seconds later, it became a Mixmaster again. 137 00:08:29,344 --> 00:08:32,827 I yelled out: "Emergency, grab your ankles, get your heads down." 138 00:08:33,724 --> 00:08:35,655 Grab your ankles, get your heads down! 139 00:08:35,724 --> 00:08:39,068 And I kept yelling that, and then I assumed my brace position. 140 00:08:39,517 --> 00:08:41,793 You could hear people screaming and yelling. 141 00:08:41,862 --> 00:08:44,103 There were loud, horrible sounds. 142 00:08:44,172 --> 00:08:46,137 We were clearly crashing. 143 00:08:47,586 --> 00:08:49,241 The pilots are helpless. 144 00:08:52,206 --> 00:08:54,517 Forty-nine seconds after lifting off... 145 00:08:57,172 --> 00:09:00,758 ...Air Ontario Flight 1363 crash-lands in the bush... 146 00:09:01,482 --> 00:09:04,655 ...950 metres west of Runway 29. 147 00:09:14,827 --> 00:09:18,965 There is carnage of, uh, the aircraft all over the place. 148 00:09:19,034 --> 00:09:20,586 I didn't know where I was. 149 00:09:21,206 --> 00:09:23,965 And at that point I thought: Oh, my gosh, I'm alive, 150 00:09:24,034 --> 00:09:27,000 I'm still alive, this is all happening so quickly. 151 00:09:28,379 --> 00:09:30,379 When we crashed, 152 00:09:30,448 --> 00:09:32,448 we came down on an angle, 153 00:09:32,517 --> 00:09:35,448 it ripped the right side of the plane open, 154 00:09:35,517 --> 00:09:39,551 and that's how we got out; or else we probably would've never gotten out. 155 00:09:40,931 --> 00:09:43,551 Now, the prisoner was still in handcuffs, 156 00:09:43,620 --> 00:09:48,517 so I reached over and I took the cuffs off of him there, but he never left me. 157 00:09:49,482 --> 00:09:51,482 And then we exited the aircraft. 158 00:09:52,413 --> 00:09:55,379 There's fire all around, there's explosions. 159 00:09:56,241 --> 00:10:00,000 I'm thinking: Oh, my God, we're full of fuel. Guys, come this way. 160 00:10:00,068 --> 00:10:02,965 And I started yelling: "Come this way, come this way!" 161 00:10:03,034 --> 00:10:05,620 For people to follow my voice. Come this way! 162 00:10:05,689 --> 00:10:07,206 Come on... 163 00:10:07,275 --> 00:10:10,344 Passengers scramble for safety before the fire spreads. 164 00:10:13,000 --> 00:10:15,206 Forty-five people survive the accident... 165 00:10:16,931 --> 00:10:19,172 ...but 24 people do not, 166 00:10:19,241 --> 00:10:22,379 including Captain Morwood and First Officer Mills. 167 00:10:39,586 --> 00:10:42,758 Emergency crews rush to the crash site, deep in the woods. 168 00:10:48,827 --> 00:10:51,137 The injured are taken to hospital in Dryden. 169 00:10:55,344 --> 00:10:57,517 I was very concerned, because I kept looking out the window. 170 00:10:57,586 --> 00:10:59,275 I thought there was a lot of snow. 171 00:10:59,344 --> 00:11:03,655 I didn't notice anything wrong going down the runway. When we started hitting trees, 172 00:11:03,724 --> 00:11:05,241 I knew there was something wrong. 173 00:11:09,655 --> 00:11:11,137 Within 24 hours, 174 00:11:11,206 --> 00:11:14,517 a team of investigators from the Canadian Aviation Safety Board 175 00:11:14,586 --> 00:11:16,172 arrives at the scene. 176 00:11:22,241 --> 00:11:24,241 You're going there hopefully with the idea 177 00:11:24,310 --> 00:11:26,379 that you can find out what happened, why it happened, 178 00:11:26,448 --> 00:11:28,862 and how do you prevent it from happening in the future. 179 00:11:29,931 --> 00:11:33,275 We walked the entire path of the airplane to the threshold of the runway, 180 00:11:33,344 --> 00:11:37,310 and then we walked the flight path of the airplane right to the crash site. 181 00:11:37,379 --> 00:11:39,379 That was the first thing that I did. 182 00:11:40,551 --> 00:11:43,862 I wanted to document what I was seeing by photographing. 183 00:11:45,103 --> 00:11:47,206 When you walk in on an accident site like that, 184 00:11:47,275 --> 00:11:48,724 there are two things that overwhelm you: 185 00:11:48,793 --> 00:11:54,517 the smell of aviation jet fuel and the smell of death. 186 00:12:06,517 --> 00:12:09,344 The trees just past the end of Runway 29 187 00:12:09,413 --> 00:12:14,655 give investigator David Rohrer and his team vital clues about the F-28's failed flight. 188 00:12:16,275 --> 00:12:19,517 What happened was the airplane went off the end of the runway 189 00:12:19,586 --> 00:12:22,586 in what we would call "ground effect," and just stayed at that height, 190 00:12:22,655 --> 00:12:24,931 simply clipping the tops of the trees. 191 00:12:25,965 --> 00:12:28,275 Look at how these treetops have been clipped off. 192 00:12:30,586 --> 00:12:32,137 It didn't ever fly. 193 00:12:34,379 --> 00:12:36,931 You've got 24 people that died, 194 00:12:37,000 --> 00:12:39,931 you've got two pilots that died and a flight attendant that died. 195 00:12:40,000 --> 00:12:43,241 And they died, for the most part, trying to do their job. 196 00:12:43,310 --> 00:12:46,344 So you really want to do them justice, 197 00:12:46,413 --> 00:12:48,689 but you also have to be fair. 198 00:12:48,758 --> 00:12:52,758 And if there were mistakes made, the mistakes have to be fixed. 199 00:12:54,965 --> 00:12:56,896 From the rear of the fuselage, 200 00:12:56,965 --> 00:13:00,551 investigators recover the F-28's two black boxes: 201 00:13:00,620 --> 00:13:04,413 the flight-data recorder and the cockpit voice recorder. 202 00:13:11,793 --> 00:13:15,586 The devices are designed to withstand temperatures of 1100° Celsius 203 00:13:15,655 --> 00:13:17,206 for up to 30 minutes. 204 00:13:18,275 --> 00:13:20,206 Investigators are frustrated to learn 205 00:13:20,275 --> 00:13:24,517 that the Mylar tape from the recorders has suffered extreme heat damage. 206 00:13:26,448 --> 00:13:30,586 It's estimated the black boxes were scorched by an 1100° inferno 207 00:13:30,655 --> 00:13:32,310 for at least 90 minutes, 208 00:13:32,379 --> 00:13:33,862 far beyond their limit. 209 00:13:33,931 --> 00:13:36,137 The data is unrecoverable. 210 00:13:36,689 --> 00:13:39,068 That was a big blow to us, because... 211 00:13:39,137 --> 00:13:42,413 now you have to try and gather information 212 00:13:42,482 --> 00:13:44,034 and try... 213 00:13:44,103 --> 00:13:48,344 and establish that it's factual by independent routes. 214 00:13:50,103 --> 00:13:52,965 We were just about to leave Thunder Bay and they gave us 10 new passengers. 215 00:13:55,551 --> 00:13:58,379 Investigators must now rely heavily on eyewitness reports 216 00:13:58,448 --> 00:14:01,793 to reconstruct the events leading up to the doomed takeoff. 217 00:14:02,758 --> 00:14:06,241 They learn that the F-28 began its day in Winnipeg 218 00:14:06,310 --> 00:14:09,862 and was scheduled to fly a return route to Thunder Bay and back, 219 00:14:09,931 --> 00:14:12,206 with a stopover in Dryden. 220 00:14:15,000 --> 00:14:17,517 But in Thunder Bay, plans changed. 221 00:14:18,034 --> 00:14:20,482 The cancellation of another flight forced the crew 222 00:14:20,551 --> 00:14:22,551 to pick up 10 additional passengers. 223 00:14:23,344 --> 00:14:26,586 And when they did their calculations, 224 00:14:26,655 --> 00:14:30,344 they realized that we were overloaded and something had to come off. 225 00:14:30,413 --> 00:14:34,103 Alright, let's, um, offload some fuel, then. 226 00:14:34,758 --> 00:14:38,482 They ended up removing fuel in order to be within the proper weight. 227 00:14:38,551 --> 00:14:40,965 Dispatch, Ontario 363... 228 00:14:41,034 --> 00:14:43,310 So the flight was delayed an hour. 229 00:14:44,206 --> 00:14:47,689 The extra weight of the new passengers left the crew no choice. 230 00:14:47,758 --> 00:14:50,620 They had to unload fuel to lighten their load. 231 00:14:52,034 --> 00:14:54,517 That meant, when they arrived in Dryden, 232 00:14:54,586 --> 00:14:57,310 they needed to pump in more than the usual amount of fuel 233 00:14:57,379 --> 00:14:59,310 for the final leg back to Winnipeg. 234 00:15:02,172 --> 00:15:04,379 Rohrer wonders if the change in plans 235 00:15:04,448 --> 00:15:07,517 somehow led to a miscalculation of the weight and balance. 236 00:15:09,413 --> 00:15:11,896 Was the F-28 too heavy for takeoff? 237 00:15:15,275 --> 00:15:17,620 He then uncovers a puzzling detail: 238 00:15:17,689 --> 00:15:21,551 The plane's weight and balance form for the takeoff from Dryden was never collected, 239 00:15:21,620 --> 00:15:23,310 as required. 240 00:15:23,379 --> 00:15:24,931 It burned in the fire. 241 00:15:27,758 --> 00:15:31,310 Rohrer is forced to use Air Ontario's standard averages 242 00:15:31,379 --> 00:15:34,206 to calculate passenger and baggage weights. 243 00:15:36,103 --> 00:15:39,655 The data, combined with the airport's fuel records, 244 00:15:39,724 --> 00:15:42,379 allows him to estimate the plane's gross takeoff weight. 245 00:15:43,724 --> 00:15:46,310 We knew how many people we had on board, 246 00:15:46,379 --> 00:15:49,310 we knew how many bags we had on the airplane, 247 00:15:49,379 --> 00:15:51,551 and we knew what our fuel load was. 248 00:15:53,172 --> 00:15:58,827 He estimates the F-28 weighed between 62,000 and 64,000 pounds. 249 00:16:00,551 --> 00:16:03,793 And the airplane's max takeoff weight was 65,000 pounds, 250 00:16:03,862 --> 00:16:07,241 so we came to the conclusion that the airplane was not overweight. 251 00:16:08,827 --> 00:16:11,551 The cause of the crash remains a mystery. 252 00:16:15,827 --> 00:16:17,413 Eighteen days into the investigation, 253 00:16:17,482 --> 00:16:20,379 the Canadian government appoints Justice Virgil Moshansky 254 00:16:20,448 --> 00:16:23,758 to lead a more wide-ranging inquiry into all aspects 255 00:16:23,827 --> 00:16:28,000 of the aviation system that might've contributed to the Air Ontario tragedy. 256 00:16:29,896 --> 00:16:33,379 The government was looking for an experienced trial judge, 257 00:16:33,448 --> 00:16:36,310 and preferably one with an aviation background. 258 00:16:36,379 --> 00:16:40,586 Moshansky is an experienced pilot with 13 years on the bench. 259 00:16:41,206 --> 00:16:44,172 He will work closely with crash investigator David Rohrer 260 00:16:44,241 --> 00:16:46,517 and aviation consultant Frank Black. 261 00:16:47,068 --> 00:16:51,379 The new team's first step: Assessing the plane's technical systems. 262 00:16:51,448 --> 00:16:54,827 The electrical system, the hydraulic system, the fuel system, 263 00:16:54,896 --> 00:16:57,310 all of these systems are looked at, 264 00:16:57,379 --> 00:17:01,448 both in terms of what is their history leading up to the accident, 265 00:17:01,517 --> 00:17:05,551 and what remnants are remaining at the crash site that can be examined. 266 00:17:10,206 --> 00:17:12,724 Clues to a possible system failure arise 267 00:17:12,793 --> 00:17:16,551 when Sonia Hartwick recalls a troubling event aboard the same plane 268 00:17:16,620 --> 00:17:18,965 just days before the fatal crash. 269 00:17:19,586 --> 00:17:21,379 I think it was Monday or Tuesday. 270 00:17:22,689 --> 00:17:25,862 When we took off, there was this smoke that filled the aircraft, 271 00:17:25,931 --> 00:17:27,413 and there was this horrible smell. 272 00:17:28,862 --> 00:17:31,310 I thought: Oh, my God, we have a fire in the lav. 273 00:17:33,862 --> 00:17:36,758 But there was no fire in the lavatory, 274 00:17:36,827 --> 00:17:38,689 or anywhere else in the cabin. 275 00:17:40,034 --> 00:17:41,517 They told us that, apparently, 276 00:17:41,586 --> 00:17:45,862 it had something to do with oil sitting in the APU system. 277 00:17:45,931 --> 00:17:48,931 So every takeoff that day, this would happen. 278 00:17:51,241 --> 00:17:54,137 The Auxiliary Power Unit is a generator 279 00:17:54,206 --> 00:17:56,965 that provides the power needed to start the engines. 280 00:17:58,379 --> 00:18:01,827 Did burning oil in the APU somehow cause a fire 281 00:18:01,896 --> 00:18:04,586 and ultimately doom Flight 1363? 282 00:18:06,379 --> 00:18:10,931 Rohrer searches the week's journey log for any mention of the Auxiliary Power Unit. 283 00:18:11,827 --> 00:18:13,931 He makes a surprising discovery. 284 00:18:14,448 --> 00:18:17,931 The APU wasn't working on the day of the crash. 285 00:18:18,000 --> 00:18:20,275 It couldn't possibly have caused the fire. 286 00:18:21,413 --> 00:18:25,103 But the inoperative power unit may still have played a role in the tragedy. 287 00:18:26,758 --> 00:18:30,862 Investigators learn that it forced the crew to make a risky decision in Dryden. 288 00:18:30,931 --> 00:18:33,241 ...the connectors. Let's hope it holds. 289 00:18:33,620 --> 00:18:37,103 Normally the captain would rely on the APU to restart his engines 290 00:18:37,172 --> 00:18:39,758 after shutting them both down for refuelling. 291 00:18:41,172 --> 00:18:43,758 If he couldn't use his APU, he couldn't shut his engines down. 292 00:18:44,862 --> 00:18:49,793 That meant Flight 1363 had to be refuelled with one engine still running. 293 00:18:50,413 --> 00:18:54,103 Captain Morwood is in a situation where he's gotta hot refuel - 294 00:18:54,172 --> 00:18:56,206 with passenger on board the aircraft. 295 00:18:56,275 --> 00:18:59,206 He's gotta keep an engine running to refuel the airplane. 296 00:19:01,586 --> 00:19:04,413 Hot refuelling isn't against regulations. 297 00:19:04,482 --> 00:19:07,275 But the risk of a fuel spill makes it potentially dangerous. 298 00:19:11,068 --> 00:19:13,310 In Toronto, in 1973, 299 00:19:13,379 --> 00:19:15,137 a maintenance person was killed 300 00:19:15,206 --> 00:19:19,793 when an Air Canada DC-8 jet was consumed by fire during refuelling. 301 00:19:21,862 --> 00:19:24,206 Hot refuelling is not a normal practice. 302 00:19:24,931 --> 00:19:28,241 Could the hot refuelling have caused some kind of damage 303 00:19:28,310 --> 00:19:29,862 to the engines? 304 00:19:34,482 --> 00:19:37,551 The Dryden Airport manager, a former military pilot, 305 00:19:37,620 --> 00:19:40,103 suspects there was trouble with the plane's engines. 306 00:19:41,172 --> 00:19:43,793 He tells Rohrer he saw the takeoff from his office, 307 00:19:43,862 --> 00:19:45,931 and heard a sharp, explosive noise 308 00:19:46,000 --> 00:19:48,344 just as it disappeared from view. 309 00:19:48,413 --> 00:19:51,758 To him, it signified a flameout, or engine failure. 310 00:19:58,517 --> 00:20:00,655 I thought: This is gonna be... 311 00:20:00,724 --> 00:20:04,482 a high-profile and potentially controversial investigation. 312 00:20:04,551 --> 00:20:08,620 And the only way to ensure that the truth stands up 313 00:20:08,689 --> 00:20:11,827 is to have hard evidence from the aircraft accident. 314 00:20:12,482 --> 00:20:14,793 And so we took the airplane completely, 315 00:20:14,862 --> 00:20:17,172 and we put it in our lab in Ottawa. 316 00:20:18,482 --> 00:20:20,172 Anything? 317 00:20:20,241 --> 00:20:23,827 With signs pointing to engine failure as the cause of the crash... 318 00:20:23,896 --> 00:20:27,344 - Strip it down. - ...Rohrer orders extensive engine testing. 319 00:20:28,827 --> 00:20:31,896 Those engines were examined in detail for damage. 320 00:20:33,379 --> 00:20:36,482 Rohrer finds the F-28's two Rolls-Royce engines suffered 321 00:20:36,551 --> 00:20:38,137 only minor structural damage. 322 00:20:39,206 --> 00:20:41,689 There's no evidence of an engine fire, 323 00:20:41,758 --> 00:20:44,793 nothing at all to suggest the engines had failed. 324 00:20:51,137 --> 00:20:54,482 With little physical evidence to explain the failed takeoff, 325 00:20:54,551 --> 00:20:56,758 investigators are back to square one. 326 00:21:00,034 --> 00:21:03,724 To solve the mystery, they comb through survivor and eyewitness statements. 327 00:21:05,103 --> 00:21:06,655 A common thread emerges. 328 00:21:06,724 --> 00:21:09,068 They said, in their witness statements, 329 00:21:09,137 --> 00:21:12,448 there was snow and ice on the wings when the airplane attempted to take off. 330 00:21:18,206 --> 00:21:20,482 Rohrer studies weather charts for clues. 331 00:21:20,965 --> 00:21:23,413 We had very good meteorological information. 332 00:21:24,344 --> 00:21:27,206 The charts show that during the half-hour 333 00:21:27,275 --> 00:21:29,620 the F-28 was on the ground at Dryden Airport, 334 00:21:29,689 --> 00:21:33,206 visibility shrank from four kilometres to less than one kilometre 335 00:21:33,275 --> 00:21:35,034 because of the snowstorm. 336 00:21:35,103 --> 00:21:37,241 And though we may find other reasons, 337 00:21:37,310 --> 00:21:41,827 for sure, snow and ice on the wings was a factor in this accident. 338 00:21:42,758 --> 00:21:44,862 Sonia Hartwick tells investigators 339 00:21:44,931 --> 00:21:47,241 about an unusual sight during takeoff. 340 00:21:48,586 --> 00:21:50,413 As we took off, 341 00:21:50,482 --> 00:21:55,241 I noticed that the wings just became a solid sheen of grey, shiny ice. 342 00:21:59,103 --> 00:22:03,965 Investigators consult the F-28's manuals to study its anti-icing systems. 343 00:22:04,517 --> 00:22:07,862 They find that only the wing's leading edges are protected. 344 00:22:08,758 --> 00:22:11,931 The aircraft had heated leading edges on the wings. 345 00:22:12,655 --> 00:22:15,172 I wonder if the anti-icing system was working. 346 00:22:15,620 --> 00:22:17,862 And the heat was provided by bleed air 347 00:22:17,931 --> 00:22:20,034 from the compressors on the engine. 348 00:22:20,103 --> 00:22:23,931 They found the valves that allow the, uh... 349 00:22:24,000 --> 00:22:26,275 compressed air access to the leading edges. 350 00:22:30,655 --> 00:22:33,517 And they tested the valve to see if it functioned, and it did. 351 00:22:35,448 --> 00:22:37,724 The anti-icing system was working. 352 00:22:38,620 --> 00:22:41,310 But since it only heats the leading edge, 353 00:22:41,379 --> 00:22:46,413 it likely didn't clear ice that formed on the surface of Flight 1363's wings. 354 00:22:50,586 --> 00:22:53,551 Investigators suspect that snow and ice buildup, 355 00:22:53,620 --> 00:22:56,137 what experts call "wing contamination," 356 00:22:56,206 --> 00:22:58,827 may have played a major role in the crash. 357 00:23:02,206 --> 00:23:06,793 To verify that suspicion, Rohrer and his team meet with engineers from Fokker. 358 00:23:08,862 --> 00:23:11,448 Thanks for coming. I'm curious to see what you have. 359 00:23:12,275 --> 00:23:15,000 Jack van Hanks, who was the chief engineer, 360 00:23:15,068 --> 00:23:17,965 had extensive aerodynamic studies and data 361 00:23:18,034 --> 00:23:21,448 on the effects of contamination on an F-28 airplane. 362 00:23:22,310 --> 00:23:25,275 Fokker engineers have run simulations of the crash. 363 00:23:26,482 --> 00:23:30,068 They were able to get some very good data in terms... 364 00:23:30,137 --> 00:23:34,344 of the performance of the airplane simulating the type of loads, 365 00:23:34,413 --> 00:23:36,206 temperatures, etc. 366 00:23:36,275 --> 00:23:39,034 that the Dryden aircraft would've been exposed to. 367 00:23:41,793 --> 00:23:45,965 Investigators make a crucial discovery about the design of the F-28. 368 00:23:46,862 --> 00:23:49,034 Because of the angle of the wings, 369 00:23:49,103 --> 00:23:52,758 a very small amount of ice makes the plane susceptible to stalling. 370 00:23:55,137 --> 00:24:00,379 They concluded that even the most minute bit of contamination on the wing 371 00:24:00,448 --> 00:24:04,241 would disrupt the airflow and... 372 00:24:04,310 --> 00:24:06,241 cause a loss of lift. 373 00:24:07,103 --> 00:24:09,068 Well, that answers a lot of questions. 374 00:24:09,137 --> 00:24:11,827 The simulations support what witnesses saw. 375 00:24:11,896 --> 00:24:15,103 It just barely got airborne, 376 00:24:15,172 --> 00:24:18,344 dropping wings, losing lift, and then hitting trees, 377 00:24:18,413 --> 00:24:21,724 decelerating to the point where it broke up. 378 00:24:25,931 --> 00:24:27,689 Investigators are now certain 379 00:24:27,758 --> 00:24:30,068 that contaminated wings caused the crash. 380 00:24:31,655 --> 00:24:35,862 But what's still unclear is why the plane was not de-iced before takeoff. 381 00:24:38,379 --> 00:24:41,931 Almost all airports in cold climates, including Dryden, 382 00:24:42,000 --> 00:24:45,310 are equipped with the technology to remove ice from a plane. 383 00:24:50,344 --> 00:24:52,965 But Captain Morwood never requested de-icing. 384 00:24:53,620 --> 00:24:56,172 It's getting worse. What's the latest? 385 00:24:56,241 --> 00:24:58,517 ...and it won't clear until late afternoon. 386 00:24:58,586 --> 00:25:01,034 Investigators need to figure out why. 387 00:25:01,103 --> 00:25:04,241 They want to understand what made him risk his own life... 388 00:25:04,310 --> 00:25:05,862 Let's hope it holds. 389 00:25:06,689 --> 00:25:11,068 ...and the lives of the 68 other people on board Flight 1363. 390 00:25:16,517 --> 00:25:20,896 Investigators dig through Captain George Morwood's flight records and work history. 391 00:25:21,620 --> 00:25:25,206 They interview crew members, searching for clues to his behaviour. 392 00:25:26,034 --> 00:25:27,793 Captain Morwood was a very... 393 00:25:27,862 --> 00:25:30,965 very professional, very old-school pilot. 394 00:25:31,034 --> 00:25:34,137 He had his view on how things should be done properly, 395 00:25:34,206 --> 00:25:37,482 and what his definition of proper and professional would be. 396 00:25:38,103 --> 00:25:41,206 He also was very concerned about his passengers. 397 00:25:41,275 --> 00:25:44,827 He enjoyed making sure that they got on their flights on time 398 00:25:44,896 --> 00:25:46,793 and got to their destinations on time. 399 00:25:47,827 --> 00:25:50,551 You know, Air Ontario was a growing company. 400 00:25:50,620 --> 00:25:54,310 It was their first foray into jet operations. 401 00:25:54,379 --> 00:25:57,068 I'm sure that there were many things 402 00:25:57,137 --> 00:26:00,241 that Captain Morwood would've thought in his own mind... 403 00:26:00,310 --> 00:26:02,344 this is not how he would do it. 404 00:26:02,413 --> 00:26:06,379 And I'm sure at times he probably let, uh, the superiors know that. 405 00:26:06,448 --> 00:26:10,586 Morwood's history shows he's delayed and cancelled flights in the past 406 00:26:10,655 --> 00:26:12,620 because of icing concerns. 407 00:26:12,689 --> 00:26:14,448 Rohrer is stumped. 408 00:26:14,517 --> 00:26:17,000 Why didn't he request de-icing in Dryden? 409 00:26:20,068 --> 00:26:24,586 Another pilot who was at Dryden Airport that day provides part of the answer. 410 00:26:25,310 --> 00:26:28,206 He heard Morwood on the phone to Air Ontario. 411 00:26:30,965 --> 00:26:33,827 That is what I have been trying to tell you! 412 00:26:33,896 --> 00:26:38,379 He was very frustrated and he was really concerned about his passengers. 413 00:26:38,448 --> 00:26:42,068 Morwood complained to the off-duty pilot about the company. 414 00:26:42,448 --> 00:26:44,000 These guys. 415 00:26:44,413 --> 00:26:47,896 You want to guess my weight before I left Thunder Bay? Sixty-six and change. 416 00:26:47,965 --> 00:26:50,379 I had to offload fuel. Now that-- 417 00:26:52,896 --> 00:26:55,517 Right. So now what am I supposed to do? 418 00:26:55,586 --> 00:26:58,793 No... you figure it out. 419 00:27:00,862 --> 00:27:02,448 When he left the terminal, 420 00:27:02,517 --> 00:27:04,862 he was observed by witnesses 421 00:27:04,931 --> 00:27:08,344 to appear be very upset and very angry. 422 00:27:10,896 --> 00:27:13,620 Investigators wonder what set Morwood off. 423 00:27:14,448 --> 00:27:17,724 They try to piece together the pilot's day on March the 10th. 424 00:27:18,620 --> 00:27:21,931 This was the fifth day of a very long week for Captain Morwood, 425 00:27:22,000 --> 00:27:25,586 and he was, the next day, leaving with his family on a ski vacation. 426 00:27:28,172 --> 00:27:30,586 Before his first flight of the day, 427 00:27:30,655 --> 00:27:33,034 he'd learned the plane's APU still wasn't working. 428 00:27:37,517 --> 00:27:40,275 And then, once in Thunder Bay, more bad news. 429 00:27:41,068 --> 00:27:45,620 After refuelling, the dispatcher forces Morwood to take on 10 extra passengers. 430 00:27:47,724 --> 00:27:50,724 Now he must offload fuel and lose more time. 431 00:27:51,724 --> 00:27:53,551 There goes the schedule. 432 00:27:53,620 --> 00:27:56,310 Let's offload some fuel, then. 433 00:27:56,379 --> 00:27:59,413 This meant Morwood would leave Thunder Bay behind schedule. 434 00:27:59,482 --> 00:28:01,344 Dispatch, Ontario 363... 435 00:28:01,413 --> 00:28:04,862 And Captain Morwood is the type of captain who didn't want to be late. 436 00:28:07,758 --> 00:28:10,758 Now enroute to Dryden and an hour behind schedule, 437 00:28:10,827 --> 00:28:14,000 the weather forecast the crew was given of light rain and fog 438 00:28:14,068 --> 00:28:15,689 is no longer accurate. 439 00:28:15,758 --> 00:28:18,448 And... Captain Morwood... 440 00:28:18,517 --> 00:28:21,931 didn't get the forecast of freezing rain coming into Dryden, 441 00:28:22,000 --> 00:28:23,482 which he should've had. 442 00:28:24,482 --> 00:28:27,206 As Flight 1363 lands in Dryden, 443 00:28:27,275 --> 00:28:29,896 the weather was getting worse by the minute. 444 00:28:31,241 --> 00:28:33,310 The plane sat there for half an hour 445 00:28:33,379 --> 00:28:35,172 while snow built up on the wings. 446 00:28:38,310 --> 00:28:40,551 I gotta talk to somebody about this. 447 00:28:40,620 --> 00:28:44,586 Investigators may never know how concerned Morwood was about the weather. 448 00:28:48,896 --> 00:28:51,344 But there is evidence that it was on his mind. 449 00:28:52,862 --> 00:28:55,206 When Rohrer questions the fuelling agent, 450 00:28:55,275 --> 00:28:59,931 he learns that Morwood did ask about de-icing moments before takeoff. 451 00:29:01,172 --> 00:29:03,172 Is there de-icing available? 452 00:29:05,551 --> 00:29:09,724 The fuelling agent says he pointed out the de-icing ground crew to Morwood. 453 00:29:13,655 --> 00:29:16,000 The agent then offers a compelling reason 454 00:29:16,068 --> 00:29:18,862 that could explain why the captain didn't de-ice. 455 00:29:22,448 --> 00:29:26,586 Air Ontario had a policy prohibiting him from de-icing with an engine running. 456 00:29:29,413 --> 00:29:31,413 The fluid can be ingested in the engines, 457 00:29:31,482 --> 00:29:35,172 and then find its way from there to the air conditioning on the airplane 458 00:29:35,241 --> 00:29:39,379 and make it extremely noxious in the cabin portion of the airplane. 459 00:29:41,000 --> 00:29:43,172 But if Morwood had shut down both engines, 460 00:29:43,241 --> 00:29:46,275 he wouldn't have been able to restart his plane. 461 00:29:46,344 --> 00:29:49,620 Now, the only other way to start the airplane on the ground 462 00:29:49,689 --> 00:29:54,379 is with a ground-based air cart that can provide the compressed air. 463 00:29:54,448 --> 00:29:59,586 And, uh, Dryden did not have the capability to start the airplane. 464 00:30:00,310 --> 00:30:02,896 The equipment would've had to be flown in from Winnipeg. 465 00:30:03,655 --> 00:30:06,034 It would've been a costly decision. 466 00:30:06,103 --> 00:30:08,448 If he shut it down, he would, uh... 467 00:30:08,517 --> 00:30:11,103 ground the aircraft there effectively, 468 00:30:11,172 --> 00:30:15,137 requiring the... billeting of passengers in hotels 469 00:30:15,206 --> 00:30:18,793 and added expense to the airline for which he would be answerable. 470 00:30:18,862 --> 00:30:21,448 - Right. So now what... - So he was under a great deal of pressure. 471 00:30:21,517 --> 00:30:24,379 No... you figure it out. 472 00:30:25,758 --> 00:30:28,586 And I believe the conversation on the phone 473 00:30:28,655 --> 00:30:31,965 would've been about that scenario and his displeasure with it. 474 00:30:32,793 --> 00:30:35,034 But he didn't have any other chance. 475 00:30:35,103 --> 00:30:36,965 It's getting worse. What's the latest? 476 00:30:37,034 --> 00:30:39,793 Quite heavy snow. Looks like it's gonna be a bad one. 477 00:30:39,862 --> 00:30:42,413 It's still within our takeoff limits. - Well, that's good. 478 00:30:42,482 --> 00:30:45,724 We got a lot of people who want to make their connectors. Let's hope it holds. 479 00:30:45,793 --> 00:30:49,379 Though the amount of snow on the wings was still within limits, 480 00:30:49,448 --> 00:30:52,172 it's what lay under the snow that doomed the flight. 481 00:30:53,344 --> 00:30:57,620 The fuel in a plane's wing can get as cold as -40° Celsius. 482 00:30:58,620 --> 00:31:01,689 The frigid fuel cools the metal surface of the wing. 483 00:31:02,413 --> 00:31:05,172 When snow hits this super-cooled surface, 484 00:31:05,241 --> 00:31:09,068 it freezes instantly into a barely visible layer of ice. 485 00:31:09,137 --> 00:31:11,344 It's a process called "cold soaking." 486 00:31:11,413 --> 00:31:14,310 And this, of course, is what's disrupting the airflow on the wing 487 00:31:14,379 --> 00:31:15,965 and destroying the lifting capabilities. 488 00:31:16,034 --> 00:31:18,068 Tell them we're going immediately. 489 00:31:19,172 --> 00:31:21,551 Kenora, Ontario, we're taxiing out at this time... 490 00:31:23,172 --> 00:31:26,793 The only reason that I can possibly think of that led... 491 00:31:26,862 --> 00:31:29,620 to his decision to execute the takeoff 492 00:31:29,689 --> 00:31:33,655 was the fact that he didn't consider the cold-soaking phenomena, 493 00:31:33,724 --> 00:31:36,517 and the fact that those wings could still have ice on them. 494 00:31:37,379 --> 00:31:39,448 Advise Kenora we're ready to proceed. 495 00:31:39,517 --> 00:31:41,275 And Kenora, Dryden, Ontario... 496 00:31:41,344 --> 00:31:45,310 Perhaps not wanting to face the consequences of shutting down his engines, 497 00:31:45,379 --> 00:31:49,413 Morwood opted to take off for Winnipeg without de-icing his plane. 498 00:31:51,896 --> 00:31:55,034 He must've concluded that the ice would blow off on takeoff. 499 00:31:56,551 --> 00:31:59,379 That is where he made a mistake, 500 00:31:59,448 --> 00:32:01,137 a tragic mistake. 501 00:32:02,275 --> 00:32:04,689 But Moshansky concludes that despite his mistake, 502 00:32:04,758 --> 00:32:08,379 Captain Morwood is not solely responsible for the crash. 503 00:32:09,034 --> 00:32:10,517 It wasn't simply pilot error. 504 00:32:10,586 --> 00:32:15,344 There were a myriad of factors which were the cause of the accident. 505 00:32:20,620 --> 00:32:22,896 One of the most important factors: 506 00:32:22,965 --> 00:32:27,068 Air Ontario's decision to let the plane fly with a broken APU. 507 00:32:28,241 --> 00:32:30,517 They were deferring a lot of the maintenance 508 00:32:30,586 --> 00:32:34,379 that should've been done because of a shortage of parts. 509 00:32:34,448 --> 00:32:38,310 And then they had to scrounge around all across Canada 510 00:32:38,379 --> 00:32:40,724 with various F-28 operators 511 00:32:40,793 --> 00:32:43,275 to borrow parts from them. 512 00:32:43,344 --> 00:32:48,931 And this was a very bad move on the part of Air Ontario management. 513 00:32:49,620 --> 00:32:52,620 The investigation determines that by cutting corners 514 00:32:52,689 --> 00:32:55,793 and focusing too much on the bottom line, 515 00:32:55,862 --> 00:32:59,827 the airline was putting all their passengers and employees at risk. 516 00:32:59,896 --> 00:33:02,793 Because the F-28s were new to Air Ontario, 517 00:33:02,862 --> 00:33:06,827 there was this urgency to get one crew off and get the next crew on flying. 518 00:33:06,896 --> 00:33:10,413 This urgency to have them in the air producing money. 519 00:33:11,551 --> 00:33:15,931 I came to the conclusion, after a lot of thought about this accident, 520 00:33:16,000 --> 00:33:18,965 that there were a lot of other hands... 521 00:33:19,034 --> 00:33:21,517 on those throttles, pushing those throttles forward. 522 00:33:25,620 --> 00:33:28,655 There were a lot of people that were involved 523 00:33:28,724 --> 00:33:33,000 in the sequence of events that led to this tragic outcome. 524 00:33:36,275 --> 00:33:38,206 This was a preventable accident. 525 00:33:38,275 --> 00:33:40,965 But everything conspired against the pilots. 526 00:33:41,344 --> 00:33:43,310 I gotta talk to somebody about this. 527 00:33:44,034 --> 00:33:48,172 Because Air Ontario management did not have a safety culture. 528 00:33:50,068 --> 00:33:53,206 And you have to have a safety culture from the top management down. 529 00:34:01,344 --> 00:34:03,862 Knowing there are dozens of Fokker F-28s 530 00:34:03,931 --> 00:34:05,689 flying around the world, 531 00:34:05,758 --> 00:34:07,896 Justice Moshansky takes an unusual step. 532 00:34:09,344 --> 00:34:12,931 He releases a report well before his inquiry concludes. 533 00:34:13,000 --> 00:34:14,965 Good afternoon. 534 00:34:15,034 --> 00:34:18,344 It warns of the plane's vulnerability to ice buildup, 535 00:34:18,413 --> 00:34:21,724 and stresses the need for frequent de-icing in winter conditions. 536 00:34:23,068 --> 00:34:26,758 Even a small amount of icing would be disastrous on an F-28. 537 00:34:32,551 --> 00:34:34,551 But 15 months later, 538 00:34:34,620 --> 00:34:38,344 it becomes clear that Moshansky's warnings have not been heard. 539 00:34:40,344 --> 00:34:42,896 USAir Flight 405 is preparing to fly 540 00:34:42,965 --> 00:34:46,172 from New York to Cleveland on March the 22nd, 1992. 541 00:34:48,344 --> 00:34:50,413 The plane is a Fokker F-28. 542 00:34:52,000 --> 00:34:53,482 And it's snowing. 543 00:34:56,068 --> 00:34:58,413 It's one degree below freezing. 544 00:34:58,551 --> 00:35:00,137 At 9 p.m., 545 00:35:00,206 --> 00:35:04,413 the jet is being de-iced for a second time since its arrival from Florida. 546 00:35:05,448 --> 00:35:10,448 In the past hour, an inch of snow has fallen and shows no signs of stopping. 547 00:35:10,517 --> 00:35:14,000 USAir 405, clear to taxi, Runway 13. 548 00:35:15,103 --> 00:35:16,965 The crew prepares for takeoff. 549 00:35:18,931 --> 00:35:22,965 Flight 405 is an hour and 45 minutes behind schedule 550 00:35:23,034 --> 00:35:27,137 when Captain Wallace Majure starts taxiing to Runway 13. 551 00:35:28,862 --> 00:35:30,275 Then, unexpectedly... 552 00:35:30,344 --> 00:35:34,068 USAir 405, turn left and hold short of Echo. 553 00:35:37,827 --> 00:35:39,862 Left... hold short of Echo. 554 00:35:39,931 --> 00:35:41,551 ...at 9:07 p.m., 555 00:35:41,620 --> 00:35:45,793 Flight 405 is forced to wait on the taxiway near Runway 13. 556 00:35:47,758 --> 00:35:49,827 Another 23 minutes pass. 557 00:35:51,448 --> 00:35:55,000 First Officer John Rachuba turns on a light that illuminates his wings. 558 00:35:55,068 --> 00:35:58,896 He checks the right wing for ice; he sees none. 559 00:35:58,965 --> 00:36:01,517 Looks pretty good to me, as far as I can see. 560 00:36:03,413 --> 00:36:06,413 USAir 405, Runway 13 clear for takeoff. 561 00:36:07,620 --> 00:36:09,793 Even though it's now been 35 minutes 562 00:36:09,862 --> 00:36:11,689 since their last de-icing, 563 00:36:11,758 --> 00:36:13,517 the crew does not request another. 564 00:36:13,586 --> 00:36:17,620 Takeoff thrust set. Temp's okay. 565 00:36:18,827 --> 00:36:22,724 Everything proceeds as it should, until... 566 00:36:22,793 --> 00:36:24,413 V1. 567 00:36:26,724 --> 00:36:28,206 Rotate. 568 00:36:28,275 --> 00:36:30,965 ...just after the F-28 begins its rotation. 569 00:36:32,896 --> 00:36:35,620 The aircraft had enough flying speed to... 570 00:36:36,586 --> 00:36:39,034 ...to lift off, barely lift off. 571 00:36:40,413 --> 00:36:44,517 The wings just could not support the airplane. They knew they were in trouble. 572 00:36:45,103 --> 00:36:47,310 Thirteen seconds after lifting off, 573 00:36:47,379 --> 00:36:50,896 Flight 405 crashes on the shore of Flushing Bay. 574 00:36:57,344 --> 00:37:01,206 I don't think any pilot really... thinks he's gonna crash. 575 00:37:01,275 --> 00:37:03,724 They were trying to save the airplane right to the end. 576 00:37:08,655 --> 00:37:11,241 Twenty-seven of the 51 people on board are killed. 577 00:37:13,241 --> 00:37:17,827 Another Fokker F-28 has crashed with tragic consequences. 578 00:37:19,068 --> 00:37:21,344 My reaction, when I heard about it, was: 579 00:37:21,413 --> 00:37:23,344 My god, it's Dryden all over again. 580 00:37:24,655 --> 00:37:26,137 Within days, 581 00:37:26,206 --> 00:37:28,448 Investigator-in-Charge Robert Benzon suspects 582 00:37:28,517 --> 00:37:30,965 that ice on the wings was the major cause. 583 00:37:31,034 --> 00:37:33,689 It would be very difficult for either of the pilots 584 00:37:33,758 --> 00:37:35,793 to really detect ice on the wings 585 00:37:35,862 --> 00:37:37,758 looking backwards over their shoulders 586 00:37:37,827 --> 00:37:39,965 through the side windows of the airplane. 587 00:37:40,034 --> 00:37:42,275 Looks pretty good to me, as far as I can see. 588 00:37:42,344 --> 00:37:44,758 So the captain was faced with quite a problem. 589 00:37:45,413 --> 00:37:47,275 If he wanted to be de-iced a third time, 590 00:37:47,344 --> 00:37:49,068 he would've had to get out of the line, 591 00:37:49,137 --> 00:37:51,344 taxi all the way back into the parking area 592 00:37:51,413 --> 00:37:53,448 and meet up with a de-icing truck again. 593 00:37:53,517 --> 00:37:55,034 Takeoff thrust. 594 00:37:55,103 --> 00:37:57,517 That would've put him very, very late, 595 00:37:57,586 --> 00:38:00,931 and it may have even caused the cancellation of the flight. 596 00:38:02,586 --> 00:38:04,448 After all of this work, 597 00:38:04,517 --> 00:38:06,793 after all of the efforts, 598 00:38:06,862 --> 00:38:09,275 to see it happen again... 599 00:38:09,344 --> 00:38:11,413 was extremely frustrating. 600 00:38:16,620 --> 00:38:18,620 There were no regulations in place 601 00:38:18,689 --> 00:38:22,482 requiring the crew to seek another de-icing after their extended delay. 602 00:38:24,034 --> 00:38:27,620 But Justice Moshansky had called attention to the dangers of long wait times 603 00:38:27,689 --> 00:38:29,620 when he issued his interim report. 604 00:38:31,827 --> 00:38:35,551 If they had followed the recommendations in my second interim report, 605 00:38:35,620 --> 00:38:37,793 this accident certainly could've been averted. 606 00:38:44,241 --> 00:38:46,620 He also had drawn attention to the limitations 607 00:38:46,689 --> 00:38:49,206 of the de-icing fluid being used at the time. 608 00:38:49,586 --> 00:38:51,896 Called "Type I fluid," 609 00:38:51,965 --> 00:38:54,724 it's a mixture of antifreeze and water. 610 00:38:54,793 --> 00:38:58,517 Those chemicals are designed that as you accelerate down the runway, 611 00:38:58,586 --> 00:39:00,896 they'll actually shed off your wing, 612 00:39:00,965 --> 00:39:05,172 so that when you actually want the wing to lift and produce lift, 613 00:39:05,241 --> 00:39:06,793 that it's not contaminated. 614 00:39:07,517 --> 00:39:11,241 Type I fluid is applied hot to de-ice the plane's surfaces. 615 00:39:12,827 --> 00:39:14,379 But it doesn't last long. 616 00:39:15,896 --> 00:39:18,172 Type I fluid had a holdover time, 617 00:39:18,241 --> 00:39:20,000 in their best conditions, 618 00:39:20,068 --> 00:39:22,275 uh, of about 15 minutes. 619 00:39:22,344 --> 00:39:24,931 Under poor conditions such as freezing rain, 620 00:39:25,000 --> 00:39:26,827 it could be as low as six minutes. 621 00:39:27,758 --> 00:39:30,000 During the Air Ontario investigation, 622 00:39:30,068 --> 00:39:32,517 Moshansky's team reached a stark conclusion 623 00:39:32,586 --> 00:39:34,931 about the effectiveness of Type I fluid. 624 00:39:35,965 --> 00:39:39,034 Even if Captain Morwood could've de-iced his plane in Dryden... 625 00:39:39,103 --> 00:39:43,000 We're fired up, taxiing for departure. Requesting airways to Winnipeg. 626 00:39:43,620 --> 00:39:45,344 ...it may have made no difference. 627 00:39:48,310 --> 00:39:50,896 Hang on a sec, guys. Is there a chance that plane can hold? 628 00:39:50,965 --> 00:39:53,551 We're having some bad weather up here. - Unbelievable. 629 00:39:53,620 --> 00:39:57,793 Flight 1363 had to wait for the troubled Cessna 150 to land. 630 00:39:58,413 --> 00:40:01,896 By the time he waited for this 150 aircraft and pilot to land, 631 00:40:01,965 --> 00:40:05,034 and then they backtracked and got into position, 632 00:40:05,103 --> 00:40:07,379 now they're in a serious snowstorm. 633 00:40:07,448 --> 00:40:09,172 And they are getting contaminated. 634 00:40:12,586 --> 00:40:16,448 Even if Morwood had de-iced during his 30 minutes on the ground... 635 00:40:16,517 --> 00:40:18,620 Rotate. 636 00:40:18,689 --> 00:40:21,551 ...the delay may have been enough for the fluid to stop working. 637 00:40:21,620 --> 00:40:24,965 The plane's wings may once again have become coated in ice. 638 00:40:33,379 --> 00:40:35,206 It came out in the, uh, 639 00:40:35,275 --> 00:40:37,896 examination of Air Ontario pilots 640 00:40:37,965 --> 00:40:41,551 there was a... a dire need for training, uh... 641 00:40:41,620 --> 00:40:46,655 in terms of how the de-icing, anti-icing systems worked, 642 00:40:46,724 --> 00:40:49,931 and how long your aircraft was protected. 643 00:40:50,931 --> 00:40:53,344 As soon as, uh, our accident occurred... 644 00:40:53,413 --> 00:40:55,448 up in New York, we, of course, 645 00:40:55,517 --> 00:40:57,517 understood it was a similar aircraft; 646 00:40:57,586 --> 00:41:01,000 in fact, almost identical aircraft to the Dryden accident airplane. 647 00:41:01,068 --> 00:41:05,241 And the circumstances were similar in both accidents. 648 00:41:05,310 --> 00:41:09,206 And the Dryden report was a tour de force, 649 00:41:09,275 --> 00:41:11,896 which helped us focus our investigation quite a bit. 650 00:41:13,172 --> 00:41:16,206 Justice Moshansky had released his interim report 651 00:41:16,275 --> 00:41:19,448 more than a year before the crash of Flight 405. 652 00:41:20,655 --> 00:41:22,724 His recommendations could've prevented it. 653 00:41:25,620 --> 00:41:29,482 Moshansky would soon discover that a breakdown in communication 654 00:41:29,551 --> 00:41:32,827 had cost the lives of 28 people in New York. 655 00:41:40,620 --> 00:41:43,137 During his inquiry, Justice Moshansky learned 656 00:41:43,206 --> 00:41:47,103 that there was another type of de-icing fluid available to the airline industry. 657 00:41:50,517 --> 00:41:52,275 It's called Type II fluid. 658 00:41:53,724 --> 00:41:55,724 It's thicker than Type I, 659 00:41:55,793 --> 00:41:58,172 which prevents it from immediately flowing off an aircraft. 660 00:41:59,827 --> 00:42:02,586 Type II fluid is, uh, 661 00:42:02,655 --> 00:42:04,862 a much more gooey substance. 662 00:42:04,931 --> 00:42:07,103 I've heard it referred to as almost mucous-like. 663 00:42:07,896 --> 00:42:10,758 With holdover times of up to 45 minutes, 664 00:42:10,827 --> 00:42:13,310 it keeps ice from accumulating, 665 00:42:13,379 --> 00:42:15,862 then blows off the plane's surfaces at takeoff. 666 00:42:17,275 --> 00:42:19,758 Fifteen months before the USAir crash, 667 00:42:19,827 --> 00:42:23,482 Moshansky recommended greater use of the thicker Type II fluid. 668 00:42:26,448 --> 00:42:31,689 Moshansky's investigators also studied de-icing practices at Toronto's Pearson Airport. 669 00:42:32,724 --> 00:42:35,068 We got hold of a film crew, 670 00:42:35,137 --> 00:42:38,172 and we waited and watched the weather very carefully 671 00:42:38,241 --> 00:42:41,344 until we found a forecast of freezing rain. 672 00:42:42,379 --> 00:42:46,689 And we tracked one aircraft which was heading for the Caribbean. 673 00:42:47,689 --> 00:42:50,137 The investigators discovered an alarming gap 674 00:42:50,206 --> 00:42:52,965 in the time between de-icing and takeoff. 675 00:42:53,310 --> 00:42:57,172 And from the time the aircraft was de-iced on the gate 676 00:42:57,241 --> 00:42:59,172 until the time the aircraft took off 677 00:42:59,241 --> 00:43:01,724 was somewhere in the order of 41 minutes. 678 00:43:01,793 --> 00:43:05,551 So there was no doubt that aircraft were departing... 679 00:43:05,620 --> 00:43:07,482 Pearson Airport, uh, 680 00:43:07,551 --> 00:43:10,137 with a partially or... 681 00:43:10,206 --> 00:43:12,551 largely contaminated wing surface. 682 00:43:14,551 --> 00:43:17,551 We then went to Chicago O'Hare. 683 00:43:18,379 --> 00:43:21,793 This was the first airport to actually put in place 684 00:43:21,862 --> 00:43:24,379 runway-end de-icing pads. 685 00:43:24,931 --> 00:43:28,482 And it was very useful in terms of explaining to us 686 00:43:28,551 --> 00:43:30,310 how these had evolved, 687 00:43:30,379 --> 00:43:34,172 what type of de-icing equipment they were using on them, how they worked. 688 00:43:35,137 --> 00:43:37,448 At the time of the USAir crash, 689 00:43:37,517 --> 00:43:40,689 La Guardia did not offer de-icing at the runway, 690 00:43:40,758 --> 00:43:42,275 only at the gate. 691 00:43:44,413 --> 00:43:46,896 Again, 15 months before the crash, 692 00:43:46,965 --> 00:43:51,206 Justice Moshansky recommended the placement of de-icing facilities at runways 693 00:43:51,275 --> 00:43:52,862 instead of terminal gates. 694 00:43:55,137 --> 00:43:57,103 Moshansky also recommended that pilots 695 00:43:57,172 --> 00:43:59,793 not only inspect their wings from the cockpit... 696 00:43:59,862 --> 00:44:02,689 Looks pretty good to me, as far as I can see. 697 00:44:02,758 --> 00:44:04,344 ...but also from the cabin. 698 00:44:04,413 --> 00:44:07,862 USAir 405, Runway 13 clear for takeoff. 699 00:44:07,931 --> 00:44:09,931 Moshansky claims that his report 700 00:44:10,000 --> 00:44:12,241 could've prevented the crash at La Guardia. 701 00:44:15,689 --> 00:44:17,896 But the Federal Aviation Administration claims 702 00:44:17,965 --> 00:44:20,827 it never received his report in 1990, 703 00:44:20,896 --> 00:44:24,620 and therefore couldn't pass the information along to airlines and pilots. 704 00:44:25,310 --> 00:44:27,586 But Justice Moshansky doesn't accept that. 705 00:44:29,000 --> 00:44:33,448 My second interim report went out in, uh... December of 1990. 706 00:44:35,620 --> 00:44:39,344 It was about a year and a half before the La Guardia crash occurred. 707 00:44:41,931 --> 00:44:43,793 So I think, uh, 708 00:44:43,862 --> 00:44:45,896 it probably sat on somebody's desk. 709 00:44:48,827 --> 00:44:52,379 The crash of Flight 1363 resulted in dozens of recommendations 710 00:44:52,448 --> 00:44:54,448 that could save lives. 711 00:44:56,655 --> 00:45:01,689 The crash of Flight 405 insured those recommendations were widely implemented. 712 00:45:03,034 --> 00:45:04,793 There was a lot that came out of Dryden. 713 00:45:04,862 --> 00:45:08,379 I mean, the commission came up with 192 recommendations. 714 00:45:08,448 --> 00:45:10,206 It changed, uh... 715 00:45:10,275 --> 00:45:13,620 the whole nature of how we approach contamination. 716 00:45:17,241 --> 00:45:20,965 We now have runway-end, uh, de-icing pads, 717 00:45:21,034 --> 00:45:24,620 so they can get a final de-icing before they take off. 718 00:45:26,310 --> 00:45:29,931 This was something directly the result of the Dryden Commission Inquiry. 719 00:45:32,172 --> 00:45:35,758 Today, most airlines use a new type of de-icing fluid. 720 00:45:36,620 --> 00:45:39,275 Type IV de-icing fluid lasts longer. 721 00:45:40,379 --> 00:45:42,862 It will stick to a wing for up to two hours. 722 00:45:44,896 --> 00:45:47,827 As well, air-traffic controllers must now be able to tell flight crews 723 00:45:47,896 --> 00:45:52,034 how long they will be delayed at the runway after being de-iced. 724 00:45:54,103 --> 00:45:58,206 Dryden is really the first accident that explored... 725 00:45:58,275 --> 00:46:01,448 not only what happens in the pointed end of an airplane, 726 00:46:01,517 --> 00:46:05,172 but what happens within a corporate culture. 727 00:46:05,241 --> 00:46:08,310 It put CEOs on notice that, uh... 728 00:46:09,344 --> 00:46:12,275 ...they can't hide in the woodwork when an accident occurs. 729 00:46:15,965 --> 00:46:19,206 Dutch manufacturer Fokker went bankrupt in 1996. 730 00:46:20,241 --> 00:46:22,206 Despite this, in 2009, 731 00:46:22,275 --> 00:46:26,827 there were still 55 Fokker F-28 jets in operation worldwide... 732 00:46:27,827 --> 00:46:29,551 ...mostly in warmer climates. 733 00:46:30,620 --> 00:46:33,620 Nobody should ever lose their life due to a contamination accident again 734 00:46:33,689 --> 00:46:38,000 in commercial aviation anywhere in a snow-and-ice environment. 735 00:46:38,689 --> 00:46:40,275 We've learned all the lessons. 736 00:46:59,724 --> 00:47:01,827 difuze