Original subtitles

New York City's La Guardia Airport,

March 22, 1992.

A commuter plane with 51 people on board

tries to lift off the runway.

Rotate.

But the pilots can't get it to climb.

They knew they were in trouble,

but they were fighting all the way to the end.

U.S. Air flight 405 plunges into the icy waters

of Flushing Bay.

27 people die.

For U.S. investigators, it's an open and shut case.

This accident was not a huge surprise to us.

But Canadian investigators are stunned.

They know the New York accident should never have happened.

My reaction when I heard about it was:

"My God, it's Dryden all over again".

Three years earlier an exhaustive investigation

into a crash at a remote northern airport

had identified a killer

and spelled out ways to keep it from striking again.

Certainly, if they had followed

the recommendations in my report,

the F-28 crash at La Guardia could have been averted.

The La Guardia accident makes one thing clear--

the right people never got the warning.

Ladies and gentlemen,

we are starting our approach.

We lost both engines!

Put the mask over your nose.

Emergency descent.

Mayday, mayday.

Brace for impact!

I think I lost one.

Investigation starting...

He's gonna crash!

March 10, 1989.

It's 11:39 a.m. at Dryden Ontario's Airport.

Light snow falls as Air Ontario flight 1363 stops

in the remote northern community

on its way from Thunder Bay to Winnipeg.

The passengers stay on board while the plane is refueled.

For flight attendant Sonia Hartwick

and the crew aboard the Fokker F-28,

it's been a frustrating day of delays.

Big, fluffy white snowflakes, at this time,

were falling gently to the ground,

and it was very, very gray.

And I thought: "Hmm,

"I guess this means we're going to be delayed again".

I can't see us making it to winnipeg on time.

It's a Friday in March

and the beginning of spring break.

Already an hour behind schedule,

another delay could jeopardize the vacation plans

of many of the 69 passengers and crew.

There was a lot of families

traveling on board with plans.

Most of them were going skiing.

And so they were very concerned

about meeting their connections in Winnipeg.

Kenora, Dryden, it's Ontario 363.

Ontario 363, Kenora.

As first officer Keith Mills

checks on weather conditions,

Captain George Morwood returns from making a phone call

inside the airport.

It's getting worse. What's the latest?

...and it won't clear till late afternoon.

Check that. Quite heavy snow.

It looks like it's going to be a bad one.

It's still within our takeoff limits.

Well, that's good,

we've got a lot of people who want to make their connectors.

Let's hope it holds.

Temperatures hover around freezing.

Visibility is decreasing.

If the flight doesn't leave soon,

it could be grounded indefinitely.

Dryden is a very small city.

It's a very remote part of Ontario.

With a population of about 6,500,

the isolated community lies halfway

between Thunder Bay and Winnipeg.

Harsh Canadian winters with bitter cold

reaching minus 35 degrees Fahrenheit are the norm here.

It's not the place to be stranded

in the middle of a snowstorm.

Royal Canadian mounted police officer Don Crawshaw

and his partner are escorting a prisoner to Winnipeg.

When we did a criminal check on the prisoner

before we left, he came up as a violent person.

So two of us had to go with him.

He was wanted in Banff on a fraud charge,

and that's what he was being brought back to Alberta for.

Ok, no smoking and seatbelts.

On.

Instruments.

Synched.

Crosscheck.

Captain Morwood uses the power of engine number two,

already running, to fire engine number one.

Morwood and Mills are both highly experienced pilots.

However, they've each flown fewer than 100 hours

in the Fokker F-28.

The multi-million dollar aircraft

is the first Air Ontario jet

to serve the remote northern Ontario region.

24 minutes after landing in Dryden,

flight 1363 is ready to leave.

Inform Kenora, we're rolling.

We're fired up, taxiing for departure,

requesting airways to Winnipeg.

Hang on a sec, guys.

Is there a chance that plane can hold?

We're having some bad weather up here.

An approaching aircraft's

urgent request to land...

Unbelievable.

...gives Captain Morwood little choice.

He delays takeoff.

Ok, 363's holding short of the active.

We are going to be a few moments

until a small plane lands safely.

We're sorry, folks, this just isn't our day.

In the two years that I had flown with Air Ontario,

I had never come across anything like this before.

The Cessna 150 lands safely,

clearing the runway for flight 1363's departure.

Tell them we're going immediately.

Kenora, Ontario, we're taxiing out at this time,

363 Dryden.

Finally, an hour behind schedule,

the plane taxis to runway 29.

As we were going down the runway

to position for takeoff, a blanket of snow was falling,

and I couldn't see the treeline anymore,

it was like looking through a sheer.

Folks, we're sorry for the delay.

Flight attendants, please be seated for takeoff.

At 12:09 p.m., flight 1363

is ready for takeoff.

Advise Kenora, we're ready to proceed.

And Kenora, Dryden, Ontario,

363 is about to roll 29 at Dryden.

Ontario 363, Kenora, Roger.

Captain Morwood performs a brief engine run up,

heating the engines to rid them of any accumulated snow and ice.

Then he begins his roll down the runway.

When we're taking off,

I'm usually very quiet and focused,

meticulously going through a checklist in my own mind,

what would I do in the case of an emergency.

V-one.

The F-28 reaches its takeoff speed.

Rotate.

80 knots.

Our takeoff was very slow and sluggish,

like a slow, sluggish person running up a hill.

Clearly, there's something wrong.

The F-28 struggles to get airborne.

We cleared the trees.

The plane started shaking.

I thought: "Oh, my God, we're going to crash".

That's when all hell broke loose.

If you can equate to being in a mixmaster,

that's what the plane felt like at the time.

And there was this dip to the left

and then dip to the right.

The pilot's trying to get this plane up.

Then all of a sudden, there was a power burst.

The plane seemed to stabilize itself.

You could feel the pilots

trying to get control of it.

But a few seconds later,

it became a mixmaster again.

I yelled out: "Emergency, grab your ankles,

get your heads down."

Grab your ankles, get your heads down!

And I kept yelling that,

and then I assumed my brace position.

You could hear people screaming and yelling.

There was loud, horrible sounds.

We were clearly crashing.

The pilots are helpless.

49 seconds after lifting off...

Air Ontario flight 1363 crash lands in the brush,

west of runway 29.

There is carnage of the aircraft all over the place.

I didn't know where I was.

And at that point I thought: "Oh, my gosh, I'm alive,

I'm still alive, this is all happening so quickly".

When we crashed, we came down on an angle,

it ripped the right side of the plane open,

and that's how we got out,

or else we probably would have never gotten out.

Now, the prisoner was still in handcuffs,

so I reached over and I took the cuffs off of him there,

but he never left me.

And then we exited the aircraft.

There's fire all around,

there's explosions,

and I'm thinking: "Oh, my God, we're full of fuel".

Guys, come this way.

And I started yelling: "Come this way, come this way,"

for people to follow my voice.

Come this way.

Passengers scramble to safety

before the fire spreads.

45 people survive the accident...

...but 24 people do not,

including Captain Morwood and first officer Mills.

Emergency crews rush to the crash site

deep in the woods.

The injured are taken to the hospital in Dryden.

I was very concerned,

because I kept looking at the wing all the time,

I thought, there was a lot of snow.

I didn't notice anything wrong going down the runway.

Like I said, it was just when we started hitting the trees,

I knew there was something wrong.

Within 24 hours, a team of investigators

from the Canadian Aviation Safety Board

arrives at the scene.

You're going there hopefully with the idea

that you can find out what happened, why it happened,

and how do you prevent it from happening in the future.

We walked the entire path of the airplane

to the threshold of the runway,

and then we walked the flight path of the airplane

right to the crash site.

That was the first thing that I did.

I wanted to document what I was seeing by photographing.

When you walk in on an accident site like that,

there are two things that overwhelm you--

the smell of aviation jet fuel

and the smell of death.

The trees just past the end of runway 29

give investigator David Rohrer and his team

vital clues about the F-28's failed flight.

What happened was the airplane went off

the end of the runway in what we would call ground effect,

and just stayed at that height,

simply clipping the tops of the trees.

Look at how these treetops have been clipped off.

It didn't ever fly.

You've got 24 people that died, you've got two pilots that died,

and a flight attendant that died.

And they died, for the most part, trying to do their job.

So you really want to do them justice,

but you also have to be fair.

If there were mistakes made, the mistakes have to be fixed.

From the rear of the fuselage,

investigators recover the F-28's two black boxes--

the flight data recorder and the cockpit voice recorder.

The devices are designed to withstand temperatures

of 2,000 degrees Fahrenheit for up to 30 minutes.

Investigators are frustrated to learn

that the mylar tape from the recorders

has suffered extreme heat damage.

It's estimated the black boxes were scorched

by a 2,000-degree inferno for at least 90 minutes,

far beyond their limit.

The data is unrecoverable.

That was a big blow to us,

because now you have to try and gather information

and try and establish that it's factual

by independent routes.

Investigators must now rely heavily

on eyewitness reports to reconstruct events

leading up to the doomed takeoff.

They learn that the F-28 began its day in Winnipeg

and was scheduled to fly a return route

to Thunder Bay and back, with a stopover in Dryden.

But in Thunder Bay, plans changed.

The cancellation of another flight

forced the crew to pick up 10 additional passengers.

And when they did their calculations,

they realized that we were overloaded

and something had to come off.

Alright, let's offload some fuel, then.

They ended up removing fuel

in order to be within the proper weight.

Dispatch, Ontario 363.

So the flight was delayed an hour.

The extra weight of the new passengers

left the crew no choice.

They had to unload fuel to lighten their load.

That meant when they arrived in Dryden,

they needed to pump in more than the usual amount of fuel

for the final leg back to Winnipeg.

Rohrer wonders if the change in plans

somehow led to a miscalculation of the weight and balance.

Was the F-28 too heavy for takeoff?

He then uncovers a puzzling detail--

the plane's weight and balance form for the takeoff from Dryden

was never collected, as required.

It burned in the fire.

Rohrer is forced to use Air Ontario's standard averages

to calculate passenger and baggage weights.

The data, combined with the airport's fuel records,

allows him to estimate the plane's gross takeoff weight.

We knew how many people we had on board.

We knew how many bags we had on the airplane,

and we knew what our fuel load was.

He estimates the F-28 weighed

between 62,000 and 64,000 pounds.

And the airplane's max takeoff

weight was 65,000 pounds,

and so we came to the conclusion

that the airplane was not overweight.

The cause of the crash remains a mystery.

18 days into the investigation,

the Canadian government appoints Justice Virgil Moshansky

to lead a more wide-ranging inquiry

into all aspects of the aviation system

that might have contributed to the Air Ontario tragedy.

The government was looking for

an experienced trial judge,

and preferably one with an aviation background.

Moshansky is an experienced pilot

with 13 years on the bench.

He will work closely with crash investigator David Rohrer

and aviation consultant Frank Black.

The new team's first step,

assessing the plane's technical systems.

The electrical system, the hydraulic system,

the fuel system, all of these systems are looked at,

both in terms of what is their history

leading up to the accident,

and what remnants are remaining at the crash site

that can be examined.

Clues to a possible system failure arise

when Sonia Hartwick recalls a troubling event

aboard the same plane just days before the final crash.

I think it was Monday or Tuesday.

When we took off, there was this smoke that filled the aircraft,

and there was this horrible smell.

I thought: "Oh, my God, we have a fire in the lav".

But there was no fire in the lavatory

or anywhere else in the cabin.

They told us that apparently

it had something to do with oil sitting in the A.P.U. system.

So every takeoff that day, this would happen.

The auxiliary power unit is a generator

that provides the power needed to start the engines.

Did burning oil in the A.P.U. somehow cause a fire

and ultimately doom flight 1363?

Rohrer searches the week's journey log

for any mention of the auxiliary power unit.

He makes a surprising discovery--

the A.P.U. wasn't working on the day of the crash.

It couldn't possibly have caused the fire.

But the inoperative power unit may still have played a role

in the tragedy.

Investigators learn that it forced the crew

to make a risky decision in Dryden.

...these people on to their connectors.

Let's hope it holds.

Normally, the Captain would rely on the A.P.U.

to restart his engines

after shutting them both down for refueling.

But if he couldn't use his A.P.U.,

he couldn't shut his engines down.

That meant flight 1363 had to be refueled

with one engine still running.

Captain Morwood was in a situation

where he's got to hot refuel

with passengers on board the aircraft.

He's got to keep an engine running to refuel the airplane.

Hot refueling isn't against regulations.

But the risk of a fuel spill makes it potentially dangerous.

Could the hot refueling have caused some kind of damage

to the engines?

The Dryden Airport manager, a former military pilot,

suspects there was trouble with the plane's engines.

He tells Rohrer he saw the takeoff from his office

and heard a sharp, explosive noise

just as it disappeared from view.

To him, it signified a flameout, or engine failure.

I thought: "This is going to be a high profile

"and potentially controversial investigation.

"And the only way to ensure that the truth stands up

is to have hard evidence from the aircraft accident".

And so we took the airplane completely

and we put it in our lab in Ottawa.

Anything?

With signs pointing to engine failure

as the cause of the crash...

Strip it down.

Rohrer orders extensive engine testing.

Those engines were examined in detail for damage.

Rohrer finds the F-28's two Rolls-Royce engines

suffered only minor structural damage.

There's no evidence of an engine fire,

nothing at all to suggest the engines had failed.

With little physical evidence to explain the failed takeoff,

investigators are back to square one.

To solve the mystery,

they comb through survivor and eyewitness statements.

A common thread emerges.

They said in their witness statements,

there was snow and ice on the wings

when the airplane attempted to take off.

Rohrer studies weather charts for clues.

We had very good meteorological information.

The chart shows that during the half hour

the F-28 was on the ground at Dryden Airport,

visibility shrank from two and a half miles

to just half a mile because of the snowstorm.

And though we may find other reasons, for sure,

snow and ice on the wings was a factor in this accident.

Sonia Hartwick tells investigators

about an unusual sight during takeoff.

As we took off, I noticed that the wings

just became a solid sheen of gray, shiny ice.

Investigators consult the F-28's manuals

to study its deicing systems.

They find that only the wing's leading edges are protected.

The aircraft had heated leading edges on the wings.

I wonder if the anti-icing system was working.

And the heat was provided by bleed air

from the compressors on the engine.

They found the valves that allow the compressed air

access to the leading edges.

And they tested the valve to see if it functioned, and it did.

The anti-icing system was working.

But since it only heats the leading edge,

it likely didn't clear ice

that formed on the surface of flight 1363's wings.

Investigators suspect that snow and ice buildup,

what experts call wing contamination,

may have played a major role in the crash.

To verify that suspicion,

Rohrer and his team meet with engineers from Fokker.

Thanks for coming.

I'm curious to see what you have.

Jack Van Hanks, who was the chief engineer,

had extensive aerodynamic studies and data

on the effects of contamination on an F-28 airplane.

Fokker engineers have run simulations of the crash.

They were able to get some very good data

in terms of the performance of the airplane

simulating the type of loads, temperatures, et cetera,

that the Dryden aircraft would have been exposed to.

Investigators make a crucial discovery

about the design of the F-28.

Because of the angle of the wings,

a very small amount of ice

makes the plane susceptible to stalling.

They concluded that

even the most minute bit of contamination on the wing

would disrupt the airflow

and cause a loss of lift.

Well, that answers a lot of questions.

The simulations support what witnesses saw.

It just barely got airborne, dropping wings,

losing lift, and then hitting trees,

decelerating to the point where it broke up.

Investigators are now certain

that contaminated wings caused the crash.

But what's still unclear

is why the plane was not deiced before takeoff.

Almost all airports in cold climates, including Dryden,

are equipped with technology to remove ice from a plane.

But Captain Morwood never requested deicing.

It's getting worse. What's the latest?

...and it won't clear till late afternoon.

Investigators need to figure out why.

They want to understand what made him risk his own life...

Let's hope it holds.

...and the lives of the 68 other people

on board flight 1363.

Investigators dig through

Captain George Morwood's flight records and work history.

They interview crew members,

searching for clues to his behavior.

Captain Morwood was a very, very professional,

very old school pilot.

He had his view on how things should be done properly

and what his definition of proper and professional

would be.

He also was very concerned about his passengers.

He enjoyed making sure that they got on their flights on time

and got to their destinations on time.

Morwood's history shows

he's delayed and canceled flights in the past

because of icing concerns.

Rohrer is stumped.

Why didn't he request deicing in Dryden?

Another pilot who was at Dryden Airport that day

provides part of the answer.

He heard Morwood on the phone to Air Ontario.

That is what I have been trying to tell you!

He was very frustrated,

and he was really concerned about his passengers.

Morwood complained to the off-duty pilot

about the company.

These guys!

You want to guess my weight before I left Thunder Bay?

66 and change.

I had to offload fuel.

Now that--

Right. So now what am I supposed to do?

No, you figure it out.

When he left the terminal,

he was observed by witnesses

to appear to be very upset and very angry.

Investigators wonder what set Morwood off.

They try to piece together the pilot's day on March the 10th.

This was the fifth day of a very long week

for Captain Morwood,

and he was the next day leaving

with his family on a ski vacation.

Before his first flight of the day,

he'd learned the plane's A.P.U. still wasn't working.

And then, once in Thunder Bay, more bad news.

After refueling,

the dispatcher forces Morwood to take on 10 extra passengers.

Now he must offload fuel and lose more time.

There goes the schedule.

Let's offload some fuel, then.

This meant Morwood would leave Thunder Bay

behind schedule.

Dispatch, Ontario 363.

And Captain Morwood is the type of Captain

who didn't want to be late.

Now en route to Dryden

and an hour behind schedule,

the weather forecast the crew was given of light rain and fog

is no longer accurate.

And Captain Morwood didn't get the forecast

of freezing rain coming into Dryden,

which he should have had.

As flight 1363 lands in Dryden,

the weather was getting worse by the minute.

The plane sat there for half an hour

while snow built up on the wings.

I got to talk to somebody about this.

Investigators may never know

how concerned Morwood was about the weather.

But there is evidence that it was on his mind.

When Rohrer questions the fueling agent,

he learns that Morwood did ask about deicing

moments before takeoff.

Is there deicing available?

The fueling agent says he pointed out

the deicing ground crew to Morwood.

The agent then offers a compelling reason

that could explain why the Captain didn't deice.

Air Ontario had a policy prohibiting him from deicing

with an engine running.

But if Morwood had shut down both engines,

he wouldn't have been able to restart his plane.

Now, the only other way to start the airplane

on the ground is with a ground-based air cart

that can provide the compressed air.

And Dryden did not have the capability

to start the airplane.

The equipment would have had

to be flown in from Winnipeg.

It would have been a costly decision.

If he shut it down,

he would ground the aircraft there effectively,

requiring the billeting of passengers in hotels

and added expense to the airline

for which he would be answerable.

So he was under a great deal of pressure.

No, you figure it out.

And I believe that the conversation on the phone

would have been about that scenario

and his displeasure with it.

But he didn't have any other chance.

It's getting worse. What's the latest?

Quite heavy snow.

Looks like it's going to be a bad one.

It's still within our takeoff limits.

Well, that's good.

We've got a lot of people who want to make their connectors.

Let's hope it holds.

Though the amount of snow on the wings

was still within limits,

it's what lay under the snow that doomed the flight.

The fuel in a plane's wing

can get as cold as minus 100 degrees Fahrenheit.

The frigid fuel cools the metal surface of the wing.

When snow hits this super cooled surface,

it freezes instantly into a barely visible layer of ice.

It's a process called cold soaking.

And this, of course, is what's disrupting the airflow

on the wing and destroying the lifting capabilities.

Advise Kenora we're ready to proceed.

And Kenora, Dryden, Ontario...

Perhaps not wanting to face the consequences

of shutting down his engines,

Morwood opted to take off for Winnipeg

without deicing his plane.

He must have concluded

that the ice would blow off on takeoff.

That is where he made a mistake, a tragic mistake.

But Moshansky concludes

that despite his mistake,

Captain Morwood is not solely responsible for the crash.

It wasn't simply pilot error.

There were a myriad of factors

which were the cause of the accident.

One of the most important factors--

Air Ontario's decision to let the plane fly

with a broken A.P.U.

They were deferring

a lot of the maintenance that should have been done

because of a shortage of parts.

And then they had to scrounge around all across Canada

with various F-28 operators to borrow parts from them.

And this was a very bad move

on the part of Air Ontario management.

The investigation determines

that by cutting corners

and focusing too much on the bottom line,

the airline was putting all their passengers and employees

at risk.

Because the F-28S were new to Air Ontario,

there was this urgency to get one crew off

and get the next crew on flying.

This urgency to have them in the air producing money.

I came to the conclusion

after a lot of thought about this accident

that there were a lot of other hands on those throttles,

pushing those throttles forward.

There were a lot of people that were involved

in the sequence of events that led to this tragic outcome.

This was a preventable accident.

But everything conspired against the pilots.

I got to talk to somebody about this.

Because Air Ontario management

did not have a safety culture.

And you have to have a safety culture

from the top management down.

Knowing there are dozens of Fokker F-28S

flying around the world,

justice Moshansky takes an unusual step.

He releases a report well before his inquiry concludes.

Good afternoon.

It warns of the plane's

vulnerability to ice buildup

and stresses the need for frequent deicing

in winter conditions.

Even a small amount of icing would be disastrous

on an F-28.

But 15 months later, it becomes clear

that Moshansky's warnings have not been heard.

U.S. Air flight 405 is preparing to fly

from New York to Cleveland on March 22, 1992.

The plane is a Fokker F-28.

And it's snowing.

It's one degree below freezing.

At 9:00 p.m., the jet is being deiced for a second time

since its arrival from Florida.

In the past hour, an inch of snow has fallen

and shows no signs of stopping.

U.S. Air 405, clear to taxi runway 13.

The crew prepares for takeoff.

Flight 405 is an hour and 45 minutes behind schedule

when Captain Wallace Majure starts taxiing to runway 13.

Then, unexpectedly...

U.S. Air 405, turn left and hold short of echo.

Left on the inner, hold short of echo.

At 9:07 PM,

flight 405 is forced to wait on the taxiway

near runway 13.

Another 23 minutes pass.

First Officer John Rachuba turns on a light

that illuminates his wings.

He checks the right wing for ice.

He sees none.

Looks pretty good to me, as far as I can see.

U.S. Air 405, runway 13, clear for takeoff.

Even though it's now been 35 minutes

since their last deicing, the crew does not request another.

Takeoff thrust's set, temp's okay.

Everything proceeds as it should,

until...

V-one.

Rotate.

...just after the F-28 begins its rotation.

The aircraft had enough flying speed to,

to lift off,

barely lift off.

The wings just could not support the airplane.

They knew they were in trouble.

13 seconds after lifting off,

flight 405 crashes on the shore of Flushing Bay.

I don't think any pilot really thinks he's gonna crash.

They were trying to save the airplane right to the end.

27 of the 51 people on board are killed.

Another Fokker F-28 has crashed with tragic consequences.

My reaction when I heard about it was:

"My God, it's Dryden all over again".

Within days, investigator

in charge Robert Benzon

suspects that ice on the wings was the major cause.

It would be very, very difficult

for either of the pilots to really detect ice on the wings

looking backwards over their shoulders

through the side windows of the airplane.

Looks pretty good to me, as far as I can see.

So the Captain was faced with quite a problem.

If he wanted to be deiced a third time,

he would have had to get out of the lines,

taxi all the way back into the parking area

and meet up with a deicing truck again.

Take off thrusts.

That would have put him very, very late,

and it may have even caused the cancellation of the flight.

After all of this work, after all of the efforts,

to see it happen again was extremely frustrating.

There were no regulations in place

requiring the crew to seek another deicing

after their extended delay.

But Justice Moshansky had called attention

to the dangers of long wait times

when he issued his interim report.

If they had followed the recommendations

in my second interim report,

this accident certainly could have been averted.

He also had drawn attention

to the limitations of the deicing fluid

being used at the time.

Called type one fluid,

it's a mixture of antifreeze and water.

Those chemicals are designed

that as you accelerate down the runway,

that they'll actually shed off your wing,

so that when you actually want the wing to lift

and produce lift, that it's not contaminated.

Type one fluid is applied hot

to deice the plane's surfaces.

But it doesn't last long.

Type one fluid had a holdover time,

in their best conditions, of about 15 minutes.

Under poor conditions such as freezing rain,

it could be as low as six minutes.

During the Air Ontario investigation,

Moshansky's team reached a stark conclusion

about the effectiveness of type one fluid.

Even if Captain Morwood

could have deiced his plane in Dryden...

We're fired up, taxiing for departure,

requesting airways to Winnipeg.

...it might have made no difference.

Hang on a sec, guys.

Is there a chance that plane can hold?

We're having some bad weather up here.

Unbelievable.

Flight 1363 had to wait

for the troubled Cessna 150 to land.

By the time he waited

for this 150 aircraft and pilot to land,

and then they backtracked and got into position,

now they're in a serious snowstorm,

and they are getting contaminated.

Even if Morwood had deiced

during his 30 minutes on the ground...

Rotate.

...the delay may have been enough

for the fluid to stop working.

The plane's wings may once again have been coated in ice.

It came out in the examination

of Air Ontario pilots that there was a dire

need for training,

in terms of how the deicing, anti-icing systems worked

and how long your aircraft was protected.

As soon as our accident occurred up in New York,

we, of course, understood that it was a similar aircraft,

in fact, a nearly identical aircraft

to the Dryden accident airplane.

The circumstances were similar in both accidents,

and the Dryden report was a tour de force,

which helped us focus our investigation quite a bit.

Justice Moshansky had released his interim report

more than a year before the crash of flight 405.

His recommendations could have prevented it.

Moshansky would soon discover

that a breakdown in communication

had cost the lives of 27 people in New York.

During his inquiry, Justice Moshansky learned

that there was another type of deicing fluid

available to the airline industry.

It's called type two fluid.

It's thicker than type one, which prevents it

from immediately flowing off an aircraft.

A type two fluid

is a much more gooey substance.

I've heard it referred to as almost mucus-like.

With holdover times of up to 45 minutes,

it keeps ice from accumulating,

then blows off the plane's surfaces at takeoff.

15 months before the U.S. air crash,

Moshansky recommended greater use

of the thicker type two fluid.

Moshansky's investigators also studied deicing practices

at Toronto's Pearson Airport.

We got hold of a film crew,

and we waited and watched the weather very carefully

until we found a forecast of freezing rain.

And we tracked one aircraft

which was heading for the Caribbean.

The investigators discovered an alarming gap

in the time between deicing and takeoff.

And from the time the aircraft was deiced on the gate

until the time the aircraft took off

was somewhere in the order of 41 minutes.

So there was no doubt that aircraft were departing

Pearson Airport

with a partially,

or largely contaminated wing surface.

We then went to Chicago O'Hare.

This was the first airport to actually put in place

runway end deicing pads.

And it was very useful

in terms of explaining to us how these had evolved,

what type of deicing equipment they were using on them,

how they worked.

At the time of the U.S. air crash,

La Guardia did not offer deicing at the runway, only at the gate.

Again, 15 months before the crash,

Justice Moshansky recommended the placement

of deicing facilities at runways instead of terminal gates.

Moshansky also recommended that pilots

not only inspect their wings from the cockpit...

Looks pretty good to me, as far as I can see.

...but also from the cabin.

U.S. Air 405, runway 13, clear for takeoff.

Moshansky claims that his report could have prevented

the crash at La Guardia.

But the Federal Aviation Administration claims

it never received his report in 1990,

and therefore couldn't pass the information along

to airlines and pilots.

But justice Moshansky doesn't accept that.

My second interim report went out

in December of 1990.

It was about a year and a half

before the La Guardia crash occurred.

So I think it probably sat on somebody's desk.

The crash of flight 1363 resulted

in dozens of recommendations that could save lives.

The crash of flight 405 ensured those recommendations

were widely implemented.

Well, there was a lot that came out of Dryden.

I mean, the commission came up with 192 recommendations.

It changed the whole nature

of how we approach contamination.

We now have runway end deicing pads,

so they can get a final deicing before they take off.

This was something directly the result

of the Dryden Commission Inquiry.

Today, most airlines use a new type of deicing fluid.

Type four deicing fluid lasts longer.

It will stick to a wing for up to two hours.

And air traffic controllers must now

be able to tell flight crews how long they will be delayed

at the runway after being deiced.

Dryden is really the first accident that explored

not only what happens in the pointed end of an airplane,

but what happens within a corporate culture.

It put CEOs on notice

that they can't hide in the woodwork

when an accident occurs.

Dutch manufacturer Fokker went bankrupt in 1996.

Despite this, in 2009,

there were still 55 Fokker F-28 jets in operation worldwide,

mostly in warmer climates.

Nobody should ever lose their life

due to a contamination accident again in commercial aviation

anywhere in a snow and ice environment.

We've learned all the lessons.