Mayday Air Crash Investigations - S09 E06 - Cold Case
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00:00New York City's LaGuardia Airport, March the 22nd, 1992.
00:08A commuter plane with 51 people on board tries to lift off the runway.
00:13Rotate.
00:14But the pilots can't get it to climb.
00:16They knew they were in trouble, but they were fighting all the way to the end.
00:21U.S. Air Flight 405 plunges into the icy waters of Flushing Bay.
00:2727 people die.
00:30For U.S. investigators, it's an open and shut case.
00:34This accident was not a huge surprise to us.
00:37But Canadian investigators are stunned.
00:40They know the New York accident should never have happened.
00:43My reaction when I heard about it was, my God, it's driving all over again.
00:47Three years earlier, an exhaustive investigation into a crash at a remote northern airport had identified a killer
00:54and spelled out ways to keep it from striking again.
00:57Certainly, if they had followed the recommendations in my report,
01:01the F-28 crash at LaGuardia could have been averted.
01:04The LaGuardia accident makes one thing clear.
01:07The right people never got the warning.
01:09March the 10th, 1989.
01:36It's 11.39 a.m. at Dryden, Ontario's airport.
01:43Light snow falls as Air Ontario Flight 1363 stops in the remote northern community on its way from Thunder Bay to Winnipeg.
01:50The passengers stay on board while the plane is refuelled.
01:56For flight attendant Sonia Hartwick and the crew aboard the Fokker F-28, it's been a frustrating day of delays.
02:12Big, fluffy, white snowflakes.
02:15At this time, we're falling gently to the ground.
02:17And it was very, very grey.
02:21And I thought, hmm, I guess this means we're going to be delayed again.
02:25I can't see us making it to Winnipeg on time.
02:28It's Friday, the beginning of March break.
02:34Already an hour behind schedule, another delay could jeopardize the vacation plans of many of the 69 passengers and crew.
02:42There was a lot of families traveling on board with plans.
02:46Most of them were going skiing.
02:49And so they were very concerned about meeting their connections in Winnipeg.
02:55Kenora Dryden, it's Ontario 363.
02:58Ontario 363, Kenora.
03:00As First Officer Keith Mills checks on weather conditions, Captain George Moorwood returns from making a phone call inside the airport.
03:08It's getting worse.
03:09It's the latest.
03:10It won't clear until late afternoon.
03:12Check that.
03:13Quite heavy snow.
03:14Looks like it's going to be a bad one.
03:16It's still within our takeoff limits.
03:18Well, that's good.
03:19We've got a lot of people who want to make their connectors.
03:21Let's hope it holds.
03:24Temperatures hover around freezing.
03:27Visibility is decreasing.
03:30If the flight doesn't leave soon, it could be grounded indefinitely.
03:34Dryden is a very small city.
03:36It's a very remote part of Ontario.
03:39With a population of about 6,500,
03:42the isolated community lies halfway between Thunder Bay and Winnipeg.
03:48Harsh Canadian winters with bitter cold reaching minus 35 degrees Celsius are the norm here.
03:55It's not the place to be stranded in the middle of a snowstorm.
03:58Royal Canadian Mounted Police Officer Don Crawshaw and his partner are escorting a prisoner to Winnipeg.
04:11When we did a criminal check on the prisoner before we left,
04:16he came up as a violent person.
04:18So two of us have to go with him.
04:21He was wanted in Banff on a fraud charge,
04:23and that's what he was bringing back to Alberta for.
04:26Captain Moorwood uses the power of engine number two, already running, to fire engine number one.
04:46Moorwood and Mills are both highly experienced pilots.
04:53However, they've each flown fewer than 100 hours in the Fokker F-28.
04:58The multi-million dollar aircraft is the first Air Ontario jet to serve the remote northern Ontario region.
05:0724 minutes after landing in Dryden, flight 1363 is ready to leave.
05:13Inform Canora, we're rolling.
05:16We're fired up, taxiing for departure, requesting airways to Winnipeg.
05:20Hang on a sec, guys. Is there a chance that plane can hold?
05:23We're having some bad weather up here.
05:25An approaching aircraft's urgent request to land...
05:28Unbelievable.
05:29...gives Captain Moorwood little choice.
05:32He delays takeoff.
05:33Okay, 363's holding short of the active.
05:38We are going to be a few moments until a small plane lands safely.
05:42We're sorry, folks. This just isn't our day.
05:44In the two years that I had flown with Air Ontario, I'd never come across anything like this before.
05:51The Cessna 150 lands safely, clearing the runway for flight 1363's departure.
06:01Tell them we're going immediately.
06:04Canora, Ontario, we're taxiing out at this time.
06:06363, Dryden.
06:07Finally, an hour behind schedule, the plane taxis to runway 29.
06:16As we're going down the runway to position for takeoff,
06:22the blanket of snow is falling and I couldn't see the tree line anymore.
06:26It was like looking through a shear.
06:27Folks, we're sorry for the delay.
06:32Flight attendants, please be seated for takeoff.
06:36At 12.09pm, flight 1363 is ready for takeoff.
06:42Advise Canora, we're ready to proceed.
06:47And Canora, Dryden, Ontario, 363 is about to roll 29 at Dryden.
06:52Carry on 363, Canora. Roger.
06:54Captain Moorwood performs a brief engine run-up,
06:59heating the engines to rid them of any accumulated snow and ice.
07:04Then he begins his roll down the runway.
07:09When we're taking off, I'm usually very quiet and focused,
07:13meticulously going through a checklist in my own mind,
07:15what would I do in the case of an emergency?
07:20E1.
07:21The F-28 reaches its takeoff speed.
07:23Rotate.
07:24Eighty knots.
07:32Our takeoff was very slow and sluggish.
07:35Like a slow, sluggish person running up a hill.
07:40Clearly, there's something wrong.
07:43The F-28 struggles to get airborne.
07:45We cleared the trees.
07:48The plane started shaking.
07:51I thought, oh, my God, we're in a crash.
07:57That's when all hell broke loose.
07:58If you can equate to being in a mixmaster, that's what the plane felt like at the time.
08:06There's this dip to the left and then dip to the right, the pilot's trying to get this plane up.
08:12Then all of a sudden, there was a power burst.
08:15The plane seemed to stabilize itself.
08:18You could feel that the pilot's trying to get control of it.
08:21But a few seconds later, it became a mixmaster again.
08:26I yelled out, emergency, grab your ankles, get your heads down.
08:34Grab your ankles, get your heads down.
08:36And I kept yelling that.
08:38And then I assumed my brace position.
08:40You could hear people screaming and yelling.
08:42There's loud, horrible sounds.
08:45We are clearly crashing.
08:46The pilots are helpless.
08:5249 seconds after lifting off, Air Ontario Flight 1363 crash lands in the bush, 950 meters west of Runway 29.
09:05There was carnage of the aircraft all over the place.
09:20I didn't know where I was.
09:22And at that point, I thought, oh, my gosh, I'm alive.
09:24I'm still alive that this is all happening so quickly.
09:27When we crashed, we came down on an angle, it ripped the right side of the plane open, and that's how we got out.
09:38Or else we probably would have never have gotten out.
09:41Now, the prisoner was still in handcuffs, so I reached over and I took the cuffs off of him there, but he never left me.
09:50And then we exited the aircraft.
09:53There's fire all around.
09:54There's explosions.
09:55I'm thinking, oh, my God, we're full of fuel.
09:59Guys, come this way.
10:00And I started yelling, come this way, come this way, for people to follow my voice.
10:05Come this way.
10:07Passengers scramble for safety before the fire spreads.
10:1345 people survive the accident.
10:17But 24 people do not, including Captain Moorwood and First Officer Mills.
10:25Emergency crews rush to the crash site deep in the woods.
10:43The injured are taken to hospital in Dryden.
10:51I was very concerned because I kept looking at the wing all the time.
10:58I thought there was a lot of snow.
11:00I didn't notice anything wrong going down the runway.
11:01Like I said, it was just when we started hitting the trees, I knew there was something wrong.
11:04Within 24 hours, a team of investigators from the Canadian Aviation Safety Board arrives at the scene.
11:16You'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.
11:29We 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.
11:38That was the first thing that I did.
11:39I wanted to document what I was seeing by photographing.
11:45When you walk in on an accident site like that, there are two things that overwhelm you.
11:49The smell of aviation jet fuel and the smell of death.
11:54The trees just past the end of runway 29 give investigator David Rohr and his team vital clues about the F-28's failed flight.
12:15What 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.
12:26Look at how these treetops have been clipped off.
12:31It didn't ever fly.
12:35You've got 24 people that died.
12:37You've got two pilots that died and a flight attendant that died.
12:40And they died, for the most part, trying to do their job.
12:43So you really want to do them justice, but you also have to be fair.
12:49And if there were mistakes made, mistakes have to be fixed.
12:55From the rear of the fuselage, investigators recover the F-28's two black boxes.
13:01The flight data recorder and the cockpit voice recorder.
13:05The devices are designed to withstand temperatures of 1100 degrees Celsius for up to 30 minutes.
13:19Investigators are frustrated to learn that the mylar tape from the recorders has suffered extreme heat damage.
13:25It's estimated the black boxes were scorched by an 1100 degree inferno for at least 90 minutes, far beyond their limit.
13:35The data is unrecoverable.
13:37That 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.
13:48We were just about to leave Thunder Bay and they gave us 10 new passengers.
13:55Investigators must now rely heavily on eyewitness reports to reconstruct the events leading up to the doomed takeoff.
14:03They learned 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.
14:11But in Thunder Bay, plans changed.
14:18The cancellation of another flight forced the crew to pick up 10 additional passengers.
14:24And when they did their calculations, they realized that we were overloaded and something had to come off.
14:31All right, let's offload some fuel then.
14:35They ended up removing fuel in order to be within the proper weight.
14:39Dispatch, Ontario 363.
14:40So the flight was delayed an hour.
14:44The extra weight of the new passengers left the crew no choice.
14:48They had to unload fuel to lighten their load.
14:52That 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.
15:02Roa wonders if the change in plans somehow led to a miscalculation of the weight and balance.
15:07Was the F-28 too heavy for takeoff?
15:15He then uncovers a puzzling detail.
15:17The plane's weight and balance form for the takeoff from Dryden was never collected as required.
15:23It burned in the fire.
15:24It burned in the fire.
15:28Roa is forced to use Air Ontario's standard averages to calculate passenger and baggage weights.
15:34The data, combined with the airport's fuel records, allows him to estimate the plane's gross takeoff weight.
15:43We knew how many people we had on board.
15:46We knew how many bags we had on the airplane.
15:48And we knew what our fuel load was.
15:53He estimates the F-28 weighed between 62,000 and 64,000 pounds.
16:00And the airplane's max takeoff weight was 65,000 pounds.
16:04And so we came to the conclusion that the airplane was not overweight.
16:07The cause of the crash remains a mystery.
16:15Eighteen days into the investigation, the Canadian government appoints Justice Virgil Mushansky
16:20to lead a more wide-ranging inquiry into all aspects of the aviation system
16:25that might have contributed to the Air Ontario tragedy.
16:28The government was looking for an experienced trial judge,
16:33and preferably one who had an aviation background.
16:37Mushansky is an experienced pilot with 13 years on the bench.
16:41He will work closely with crash investigator David Roa
16:44and aviation consultant Frank Blank.
16:47The new team's first step, assessing the plane's technical systems.
16:51The electrical system, the hydraulic system, the fuel system,
16:55all of these systems are looked at both in terms of what is their history leading up to the accident
17:01and what remnants are remaining at the crash site that can be examined.
17:10Clues to a possible system failure arise when Sonia Hartwick recalls a troubling event
17:15aboard the same plane just days before the fatal crash.
17:19I think it was Monday or Tuesday.
17:21When we took off, there was a smoke that filled the aircraft,
17:26and there was this horrible smell.
17:28I thought, oh my God, we have a fire in the lab.
17:34But there was no fire in the lavatory or anywhere else in the cabin.
17:39They told us that apparently it had something to do with oil sitting in the APU system.
17:46So every takeoff that day, this would happen.
17:49The auxiliary power unit is a generator that provides the power needed to start the engines.
17:58Did burning oil in the APU somehow cause a fire and ultimately doom flight 1363?
18:06Roa searches the week's journey log for any mention of the auxiliary power unit.
18:10He makes a surprising discovery.
18:14The APU wasn't working on the day of the crash.
18:18It couldn't possibly have caused the fire.
18:21But the inoperative power unit may still have played a role in the tragedy.
18:27Investigators learned that it forced the crew to make a risky decision in Dryden.
18:31Normally, the captain would rely on the APU to restart his engines after shutting them both down for refueling.
18:41But if he couldn't use his APU, he couldn't shut his engines down.
18:45That meant flight 1363 had to be refueled with one engine still running.
18:50Captain Moorwood is in a situation where he's got to hot refuel with passengers on board the aircraft.
18:56He's got to keep an engine running to refuel the airplane.
19:01Hot refueling isn't against regulations.
19:04But the risk of a fuel spill makes it potentially dangerous.
19:07In Toronto, in 1973, a maintenance person was killed when an Air Canada DC-8 jet was consumed by fire during refueling.
19:21Hot refueling is not a normal practice.
19:25Could the hot refueling have caused some kind of damage to the engines?
19:29The Dryden airport manager, a former military pilot, suspects there was trouble with the plane's engines.
19:41He tells Rower he saw the take-off from his office and heard a sharp, explosive noise just as it disappeared from view.
19:48To him, it signified a flame-out or engine failure.
19:51I thought, this is going to be a high-profile and potentially controversial investigation.
20:04And the only way to ensure that the truth stands up is to have hard evidence from the aircraft accident.
20:12And so we took the airplane completely and we put it in our lab in Ottawa.
20:18Anything?
20:19With signs pointing to engine failure as the cause of the crash,
20:24Strip it down.
20:25Rower orders extensive engine testing.
20:28Those engines were examined in detail for damage.
20:33Rower finds the F-28's two Rolls-Royce engines suffered only minor structural damage.
20:39There's no evidence of an engine fire, nothing at all to suggest the engines had failed.
20:49With little physical evidence to explain the failed take-off, investigators are back to square one.
20:59To solve the mystery, they comb through survivor and eyewitness statements.
21:04A common thread emerges.
21:06They said, in their witness statements, there was snow and ice on the wings when the airplane attempted to take off.
21:12Rower studies weather charts for clues.
21:20We had very good meteorological information.
21:24The charts show that during the half hour the F-28 was on the ground at Dryden Airport.
21:29Visibility shrank from four kilometers to less than one kilometer because of the snowstorm.
21:35And we may find other reasons.
21:38For sure, snow and ice on the wings was a factor in the sight.
21:42Sonia Hartwick tells investigators about an unusual sight during take-off.
21:47As we took off, I noticed that the wings just became a solid sheen of gray, shiny ice.
21:59Investigators consult the F-28's manuals to study its anti-icing systems.
22:04They find that only the wings' leading edges are protected.
22:08The aircraft had heated leading edges on the wings.
22:12I wonder if the anti-icing system was working.
22:15And the heat was provided by bleed air from the compressors on the engine.
22:20They found the valves that allow the compressed air access to the leading edges.
22:30And they tested the valve to see if it functioned, and it did.
22:35The anti-icing system was working.
22:38But since it only heats the leading edge,
22:40it likely didn't clear ice that formed on the surface of Flight 1363's wings.
22:50Investigators suspect that snow and ice build-up,
22:53what experts call wing contamination,
22:56may have played a major role in the crash.
22:58To verify that suspicion,
23:04Roha and his team meet with engineers from Fokker.
23:08Thanks for coming.
23:09Curious to see what you have.
23:12Jack Van Hengst, who was the chief engineer,
23:14had extensive aerodynamic studies and data
23:18on the effects of contamination on an F-28 airplane.
23:21Fokker engineers have run simulations of the crash.
23:26They were able to get some very good data
23:29in terms of the performance of the airplane,
23:32simulating the type of loads, temperatures, etc.,
23:36that the Dryden aircraft would have been exposed to.
23:41Investigators make a crucial discovery about the design of the F-28.
23:45Because of the angle of the wings,
23:49a very small amount of ice makes the plane susceptible to stalling.
23:54They concluded that even the most minute bit of contamination on the wing
24:00would disrupt the airflow and cause a loss of lift.
24:06That answers a lot of questions.
24:08The simulations support what witnesses saw.
24:11It just barely got airborne, dropping wings, losing lift,
24:17and then hitting trees, decelerating to the point where it broke up.
24:26Investigators are now certain that contaminated wings caused the crash.
24:31But what's still unclear is why the plane was not de-iced before take-off.
24:35Almost all airports in cold climates, including Dryden,
24:42are equipped with the technology to remove ice from a plane.
24:49But Captain Morwood never requested de-icing.
24:54It's getting worse. What's the latest?
24:56And it won't clear until late afternoon.
24:58Investigators need to figure out why.
25:00They want to understand what made him risk his own life.
25:04Let's hope it holds.
25:06And the lives of the 68 other people on board flight 1363.
25:16Investigators dig through Captain George Morwood's flight records and work history.
25:21They interview crew members, searching for clues to his behavior.
25:25Captain Morwood was a very, very professional, very old-school pilot.
25:30He had his view on how things should be done properly
25:34and what his definition of proper and professional would be.
25:37He also was very concerned about his passengers.
25:41He enjoyed making sure that they got on their flights on time
25:45and got to their destinations on time.
25:46You know, Air Ontario was a growing company.
25:50It was their first foray into jet operations.
25:54I'm sure that there were many things that Captain Morwood would have thought in his own mind,
25:59this is not how he would do it.
26:02And I'm sure at times he probably let the superiors know that.
26:06Morwood's history shows he's delayed and canceled flights in the past because of icing concerns.
26:11Morwood is stumped.
26:14Why didn't he request de-icing in Dryden?
26:19Another pilot who was at Dryden Airport that day provides part of the answer.
26:25He heard Morwood on the phone to Air Ontario.
26:29That is what I have been trying to tell you.
26:33He was very frustrated and he was really concerned about his passengers.
26:38Morwood complained to the off-duty pilot about the company.
26:42These guys.
26:44You want to guess my weight before I left Thunder Bay?
26:4666 and change.
26:47I had to offload fuel.
26:49Now that...
26:51Right.
26:53So now what am I supposed to do?
26:55No.
26:57You figure it out.
27:00When he left the terminal, he was observed by witnesses
27:03to appear to be very upset and very angry.
27:10Investigators wonder what set Morwood off.
27:13They try to piece together the pilot's day on March the 10th.
27:17This was the fifth day of a very long week for Captain Morwood.
27:21And he was the next day leaving with his family on a ski vacation.
27:27Before his first flight of the day,
27:29he'd learned the plane's APU still wasn't working.
27:32And then, once in Thunder Bay, more bad news.
27:40After refuelling, the dispatcher forces Morwood to take on 10 extra passengers.
27:47Now he must offload fuel and lose more time.
27:51There goes the schedule.
27:52Let's offload some fuel then.
27:56This meant Morwood would leave Thunder Bay behind schedule.
27:59Dispatch, Ontario 363.
28:01And Captain Morwood is the type of captain who didn't want to be late.
28:07Now en route to Dryden, and an hour behind schedule,
28:10the weather forecast the crew was given of light rain and fog is no longer accurate.
28:16And Captain Morwood didn't get the forecast of freezing rain coming into Dryden,
28:22which he should have had.
28:23As flight 1363 lands in Dryden, the weather was getting worse by the minute.
28:30The plane sat there for half an hour while snow built up on the wings.
28:37I gotta talk to somebody about this.
28:40Investigators may never know how concerned Morwood was about the weather.
28:44But there is evidence that it was on his mind.
28:52When Rohr questions the fueling agent,
28:54he learns that Morwood did ask about de-icing moments before takeoff.
28:58Is there de-icing available?
29:04The fueling agent says he pointed out the de-icing ground crew to Morwood.
29:12The agent then offers a compelling reason that could explain why the captain didn't de-ice.
29:18Air Ontario had a policy prohibiting him from de-icing with an engine running.
29:28The fluid can be ingested in the engines
29:30and then find its way from there to the air conditioning on the airplane
29:34and make it extremely noxious in the cabin portion of the airplane.
29:39But if Morwood had shut down both engines,
29:42he wouldn't have been able to restart his plane.
29:45Now the only other way to start the airplane on the ground
29:48is with a ground-based air cart that can provide the compressed air.
29:54And Dryden did not have the capability to start the airplane.
29:59The equipment would have had to be flown in from Winnipeg.
30:03It would have been a costly decision.
30:05If he shut it down, he would ground the aircraft there effectively,
30:10requiring the billeting of passengers and hotels
30:14and out of the expense to the airline for which he would be answerable.
30:18Right. So now we're...
30:19So he was under a great deal of pressure.
30:21No. You figure it out.
30:25And I believe that the conversation on the phone
30:28would have been about that scenario and his displeasure with it.
30:31But he didn't have any other chance.
30:34It's getting worse. What's the latest?
30:36Quite heavy snow. Looks like it's going to be a bad one.
30:39It's still within our take-off limits.
30:41Well, that's good.
30:42We've got a lot of people who want to meet their connectors.
30:44Let's hope it holds.
30:45Though the amount of snow on the wings was still within limits,
30:49it's what lay under the snow that doomed the flight.
30:51The fuel in a plane's wing can get as cold as minus 40 degrees Celsius.
30:58The frigid fuel cools the metal surface of the wing.
31:01When snow hits this super-cooled surface,
31:04it freezes instantly into a barely visible layer of ice.
31:08It's a process called cold soaking.
31:11And this, of course, is what's disrupting the airflow on the wing
31:13and destroying the lifting capabilities.
31:16Tell them we're going immediately.
31:17The only reason that I can possibly think of
31:25that led to his decision to execute the take-off
31:28was the fact that he didn't consider the cold soaking phenomena
31:32and the fact that those wings could still have ice on them.
31:36Advise Kenora, we're ready to proceed.
31:39And Kenora Dryden on terror.
31:41Perhaps not wanting to face the consequences of shutting down his engines,
31:44because Moorwood opted to take off for Winnipeg without de-icing his plane.
31:50He must have concluded that the ice would blow off on take-off.
31:56That is where he made a mistake, a tragic mistake.
32:01But Mashansky concludes that despite his mistake,
32:04Captain Moorwood is not solely responsible for the crash.
32:08It wasn't simply pilot error.
32:09There were a myriad of factors, which were the cause of the accident.
32:19One of the most important factors,
32:22Air Ontario's decision to let the plane fly with a broken APU.
32:27They were deferring a lot of the maintenance that should have been done
32:31because of a shortage of parts.
32:33And then they had to scrounge around all across Canada
32:37with various F-28 operators to borrow parts from them.
32:42And this was a very bad move on the part of Air Ontario management.
32:48The investigation determines that by cutting corners
32:51and focusing too much on the bottom line,
32:55the airline was putting all their passengers and employees at risk.
32:58Because the F-28s were new to Air Ontario,
33:01there was this urgency to get one crew off
33:04and get the next crew on flying.
33:06This urgency to have them in the air producing money.
33:10I came to the conclusion after a lot of thought about this accident
33:15that there were a lot of other hands
33:17on those throttles, pushing those throttles forward.
33:20There were a lot of people that were involved
33:28in the sequence of events that led to this tragic outcome.
33:35This was a preventable accident.
33:37But everything conspired against the pilots.
33:40I've got to talk to somebody about this.
33:43Because Air Ontario management did not have a safety culture.
33:47And you have to have a safety culture from the top management down.
34:00Knowing there are dozens of Fokker F-28s flying around the world,
34:05Justice Mashansky takes an unusual step.
34:08He releases a report well before his inquiry concludes.
34:12Good afternoon.
34:13It warns of the plane's vulnerability to ice build-up
34:17and stresses the need for frequent de-icing in winter conditions.
34:21Even a small amount of icing would be disastrous on an F-28.
34:31But 15 months later,
34:33it becomes clear that Mashansky's warnings have not been heard.
34:37U.S. Air Flight 405 is preparing to fly from New York to Cleveland
34:43on March 22, 1992.
34:47The plane is a Fokker F-28.
34:51And it's snowing.
34:55It's one degree below freezing.
34:58At 9 p.m., the jet is being de-iced for a second time
35:01since its arrival from Florida.
35:02In the past hour, an inch of snow has fallen
35:07and shows no signs of stopping.
35:10U.S. Air 405, clear to taxi, runway 13.
35:14The crew prepares for takeoff.
35:17Flight 405 is an hour and 45 minutes behind schedule
35:22when Captain Wallace Majeure starts taxiing to runway 13.
35:25Then, unexpectedly...
35:30U.S. Air 405, clear left, and hold short of echo.
35:36Left on the inner, to hold short of echo.
35:39At 9.07 p.m., Flight 405 is forced to wait on the taxiway near runway 13.
35:46Another 23 minutes pass.
35:50First Officer John Reshuba turns on a light that illuminates his wings.
35:54He checks the right wing for ice.
35:57He sees none.
35:58Looks pretty good to me, as far as I can see.
36:02U.S. Air 405, runway 13, clear for takeoff.
36:06Even though it's now been 35 minutes since their last de-icing,
36:11the crew does not request another.
36:13Takeoff thrusts set.
36:15Temps okay.
36:17Everything proceeds as it should...
36:20until...
36:22V-1.
36:22Rotating.
36:26Just after the F-28 begins its rotation.
36:31The aircraft had enough flying speed to lift off.
36:37Barely lift off.
36:39The wings just could not support the airplane.
36:42They knew they were in trouble.
36:4413 seconds after lifting off,
36:46Flight 405 crashes on the shore of Flushing Bay.
36:50I don't think any pilot really thinks he's going to crash.
37:00They were trying to save the airplane right to the end.
37:0727 of the 51 people on board are killed.
37:10Another Fokker F-28 has crashed, with tragic consequences.
37:17My reaction when I heard about it was,
37:20my God, it's dryden all over again.
37:23Within days,
37:24investigator in charge Robert Benzen suspects that ice on the wings was the major cause.
37:29It would be very, very difficult for either of the pilots to really detect ice on the wings,
37:35looking backwards over their shoulders through the side windows of the airplane.
37:39Looks pretty good to me, as far as I can see.
37:41So, the captain was faced with quite a problem.
37:44If he wanted to be de-iced a third time, he would have had to get out on the lines,
37:48taxi all the way back into the parking area,
37:50and meet up with a de-icing truck again.
37:52Take off thrusts.
37:54That would have put him very, very late,
37:56and it may have even caused the cancellation of the flight.
38:01After all of this work,
38:03after all of the efforts,
38:05to see it happen again was extremely frustrating.
38:15There were no regulations in place requiring the crew to seek another de-icing after their extended delay.
38:22But Justice Mashansky had called attention to the dangers of long wait times when he issued his interim report.
38:29If they had followed the recommendations in my second interim report,
38:34this accident certainly could have been averted.
38:42He also had drawn attention to the limitations of the de-icing fluid being used at the time.
38:48Called type 1 fluid,
38:51it's a mixture of antifreeze and water.
38:54Those chemicals are designed that as you accelerate down the runway,
38:57that they will actually shed off your wing,
39:00so that when you actually want the wing to lift and produce lift,
39:03that it's not contaminated.
39:06Type 1 fluid is applied hot to de-ice the plane's surfaces.
39:10But it doesn't last long.
39:13Type 1 fluid had a hold over time in their best conditions of about 15 minutes.
39:21Under poor conditions such as freezing rain,
39:24it could be as low as six minutes.
39:26During the Air Ontario investigation,
39:29Mashansky's team reached a stark conclusion about the effectiveness of type 1 fluid.
39:33Even if Captain Moorwood could have de-iced his plane in Dryden...
39:38We're fired up, taxiing for departure, requesting airways to Winnipeg.
39:42...it may have made no difference.
39:47Hang on a sec, guys.
39:48Is there a chance that might be cold?
39:49We're having some bad weather around here.
39:51Unbelievable.
39:52Flight 1363 had to wait for the troubled Cessna 150 to land.
39:57By the time he waited for this 150 aircraft and pilot to land,
40:00and then they backtracked and got into position.
40:03Now they're in a serious snowstorm.
40:06And they are getting contaminated.
40:11Even if Moorwood had de-iced during his 30 minutes on the ground...
40:15Rotate.
40:16...the delay may have been enough for the fluid to stop working.
40:20The plane's wings may once again have become coated in ice.
40:30It came out in the examination of Air Ontario pilots that there was a dire need for training
40:40in terms of how the de-icing, anti-icing systems worked and how long your aircraft was protected.
40:48As soon as our accident occurred up in New York, we, of course, understood that it was a similar aircraft,
40:56in fact, a nearly identical aircraft to the Dryden accident airplane.
41:00The circumstances were similar in both accidents, and the Dryden report was a tour de force,
41:07which helped us focus our investigation quite a bit.
41:10Justice Moschansky had released his interim report more than a year before the crash of Flight 405.
41:19His recommendations could have prevented it.
41:24Moschansky would soon discover that a breakdown in communication
41:28had cost the lives of 27 people in New York.
41:31During his inquiry, Justice Moschansky learned that there was another type of de-icing fluid
41:44available to the airline industry.
41:48It's called Type 2 fluid.
41:52It's thicker than Type 1, which prevents it from immediately flowing off an aircraft.
41:57A Type 2 fluid is a much more gooey substance.
42:03I've heard it referred to as almost mucus-like.
42:06With holdover times of up to 45 minutes, it keeps ice from accumulating,
42:11then blows off the plane's surfaces at takeoff.
42:15Fifteen months before the U.S. air crash,
42:18Moschansky recommended greater use of the thicker Type 2 fluid.
42:22Moschansky's investigators also studied de-icing practices at Toronto's Pearson Airport.
42:31We got a hold of a film crew,
42:34and we waited and watched the weather very carefully
42:36until we found a forecast of freezing rain.
42:41And we tracked one aircraft which was heading for the Caribbean.
42:46The investigators discovered an alarming gap in the time between de-icing and takeoff.
42:51And from the time the aircraft was de-icing on the gate
42:55until the time the aircraft took off
42:58was somewhere in the order of 41 minutes.
43:00So there was no doubt that aircraft were departing Pearson Airport
43:05with a partially or largely contaminated wing surface.
43:11We then went to Chicago O'Hare.
43:17This was the first airport to actually put in place runway and de-icing pads.
43:23And it was very useful in terms of explaining to us how these had evolved,
43:29what type of de-icing equipment they were using on them, how they worked.
43:33At the time of the U.S. Air crash,
43:36LaGuardia did not offer de-icing at the runway, only at the gate.
43:43Again, 15 months before the crash,
43:45Justice Moschansky recommended the placement of de-icing facilities
43:49at runways instead of terminal gates.
43:53Moschansky also recommended that pilots not only inspect their wings from the cockpit...
43:58Looks pretty good to me, as far as I can see.
44:01...but also from the cabin.
44:03U.S. Air 405, runway 13 cleared for takeoff.
44:06Moschansky claims that his report could have prevented the crash at LaGuardia.
44:13But the Federal Aviation Administration claims it never received his report in 1990
44:18and therefore couldn't pass the information along to airlines and pilots.
44:23But Justice Moschansky doesn't accept that.
44:26My second interim report went out in December of 1990.
44:34It was about a year and a half before the LaGuardia crash occurred.
44:40So I think it probably sat on somebody's desk.
44:47The crash of Flight 1363 resulted in dozens of recommendations that could save lives.
44:53The crash of Flight 405 ensured those recommendations were widely implemented.
45:01Well, there was a lot that came out of Dryden.
45:03I mean, the commission came out with 192 recommendations.
45:07It changed the whole nature of how we approach contamination.
45:11We now have runway and de-icing pads so they can get a final de-icing before they take off.
45:23This was something directly the result of the Dryden Commission inquiry.
45:30Today, most airlines use a new type of de-icing fluid.
45:35Type 4 de-icing fluid lasts longer.
45:39It will stick to a wing for up to two hours.
45:41As well, air traffic controllers must now be able to tell flight crews how long they will be delayed at the runway after being de-iced.
45:52Dryden is really the first accident that explored not only what happens in the pointed end of an airplane,
45:59but what happens within a corporate culture.
46:03It puts CEOs on notice that they can't hide in the woodwork when an accident occurs.
46:13Dutch manufacturer Fokker went bankrupt in 1996.
46:18Despite this, in 2009, there were still 55 Fokker F-28 jets in operation worldwide,
46:26mostly in warmer climates.
46:28Nobody should ever lose their life due to a contamination accident again in commercial aviation.
46:33Anywhere in a snow-on-ice environment.
46:37We've learned all the lessons.
46:38We've learned all the lessons.