All language subtitles for Mayday.S09E06.Cold.Case.1080p.AMZN.WEB-DL.DD+2.0.H.264-playWEB_track3_[eng]

New York City's
LaGuardia Airport,
March the 22nd, 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.

USAir Flight 405
plunges into the icy waters
of Flushing Bay.

Twenty-seven 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've been averted.

The La Guardia accident
makes one thing clear:

The right people
never got the warning.

Mayday, mayday.

March the 10th, 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 refuelled.

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 grey.

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 Friday,
the beginning of March 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
travelling on board with plans.

Most of them were going skiing.

And, uh...

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.

Looks like it's gonna be
a bad one.

It's still within
our takeoff limits.

Well, that's good.
We 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 -35° Celsius
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.

Okay, no smoking
and seatbelts.

- On.
- Instruments.

Synced.

Crosschecked.

Captain Morwood uses
the power of engine #2,

already running,
to fire engine #1.

Morwood and Mills are both
highly experienced pilots.

However, they've each flown
fewer than 100 hours
in the Fokker F-28.

The multimillion-dollar aircraft
is the first Air Ontario jet

to serve the remote
Northern Ontario region.

Twenty-four 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.

Okay, 363's holding short
of the active.

We are gonna be a few moments
until a small plane
lands safely.

Sorry, folks.
This just isn't our day.

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

I'd 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?

V1.

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, uh...

the plane... started shaking.

I thought: Oh, my God,
we're gonna 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.

There's 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 were loud,
horrible sounds.

We were clearly crashing.

The pilots are helpless.

Forty-nine seconds
after lifting off...

...Air Ontario Flight 1363
crash-lands in the bush...

...950 metres west of Runway 29.

There is carnage of, uh,
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've
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.

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!

Come on...

Passengers scramble for safety
before the fire spreads.

Forty-five 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 hospital in Dryden.

I was very concerned,
because I kept looking
out the window.

I thought
there was a lot of snow.

I didn't notice anything wrong
going down the runway.
When we started hitting 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.

And 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 1100° Celsius

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 an 1100° 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.

We were just about to leave
Thunder Bay and they gave us
10 new passengers.

Investigators must now rely heavily
on eyewitness reports

to reconstruct the 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, um,
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,

so we came to the conclusion
that the airplane
was not overweight.

The cause of the crash
remains a mystery.

Eighteen 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've 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 fatal 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 APU 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 APU
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 APU 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.

...the connectors.
Let's hope it holds.

Normally the captain
would rely on the APU
to restart his engines

after shutting them both down
for refuelling.

If he couldn't use his APU,
he couldn't shut
his engines down.

That meant
Flight 1363 had to be refuelled
with one engine still running.

Captain Morwood
is in a situation
where he's gotta hot refuel -

with passenger
on board the aircraft.

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

Hot refuelling
isn't against regulations.

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

In Toronto, in 1973,

a maintenance person was killed

when an Air Canada DC-8 jet
was consumed by fire
during refuelling.

Hot refuelling
is not a normal practice.

Could the hot refuelling
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 gonna 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 charts show
that during the half-hour

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

visibility shrank
from four kilometres
to less than one kilometre

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 grey, shiny ice.

Investigators consult the F-28's manuals
to study its anti-icing 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, uh...

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, etc.

that the Dryden aircraft
would've 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 de-iced before takeoff.

Almost all airports
in cold climates,
including Dryden,

are equipped with the technology
to remove ice from a plane.

But Captain Morwood
never requested de-icing.

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

...and it won't clear
until 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 behaviour.

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.

You know, Air Ontario
was a growing company.

It was their first foray
into jet operations.

I'm sure
that there were many things

that Captain Morwood would've
thought in his own mind...

this is not how he would do it.

And I'm sure at times
he probably let, uh,
the superiors know that.

Morwood's history
shows he's delayed and cancelled
flights in the past

because of icing concerns.

Rohrer is stumped.

Why didn't he request de-icing
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?
Sixty-six 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 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 APU
still wasn't working.

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

After refuelling,
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 enroute 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've 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 gotta 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 fuelling agent,

he learns that Morwood did ask
about de-icing
moments before takeoff.

Is there de-icing available?

The fuelling agent
says he pointed out the de-icing
ground crew to Morwood.

The agent then offers
a compelling reason

that could explain
why the captain didn't de-ice.

Air Ontario had a policy
prohibiting him from de-icing
with an engine running.

The fluid can be ingested
in the engines,

and then find its way from there
to the air conditioning
on the airplane

and make it extremely noxious
in the cabin portion
of the airplane.

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, uh, Dryden did not have
the capability
to start the airplane.

The equipment
would've had to be flown in
from Winnipeg.

It would've been
a costly decision.

If he shut it down,
he would, uh...

ground the aircraft
there effectively,

requiring the... billeting
of passengers in hotels

and added expense to the airline
for which he would be
answerable.

- Right. So now what...
- So he was under a great deal
of pressure.

No... you figure it out.

And I believe
the conversation on the phone

would've 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 gonna be
a bad one.

It's still within
our takeoff limits.
- Well, that's good.

We 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 -40° Celsius.

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.

Tell them we're going
immediately.

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

The only reason
that I can possibly think of
that led...

to his decision
to execute the takeoff

was the fact
that he didn't consider
the cold-soaking phenomena,

and the fact that those wings
could still have ice on them.

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 de-icing his plane.

He must've 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 APU.

They were deferring
a lot of the maintenance

that should've 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 gotta 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 de-icing
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.

USAir Flight 405
is preparing to fly

from New York to Cleveland
on March the 22nd, 1992.

The plane is a Fokker F-28.

And it's snowing.

It's one degree below freezing.

At 9 p.m.,

the jet is being de-iced
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.

USAir 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...

USAir 405, turn left
and hold short of Echo.

Left... hold short of Echo.

...at 9:07 p.m.,

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.

USAir 405,
Runway 13 clear for takeoff.

Even though it's now been
35 minutes

since their last de-icing,

the crew does not request
another.

Takeoff thrust set.
Temp's okay.

Everything proceeds
as it should, until...

V1.

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.

Thirteen 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.

Twenty-seven 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 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 de-iced
a third time,

he would've had to get out
of the line,

taxi all the way back
into the parking area

and meet up
with a de-icing truck again.

Takeoff thrust.

That would've 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 de-icing
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've been averted.

He also had drawn attention
to the limitations

of the de-icing fluid
being used at the time.

Called "Type I fluid,"

it's a mixture of antifreeze
and water.

Those chemicals are designed
that as you accelerate
down the runway,

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 I fluid is applied hot
to de-ice the plane's surfaces.

But it doesn't last long.

Type I fluid
had a holdover time,

in their best conditions,

uh, 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 I fluid.

Even if Captain Morwood
could've de-iced his plane
in Dryden...

We're fired up,
taxiing for departure.
Requesting airways to Winnipeg.

...it may 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
de-iced 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 become coated in ice.

It came out in the, uh,

examination
of Air Ontario pilots

there was a...
a dire need for training, uh...

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

and how long your aircraft
was protected.

As soon as, uh,
our accident occurred...

up in New York,
we, of course,

understood
it was a similar aircraft;

in fact,
almost identical aircraft
to the Dryden accident airplane.

And 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've prevented it.

Moshansky would soon discover
that a breakdown
in communication

had cost the lives of 28 people
in New York.

During his inquiry,
Justice Moshansky learned

that there was another type
of de-icing fluid available
to the airline industry.

It's called Type II fluid.

It's thicker than Type I,

which prevents it
from immediately flowing
off an aircraft.

Type II fluid is, uh,

a much more gooey substance.

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

With holdover times
of up to 45 minutes,

it keeps ice from accumulating,

then blows off
the plane's surfaces at takeoff.

Fifteen months
before the USAir crash,

Moshansky recommended
greater use
of the thicker Type II fluid.

Moshansky's investigators
also studied de-icing 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 de-icing
and takeoff.

And from the time the aircraft
was de-iced 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, uh,

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 de-icing pads.

And it was very useful
in terms of explaining to us

how these had evolved,

what type of de-icing equipment
they were using on them,
how they worked.

At the time
of the USAir crash,

La Guardia did not offer
de-icing at the runway,

only at the gate.

Again,
15 months before the crash,

Justice Moshansky recommended
the placement of de-icing
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.

USAir 405,
Runway 13 clear for takeoff.

Moshansky claims
that his report

could've 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, uh...
December of 1990.

It was about a year and a half
before the La Guardia crash
occurred.

So I think, uh,

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 insured
those recommendations
were widely implemented.

There was a lot
that came out of Dryden.

I mean, the commission came up
with 192 recommendations.

It changed, uh...

the whole nature
of how we approach
contamination.

We now have runway-end, uh,
de-icing pads,

so they can get a final de-icing
before they take off.

This was something
directly the result of
the Dryden Commission Inquiry.

Today,
most airlines use a new type
of de-icing fluid.

Type IV de-icing fluid
lasts longer.

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

As 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.

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,
uh...

...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.

difuze