All language subtitles for Air.Disasters.S02E06.Cold.Case.1080p.PMTP.WEB-DL.DDP5.1.H.264-maldini_track3_[eng]

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.